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UW MEDICINE │ ONCOLOGY REGIONAL CARE ADVANCEMENT SYMPOSIUM (ORCA)
ENCOUNTERING OVARIAN CANCER
IN THE PRIMARY CARE SETTING
RENATA URBAN, MD MARCH 7, 2015
A patient discloses that her sister has
been diagnosed with ovarian cancer at
the age of 52. I would recommend this
patient undergo screening for breast
and ovarian cancer.
True
False
AUDIENCE RESPONSE QUESTION #1
2
URBAN Ovarian Cancer
URBAN
A 57 yo patient presents with bloating and urinary problems. A pelvic ultrasound reveals free fluid and a complex adnexal mass. You consider referral to one of the following:
Ob/Gyn
Surgical Oncology
Gynecologic Oncology
General Surgery
Hematology/Oncology
AUDIENCE RESPONSE QUESTION #2
4
URBAN Ovarian Cancer
URBAN
Following the conclusion of treatment,
patients with ovarian cancer have less
depression, but more anxiety
Yes
No
Don’t Know
AUDIENCE RESPONSE QUESTION #3
6
URBAN Ovarian Cancer
URBAN
DISCLOSURE
I am the PI of a research study that is
supported by Vermillion, Inc. I have no
other financial obligations to disclose
Describe the patterns of care in treating
ovarian cancer
Review the indications and options
for screening in the average and
high-risk population
Describe the symptoms associated
with ovarian cancer
List what tests to order when ovarian cancer
is on your differential
Discuss the surveillance and management
of ovarian cancer patients after treatment
OBJECTIVES
60 yo teacher Celiac disease, GERD
Gallbladder polyps followed by US last few years
Moderately obese with fatty liver, hyperlipidemia
G2P2, C/S x1
No family history of GI, breast or gynecologic cancer;
brother with testicular cancer
CASE PRESENTATION
6/26/14: Presents with a month of increasing bloating, without
change in bowel. Has had persistent menses, irregular, followed
by gynecologist and treated with progesterone 3 mos ago. Celiac
disease was diagnosed 3 years ago & normally managed with diet.
Symptoms initially felt like celiac, but progressed in spite of dietary
change, and a trial of Gas-ex and Zantac. Bloating waking her at
night. Acknowledges decreased food intake, no changes in urination
Exam: “Abdomen protuberant and slightly taut. Suprapubic tenderness
on palpation.” Pelvic exam not performed.
Plan: Probiotic trial, CBC and pelvic US
7/7/14: Symptoms worsening. Now occasionally nauseated,
more belching. Has not vomited, but eating very little.
Symptoms now present for 6 weeks
Exam: Abdomen very distended and tympanic. Pelvic exam limited
by distension, “uterus ill-defined, no focal mass.”
Plan : Warning signs and symptoms of partial small bowel obstruction
discussed. Orders for CT abdomen/pelvis, CBC, CMP, hCG, UA
CASE PRESENTATION
7/8/14: CT abdomen/pelvis
14 cm solid and cystic mass in mid-pelvis
Abundant ascites, peritoneal stranding, and evidence of partial SBO
Bilateral small pleural effusions
7/9/14: visit with PCP to review CT scan. Discusses plan
to order CA 125 and possible need for paracentesis
CA 125 = 1411
7/10/14: Developing symptoms of partial SBO. Paracentesis
performed, cytology reveals adenocarcinoma suspicious
for gynecologic primary
7/15/14: Visit with SCCA Gynecologic Oncology.
CASE PRESENTATION
7/17/14: Undergoes ex-lap, hysterectomy, removal of tubes &
ovaries, omentectomy, lymphadenectomy, cytoreduction and
intraperitoneal port placement
Pathology reveals IIIC high-grade serous carcinoma of the fallopian tube
Recommendations: IV & IP chemotherapy
12/29/14: Post-treatment visit at SCCA. Notes fatigue, numbness
and tingling in fingertips. Intermittent constipation
CA 125 = 12
CT C/A/P shows small lymphocele, otherwise negative for recurrence
Plan: discussed options for maintenance treatment & surveillance strategy.
Schedule visit with Medical Genetics.
