OVARIAN CANCER: Recognition & initial management / where are we now Mr. Panos Sarhanis MD FRCOG...

OVARIAN CANCER: Recognition & initial management / where are we now

Mr. Panos Sarhanis MD FRCOG

Gynaecology Cancer Lead

NWLH London

Aims & objectives

Present new disease data Focus on new developments in

recognition & initial management Present local data Highlight patient centered care

P SARHANIS LONDON UK

Key message – NCIN November 2010

23% of newly diagnosed cancer patients came through as emergency presentations. For almost all cancer types, one-year survival rates were much lower for patients presenting as emergencies than for those presenting via other routes.

Tumour biology – current targets

Targeted therapies Small molecules vs biologics Anti-angiogenic PARP Inhibitors


Introduction (NICE 2010)

Ovarian cancer is the leading cause of death from gynaecological cancer in

the UK, and its incidence is rising. It is the fifth most common cancer in

women, with a lifetime risk of about 2% in England and Wales.


Background – ovarian cancer statistics UK 2006 (Cancer Res. UK 2009)

ENGLAND WALES SCOT. NI UK

CASES 5528 380 500 188 6596

Per 100000

21.4 25 18.9 21.2 21.4

Age standardised

17.1 18.6 14 19.1 16.9

/ 100000


In the USA

Ovarian cancer is the leading cause of deaths form Gyn. Malignancies

5th commonest cause of Cancer deaths In 2010 there will be 21,900 new cases

and an estimated 13,900 deaths Less than 40% of women are cured 70% of patients present with advanced

disease (NCCN Guidelines 2011)


Background (NICE 2010)

The outcome for women with ovarian cancer is generally poor, with an overall

5-year survival rate of less than 35%. This is because most women who have

ovarian cancer present with advanced disease.

The stage of the disease is the most important factor affecting outcome.


Stage

Epithelial ovarian cancer, which is the most common type of ovarian cancer, spreads mainly by tumour shedding from the diseased ovaries. These tumour cells are then carried over to the neighbouring organs, mainly the large and small intestines by a clockwise physiological current.

To determine the stage, the patient undergoes surgery for a thorough exploration the abdomen and pelvis.


STAGE: 5 Year Survival


Risk factors

Nulliparity Early menarche & late menopause Prolonged ovulation induction BRCA 1& 2 HRT use (Morch LS et al Hormone

therapy and ovarian cancer JAMA 2009;302:298-305)


Protective factors

Early parity, breastfeeding Hysterectomy Tubal ligation COCP

These factors can reduce the incidence by 30-60%!


Screening

Preliminary results of UKCTOCS encouraging, full results awaited

SGO recommends NOT to use ROCA, OVA-1 test, OVASURE as screening tests

In the meantime there is NO EFFECTIVE screening


Patient centered care

This presentation takes into account NICE Guideline 2010 – Draft

Women with ovarian cancer should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.


Communication

Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written information tailored to the patient’s needs.

Treatment and care, and the information patients are given about it, should be culturally appropriate. It should also be

accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.

If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care.

Families and carers should also be given the information and support they need.


NICE 2010

Most women have had symptoms for months before presentation, and there are often delays between presentation and specialist referral.

There is a need for greater awareness of the disease and also for initial investigations in primary and secondary care that enable earlier referral

and maximisation of treatment options.P SARHANIS LONDON UK

Key priorities

Carry out tests in primary care if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month:– persistent abdominal distension (women often refer to this as

‘bloating’)

– difficulty eating and/or feeling full (early satiety)

– pelvic or abdominal pain

– increased urinary urgency and/or frequency.


Key priorities

Carry out appropriate assessments for ovarian cancer in any woman of 50 or over who has symptoms that suggest irritable bowel syndrome (IBS) because IBS rarely presents for the first time in women of this age.


Key priorities – first tests

Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer

If serum CA125 is greater than 35 IU/ml, arrange an ultrasound scan of the abdomen and pelvis.

Advise any woman who has normal serum CA125, or CA125 greater than 35 IU/ml but a normal ultrasound, to return to her GP for re-assessment if her symptoms persist


Malignancy indices

Calculate a risk of malignancy index I (RMI I) score (after performing an ultrasound) and refer all women with an RMI I score of 200 or greater to a specialist multidisciplinary team.


RMI

RMI I combines three pre-surgical features: serum CA125 (CA125), menopausal status (M) and ultrasound score (U).

The RMI is a product of the ultrasound scan score, the menopausal status and the serum CA125 level (IU/ml).


RMI

RMI = U x M x CA125 The ultrasound result is scored 1 point for each of the

following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2–5).

The menopausal status is scored as 1 = pre-menopausal and 3 = postmenopausal

The classification of ‘post-menopausal’ is a woman who has had no period for more than 1 year or a woman over 50 who has had a hysterectomy.

