Christopher Morse MD Fellow Gynecologic oncology UW MEDICINE CONFIDENTIAL DO NOT DISTRIBUTE Overview Introduction to ovarian cancer Diagnosis and treatment Surgery and chemotherapy Surveillance ID: 913278
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Slide1
Ovarian Cancer 101: Breakout session for recently diagnosed ovarian cancer patients
Christopher Morse, MDFellow, Gynecologic oncologyUW MEDICINE
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Slide2Overview
Introduction to ovarian cancerDiagnosis and treatmentSurgery and chemotherapy
Surveillance
Genetic testing
Quality of life and managing effects of treatmentOpen Q&A
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Slide3Ovarian Cancer - Introduction
In 2019 there will be an estimated 22,530 new cases of ovarian cancer diagnosed. Ovary, fallopian tube, primary peritonealSecond most common GYN cancer (uterine more common)
Most common cause of GYN cancer related death and ovarian cancer is the 5
th
leading cause of cancer related death among females
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American Cancer Society 2019
Slide4Ovarian cancer - Survivorship
While many patients (75%) be diagnosed with an advanced stage (III or IV), after surgery and chemotherapy most (80%) will enter remission. In 2016, there were an estimated 230,000 ovarian cancer survivors living in the US
Patients with ovarian cancer are unique:
Undergo major abdominal surgery
ChemotherapyMaintenace therapyMany unique issues that ovarian cancer survivors face that impact QOL
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Slide5Ovarian cancer - Risk factors
The lifetime risk of developing ovarian cancer is 1.3%1:80 women will be diagnosed with ovarian cancerThe average age of diagnosis is 63, younger in women with hereditary cancers
Risk factors:
Age, family history, PCOS, infertility, PID, endometriosis, cigarette smoking, environment and location
Protective factors:Prior pregnancy, history of breastfeeding, OCP use, tubal ligation
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Slide6Ovarian Cancer – diagnosis
Presenting symptoms are common and can be overlookedWomen with ovarian cancer experience frequent symptoms – 20 to 30x month
Bloating (7.4x)
Increased abdominal size (3.6x)
Urinary symptoms (2.5x)Ultrasound and/or CT scan
Pelvic mass
Ascites
Blood work
CA-125, HE4
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Goff 2004
Slide7Ovarian Cancer – subtypes
The majority (95%) of ovarian cancers originate from the surface epithelium of the ovary or from the fallopian tube Serous histology ~75%
Other types are less common
Sex cord stromal tumors
Germ cell tumorsRare subtypes
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Image from UpToDate 2019.
Slide8Ovarian Cancer – FIGO staging
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FIGO stage
Criteria
I
Tumor limited to one or both ovaries
II
Tumor involves one or both ovaries with disease confined to pelvis
III
Tumor spread outside the pelvis to the peritoneal cavity or lymph nodes
IV
Distant metastases
Slide9Ovarian Cancer – initial treatment
Evaluation by a Gynecologic OncologistApproach 1: surgery -> chemotherapy
Traditional approach to ovarian cancer treatment
For patients who are surgical candidates with
resectable diseaseApproach 2: neoadjuvant chemotherapy -> surgery -> chemotherapy
For patients that are not surgical candidates (medical comorbidities)
For patients with disease distribution that is not
resectable
Surgery: removal of uterus, cervix, fallopian tubes, ovaries, staging, debulking
Several large randomized trials have compared these approaches and demonstrated that neoadjuvant chemotherapy is not worse than doing surgery first
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Vergote 2010; Kehoe 2015
Slide10Ovarian Cancer – chemotherapy
Chemotherapy – every 21 days for six cyclesCarboplatin – inhibits DNA synthesis
Side effects: low counts (
esp
platelets), cleared by kidneysPaclitaxel – derived from the bark of the Pacific yew tree, prevents cancers cells from dividing
Side effects: low counts (
esp
WBC), neuropathy, hair loss, cleared by liver
Both: nausea/vomiting, fatigue
Alternative delivery/dosing strategies
Dose-dense paclitaxel
Weekly low-dose carbo/paclitaxel
Intraperitoneal chemotherapy
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Pacific Yew Tree
Slide11Surveillance and monitoring - overview
Following aggressive surgery and chemotherapy most patients (80%) will enter remission. Recommended to have close follow up with Gynecologic Oncologist.