CASE PRESENTATION
Describe the patterns of care in treating
ovarian cancer
OBJECTIVES
ESTIMATED NEW CANCER CASES/DEATHS
UNITED STATES, 2014
Females Estimated
Deaths Site Estimated
New Cases
Genital System
— Uterine cervix
— Uterine corpus
— Ovary
— Vulva
— Vagina and other genital
91,370
12,360
52,630
21,980
4,850
3,170
28,080
4,020
8,590
14,270
1,030
880
All
Digestive System
Respiratory System
Skin (excluding basal/squamous)
Breast
805,500
129,450
114,450
34,110
232,340
273,430
61,870
73,290
4,090
39,620
Siegel R et al. CA 2014
OVARIAN CANCER
PATTERNS OF CARE
Incidence* Age-Adjusted Cancer
Death Rate
1999 2011 %
change 1990 2010
% change
Ovary 14.3 11.3 -20% 9.5 8.1 -14%
Breast 135.4 122.0 -10% 31.7 21.9 -31%
Colorectal** 48.4 34.9 -28% 24.7 13.3 -46%
Prostate 170.8 128.3 -25% 38.6 21.8 -44%
Siegel R et al. CA 2014
*Per 100,000 population **Female only
OVARIAN CANCER
PATTERNS OF CARE
Thrall MM et al. Gynecol Oncol 2011
Bristow RE et al. Obstet Gynecol 2013
Cliby W et al. Gynecol Oncol 2015
Overall five-year survival rates for ovarian cancer
have improved from 36% to 44%
This is not consistent for all patients
Three large population-based studies have now shown that
less than 50% of women with ovarian cancer in the US receive
guideline therapy
Review the indications and options
of screening for ovarian cancer in
the average and high-risk population
OBJECTIVES
OVARIAN CANCER
SCREENING CHALLENGES
Debatable precursor or in situ lesion
Major surgical procedure required for diagnosis
Even if only 1% of tests are false-positive, 25 women would
require surgery for each diagnosed cancer
Lifetime probability of developing ovarian cancer
is <2%
USPSTF, ACOG & SGO do not recommend routine
screening for ovarian cancer in an average risk patient
OVARIAN CANCER
ESTIMATION OF RISK
The importance of identifying patients at high risk
cannot be overemphasized
Vignette-based survey of Ob/Gyns, internal medicine
and family medicine physicians found that 2/3 of
physicians underestimated the risk of ovarian cancer in a
patient at much higher risk than the general population
Baldwin LM et al. J Gen Intern Med 2013
SCREENING FOR OVARIAN CANCER
HIGH-RISK PATIENT
Definition of High Risk
Personal History
Premenopausal breast cancer
Family History
1st or 2nd degree relative with ovarian cancer at any age
1st degree relative with breast cancer <50,
bilateral breast cancer or male breast cancer
1st degree relative with colon or uterine cancer <50
Genetic syndrome
BRCA 1 or 2 mutation
Lynch syndrome
Reproductive factors
History of infertility or endometriosis
Lifetime risk
estimated
at 5%
Lifetime risk
35-45% (BRCA1)
15-25% (BRCA2)
Lifetime risk
10-12%
Clear cell
& endometrioid
ovarian cancer
SCREENING FOR OVARIAN CANCER
HIGH-RISK PATIENTS
For patients with an identified hereditary ovarian cancer
syndrome, consider TVUS & CA 125 every 6-12 months starting
at age 30-35 or 5-10 years before the earliest cancer diagnosis in
a family member
SCREENING FOR OVARIAN CANCER
HIGH-RISK PATIENTS
■ UK Familial Ovarian Cancer Screening Study
■ 3,563 women with ≥10% lifetime risk of ovarian
cancer recruited for study
■ Screening every 4 months with CA 125
and TVUS
■ Of cancers detected, 30.8% stage I/II
■ Sensitivity of 75%, PPV 25.5%, NPV 99.9%
■ Risk-reducing salpingo-oophorectomy
remains the standard of care
Rosenthal AN et al. J Clin Oncol 2013
PATTERNS OF CARE
FOR HIGH RISK WOMEN
Trivers KF et al. Cancer 201
PATTERNS OF CARE
FOR HIGH RISK WOMEN
Race – black, white
Age – 35 vs 51
Insurance – private or Medicaid
Level of risk
Vignette: A woman presents for an annual exam
VARIABLES
High
Personal hx breast cancer age 30
Paternal grandmother ovarian cancer
Paternal 1st cousin breast ca premenopausal
Outcome: Referral to genetic counseling and/or offering
BRCA1/2 testing (almost never, sometimes,
almost always)
Mom had breast cancer age 70 Average
PATTERNS OF CARE
FOR HIGH RISK WOMEN
Referral for Genetic Counseling
Vignette
Risk for Ovarian Cancer
Physicians Average HIGH
Reported adherence to USPSTF guidelines
71% 41%
Correctly identified risk 61% 47%
OVARIAN CANCER
RISK REDUCTION
OCP’s
Tubal ligation
Weight reduction?
