Ovarian Cancer

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Ovarian Cancer

• Gloria S. Huang, M.D.
• Assistant Professor
• Department of Obstetrics Gynecology and Womens
  Health
• Division of Gynecologic Oncology

Albert Einstein College of Medicine
Montefiore Medical Center

Albert Einstein Cancer Center
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Ovarian Cancer

• Who gets it?
• What are the signs and symptoms?
• How do you work it up?
• How do you treat it?
• What are the chances of survival?

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Ovarian Cancer U.S. Epidemiology

• Eighth most common cancer among women
• Estimated 20,180 new cases in 2006
• Lifetime risk of getting ovarian cancer is
  approximately 1 in 67 (1.5)
• Accounts for 3 of cancers in women

American Cancer Society 2006
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Ovarian cancer U.S. Epidemiology

• 5th most common cause of cancer death in women
• Estimated 15,310 deaths in 2006
• Lifetime risk of dying from ovarian cancer is 1
  in 95 (1)

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Histology

• 85 Epithelial
• Serous carcinoma-most common
• Endometrioid
• Mucinous carcinoma
• Clear cell carcinoma
• 5 Germ Cell
• 10 Sex cord Stromal

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Ovarian Cancer
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Ovarian Cancer Risk Factors
Increase Decrease
Age OCPs
Family history Pregnancy
Infertility/low parity Tubal ligation
Personal cancer history Breast-feeding
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Hereditary factors

• BRCA 1 and BRCA 2
• 10 of ovarian cancers
• Lifetime risk 40-50
• HNPCC
• 1 of ovarian cancers

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Ovarian Cancer

• Who gets it?
• What are the signs and symptoms?
• How do you work it up?
• How do you treat it?
• What are the chances of survival?

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Ovarian Cancer Symptoms

• 95 of women DO report symptoms.
• Symptoms can be vague and not gynecologic
• Abdominal bloating, increased girth
• Fatigue
• Gastrointestinal disturbances
• Urinary symptoms
• Abdominal/pelvic pain
• Menstrual irregularities
• Increased flatulence

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Ovarian Cancer

• Who gets it?
• What are the signs and symptoms?
• How do you work it up?
• How do you treat it?
• What are the chances of survival?

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Ovarian Cancer Diagnostic Modalities

• Rectovaginal pelvic exam
• TVS and/or CT scan or MRI
• CA-125
• If diagnosis uncertain, laparoscopy may be useful
  diagnostic tool
• Surgical exploration

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Normal Ovary
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Ovarian Cancer
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Ovarian Cancer
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Ovarian Cancer

• Who gets it?
• What are the signs and symptoms?
• How do you work it up?
• How do you treat it?
• What are the chances of survival?

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Ovarian Cancer Surgical Rx for Early Stage
Disease

• Optimal therapy TAH BSO staging (including
  pelvic and PALN)
• In younger women, reproductive conservation may
  be appropriate
• Approximately 30 will have histologic evidence
  of metastatic disease

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Ovarian Cancer Staging by Surgical Specialty
Evaluation of completeness of surgical staging Evaluation of completeness of surgical staging
Nearly half of women with early ovarian cancer were inadequately staged by general Ob/Gyns or General Surgeons Nearly half of women with early ovarian cancer were inadequately staged by general Ob/Gyns or General Surgeons
Surgeon Complete Staging
Gyn/Onc 97
Ob/Gyn 52
Surgeon 35
Source McGowen et al. Ob/Gyn 1985 Source McGowen et al. Ob/Gyn 1985
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Ovarian Cancer Surgical Treatment for Advanced
Disease

• Significant survival advantage for women
  optimally cytoreduced
• Procedures may include
• En bloc resection of uterus, ovaries and pelvic
  tumor
• Omentectomy
• Bowel resection
• Removal of diaphragmatic and peritoneal implants
• Splenectomy, appendectomy

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Ovarian Cancer Survival by Residual Disease

• GOG Protocols (PR) 52 and 97

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Ovarian Cancer Chemotherapy

• Almost all patients should receive adjuvant
  chemotherapy with platinum and a taxane
• gt70 response rate
• I.P. chemo in optimally debulked pts
• Many new agents being tested
• Encourage clinical trial participation

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Taxol and ovarian cancer
McGuire W.P. et al. New Engl J of Med, 334 (1996)
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Ovarian Cancer

• Who gets it?
• What are the signs and symptoms?
• How do you work it up?
• How do you treat it?
• What are the chances of survival?

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Ovarian Cancer Follow-up Healthcare

• RV pelvic exam and CA-125 q 3-4 mo x 2 years, q 6
  mo for years 3-5
• CT scan for symptoms
• General health maintenance(mammography, Pap
  smear, bone density, colon-rectal screening,
  cholesterol, etc.)
• Discuss HRT, diet, exercise

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Ovarian Cancer Recurrence

• 75 of patients relapse
• Treatment options include
• Secondary cytoreduction
• Retreatment with platinum/taxane
• Second-line therapies, including chemo,
  radiation, immunologic, gene therapies
• Encourage clinical trials

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Ovarian Cancer U.S. Patterns of Care
Stage Appropriate Treatment
I 10
II 15
III 71
IV 53
785 women with ovarian cancer studied
Munoz JCO 1997
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Ovarian Cancer Importance of Surgeon

• 1,866 women with ovarian cancer
• Significant advantage for those women managed by
  Gynecologic Oncologist
• More likely to have optimal cytoreduction
• Reduction in death by 25 (p 0.005) compared to
  Ob/Gyn and General Surgeons

Junor et al, Brit J Ob/Gyn, 11/99
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Ovarian Cancer Stage Distribution and 5-year
Survival
Stage Percent Survival
I 24 95
II 6 65
III 55 15-30
IV 15 0-20
Overall 50

• American Cancer Society 2002

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Relative Survival Ovarian Breast Cancers
Five-Year Relative Survival Rates by Stage at Diagnosis Five-Year Relative Survival Rates by Stage at Diagnosis Five-Year Relative Survival Rates by Stage at Diagnosis
Stage Ovary Breast
Local 93 97
Regional 55 76
Distant 25 21
All Stages 50 84
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Ovarian Cancer Future Directions

• Cost-effective screening
• Early detection
• Prevention
• Reversing chemoresistance
• Targeted therapies
• Immunotherapy
• Gene therapy