1. Advanced ovarianMalignancy -How to have quality of life?Dr. Rakhi GajbhiyeMBBS , MD , Dip lapDirector - Mauli WomensHospital,Nagpur 2. Introduction Ovarian cancer is the most commoncause of cancer deaths from Gynectumors in US. The diagnosis and management ofovarian cancer is the most importantchallenge facing the gynaecologiconcologist. lack of an effective means of earlydiagnosis for ovarian cancer and the factthat most patients with advanceddisease will eventually die of it makes itdifficult to manage . 3. Incidence EOC - 8th most common cancer in women In US Incidence is 33 cases per1lac women aged50yrs The average patient age at diagnosis is57yrs. The life time risk of a woman developing epithelialcancer 1in 70 In 2010, the American Cancer Society estimatedthat ovarian cancer would be diagnosed in 21,880women in the US and that 13,850 would die of theirdisease. Around the world more than 2 lac women areestimated to develop ovarian cancer every yearand about 1lakh die from disease (Parkin DMCancer J Cl.2005) 4. At glance - SEER Estimated New Cases in 2014 -21,980 Estimated Deaths in 2014 -14,270 5. Stage at presentation. 80% of women with ovarian malignancypresent with advanced-stage disease. Fortunately, advances in surgical andchemotherapeutic management haveimproved overall survival, with 45% ofwomen of all stages surviving 5yrs &more . Surgery with chemotherapy is theprimary treatment for the majority ofpatients. 6. Survival with Quality of life Quality of life and, more specifically, health-relatedquality of life(HRQOL) addresses importantaspects of the patients life including physical,social, psychological, financial, and sexual issues,as well as the side effects of the chemotherapeuticmedications that we rely on for treatment. Conventional endpoints such as survival, time toprogression, and response rate have long been thefoundation for cancer research. With advances in the treatment of ovarian cancer,additional endpoints are now emerging asimportant aspects of patient care like functionalstatus and QOL. 7. HRQOL assessment is a key factor inevaluating cancer burden and the effectsof treatment. HRQOL assessment has beenimplemented into patient care in mosttrials by the Gynaecologic OncologyGroup (GOG) and is being adapted tostandard of care. The benefits of using HRQOL assessmentinclude better patient-care givercommunication and overall improvementof the quality of life. 8. The GOG has begun implementingdifferent HRQOL measurements in itsstudy designs for ovarian cancer. HRQOL was measured using theFunctional Assessment of CancerTherapy-Ovarian (FACT-O)questionnaire. Higher FACT-O scoresare associated with better HRQOL. 9. NICE National Institute health and careexcellence. May 2012.It is a quality standard which describesmarkers of high quality, cost effective carethat should contribute to improvingeffectiveness, safety and experience ofpatients in following ways Preventing people from dying prematurely Enhancing QoL Ensuring that people have positiveexperience of care Treating and caring for people. 10. PROMIS Another example is the Patient-Reported OutcomesMeasurement Information System (PROMIS), a networkof primary research sites and coordinating centres thatwork collaboratively to develop a series of dynamictools in order to reliably measure reported outcomes. PROMIS provides an opportunity to improvehealth care outcomes by giving decision markers onhowhealth care affects, what patients are able to do andhowthey feel. It has a specific framework for cancerpatients.PROMIS: Patient Reported Outcomes Measurement System.http:// 11. How is the quality of Lifeaffected ? 12. Surprise and sudden shock 13. Fear of Death 14. Surgical Morbidity 15. Side effects ofChemotherapy 16. Side effects Side effects of ovarian cancer include-wtloss, bloating,ascites, fatigue, andpain. Side effects of treatment include-weightloss, body distortion, fatigue,neuropathy, hair loss, sexualdysfunction, Neutropenia, Bowel and bladder incontinence, lossof taste and appetite, poor sleep,oedema, and diminished mobility. 17. An additional burden involves theamount of time receiving treatmentthat is lost from family and working. The combined effects of these factors- chemotherapy, physical impairmentand mobility issues, psychological andemotional problems, social andfinancial difficulties, sexual issues -contribute to diminished HRQOL. 18. How to Improve the quality ofLife? Coping with the diagnosis Surgery in advanced ovarian malignancy Chemotherapy Psychological and emotional issues Financial and social issues Neoadjuvant therapy Followup & Recurrence issues Sexual issues Palliative care 19. Coping with the diagnosis It can be very difficult coping with adiagnosis of cancer, both practicallyand emotionally. At first the patientfeels very upset, frightened andconfused. People who are well informed abouttheir illness and treatment are moreable to make decisions and cope withthe situation. 