Education if history
of endometriosis
or infertility
Bilateral salpingectomy?
Definitive reduction
in risk with prophylactic
bilateral salpingo-oophorectomy
at 40 years or when childbearing
is complete
Shown to reduce both
ovarian and breast
cancer mortality
OCP’s, tubal ligation, bilateral
salpingectomy
High risk Average risk
Describe the symptoms associated
with ovarian cancer
OBJECTIVES
When (and why) should ovarian cancer be on your differential?
SYMPTOMS AS SCREEN?
Previous survey of 1,725 women with ovarian cancer
demonstrated prevalence of symptoms even in women
with early stage disease
Abdominal/GI symptoms most common
Subsequent case-control study performed to assess symptoms
Preoperative survey given to 128 patients undergoing surgery
for a pelvic mass
44 women within this group found to have ovarian cancer
Identical survey given to 1709 women presenting to primary care clinic
Goff BA et al. Cancer 2000
Goff BA et al. JAMA 2004
RESULTS — PRIMARY CARE CLINICS
SYMPTOMS OF OVARIAN CANCER
General checkup 25%
Mammogram 13%
Problem visits 62%
1,709 women in primary care clinic completed survey
95% reported at least 1 symptom in past year
Back pain 60%
Fatigue 52%
Indigestion 37%
Urinary symptoms 35%
Constipation 33%
Median number reported symptoms was 4
Median severity 2-3
OVARIAN CANCER SYMPTOMS
WOMEN WITH AND WITHOUT CANCER
Excluding patients presenting for routine checkup or mammogram only
Symptom Cancer vs. Clinic Patient Cancer vs. IBS Patients
Pelvic pain 2.2 (1.2-3.9) 2.6 (1.2-5.6)
Abdominal pain 2.3 (1.2-4.4) 0.7 (0.3-1.5)
Difficulty eating 2.5 (1.3-5.0) 1.5 (0.7-3.7)
Bloating 3.6 (1.8-7.0) 3.0 (1.3-6.7)
Abdominal size 7.4 (3.8-14.2) 4.6 (2.1-10.1)
Urinary urgency 2.5 (1.3-4.8) 2.6 (1.2-5.7)
Constipation 1.6 (0.9-3.0) 1.0 (0.5-2.2)
Fatigue 1.4 (0.7-2.7) 1.1 (0.5-2.3)
Diarrhea 0.7 (0.1-0.4) 0.2 (0.1-0.5)
MEDIAN EPISODES SYMPTOMS/MONTH
SYMPTOMS OF OVARIAN CANCER
Symptom Ovarian CA
(n=44) Primary Care Clinic
(n=1600) p
Pelvic pain 24 2 0.001
Abdominal pain 23 2 0.017
Bloating 30 2 0.004
Fatigue 30 8 0.001
Urinary symptoms 30 12 0.02
Constipation 12 2 0.001
Diarrhea 6 2 0.06
MEDIAN DURATION EACH SX IN MONTHS
SYMPTOMS OF OVARIAN CANCER
Symptom Ovarian CA
(n=44) Primary Care Clinic
(n=1600) p
Pelvic pain 3 11 0.06
Abdominal pain 5 11 0.05
Bloating 3 12 0.04
Fatigue 3 12 0.08
Urinary symptoms 3 13 0.13
Constipation 3.5 12 0.001
Diarrhea 5 12 0.001
POSSIBILITIES FOR EARLIER DETECTION
DEVELOPMENT OF OVARIAN CANCER SYMPTOM INDEX
Prospective case-control study evaluated type and frequency
of symptoms
Subsequent development of symptom index
Index considered (+) if: Abdominal/pelvic pain, abdominal size/bloating,
difficulty eating or feeling full, urinary urgency/frequency
If present <1 year and occurred >12 days/mon
Specificity of 86.7% in women >50, sensitivity of 56.7%
for early stage disease
2.6% of general population screen (+)
Goff BA et al. Cancer 2007
SYMPTOM TRIGGERED SCREENING
FEASIBILITY & ACCEPTABILITY
Prospective study of women >40
1,261 patients screened if (+) referred for CA125 & TVS
Mean score of acceptability = 4.8 (1-5)
51 (4%) women had a positive SI
2 patients identified with ovarian cancer