Serum CA125 is measured in IU/ml and can vary between 0 and hundreds or even thousands of units


RMI & referrals

refer all women with an RMI I

score of 200 or greater to a specialist multidisciplinary team


P Sarhanis Gynaecology

Workload & outcomes

2 WW referrals

Confirmed cancers 09-10

NPH/CMHNPH/CMH

NPH/CMHNPH/CMH

April 08 to Mar 09 April 08 to Mar 09 April 09 to Mar 10April 09 to Mar 10

1453 1453 17301730

endometrialendometrial 4545 28 2ww, 28 2ww, 17 non 2ww 17 non 2ww

OvarianOvarian 3636 15 2ww, 21 15 2ww, 21 non 2wwnon 2ww

CervicalCervical 1414 6 2ww, 8 6 2ww, 8 non 2wwnon 2ww

UnknownUnknown 66 6 non 2ww6 non 2ww

PeritonealPeritoneal 332 2ww, 1 2 2ww, 1 non 2wwnon 2ww

VulvaVulva 552 2ww, 3 2 2ww, 3 non 2wwnon 2ww

totaltotal 109109


KPI

The Gynaecology team has achieved the 100% target for the 2-week wait standard.

The MDT has also achieved the 31-day standard and the 62-day standard.

Breach analysis has shown that breeches occur in patients with a complex diagnostic pathway and more than one biopsy procedure.

Surgery

Optimal surgical staging constitutes: midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy;

biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum;

and retroperitoneal lymph node assessment [Winter Roach BA, Kitchener HC, Dickinson HO (2009)

Adjuvant (post-surgery) chemotherapy for early stage epithelial ovarian cancer. Cochrane Database of Systematic Reviews issue 3: CD004706]



LOS- Towards Enhanced recovery

Average LOS

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Average LOS

Chemotherapy regimens

It is recommended that paclitaxel in combination with a platinumbased compound or platinum-based therapy alone (cisplatin or carboplatin) are offered as alternatives for first-line chemotherapy (usually following surgery) in the treatment of ovarian cancer.

The choice of treatment for first-line chemotherapy for ovarian cancer should be made after discussion between the responsible clinician and the patient about the risks and benefits of the options available.



Patients expect

To be respected and kept informed A comprehensive explanation through

their journey

Ensure that information is available about: the stage of the disease, treatment options and prognosis how to manage the side effects of both the disease and its

treatments in order to maximise wellbeing sexuality and sexual activity fertility and hormone treatment symptoms and signs of disease recurrence genetics, including the chances of family members developing

ovarian cancer self-help strategies to optimise independence and coping where to go for support, including support groups, how to deal

with emotions such as sadness, depression, anxiety and a feeling of a lack of control over the outcome of the disease and treatment.



Patient satisfaction (09-10)

100% of patients who responded received their diagnosis in person. 75% of patients who responded were given their diagnosis by a consultant 93% felt waiting time were average or good 87% felt the space of the clinic was average or good 87% felt cleanliness was average or good 93% felt there was respect for privacy was good 87% felt attitude and friendliness of reception staff was good 75% of patient felt they understood the explanation of their diagnosis. 80% did receive written information at time of diagnosis,81% found it useful 79% responded yes to being offered a copy of their GP letter at diagnosis. 100% were introduced to a generic clinical nurse specialist at diagnosis. 100% felt they were adequately involved in decision regarding their

treatment.


When you had surgery, did you feel that you were given enough information about the following?

yesyes nono

Reason for needing an operationReason for needing an operation

(n=13) (n=13) 13 (100%)13 (100%) 0 (0%)0 (0%)

What the operation entailed and any What the operation entailed and any complications/side effects (n=13) complications/side effects (n=13)

10 (77%) 10 (77%) 3 (23%) 3 (23%)

Recovery and what to expect after surgeryRecovery and what to expect after surgery

(n=13) (n=13) 10 (77%)10 (77%) 3 (23%)3 (23%)

Advice as to who to contact if you developed Advice as to who to contact if you developed problems following discharge from hospital problems following discharge from hospital (n=13) (n=13)

8 (62%)8 (62%) 5 (38%)5 (38%)


GPs expect

Timely & comprehensive communication


Audit on timely GP notification of

cancer diagnosis 09-10

88% patients had proof that the confirmation form was faxed to the GP

2 patients had wrong GP recorded 3 were in patient outliers _coordinator

not informed


Research- largest recruitment in Network!Trial Name Hospital Accrual Apr 09 to 31 Mar

10

NSECG NP 10

UKFOCSS NP 39

THANK YOU!


OVARIAN CANCER: Recognition & initial management / where are we now Mr. Panos Sarhanis MD FRCOG...

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