Ovarian CancerOvarian Cancer

Amreen Husain, MDAmreen Husain, MD

Assistant ProfessorAssistant Professor

Gynecologic OncologyGynecologic Oncology

Ovarian cancerOvarian cancer

• 25,000 cases annually25,000 cases annually

• 1/70 American women 1/70 American women

• 14,000 deaths annually 14,000 deaths annually

• 44thth in cancer related deaths among women in cancer related deaths among women

• Mean age at diagnosis 59 yrsMean age at diagnosis 59 yrs

Risk factorsRisk factors

• Family history:Family history:- One 1One 1° relative 3.6 times risk, or 5% lifetime ° relative 3.6 times risk, or 5% lifetime

risk.risk.- 5- 10% of all ovarian cancers associated with 5- 10% of all ovarian cancers associated with

known gene mutations.known gene mutations.- Three familial ovarian cancer syndromes: Three familial ovarian cancer syndromes:

site-specific ovarian cancer, breast/ovarian site-specific ovarian cancer, breast/ovarian cancer syndrome, hereditary nonpolyposis cancer syndrome, hereditary nonpolyposis colorectal cancer syndrome.colorectal cancer syndrome.

BRCA1/2BRCA1/2

• Associated with site specific and Associated with site specific and breast/ovarian cancer syndromes.breast/ovarian cancer syndromes.

• BRCA1: 25-40% lifetime risk of Ov ca, 80% BRCA1: 25-40% lifetime risk of Ov ca, 80% lifetime risk of Breast Califetime risk of Breast Ca

• BRCA2 : 10% lifetime risk of ov CaBRCA2 : 10% lifetime risk of ov Ca

• Early age-onset, 10yrs younger than Early age-onset, 10yrs younger than relative, mean age 40’srelative, mean age 40’s

Reproductive factorsReproductive factors

• NulliparityNulliparity

• InfertilityInfertility

• Oral contraceptives protective 50% Oral contraceptives protective 50% decrease with 5 or more years of use.decrease with 5 or more years of use.

• Multiparity protectiveMultiparity protective

• Lactation protectiveLactation protective

ScreeningScreening

• General population : no good methodGeneral population : no good method

• High risk population : TV u/s, Ca 125 High risk population : TV u/s, Ca 125 though not fully proventhough not fully proven

• Prophylactic oophorectomy : option in Prophylactic oophorectomy : option in high-risk women who have completed high-risk women who have completed child-bearing or age 40 though small risk child-bearing or age 40 though small risk (1-3%) of peritoneal cancer(1-3%) of peritoneal cancer

DiagnosisDiagnosis

• ““silent killer”silent killer”

• Vague symptoms : abd bloating, early Vague symptoms : abd bloating, early satiety, indigestion, constipationsatiety, indigestion, constipation

• 60-70% Stage III or IV at diagnosis 60-70% Stage III or IV at diagnosis

• ascites and upper abdominal disease at ascites and upper abdominal disease at presentationpresentation

StagingStaging

• Surgically basedSurgically based

• Ovarian cancer spreads by direct Ovarian cancer spreads by direct extension within abdominal cavity, or to extension within abdominal cavity, or to lymph nodeslymph nodes

• Staging based on location of metastatic Staging based on location of metastatic diseasedisease

Early stageEarly stage

• Stage IStage I Stage IIStage II

Advanced stageAdvanced stage

Intraabdominal dxIntraabdominal dx Lymph node dx Lymph node dx

Treatment - surgicalTreatment - surgical

• Early stage: Early stage: - Intact removal of affected ovary Intact removal of affected ovary - complete staging including complete staging including

TAHBSO/omentectomy/biopsies/lymph node TAHBSO/omentectomy/biopsies/lymph node sampling/peritoneal washingssampling/peritoneal washings

• 30% patients with clinical Stage I will be 30% patients with clinical Stage I will be upstagedupstaged

• Fertility preservation can be considered in Fertility preservation can be considered in Stage I if fully stagedStage I if fully staged

• Chemotherapy for all stages greater than IAChemotherapy for all stages greater than IA

Surgical treatmentSurgical treatment

• Advanced stage :Advanced stage :- Laparotomy via midline vertical incisionLaparotomy via midline vertical incision- Hysterectomy/ oophorectomyHysterectomy/ oophorectomy- Maximal tumor debulking to any residual implants Maximal tumor debulking to any residual implants

<1cm <1cm - Bowel resection required in about 10% pts.Bowel resection required in about 10% pts.- Pts treated by gynecologic oncologists have higher Pts treated by gynecologic oncologists have higher

rates of debulkingrates of debulking- Optimal debulking impacts significantly on long term Optimal debulking impacts significantly on long term

survivalsurvival

Further therapyFurther therapy

• Majority of patients will require further Majority of patients will require further treatment with chemotherapytreatment with chemotherapy

• Current standard is Carboplatin + Taxol Current standard is Carboplatin + Taxol for 6 courses given every three weeks.for 6 courses given every three weeks.

• 70-80% complete response70-80% complete response

• a complete clinical response (remission) a complete clinical response (remission) is : nl Ca125, nl exam, is : nl Ca125, nl exam, ++ nl CT. nl CT.

22ndnd look surgery look surgery

• Done now primarily in the study settingDone now primarily in the study setting

• Can be performed by laparoscopyCan be performed by laparoscopy

• Patients with negative second looks have Patients with negative second looks have a 50% chance of recurrence.a 50% chance of recurrence.

• Potential treatments include Potential treatments include intraperitoneal chemotherapy, vaccine intraperitoneal chemotherapy, vaccine trials, further IV chemotherapytrials, further IV chemotherapy

Recurrent diseaseRecurrent disease

• ¾ patients who achieve a remission after ¾ patients who achieve a remission after initial therapy will recur, usually within 2 initial therapy will recur, usually within 2 yearsyears

• Response to second-line therapy depends Response to second-line therapy depends on the time interval from primary therapyon the time interval from primary therapy

• Several second line treatments including Several second line treatments including taxol/Pt/Doxil/Topotecan/Gemcitabinetaxol/Pt/Doxil/Topotecan/Gemcitabine

Recurrent diseaseRecurrent disease

• Surgery can be an option:Surgery can be an option:- Goal is to achieve a complete resectionGoal is to achieve a complete resection- Usually in patients who have had a longer Usually in patients who have had a longer

disease free-intervaldisease free-interval- Complicated by fact that patients have had Complicated by fact that patients have had

prior surgeryprior surgery- Almost all still will need chemotherapyAlmost all still will need chemotherapy- Radiation an option in select casesRadiation an option in select cases

New therapies – current clinical New therapies – current clinical trialstrials

• Immunotherapies – CA 125 antibody/ Immunotherapies – CA 125 antibody/ vaccine (Ovarex)vaccine (Ovarex)

• Angiogenesis inhibitors – Thalidomide, Angiogenesis inhibitors – Thalidomide, Bevacizumab (Avasttin)Bevacizumab (Avasttin)

• Biologic modulators – Iressa, CleevecBiologic modulators – Iressa, Cleevec

Ovarian Ca survivorsOvarian Ca survivors

• Issues in survivors:Issues in survivors:- Psycho sexual recoveryPsycho sexual recovery- Potential for FertilityPotential for Fertility

• National advocacy groupsNational advocacy groups- Further researchFurther research- Access to appropriate specialistsAccess to appropriate specialists- Support networkSupport network