All patients completed survey in <5 minutes
Goff BA et al. Gynecol Oncol 2012
USE OF SYMPTOM INDEX
TO TRIGGER EVALUATION
In a prospective study, 5,012 women were enrolled
to complete a symptom index (SI) assessment
SI
• Women >40 with at least one ovary and not pregnant
SI+
• Those with positive SI offered CA 125 and TVUS
• CA 125 >35 considered abnormal
SEER
• 12 months after study completion, all participants linked to Western Washington SEER to assess for diagnosis of ovarian cancer
SYMPTOM-TRIGGERED
DIAGNOSTIC EVALUATION
Of the study cohort, at baseline 8% had IBS and 20% had
GERD
241 (4.8%) had a positive SI
211 (88%) participated in additional testing with TVUS & CA 125
20 procedures were performed in study participants within
6 months of a positive SI
8 ovarian cancer cases detected
2 diagnosed within 6 months of the SI
1 had a positive SI and was diagnosed 31 days later with distant disease
1 had a negative SI; however she had a family history of ovarian cancer
and was undergoing evaluation for a pelvic mass at the time of study
participation
6 diagnosed 281-843 days after participation in the study
3 had early stage disease
Andersen MR et al. Obstet Gynecol 2014
SYMPTOM-TRIGGERED
DIAGNOSTIC EVALUATION
Evaluation resulted in 0.4% patients undergoing surgery
Very low number of ovarian cancer cases diagnosed
within 6 months of symptom index completion
Long-term follow-up identified 6 cancers
Possible that study participation provided women with education
about ovarian cancer symptoms, spurring them to seek evaluation
of subsequent symptoms
Real value may lie in its ability to act indirectly as an educational tool
Andersen MR et al. Obstet Gynecol 2014
SYMPTOM TRIGGERED SCREENING
COMBINATION WITH BIOMARKERS
The symptom index may have improved sensitivity
and specificity if combined with biomarkers
Prospective evaluation of 74 women with ovarian cancer
and 137 healthy controls
Symptom index (administered pre-diagnosis to cancer patients)
CA 125 & HE4
When symptom index plus CA125 or HE 4 was positive,
this yielded specificity of 98% for ovarian cancer
MR Andersen et al. Gynecol Oncol 2010
American Cancer Society now recommends that women
see their doctor if they experience symptoms of:
Abdominal swelling or bloating
Pelvic pressure or pain
Difficulty eating or feeling full
Problems with urination
Not all symptoms = ovarian cancer,
but consider it on your differential!
REVIEWING THE SYMPTOMS…
List what tests to order when ovarian cancer
is on your differential
OBJECTIVES
WHEN CONSIDERING OVARIAN CANCER ON YOUR
DIFFERENTIAL FOR THE PATIENT WITH SYMPTOMS
Labs
CA 125
Consider poor specificity of this test
in premenopausal women!
Presence of other conditions
that can increase CA 125
HE4
Increased sensitivity for ovarian cancer
compared with CA 125
More often expressed in endometrioid
and clear cell tumors compared
with CA 125
Clarke-Pearson DL. N Engl J Med 2009
Endometriosis
Uterine leiomyoma
Cirrhosis (with
or without ascites)
Pelvic inflammatory
disease
Cancer of the
endometrium
or pancreas
Presence of pleural
or peritoneal fluid
from any cause
(e.g. CHF)
WHEN CONSIDERING OVARIAN CANCER ON YOUR
DIFFERENTIAL FOR THE PATIENT WITH SYMPTOMS
Pelvic exam?