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0-2 years
2-3 years
3-5 years
>5 years
Symptom review and exam
3-4 months
4-6 months
6 months
Yearly
Pap test/cytology
Not indicated
CA-125 (tumor marker)
Optional, may be useful if initially elevated
Radiographic Imaging
Insufficient date to support routine use
Recurrence suspected
Imaging (CT or PET CT scan), CA-125
SGO Post-treatment surveillance guidelines 2017.
Slide12Surveillance and monitoring – tumor markers
CA-125 – a protein in the blood that is commonly elevated in ovarian cancerMost commonly followed tumor marker Approximately 1 of 4 patients will have normal CA-125 at diagnosisNon-specific – many things can elevate
HE4 – an alternative biomarker, may be elevated in patients with normal CA-125
May be elevated in endometrioid subtype
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Structure of CA-125
Slide13Surveillance and monitoring – tumor markers
Do you have to follow CA-125? 529 women with ovarian cancer randomized to exam and CA-125 every 3 monthsPatients and investigators blinded to CA-125 results
Once CA-125 >2x upper limit of normal:
Early treatment – chemotherapy started with CA-125 elevation
Delayed treatment - chemotherapy started with symptoms There was no difference in overall survival between the two groups2
nd
line chemotherapy was started on average 5 months earlier in early treatment arm
To follow (or not) is an individual decision to make with your Gynecologic Oncologist.
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Rustin 2011, EORTC 55955
Slide14Surveillance and monitoring – imaging
Do I need a CT scan on a regular basis? There is no role for routine imaging in ovarian cancer surveillance
Most providers do not routinely perform imaging studies in asymptomatic ovarian cancer patients in surveillance
However, with onset of new symptoms or elevated tumor markers
CT or PET CT is recommended
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CT scan of a patient with ovary cancer
Slide15Genetic testing
All patients diagnosed with ovarian cancer should undergo genetic testing for hereditary breast and ovarian cancer (HBOC) genes15-20% of patients will have a mutationgermline (in all the cells) somatic (in the tumor)
It is important to undergo testing for many reasons:
Counseling and genetic testing of other family members
Maintenance strategies after primary chemotherapy (PARP inhibitors)Clinical trial eligibility
Future treatment options
Don’t wait, ask your provider for a referral to a genetic counselor
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Slide16Quality of life – during and after treatment
How does treatment affect my quality of life (QOL)? Patients on two GOG protocols (#152 and 172) completed QOL surveys during and after treatment. Functional Assessment of Cancer Therapy – Ovarian (FACT-O)
Physical, functional, social, emotional well being
Scores lower in physical, functional and emotional well being
Higher scores in social well beingMay be reflective of increased social support during/after diagnosis and treatmentBaseline physical well-being may be associated with improved overall survival
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Wenzel 2005, von
Gruenigen
2010, von
Gruenigen
2012
Slide17Managing the effects of treatmentNeurologic and cognitive
Fatigue and energyGastrointestinal toxicityLoss of fertility and sexual dysfunctionMenopause and hormone therapyPsychiatric/psychosocial issuesLiving a healthy life style
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Slide18Neurologic and cognitive effects
Chemotherapy-induced peripheral neuropathy (CIPN) can affect to 50% of patientsNumbness/tingling, sensitive to touch, burning, decreased hot/cold sensationDuring treatmentModify dosing and chemotherapy agentGabapentin – decrease in patient reported CIPN
Cold mitts and socks – limited data but intriguing
Other – multivitamins, glutamic acid, glutathione
More limited and mixed outcomesAfter treatment Physical therapy
Gabapentin, duloxetine, glutamine
Acupuncture
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Slide19Neurologic and cognitive effects
Cognitive changesGOG prospectively studied 231 women with ovarian cancer undergoing primary treatment, assessed cognitive impairment
After 4
th
cycle chemo – 25.2% After 6th cycle chemo – 21.1%6 month follow up – 17.8%
