www.SpringfieldClinic.com/DoctorIsIn

Outline1. Definition2. Epidemiology3. Risk factors4. Clinical presentation5. Treatment Strategies6. Preventive Measures

What is ovarian cancer?

Cancer that arises from the ovaries, fallopian tube, or peritoneal surfaces

Most common: epithelialLess common: germ cell, borderline tumors, endometrioid/mucinous histologies

Ovarian Cancer StagingStage I 15%

Stage II 19%

Stage III/IV 65-70%

5-year Survival Rates• Stage I >90%• Stage II 75%• Stage III/IV 35-40%

Ovarian Cancer is Deadly• Lifetime risk is 1.3%• Mortality rate high• 4th highest rate of cancer deaths among women

In 2016: 22,280 new cases 14,000 deaths

Approximately 195,000 women living with ovarian cancer in the US

Breast Cancer: 3,043,450 women living with breast cancer, 40,000 deaths 1.3%

7.5%

Trends over time• New cases falling by 1.9% each year• Death rate falling by 2.2% each year

Risk FactorsIncreased Risk• Early menarche• Late menopause• Age (>65)• Family history of ovarian

cancer• BRCA1,BRCA2• Nulliparity

Decreased Risk• Pregnancy• Breast feeding• Oral contraceptive use• Tubal ligation

Oral Contraceptives• Greater than 5 years• Reduce risk on average by 50%• More protection with more years of use• Protection lasts for decades after stopping

Tubal Ligation is Protective• Decreased blood supply• Reduced flow of carcinogens within tube

Hormonal Replacement TherapySmall increase in risk (1 per 8000 users)Risk reversed after 2 years of cessationLittle risk if used 5 or less yearsShouldn’t affect decision to use

Pelvic disease• Pelvic inflammatory disease• Endometriosis

Fertility Treatments• “We found no convincing evidence of an increase in

the risk of invasive ovarian tumours with fertility drug treatment”

Cochrane Database Review of multiple studies

Other Risk Factors?• Smoking?• Diet?• Exercise?• Weight?

NO IMPACT

Talcum powder use?

72 million dollar verdict!

Possible correlationNo confirmed causationSmall increased risk

Recommend not using it

Hereditary Ovarian Cancer• 10-15% of all ovarian cancers• All women with ovarian cancer should be tested for

genetic predisposition• BRCA1, BRCA2• Lynch syndrome

Clinical Presentation• Vague symptoms

– Bloating– Loss of appetite– Early satiety– Abdominal distention– Changes in bowel function– Nausea/vomiting

• Asymptomatic– Pelvic mass on ultrasound

Clinical Work-Up• CT scan

– Extra fluid– Ovarian mass– Carcinomatosis

• CA-125 marker– Elevated (above 500)

• CEA marker

Clinical work-up in asymptomatic patient

• Pelvic Ultrasound– Complex mass involving one or both ovaries– Range of sizes

• CA-125 level– May be normal

Mainstay of Treatment• Surgery• Chemotherapy

Surgery only helpful if planning to do chemotherapy too

Treatment within 14 days

Surgery• Open abdominal surgery• Extensive• Long• Tumor debulking procedure

– Goal is to remove ALL visible disease• Prolonged hospital stay

Chemotherapy• Intraperitoneal• Neoadjuvant • Intravenous • 6 cycles of total treatment

Chemotherapy given to all stages of ovarian cancer

Intraperitoneal Chemotherapy

Tough RegimenRequires Supportive MeasuresBetter Outcomes

Neoadjuvant Chemotherapy• Patients not fit for surgery• Patients with bulky, extensive disease

Intravenous Chemotherapy• Carboplatin• Paclitaxel/taxotere• Doxil• Gemzar• Avastin• Topotecan

New Chemotherapy Strategies• Immunotherapy• Oral chemotherapy agents

– Pazopanib– Cediranib

Tumor Profiling• Chemotherapy sensitivity assays• Molecular profiling

– “BRCAness”– MATCH trial

Lifestyle Modifications• Diet• Exercise• Mental well-being• Alternative methods?

Recurrence rates• High risk of recurrence even after complete

response • Close interval follow-up

Often becomes viewed more like a chronic disease

Prevention• NO SCREENING METHOD THAT WORKS!!!!

Risk of Ovarian Cancer Algorithm (ROCA) TEST

• Multimodality Screening Method– Age– Serial CA-125 levels– FH of ovarian cancer

• Serial CA-125 levels– Establish baseline– Change point from baseline

ROCA Test • Initial study 2013:

– 4,000 women– 10 surgeries, 6 cancers all early stage

• UK Study 2015: – 46,237 women– 50 years or older

41% of all cancers detected were stage I or II

ROCA test significance • Individual CA-125 levels not as important• THE VELOCITY of change more important

Genetic Testing• Make sure your family history is reviewed by your

doctor!• BRCA1: 40-60% lifetime risk

– Ovaries out by 35-40• BRCA2: 11-20% lifetime risk

– Ovaries out by 40-45• Lynch Syndrome: 6-8% lifetime risk

Regular Exams• Annual pelvic exam• Review of symptoms• Update family history

Pelvic mass found• Depends on age • Depends on ultrasound characteristics• Depends on clinical work-up• Important to evaluate and not ignore!• Risk of early menopause versus cancer risk

reduction

Listen to your body• Symptoms that persist• Symptoms that are unexplained• Especially depending on your age!• Don’t be afraid to ask

Support Ovarian Cancer Research• FamiliesROC.com• Norma Leah Ovarian Cancer Institute• Foundation for Women’s Cancer

Clarification of misconceptions• Pap test does not screen for ovarian cancer• Surgery will spread the cancer when the abdomen

is open• You can still develop ovarian cancer without your

ovaries• Breast cancer survivors are at higher risk

Take Home Message

Thank You!• Questions?