Evidence does not support the use of a pelvic exam to screen patients
for ovarian cancer
However, exam may reveal findings that impact diagnostic evaluation
(e.g. pelvic mass, lymphadenopathy, ascites) or identify other cause of
symptoms
Transvaginal ultrasound Presence of mass?
Free fluid in pelvis, ascites
Solid component
Thick septations
Peritoneal masses
Bloomfield HE et al. Ann Intern Med 2014
Myers ER et al. AHRQ Publication No. 06-E004
WHEN CONSIDERING OVARIAN CANCER ON YOUR
DIFFERENTIAL… FOR THE PATIENT WITH A PELVIC MASS
CA 125
Consider poor sensitivity of this test in a premenopausal woman
HE4
FDA approved to be performed in combination with pelvic US & CA 125
in the Risk of Ovarian Malignancy Algorithm (ROMA)
OVA-1
Multivariate serum assay
FDA approved to assess risk of malignancy in a patient
with a pelvic mass
WHEN CONSIDERING OVARIAN CANCER ON YOUR
DIFFERENTIAL… FOR THE PATIENT WITH A PELVIC MASS
Transvaginal ultrasound
Most cost-effective
No exposure to radiation
CT abdomen/pelvis
Presence of ascites
CONSIDERATION FOR REFERRAL OF A PATIENT
WITH AN ADNEXAL MASS TO GYNECOLOGIC ONCOLOGY
Premenopausal (<50)
CA 125 > 200 U/mL
Ascites
Evidence of abdominal or
distant metastasis (by results
of exam or imaging study)
Family history of breast
or ovarian cancer in a first
degree relative
ACOG Practice Bulletin No. 83, July 2007 (Reaffirmed 2013)
Postmenopausal
Elevated CA 125 levels
Ascites
Nodular or fixed pelvic mass
Evidence of abdominal or
distant metastasis (by results
of exam or imaging study)
Family history of breast
or ovarian cancer
in a first-degree relative
Treatments associated with improved survival
in ovarian cancer
Optimal surgical cytoreduction
Platinum-based chemotherapy
Care of ovarian cancer patients by gynecologic oncologists is
associated with improved survival
Patients treated by gynecologic oncologists more likely
to undergo primary surgery and chemotherapy
ROLE OF THE GYNECOLOGIC ONCOLOGIST
Earle CC et al. J Natl Cancer Inst 2006
Chan JK et al. Obstet Gynecol 2007
SURGICAL OUTCOMES AS A PROGNOSTIC FACTOR
99 months
36 months
29.6 months
0%
25%
50%
75%
100%
0 12 24 36 48 60 72 84 96 108 120 132 144
0%
25%
50%
75%
100%
0 12 24 36 48 60 72 84 96 108 120 132 144
0 mm
1-10 mm
>10 mm
0 mm
1-10mm
>10 mm
Progression-Free
Survival
Overall Survival
% P
FS
Months
% O
S
Months
29.6 months
36 months
99 months
1-10 mm vs. 0 mm:
>10 mm vs. 1-10 mm:
log-rank: P < 0.0001
HR (95%CI)
2.52 (2.26-2.81)
1.36 (1.24-1.50)
1-10 mm vs. 0 mm:
>10 mm vs. 1-10 mm:
log-rank: P < 0.0001
HR (95%CI)
2.70 (2.37-3.07)
1.34 (1.21-1.49)
du Bois AI et al. Cancer. 2009
Involvement of Gynecologic Oncologists in Treatment of Patients with Suspicious Ovarian Mass
3,200 physicians surveyed in 2009
Vignette-based survey of a 57 year old with pain,
bloating, suspicious right adnexal mass and ascites
Referral to Gyn Onc: FP 39.3%
IM 51.0%
Ob/Gyns 66.3%
Among Ob/Gyns, 33.7% performed the primary surgery
Factors associated with not referring
Medicaid insurance
Weekly average of 90+ patients
Rural or solo practice
ROLE OF THE GYNECOLOGIC ONCOLOGIST
Goff et al. Gynecol Oncol 2011
Discuss the surveillance and management
of ovarian cancer patients after treatment
OBJECTIVES
WHAT HAPPENED IN BETWEEN?
