AVAST(in) me maties! To IV or IP, for that is the question

I would like to first apologize in the delay in this (lengthy) blog post. What now lies ahead are three potential courses of treatment, and sub levels of treatment within the three main categories.  We must decide which one to take.  This treatment must not only allow us to beat this cancer, but can get us into the twenty percentile of stage III-C ovarian cancer patients whom survive long than five years.  As you all know I come from the real estate industry, not the medical field, so this is all the result of a self taught crash course and research.  I would greatly appreciate feedback and any comments.


Treatment Main Categories:

1. Avastin (Bevacizumba Injection) - Avastin is a biological agent which is used in conjunction with standard chemo drugs (as explained in options 2 and 3 below).  Avastin is already approved to treat lung, colon, kidney and brain cancers.  The drug will not help Candy fight the cancer, but has been shown to prolong the time she will remain in remission.  The drug is currently part of a 3 armed clinical trial study (GOG-252) by the National Clinical institute.  Candy has the opportunity to be a patient in this clinical trial and will be placed in one of the following three arms of the study at random.  At the current time, I feel that Arms I and II of the Avastin trial look very promising, I need more help understanding Arm III.
•  Arm I: (What I am calling the Japanese Dose Dense IV Study) - This regiment is was set forth by a 2009 GOG study which proved that more frequent doses of Paclitaxel through IV gave the patient an additional 28 months of survival when vs to a standard IV treatment of Paclitaxel every 21 days.  
• Patients receive Paclitaxel IV over 1 hour on days 1, 8, and 15 and Carboplatin IV over 30 minutes on day 1. Patients also receive Bevacizumba IV over 30-90 minutes on day 1 in courses 2-6. Treatment repeats every 21 days for 6 courses.  This route will require more frequent trips to the hospital, and will likely be harder on Candy.
• Arm II: (What I call The Standard IP Treatment) - This arm is based on the findings of the 2006 IP study listed in #3 below which makes the case that Carboplatin placed through a port at a higher concentration every 21 days gives patients on average 16 months longer than traditional IV (#2 below)
• Patients receive paclitaxel as in arm I and Carboplatin intraperitoneally (IP) on day 1. Patients also receive bevacizumab as in arm I. Treatment repeats every 21 days for 6 courses in the absence of disease progression or unacceptable toxicity. Patients then receive bevacizumab alone as in arm I.
• Arm III (The arm I really don't understand) - Can someone please tell me why this arm is in the study, what studies have shown that the delivery of Paclitaxel over 3 hours vs 1 hour is more beneficial and why Cisplatin (not Carboplatin) is used on the following day?
• Patients receive paclitaxel IV over 3 hours on day 1, cisplatin IP on day 2, and paclitaxel IP on day 8. Patients also receive bevacizumab as in arm I. Treatment repeats every 21 days for 6 courses in the absence of disease progression or unacceptable toxicity. Patients then receive bevacizumab alone as in arm I.
2. Intravenous (IV) Treatment (Recommended by Moffitt Cancer Center) - The injection of paclitaxel and carboplatin, the most common drugs used to fight Ovarian Cancer, will flow through the blood stream and the body to attack the cancer cells.  Based on Candy's condition, the overall median survival rate if approximately 37 months.  Moffitt recommends this course of action because Candy had a bowel perforation after her first surgery and she was forced to have a colostomy.  The advanced scar tissue on the bowel and in her system would be damaged by IP treatment and can lead to future quality of living problems.  However, we have been told as there are currently no large nodules on Candy's colon since the last surgery, this is a VERY minimal risk.  What do you think?
3. Intraperitoneal (IP) Treatment - According to a 2006 New England Journal of Medicine article (thanks to Jill for getting me the full text) patients with advanced ovarian cancer whom receive the standard chemo drugs, paclitaxel and carboplatin through a port placed in the abdomen as opposed to through an IV live on average 16 months longer.  The theory is by flooding the abdominal cavity with these drugs, they attack the cancer directly and "This route allows the escalation of the dose of chemotherapy to a level that is not possible to achieve safely with intravenous drug administration."  The higher levels of chemo and more frequent sessions of chemo result in "a reduced quality of life during the therapy and shortly after its completion, but there was a return to baseline one year after completion". 

Does anyone know of any studies performed which determine the effectiveness of carboplatin vs cisplatin when administered via IP?  As of the 2006 NEJM article it was still debatable.


I greatly appreciate everyone's input in helping us keep informed and making the right decision.


David M. Scherer