Introduction 6700 cases in UK each year 5 th commonest cancer
in women Lifetime risk 1 in 48 Higher incidence in postmenopausal
women
Slide 5
Introduction 4300 die each year Leading cause of death from
gynae cancer Advanced disease at presentation Median PFS ~1 to 2
years Median OS ~ 2.5 years 5yr survival ~ 30% 1090 patients Leeds
Cancer Centre 1990-2005 Poor prognosis & rarely cured
Aetiology Hereditary 5-10% Breast / Ovarian Cancer Syndrome
BRCA1 (up to 60% lifetime risk) BRCA2 (up to 25% lifetime risk)
Tumour suppressor genes HNPCC syndrome Mutations of mismatch repair
genes
Slide 9
FIGO Staging I confined to ovary II confined to pelvis
Slide 10
FIGO Staging III- abdominal extension or lymph nodes IV -
distant metastases
Slide 11
Staging Importance of stage 5 year survival Stage 1 - 90% Stage
2 - 65% Stage 3 - 35% Stage 4 - 10% 60% 20% 1090 patients Leeds
Cancer Centre 1990-2005
Slide 12
Symptoms Silent Killer 1 case every 5 years 1 every 25,000
consultations
Slide 13
Symptoms Ovarian cancer is not silent, rather its sound is
going unheard
Slide 14
Symptoms Earlier diagnosis and correct pathway sooner -
improved survival?
Slide 15
Symptoms Carry out tests if any of the following on a frequent
basis more than 12 times a month (esp if >50 years old)
Persistent abdo distension Feeling full, loss of appetite or both
Pelvic or abdo pain Increased urinary urgency, frequency or
both
Slide 16
Symptoms Carry out appropriate tests for ovarian cancer in any
woman of 50 or over who has experienced symptoms within the last 12
months that suggest irritable bowel syndrome (IBS) ITS NOT IBS, ITS
OVARIAN CANCER
Slide 17
Symptoms Consider tests if: Unexplained weight loss Fatigue
Changes in bowel habit Advise any woman who is not suspected of
having ovarian cancer to return to her GP if her symptoms become
more frequent and/or persistent
Slide 18
Examination Abdo / pelvic examination Ascites Abdo mass Pelvic
mass Refer the woman urgently if physical examination identifies
ascites and/or a pelvic or abdominal mass (which is not obviously
uterine fibroids)
Slide 19
Which Tests ? CA125 tumour associated antigen normal level
Slide 20
Which Tests? If CA125 >35 arrange USS abdo / pelvis
BenignMalignant
Slide 21
Measure serum CA125 Ultrasound of abdomen and pelvis Advise to
return to GP if symptoms become more frequent and/or persistent
Investigate Refer urgently Assess carefully: are other clinical
causes of symptoms apparent? Suggestive of ovarian cancer 35 IU/ml
or greater Normal Less than 35 IU/ml No First tests in primary care
Yes
Slide 22
Slide 23
Detection in primary care Women presents to GP GP assesses
symptoms Tests in primary care Urgent referral: assessment in
secondary care Suspicion of ovarian cancer Ascites and/or pelvic or
abdominal mass Support and information
Establishing the diagnosis Discuss in MDT Suspected early stage
disease local cancer unit Advanced disease cancer centre
Slide 26
Treatment of Early Ovarian Cancer
Slide 27
Surgery Suspected early stage disease Staging Laparotomy TAH /
BSO Infracolic omentectomy Pelvic / PA node sampling Peritoneal
washings Biopsies of peritoneum Fertility sparing surgery
Laparoscopic surgery
Slide 28
Surgery
Slide 29
Staging Stage important in prognosis and treatment 5 year
survival Stage 1 - 90% Stage 2 - 65% Stage 3 - 35% Stage 4 - 10%
60% 20% 1090 patients Leeds Cancer Centre 1990-2005
Slide 30
Treatment of Advanced Disease Surgery or Primary
Chemotherapy?
Slide 31
Surgery for advanced disease Debulking surgery Complete
debulking - aim to leave no macroscopic disease Optimal
debulking
Slide 32
Surgery for advanced disease MDT review Disease considered
resectable Medically fit debulking surgery
Slide 33
Surgery Volume of residual disease directly determines survival
Optimal debulking 39 months (median survival) Sub-optimal debulking
17 months (median survival) Surgical skill or tumour biology?
Slide 34
Inoperable disease
Slide 35
Neoadjuvant Chemotherapy and Interval Debulking Surgery Disease
not resectable Medically unfit Scan guided core biopsy 3 cycles
chemo IDS 3 cycles chemo
Slide 36
Neoadjuvant Chemotherapy and Interval Debulking Surgery Future
standard of care? Reduced morbidity and mortality Results of CHORUS
awaited
Slide 37
Chemotherapy Early stage disease
Slide 38
Stage I & II Died Alive
Slide 39
Early stage disease Stage I & II Adjuvant Chemotherapy -
Increase chance of cure Alive Cured by chemo Died ICON1/Action:
JNCI 2003
Slide 40
Early stage disease Current practice Likely benefit Stage 1c or
higher Grade 3 Clear cell histology Uncertainty Peri-operative
rupture (surgical 1c) Inadequate staging Chemotherapy vs repeat
staging procedure
Slide 41
Chemotherapy Advanced disease
Slide 42
Chemotherapy Stage III & IV disease Control cancer Prolong
life Improve symptoms First line Highly effective 70-80% response
rate Median Progression Free Survival 1-2 years Median Overall
Survival 3 years 30% 5 year survival Some long term survivors
Palliative
Chemotherapy Side effects Fatigue Nausea & vomiting
Myelosupression Anaemia, risk of infection Hair loss Neuropathy
Mucositis Skin & nail changes Allergic reactions
Slide 45
Future Developments Prevention Risk reducing surgery for BRCA
mutations Reduced to 1% (PPC) / Breast Ca reduced 50% Screening for
early disease Unknown Awaiting results of UKTOCSS / UKFOCSS Surgery
Ultra-radical or IDS
Future developments Intra-peritoneal chemotherapy Suggestion of
improved survival Increase in side effects
Slide 48
Summary Poor prognosis due to late presentation Early disease
curable Advanced disease treatable but not curable
Slide 49
Summary Will NICE guidelines make any difference? Investment in
additional tests in primary care Increase in referrals to secondary
care Improved outcomes due to earlier diagnosis? Less likely to
present with advanced cancer? Reduced referrals to other
specialties? ITS NOT IBS, ITS OVARIAN CANCER!!
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