Cytoreductive surgery
Bowel resection
Risk for infection following
splenectomy
Postoperative pain
Surgical menopause
Complications?
VTE
Wound issues
Chemotherapy
Neuropathy
Fatigue
Gastrointestinal issues
Bone marrow suppression
Depression
WHAT HAPPENS NOW?
Maintenance
Surveillance
Performance
MAINTENANCE
Refers to prolonged therapy to increase the probability
of remaining in remission
Options
Additional chemotherapy
Biologic agents
Clinical trial
Please encourage patients to speak to their oncologist
regarding any options for maintenance treatment
SURVEILLANCE
NCCN recommendations for surveillance
Visit and physical exam
Tumor markers
CA 125 if initially elevated
HE4 also FDA approved for monitoring for recurrent
or progressive disease
Imaging as clinically indicated
Salani et al. Am J Obstet Gynecol 2011
SURVEILLANCE PATTERNS OF RECURRENCE
26-50% of recurrences
occur in the pelvis
Other common sites
Retroperitoneal lymph nodes
Upper abdomen
Lungs
Rare sites of metastases
Brain
Cutaneous
Symptoms
Can be similar as initial
presentation
Bowel obstruction
Shortness of breath
SURVEILLANCE
Referral of ALL patients with epithelial ovarian cancer
for genetic counseling and testing
In a study of Canadian patients with high-grade serous ovarian
cancer, referral for genetic counseling based on family history
alone would have missed 35% of mutation carriers
Schrader KA et al. Obstet Gynecol 2011
PERFORMANCE
WHAT ARE PATIENTS EXPERIENCING?
Survey of 100 patients with ovarian cancer
Symptoms with highest frequency and severity
Emotional symptoms
Negative feelings about treatment or prognosis
Fatigue
Pain
Frequent symptoms (variable severity)
Dyspareunia
Neurologic symptoms (cognitive impairment, neuropathy)
Less frequent, more severe symptoms
Socio-economic concerns
Negative body image
Insomnia
Stavraka C et al. Gynecol Oncol 2012
PERFORMANCE
SYMPTOM MANAGEMENT
Fatigue
Neurotoxicity
Most often due to chemotherapy
Numbness & weakness in hands, discomfort in feet, muscle cramps
GI toxicity
Can be due to both surgery and chemotherapy
Risk of bowel obstruction
May be herald of recurrent disease
Abdominal pain, diarrhea and/or constipation
Lymphedema
Gynecologic
Menopause
Sexual dysfunction
Mirabeau-Beale KL et al. Gynecol Oncol 2009
PERFORMANCE
SYMPTOM MANAGEMENT
Neurotoxicity
Gabapentin
CAM: Vitamin B6 complex, L-glutamine
Lymphedema
Compression stockings
Physical therapy, manual decompression treatment
Gynecologic
Consider either systemic or local estrogen replacement therapy
Venlafaxine for vasomotor symptoms
Mirabeau-Beale KL et al. Gynecol Oncol 2009
Ibeanu O et al. Gynecol Oncol 2011
PERFORMANCE
SURVIVORSHIP AND PHYSICAL HEALTH
Fatigue
Estimated to occur in 70-100% of patients with cancer
Can be due to anemia, malnutrition, medications, depression, insomnia
May also contribute to cognitive dysfunction
Encourage exercise!
Participating in physical activity has been associated with a lower risk
of ovarian cancer mortality
Zhou Y et al. Gynecol Oncol 2014
PERFORMANCE
SURVIVORSHIP – MENTAL AND EMOTIONAL HEALTH
“Chemo brain”
Studies have shown variable rates of cognitive dysfunction following
therapy for ovarian cancer
Consider relaxation techniques, physical exercise programs,
“brain training”
Avoid continuing benzodiazepines!