A subset of patients had evidence of cognitive decline during chemotherapy but was limited to no more than one domain
Hard to separate the effects of treatment from the underlying effects of the disease itself
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Hess 2015
Slide20FatigueSome fatigue is almost universal during treatment
Fatigue may persist for 6-12 months after chemotherapyAmong survivors of ovarian cancer, 22% experience chronic fatigue. Fatigue can have a negative impact of emotional functioning and QOLSmall studies support a benefit of physical activity behavioral interventions to combat fatigue
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Liavaag
2007, Donnelly 2011
Slide21Gastrointestinal effects Many women had gastrointestinal (GI) symptoms at time of diagnosis
Persistent worry that new GI symptoms related to recurrenceGI symptoms may be a result of complications from surgery (adhesions), related to disease recurrence, or from unrelated medical conditions (IBS)Should always be reported to treatment team and investigatedPain and abdominal symptoms associated with lower QOL, emotional status, and more fear of recurrence in ovarian cancer survivors
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Mirabeau-Beale 2009
Slide22Gynecologic effects
Fertility – 15% of ovarian cancer pts will be <40 yo at diagnosis. Fertility loss is an important part of counseling at diagnosis and should be addressed with referral to fertility specialist as soon as possible.
Sexual dysfunction - 60% of ovarian cancer survivors report that cancer has affected their sexual life in a negative way
Decrease interest in sex and decreased sexual activity
Treatment: vulvovaginal atrophy, addressing dyspareunia, loss of libido, partner and relationship factors - sexual health programs for cancer survivors
Session 4, Saturday afternoon breakout session
Sexual Health after Cancer (
Saketh
Guntupalli
, Colorado)
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Slide23Gynecologic effects
MenopauseAverage age of ovarian cancer diagnosis – early 60s. Many patients are postmenopausal will not experience significant side effects
Symptoms: hot flushes, mood changes, sleep disturbances, vaginal atrophy
Hormone replacement therapy (HRT)
Vulvovaginal atrophy – topical estrogen, low systemic absorption
May consider systemic treatment with estrogen in select women
No conclusive data that HRT negatively affects survival or recurrence
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Slide24Psychiatric effects
DepressionUp to 15% of ovarian cancer survivors meet criteria for depressionSymptoms of depression are associated with sleep disorders
Anxiety - may
have an even greater impact on QOL than depression
Fear of recurrence – affects more than half of survivorsPreoccupation with CA-125 value - anxiety about CA-125 is common
Guilt and cancer-related distress
Delay in diagnosis, familial guilt (HBOC), survivors' guilt
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Slide25Living a healthy lifestyle
Living healthyObesity is a risk factor for cancer (breast, endometrial, colon)American Cancer Society Recommendations
Maintain a healthy weight, attempt weight loss if overweight/obese
Engage in 30 minute of moderate activity 5x weekly
Consume a healthy diet with 5 or more servings of fruits or vegetables dailyLimit alcohol intake
No more than 1 drink/day for women, 2/day for men
Clinical trial opportunity
Currently enrolling patients in a study of Moderate Exercise in Ovarian Cancer Survivors (University of Washington, PI: Pennington)
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Slide26Patient Resources
SGO.orgSurvivorship toolkit for gynecologic cancersOCRAhope.orgPatient resources: general information, support groups, financial assistance, end of life, advocacy
American Cancer Society
Nat'l Cancer Survivorship Resource Center
Survivorship support groups through your local cancer center
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Slide28Questions
What side effects from treatment (surgery or chemotherapy) did you find most difficult?
What did you find most effective to treat or cope with these side effects?
When during your treatment did you discuss the role of genetic testing?
How has ovarian cancer affected your well-being?
Physical, functional, emotional, and social
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Slide29Thank you!
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