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OVARIAN CANCER

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6th most common malignancy in women (excluding skin cancers) ... Diverticulitis. Hepatic failure. Colitis. Irritable Bowel Syndrome. Inflammatory Bowel Disease ... – PowerPoint PPT presentation

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Title: OVARIAN CANCER


1
OVARIAN CANCER
  • February 26, 2007
  • Paula Kwong, RPh
  • Pharm D Candidate

2

3
INTRODUCTION
  • 6th most common malignancy in women (excluding
    skin cancers)
  • 4th leading cause of cancer related death in
    women
  • Incidence highest in US, Europe, Israel
  • Lowest incidence developing countries Japan
  • 1 in 56 to 1 in 70 women will develop ovarian
    cancer lifetime risk of about 1-2
  • 2006 estimates 20,180 cases and 15,310 deaths

4
INTRODUCTION
  • 5 yr survival for all stages nearly 50
  • Survival for patients with localized disease
    nearly 90, but only 10-30 with disseminated
    disease
  • 70 of patients diagnosed with disseminated
    disease
  • Early detection is critical

5
PRESENTATION- symptoms
  • Vague and non-specific can be confused with GI,
    urinary tract, stress, and menstrual problems
  • Early symptoms nausea, dyspepsia, flatulence,
    bloating, fullness, early satiety, abdominal
    pain, urinary urgency frequency

6
PRESENTATION-symptoms (2)
  • May also complain of
  • Dyspareunia
  • Low back pain
  • Lack of energy
  • Menstrual irregularities

7
PRESENTATION-physical signs
  • May have palpable abdominal mass
  • May have lymphadenopathy
  • May have signs of ascites
  • May have abnormal hair growth
  • Red flag palpable ovary in postmenopausal woman
    or before puberty

8
PRESENTATION- other facts
  • Two-thirds of women with ovarian cancer are 55yo
    or older
  • More common in caucasians
  • Can occur in females before puberty
  • Majority of cases occur sporadically with only 5
    to 10 being familial

9
DIFFERENTIAL (1)
  • Ovarian Cysts
  • Ectopic Pregnancy
  • Pelvic Inflammatory Disease
  • Uterine Fibroids
  • Other gynecologic cancers
  • Other cancers GI, pancreatic, colon/rectal

10
DIFFERENTIAL (2)
  • Pelvic kidney
  • Diverticulitis
  • Hepatic failure
  • Colitis
  • Irritable Bowel Syndrome
  • Inflammatory Bowel Disease

11
METASTATIC SPREAD
  • Intraperitoneal pelvic abdominal viscera,
    omentum
  • Bladder bowel
  • Transdiaphragmatic spread to pleura, liver
  • Lymphatics
  • Hematogenous spread (advanced stage)

12
RISK FACTORS (1)
  • Inherited gene mutations
  • Age
  • Family history
  • Menstrual periods
  • Nulliparity/Infertility/1st child after 30yo
  • Obesity
  • HRT (hormone replacement therapy)

13
RISK FACTORS (2)
  • Breast Cancer
  • Ovarian Cysts
  • Sedentary lifestyle
  • Smoking alcohol
  • Talc
  • Clomid

14
PREVENTION
  • BCP (birth control pills)
  • Tubal ligation/hysterectomy/oophorectomy
  • Pregnancy and breast feeding
  • Diet/Exercise
  • Aspirin
  • Acetaminophen

15
DIAGNOSIS
  • Thorough Physical Exam
  • Comprehensive Family History
  • Chest X-ray
  • Imaging studies MRI/CT/Ultrasound/Mammogram
  • Colonoscopy, UGI
  • Lab tests
  • SURGERY

16
LAB TESTS for DIAGNOSIS
  • Chem profile including tests for hepatic and
    renal function
  • CBC assess internal bleeding
  • Pregnancy test if premenopausal
  • Pap smear
  • Tumor markers CA-125, hCG, AFP, CEA

17
TUMOR MARKERS
  • CA-125 Normal lt35 u/ml
  • Elevated in 85 of ovarian cancers but only 50
    of the time in early stage
  • Elevated in other cancers/benign conditions
  • Lacks sensitivity and specificity therefore is
    not diagnostic for ovarian cancer
  • Most useful for monitoring response to therapy
    and in detecting recurrence

18
PROBLEMS WITH CURRENT SCREENING TOOLS
  • Rectovaginal Pelvic Exam lacks sensitivity and
    specificity
  • Cancer Antigen-125 CA-125 elevated only 50 of
    the time in early stage
  • Transvaginal Sonography TVS lacks specificity

