Ovarian Cancer

Gloria S. Huang, M.D.Assistant Professor

Department of Obstetrics & Gynecology and Women’s Health

Division of Gynecologic Oncology

Albert Einstein College of Medicine Montefiore Medical

Center Albert Einstein Cancer

Center

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?

Ovarian Cancer

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

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%)

Histology

• 85% Epithelial– Serous carcinoma-most common– Endometrioid– Mucinous carcinoma– Clear cell carcinoma

• 5% Germ Cell

• 10% Sex cord Stromal

Ovarian Cancer

Ovarian Cancer: Risk Factors

Increase Decrease

Age OCPs

Family history Pregnancy

Infertility/low parity

Tubal ligation

Personal cancer history

Breast-feeding

Hereditary factors

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

• HNPCC– 1% of ovarian cancers

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?

Ovarian Cancer

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

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?

Ovarian Cancer

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

Normal Ovary

Ovarian Cancer

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?

Ovarian Cancer

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

Ovarian Cancer: Staging by Surgical Specialty

Evaluation of completeness of surgical staging

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

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

Ovarian Cancer: Survival by Residual Disease

GOG Protocols (PR) 52 and 97

Ovarian Cancer: Chemotherapy

• Almost all patients should receive adjuvant chemotherapy with platinum and a taxane

• >70% response rate

• I.P. chemo in optimally debulked pts

• Many new agents being tested

• Encourage clinical trial participation

Taxol and ovarian cancer

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

McGuire W.P. et al. New Engl J of Med, 334 (1996)

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?

Ovarian Cancer

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

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

Ovarian Cancer: U.S. Patterns of Care

StageAppropriate Treatment

I 10%

II 15%

III 71%

IV 53%

785 women with ovarian cancer studied

Munoz JCO 1997

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

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

Relative Survival: Ovarian & Breast Cancers

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%

Ovarian Cancer: Future Directions

• Cost-effective screening

• Early detection

• Prevention

• Reversing chemoresistance

• Targeted therapies

• Immunotherapy

• Gene therapy