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Ovarian CancerOvarian Cancer
Amreen Husain, MDAmreen Husain, MD
Assistant ProfessorAssistant Professor
Gynecologic OncologyGynecologic Oncology
Ovarian cancerOvarian cancer
• 25,000 cases annually25,000 cases annually
• 1/70 American women 1/70 American women
• 14,000 deaths annually 14,000 deaths annually
• 44thth in cancer related deaths among women in cancer related deaths among women
• Mean age at diagnosis 59 yrsMean age at diagnosis 59 yrs
Risk factorsRisk factors
• Family history:Family history:- One 1One 1° relative 3.6 times risk, or 5% lifetime ° relative 3.6 times risk, or 5% lifetime
risk.risk.- 5- 10% of all ovarian cancers associated with 5- 10% of all ovarian cancers associated with
known gene mutations.known gene mutations.- Three familial ovarian cancer syndromes: Three familial ovarian cancer syndromes:
site-specific ovarian cancer, breast/ovarian site-specific ovarian cancer, breast/ovarian cancer syndrome, hereditary nonpolyposis cancer syndrome, hereditary nonpolyposis colorectal cancer syndrome.colorectal cancer syndrome.
BRCA1/2BRCA1/2
• Associated with site specific and Associated with site specific and breast/ovarian cancer syndromes.breast/ovarian cancer syndromes.
• BRCA1: 25-40% lifetime risk of Ov ca, 80% BRCA1: 25-40% lifetime risk of Ov ca, 80% lifetime risk of Breast Califetime risk of Breast Ca
• BRCA2 : 10% lifetime risk of ov CaBRCA2 : 10% lifetime risk of ov Ca
• Early age-onset, 10yrs younger than Early age-onset, 10yrs younger than relative, mean age 40’srelative, mean age 40’s
Reproductive factorsReproductive factors
• NulliparityNulliparity
• InfertilityInfertility
• Oral contraceptives protective 50% Oral contraceptives protective 50% decrease with 5 or more years of use.decrease with 5 or more years of use.
• Multiparity protectiveMultiparity protective
• Lactation protectiveLactation protective
ScreeningScreening
• General population : no good methodGeneral population : no good method
• High risk population : TV u/s, Ca 125 High risk population : TV u/s, Ca 125 though not fully proventhough not fully proven
• Prophylactic oophorectomy : option in Prophylactic oophorectomy : option in high-risk women who have completed high-risk women who have completed child-bearing or age 40 though small risk child-bearing or age 40 though small risk (1-3%) of peritoneal cancer(1-3%) of peritoneal cancer
DiagnosisDiagnosis
• ““silent killer”silent killer”
• Vague symptoms : abd bloating, early Vague symptoms : abd bloating, early satiety, indigestion, constipationsatiety, indigestion, constipation
• 60-70% Stage III or IV at diagnosis 60-70% Stage III or IV at diagnosis
• ascites and upper abdominal disease at ascites and upper abdominal disease at presentationpresentation
StagingStaging
• Surgically basedSurgically based
• Ovarian cancer spreads by direct Ovarian cancer spreads by direct extension within abdominal cavity, or to extension within abdominal cavity, or to lymph nodeslymph nodes
• Staging based on location of metastatic Staging based on location of metastatic diseasedisease
Early stageEarly stage
• Stage IStage I Stage IIStage II
Advanced stageAdvanced stage
Intraabdominal dxIntraabdominal dx Lymph node dx Lymph node dx
Treatment - surgicalTreatment - surgical
• Early stage: Early stage: - Intact removal of affected ovary Intact removal of affected ovary - complete staging including complete staging including
TAHBSO/omentectomy/biopsies/lymph node TAHBSO/omentectomy/biopsies/lymph node sampling/peritoneal washingssampling/peritoneal washings
• 30% patients with clinical Stage I will be 30% patients with clinical Stage I will be upstagedupstaged
• Fertility preservation can be considered in Fertility preservation can be considered in Stage I if fully stagedStage I if fully staged
• Chemotherapy for all stages greater than IAChemotherapy for all stages greater than IA
Surgical treatmentSurgical treatment
• Advanced stage :Advanced stage :- Laparotomy via midline vertical incisionLaparotomy via midline vertical incision- Hysterectomy/ oophorectomyHysterectomy/ oophorectomy- Maximal tumor debulking to any residual implants Maximal tumor debulking to any residual implants
<1cm <1cm - Bowel resection required in about 10% pts.Bowel resection required in about 10% pts.- Pts treated by gynecologic oncologists have higher Pts treated by gynecologic oncologists have higher
rates of debulkingrates of debulking- Optimal debulking impacts significantly on long term Optimal debulking impacts significantly on long term
survivalsurvival
Further therapyFurther therapy
• Majority of patients will require further Majority of patients will require further treatment with chemotherapytreatment with chemotherapy
• Current standard is Carboplatin + Taxol Current standard is Carboplatin + Taxol for 6 courses given every three weeks.for 6 courses given every three weeks.
• 70-80% complete response70-80% complete response
• a complete clinical response (remission) a complete clinical response (remission) is : nl Ca125, nl exam, is : nl Ca125, nl exam, ++ nl CT. nl CT.
22ndnd look surgery look surgery
• Done now primarily in the study settingDone now primarily in the study setting
• Can be performed by laparoscopyCan be performed by laparoscopy
• Patients with negative second looks have Patients with negative second looks have a 50% chance of recurrence.a 50% chance of recurrence.
• Potential treatments include Potential treatments include intraperitoneal chemotherapy, vaccine intraperitoneal chemotherapy, vaccine trials, further IV chemotherapytrials, further IV chemotherapy
Recurrent diseaseRecurrent disease
• ¾ patients who achieve a remission after ¾ patients who achieve a remission after initial therapy will recur, usually within 2 initial therapy will recur, usually within 2 yearsyears
• Response to second-line therapy depends Response to second-line therapy depends on the time interval from primary therapyon the time interval from primary therapy
• Several second line treatments including Several second line treatments including taxol/Pt/Doxil/Topotecan/Gemcitabinetaxol/Pt/Doxil/Topotecan/Gemcitabine
Recurrent diseaseRecurrent disease
• Surgery can be an option:Surgery can be an option:- Goal is to achieve a complete resectionGoal is to achieve a complete resection- Usually in patients who have had a longer Usually in patients who have had a longer
disease free-intervaldisease free-interval- Complicated by fact that patients have had Complicated by fact that patients have had
prior surgeryprior surgery- Almost all still will need chemotherapyAlmost all still will need chemotherapy- Radiation an option in select casesRadiation an option in select cases
New therapies – current clinical New therapies – current clinical trialstrials
• Immunotherapies – CA 125 antibody/ Immunotherapies – CA 125 antibody/ vaccine (Ovarex)vaccine (Ovarex)
• Angiogenesis inhibitors – Thalidomide, Angiogenesis inhibitors – Thalidomide, Bevacizumab (Avasttin)Bevacizumab (Avasttin)
• Biologic modulators – Iressa, CleevecBiologic modulators – Iressa, Cleevec
Ovarian Ca survivorsOvarian Ca survivors
• Issues in survivors:Issues in survivors:- Psycho sexual recoveryPsycho sexual recovery- Potential for FertilityPotential for Fertility
• National advocacy groupsNational advocacy groups- Further researchFurther research- Access to appropriate specialistsAccess to appropriate specialists- Support networkSupport network