Psychological effects
In a prospective study of ovarian cancer patients, depression levels
were found to decrease 3 months after chemotherapy, however levels
of anxiety were found to increase
Cognitive behavioral therapy, antidepressant/antianxiety medication
Hipkins J et al. Br J Health Psychol 2004
SURVIVORSHIP PLAN
In 2006, the Institute of Medicine (IOM) met to review the
challenge of the growing number of cancer survivors
outstripping capacity of providers
IOM recommended that cancer patients should have a
treatment summary and follow-up care plan the survivorship
care plan
Unclear if these plans impact care
Prospective study in patients with gynecologic cancers found
no difference in evaluation of health services and satisfaction
Institute of Medicine of the National Academies:
Cancer Survivorship Care Planning
Brothers BM et al. Gynecol Oncol 2013
A patient discloses that her sister has
been diagnosed with ovarian cancer at
the age of 52. I would consider
screening this patient for breast cancer
and ovarian cancer
True
False
AUDIENCE RESPONSE QUESTION #1
64
A 57 yo patient presents with bloating and urinary problems. A pelvic ultrasound reveals free fluid and a complex adnexal mass. You consider referral to one of the following:
Ob/Gyn
Surgical Oncology
Gynecologic Oncology
General Surgery
Hematology/Oncology
AUDIENCE RESPONSE QUESTION #2
65
Following the conclusion of treatment,
patients with ovarian cancer have less
depression, but more anxiety
Yes
No
Don’t Know
AUDIENCE RESPONSE QUESTION #3
66
Primary care providers are crucial to both the diagnosis and management of ovarian cancer patients
Identification of patients at high risk for ovarian cancer
Recognize symptoms that may indicate ovarian cancer on a differential
Evaluation & diagnosis of a patient with possible ovarian cancer
Referring patient with concerning history and/or findings to a gynecologic oncologist
Discussing genetic counseling with patients with a concerning medical history and/or diagnosis of ovarian cancer
SUMMARY
67
PROVIDER AND PATIENT RESOURCES
Survivorship Clinic at the Seattle Cancer Care Alliance
Society for Gynecologist Oncologists
www.sgo.org
National Cancer Comprehensive Network
Marsha Rivkin Center for Ovarian Cancer Research
Foundation for Women’s Cancer
www.foundationforwomenscancer.org
Ovarian Cancer Together
http://www.ovariancancertogether.org/Pages/FriendsTOGETHERWA.aspx
Schrader KA et al. Obstet Gynecol 2011
DIVISION OF GYNECOLOGIC ONCOLOGY
UNIVERSITY OF WASHINGTON
Barbara Goff, MD Heidi Gray, MD
Benjamin Greer, MD
Hisham Tamimi, MD Elizabeth Swisher, MD John Liao, MD, PhD
Renata Urban, MD Barbara Norquist, MD Barbara Silko, ARNP Listya Shah, PA-C
Questions? We are available 24-7 through MedCon (206) 520-5000 or 1 (877) 520-5000
Referrals? (206) 288-7155
71
Annual transvaginal ultrasound scan (TVS) and CA125 screening.
Adam N. Rosenthal et al. JCO 2013;31:49-57
©2013 by American Society of Clinical Oncology
RISK OF OVARIAN CA IN WOMEN
WITH SYMPTOMS IN PRIMARY CARE
212 ovarian cancer patients with 1,060 matched controls
Charts photocopied and anonymously scored for symptoms
85% of cancer cases and 15% of controls had one
of 7 symptoms
Abdominal distension, urinary frequency and abdominal pain
were significantly associated with ovarian cancer,
even at 6 months prior to diagnosis
Hamilton W et al. BMJ 2009
Population-Based Case-Control Study
Pilot project involving public dissemination of
information regarding ovarian cancer symptoms
1455 Canadian patients underwent CA 125,
followed by TVUS
16% had abnormal initial test result
Only one patient underwent surgery who was found
to have benign disease
72% patients with ovarian cancer had complete
resection
OPEN ACCESS SYMPTOMS SCREENING
The DOvE Study
Gilbert et al. Lancet Oncol 2012.
REFERRALS/CONSULTS FOR OVARIAN CANCER
BY FPS OR IMS MULTIVARIATE REGRESSION
Goff BA et al. Obstet Gynecol 2011.
Other vs Solo
Group vs Solo
Int Med vs Fam Med
Female vs Male MD
Urban vs Rural Practice
61–90 vs ≥91
1–60 vs ≥91
Private Ins vs Medicaid
Afr Amer vs Cauc
Practice Type:
Average # Patients/wk:
0 1 2 Risk Ratio (95% Confidence Interval)
URBAN Ovarian Cancer
URBAN
URBAN Ovarian Cancer
URBAN
URBAN Ovarian Cancer
URBAN