19
HISTOLOGY
  • Three major histologic (cell) types of ovarian
    cancer
  • Epithelial Cell 85-95 of cases, cells covering
    ovaries 45-75yo
  • Stromal Cell connective tissue cells that hold
    the ovary together and that make hormones
  • Germ Cell egg producing cells most common
    before age 20

20
EPITHELIAL CLASSIFICATION
  • Developed by WHO/FIGO
  • Serous gt50 of cases
  • Mucinous approx 12
  • Endometrioid approx 10
  • Clear cell approx 3
  • Transitional (Brenner), Undifferentiated, Mixed
  • Low-malignant Potential Borderline
  • Metastatic from other primary
  • Benign

21
EPITHELIAL HISTOLOGY
  • Grading Important
  • Gx grade cannot be assesed
  • G1 well differentiated
  • G2 moderately differentiated
  • G3 poorly differentiated
  • Grade 1 more closely resembles normal tissue and
    G3 the least

22
FIGO STAGING OF EPITHELIAL OVARIAN CANCER
  • Stage I tumor confined to one or both ovaries
  • Stage II tumor involves one or both ovaries
    with pelvic extension (metastasis with in pelvis)
  • Stage III tumor involves one or both ovaries
    with metastasis outside pelvis /- lymph node
    involvement
  • Stage IV distant metastasis beyond the
    peritoneal cavity

23
TREATMENT OF EPITHELIAL OVARIAN CANCER
  • Guidelines developed by the American Cancer
    Society and the National Comprehensive Cancer
    Network
  • NCCN guidelines available at www.nccn.org

24
INITIAL TREATMENT
  • 1st step-Surgical debulking at staging laparotomy
  • 2nd-Adjuvant chemotherapy
  • 3rd-Radiation
  • Participation in clinical trials encouraged

25
PROGNOSIS
  • Related to stage, subtype grade, volume of
    residual disease
  • Well differentiated IA/IB have 5 yr survival
    rates of 90 vs 5-10 Stage IV
  • Survival strongly correlated to size of residual
    tumors after debulking surgery
  • Residual tumors lt0.5cm median survival of 40
    months 0.5-218 months gt2cm 6-12 months

26
NIH SCREENING GUIDELINES
  • No reliable, sensitive, specific screening tool
    exists for women of average risk
  • ALL WOMEN assess family history and yearly
    rectovaginal pelvic exam with Pap smear
  • No family Hx or 1 relative participation in
    ovarian cancer screening trials
  • Pos family Hx in 2 relatives counseling by
    gynecologic oncologist (specialist)

27
SCREENING GUIDELINES cont.
  • Hereditary Cancer Syndromes yearly CA-125 TVS
    until age 35 or childbearing complete.
    Prophylactic bilateral oophorectomy should then
    be considered to reduce overall risk.
  • Screening trials

28
CANCER Jan 15, 2007 Goff, Barbara et al
  • Case-control 149 cancer/458 controls
  • Symptom index developed
  • Pelvic/abdominal pain, urinary urgency/frequency,
    abdominal bloating, early satiety
  • Frequency/Duration gt12x/mo, lt12mo
  • Correlated to presence of ovarian cancer
  • Symptoms similar in both early/late stage

29
CANCER Jan 15, 2007 continued
  • Screening test sensitivity 56.7 early stage
    79.5 for late stage
  • Specificity was 90 for women gt 50 years old and
    86.7 for women lt 50 years old
  • National Institute of Health website
    (medlineplus) says doctors and patients can use
    the screening test now but more research needed
    to see if results hold up in larger study

30
ROLE OF PHARMACIST
  • Inpatient/IV infusion pharmacist dose as per
    protocol, medication related side effects,
    nutrition, monitoring for the fifth vital sign
    (JCAHO requirement)
  • Retail symptom recognition referral,
    medication related side effects, fifth vital
    sign

31
REFERENCES (1)
  • National Comprehensive Cancer Network-Practice
    guidelines in Oncology-Ovarian Cancer. V.1. 2007
    www.nccn.org/professionals/physician_gls/PDF/ovari
    an.pdf
  • DiPiro, JT et al. PHARMACOTHERAPY, A Pathologic
    Approach. 6th edition, 2005. Ovarian Cancer.
    Section 17, pp 2467-84.

32
REFERENCES (2)
  • American Family Physician Sep 15, 2003. Serum
    Tumor Markers. www.aafp.org/afp/20030915/1075.htm
    l
  • American Family Physician December 15, 2004. US
    Preventative Services Task Force-Screening
    Recommendations for Ovarian Cancer.
    www.aafp.org/afp/20050215/us.html

33
REFERENCES (3)
  • Naational Cancer Institute Announces Preferred
    Method of Treatment for Advanced Ovarian Cancer.
    Jan 4, 2006. www.cancer.govnewscenter/pressrelease
    s/IPchemotherapyrelease
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