20. keep talking to your friends and family,as they can be a powerful supportsystem. communicate with other women in thesame situation. know about your condition set reasonable goals take time out for yourself 21. Primary CytoreductiveSurgeryPatients whoundergooptimalcytoreduction haveimproved response rates to chemotherapy,prolonged disease free survival, andimproved overall survival.If cytoreduction is suboptimal, there is nosurvival benefit to surgical debulking.Optimal cytoreduction is generally definedas residual tumor measuring 1cm or less,but best survival rates are seen when nogross visible tumor is remaining. 22. Meta-analysis showed improvedsurvival rates among patients referredto expert centers for primary surgery.RE Bristow et al, J Clin Oncol.2002 Overall survival for patients withoptimally debulked advanced diseaseis 47-66 months compared to 33-36months with suboptimally debulkeddisease. 23. Bowel Obstruction Bowel obstruction is a commonterminal effect of progressive ovariancancer. Rectosigmoid obstruction in the faceof progressive disease is bestpalliated with a transverse loopcolostomy. 24. Small bowel obstruction is morechallenging. Multiple areas of partialsmall bowel obstruction are typicallynot amenable to surgical correction Palliation is achieved with apercutaneous gastrostomy tubedraining by gravity or with anasogastric tube on suction. 25. MANAGEMENT OF MALIGNANT BOWELOBSTRUCTION IN RELAPSED DISEASE There is no clear evidence norconsensus on the surgicalmanagement of patients withadvanced cancer. Surgery can onlybenefit selected patients withmechanical obstruction and should notbe routine practice.Feuer DJ, Broadley KE. (Cochrane Review). In:The Cochrane Library, Issue 1, 2003. 26. There is no perfect model that cancompletely predict patients whereoptimal debulking may be achieved. Radical upper abdominal procedureshave been introduced to many gyneconco centres which requires closeworking with hepatobilliary andcolorectal surgeons. 27. Relative contraindication ofprimary surgery Extensive upper abdominal disease orcarcinomatosis. Large tumor burden in bowel mesentry Bulky omental disease with splenicextension Suprarenal lymphdenopathy Patient co-morbidities Patient wishes 28. Interval CytoreductiveSurgery Chemotherapy followed by surgery isused in patients who are not goodoperative candidates or where it isknown that an optimal cytoreductivesurgery cannot be performed. Recent study shows no difference insurvival between patients randomised toprimary cytoreductive surgery andpatients treated with neoadjuvantchemotherapy.Vergote L at al, Eur J Cancer, 2011 29. Chemotherapy Two high quality RCTs support the useof paclitaxel and cisplatin as anefficacious combination for advancedovarian cancer. (Mugia FM J Clin.Oncol.2000 & Piccart et al, J NatlCancer Inst.2000) Paclitaxel is recommended incombination therapy with platinum inthe first line post-surgery treatment ofepithelial ovarian cancer where thepotential benefits justify the toxicity ofthe therapy. 30. Concerns have been raised regarding theneurotoxicity associated with combinations ofpaclitaxel with carboplatin.In a study ,139 patients treated as first-linetherapy combination of carboplatin plusdocetaxel yielded an overall response rate of66% and a median progression-free survivalof 16.6 months, with extremely low levels ofneurotoxicity.Vasey P, on behalf of the Scottish Gynaecologic CancerTrials Group.Preliminary Results of the SCOTROC Trial: aPhase III Comparison of Paclitaxel-Carboplatin (PC) andDocetaxel-Carboplatin (DC) as First-Line Chemo for Stage Ic-IV Epithelial Ovarian Cancer (EOC). Proc Am Soc Clin Oncol.2001;20:804. 31. Similarities in chemical structure andmode of action, docetaxel and paclitaxelcannot be regarded as having the sameproperties when used clinically. Mostpatients with ovarian cancer receivepaclitaxel as a 3-hour infusion, whereasdocetaxel is given over1hr. This shortened infusion time suggestsa potential advantage in terms of patientconvenience and factors such as clinictime and resources. 32. CHOICE OF PLATINUM AGENTS Patients who choose less toxictherapy or who are unfit for taxanesshould be offered single agentcarboplatin. The platinum-based drugs cisplatinand carboplatin are equally efficaciousin the treatment of epithelial ovariancancer. Carboplatin is the platinum drug ofchoice in both single and combinationtherapy. 33. Lakusta et al ( Gynecol Oncol 2001 ) did a studyinvolving a chart review of 60 women with ovariancancer undergoing chemotherapy with platinumagents. Analysis of questionnaire responses fromthese patients was used to relate biomedicalvariables to HCQOL outcomes and to comparepatients receiving cisplatin as first-line therapy withthose receiving palliative carboplatin for recurrentdisease. Women receiving first-line cisplatin reported moreappetite disturbance,diarrhea, and nausea thanthose on palliative carboplatin. 34. In the Gynecologic Cancer IntergroupInternational Collaboration on OvarianNeoplasms 7 (ICON7) trial,bevacizumab(monoclonal ab) improvedprogression-free survival in patients whenused in combination with first-linechemotherapy and as a single-drugcontinuation treatment for 18 cycles. In apreliminary analysis of a high-risk subset ofpatients, there was also an improvement inoverall survival. This study aims to describethe HRQoL outcomes from ICON7.Stark D1, Nankivell M, Pujade-Lauraine The Lancet oncology2013 35. In cases where different drugs showsimilar survival benefit in advancedmalignant disease, issues relating totoxicity and quality of life neurotoxicity, alopecia,neutropenia,myelosuppression, stomatitis, fatigue,and nausea become increasinglyimportant. 36. Weekly Carboplatin PlusPaclitaxel Improves Quality ofLife (March 14, 2014) A large Europeanclinical trial showed that carboplatin pluspaclitaxel once a week (versus everythree weeks) can be an effective front-linetreatment for women with advancedovarian cancer. Pingata et al,The LancetOncology. Researchers found that the weeklyregimen increased progression freesurvival from a median of 17.3 months to18.3 months. It also significantlyimproves the Qol, as measured by theFACT-O/TOI scoring system. 37. With treatment every 3 weeks, FACT-O/TOIscores worsened at every cycle, whereas forthe weekly schedule, after transientworsening at week 1, FACT-O/TOI scoresremained stable. The researchers conclude that a weeklyschedule of carboplatin plus paclitaxel iseffective and may also offer better Qol forpatients. 38. Chemotherapy for persistentdisease. Platinum sensitive-recurrence after6mo(give carbo+pacli) Platinum resistance-recurrence within6mo.(give 2nd line chemo)Thesepatients are for clinical trials. 39. HRQOL effects of intraperitonealvs intravenous treatmentDuring active treatment, patients onthe intraperitoneal arm experiencedmore HRQOL disruption, abdominaldiscomfort, and neurotoxicity comparedwith patients receiving conventionalintravenous therapy.Wenzel LB, Huang HQ, Armstrong DK, et al. aGynecologic Oncology Group Study.J Clin Oncol.2007;25(4):437-443 40. Palliative Care 41. Palliative care As with most incurable cancers, paincontrol is the dominant issue and mustbe addressed. Judicious use of narcotics andnonnarcotic pain remedies is essential. Optimal palliative care is provided by atreatment team that includes agynecologic oncologist, a radiationoncologist, a radiologist, a pain specialistfrom hospice services, and/or a palliativecare physician. The skills of the interventional radiologistare also useful for palliation of urinaryfistulas and ureteral obstruction. 42. Physical and MobilityIssues All patients suffering from physical andmobility problems related to cancer andtreatment should be evaluated byphysical therapy and rehabilitationmedicine with an early consultation. Even preoperative evaluation may bebeneficial to prepare for thepostoperative physical limitations and thespecific interventions that will beemployed.January 2011, Vol 18, No.1 CancerControl 55 43. Emotional and mentalsupport 44. Depression and anxiety Clinical depression was reported in 21%of patients, while 29% scored above the75th percentile for anxiety. Astandardized HRQOL form with eachvisit can track these issues and help torecognize the need for interventions. Psychological distress should bemanaged with appropriatecounseling,support groups, medications(eg, antidepressants, anxiolytics),andreferral to mental health professionalswho have experience in working withcancer patients. 45. Social and FinancialDifficulties Economics and the availability of apersonal support system also needs tobe evaluated. As a patients functional status declines,additional assistance may be required athome, and it is important to know whenreferral to a home care agency might behelpful. Community services that are oftenavailable are individuals or group whogive psychological counseling,transportation, assistance withmeals,household chores, and nursingcare. 46. Early involvement of a social worker isusually the most appropriate step inevaluating a patients supportive careneeds and in determining appropriateresources.One recent study concluded that ovariancancer patients may compensate fordecreased HRQOL in physical, functionaland emotional areas with increasedsocial support.von Gruenigen VE, Huang HQ, Gil KM, et al. Acomparison of qualityof- life domains and clinical factorsin ovarian cancer patients: a Gynecologic OncologyGroup study. J Pain Symptom Manage. 2010;39(5):839-846. 47. The Americans with Disabilities Act of1991 now provides federal protection tocancer patients. According to these acts,employers must accommodate patientsreceiving cancer treatment by allowingchanges in schedules or workloads. Vocational counselling should beconsidered for individuals who lose theirjobs or who are unable to continue intheir previous employment secondary tothe effects of cancer and/or its treatment. 48. Sexual issuesSexual dysfunction, decreased libido, andvaginal dryness can be precipitated byenervation damage from abdominal and pelvicsurgical procedures, prematuremenopause,and estrogen deficiency.A pretreatment discussionof sexuality andintimacy provides a baseline for comparisonduring subsequent revaluation after treatment.Schover LR. The impact of breast cancer on sexuality, bodyimage, and intimate relationships. CA Cancer J Clin.1991;41(2):112-120. 49. Fatigue and dyspnoea Fatigue or dyspnea secondary toanemia can be treated with bloodtransfusions or erythropoietin.Transfusions provide immediateimprovement, whereas erythropoietininjections may take weeks to improvefatigue. 50. Ascites Ascites can result from widespreadmicroscopic and macroscopic tumorinfiltration over the peritoneum, preventingabsorption of peritoneal fluid. This symptom can become quite troublingwhen progressive disease is unresponsive tochemotherapy. Patients complain of pain, early satiety,vomiting, fatigue, and shortness of breath.Diuretics are of limited efficacy in relievingmalignant ascites, and relief is best obtainedby repetitive paracentesis. 51. Placement of a semipermanentdrainage tube, Pleurx, has been FDA-approvedfor symptomatic relief inpatients with recurrent ascites 52. Anorexia Anorexia seldom occurs without bowelobstruction or ascites. For anorexiawithout associated bowel obstruction,treatment with megestrol acetate orsteroids can stimulate appetite and leadto an increased sense of well-being. Parenteral nutritional support might beappropriate as a short-term measureperioperatively following relief of bowelobstruction or other intervention. 53. Constipation Constipation may be an adverse effect ofnarcotic analgesics or colonic dysmotilityfrom tumor involvement. Treatment options range from behavioralchanges to medicinal agents. When possible, an increase in fluidintake and exercise can be of benefit, ascan close attention to bodily signals ofdefecation. More useful to the patientwith cancer is the addition of fiber,colonic stimulants, and laxatives to theirregimen. 54. Recurrent ovarian cancer Recurrent ovarian cancer is seldomcurable. Second-, third-, or even fourth-linechemotherapy is often administeredin a palliative fashion, as a means ofdiminishing symptoms and prolonginglife. When chemotherapy is consideredfor patients with good performancestatus, it is most appropriate to offerenrollment in formal clinical studies, suchas those coordinated by the GynecologicOncology Group 55. Try to deal with hair loss in a positive way, if youcan: It is hard for most women with ovarian cancerto deal with the hair loss that results fromchemotherapy. 56. Conclusions HRQOL assessment plays an importantrole in medical care, and this is especiallysignificant in ovarian cancer treatment as80% of newly diagnosed patients presentwith advanced disease and requireextensive surgical and chemotherapeutictreatment regimens that are associated withsignificant morbidity. 57. Prolongation of life, without regard for thequality of that life, is not a universally desiredgoal. HRQOL data can be utilized in clinical trials,with an endpoint of improvement ofHRQOL. The data can also be used as a tool instandardizing the efficacy and tolerability oftreatment and end-of-life decisions. 58. The use of an interdisciplinary treatment,team approach is vital to each patientsneeds. To optimize treatment decisions for patientswith ovarian cancer, clinicians need to befamiliar with differences between regimensin terms of toxicity, dosage, andadministration, and emerging data fromHRQOL assessments. 59. Emotional support 60. Will power 61. Strength does not come from physicalcapacity,it comes from indomitable will Mahatma Gandhi 62. Manisha Koirala, who has returned tonormal life which she treasures the most afterdefeating ovarian cancer. 63. THANKYOU