Voices

21  Nov  12

Ovarian Cancer

Ovarian Cancer Home | General information | Risk Factors | Symptoms
First Appointment | Diagnostic Tests | Stages | Treatment Options | Post-Treatment

What is Ovarian Cancer?

Ovarian cancer develops in the ovary and can spread to other parts of the body. Many people currently use “ovarian cancer” as an umbrella term to include not only ovarian cancer but also fallopian tube cancer and primary peritoneal cancer. Ovarian cancer is the ninth most common cancer in women. Of all the cancers affecting women, ovarian cancer is the fifth most deadly. It is estimated that 22,240 women will be diagnosed with ovarian cancer this year, and 14,070 will die from this disease.

Ovarian cancer is usually not inherited. However, up to 24 percent of cases may be related to inheriting a genetic mutation, even if the family history does not include ovarian or breast cancer. For that reason, it is critical for a woman to have a discussion with her health care team about her genetic predisposition to ovarian and other types of cancers at the time of diagnosis. The National Comprehensive Cancer Network (NCCN) recommends that all women with ovarian, fallopian tube or peritoneal cancer undergo genetic counseling and consider genetic testing.

Photo courtesy of the Ovarian Cancer Alliance of Ohio

Voices

20  Nov  12

Ovarian Cancer

Ovarian Cancer Home | General information | Risk Factors | Symptoms
First Appointment | Diagnostic Tests | Stages | Treatment Options | Post-Treatment

What happens after treatment?

If you receive surgery first then your doctor will likely wait one to four weeks after surgery to give you chemotherapy. Not all patients with ovarian cancer require chemotherapy, but the vast majority will. The recommended treatment will depend on your stage. Your chemotherapy may be given via the vein (intravenously) or into the abdomen (intraperitoneally) or both. The main drugs involved in front line treatment of ovarian cancer are platinums (cis or carboplatinum) and taxanes.

Once you have completed treatment and there is no evidence of cancer remaining, you will need to have continued visits with your doctor to make sure there is no sign the cancer is returning.

Clinical Trial

Finally, your gynecologic oncologist may consider you eligible or a good candidate for a clinical trial. A clinical trial is a study that looks at improving or changing treatment options for women with ovarian cancer. This is a voluntary decision for you. If you choose to go on a clinical trial, you have a chance of getting a new medication or approach that might help to improve how this disease is treated.

Survivorship Toolkit

The SGO Survivorship Toolkit helps survivors organize their treatment history and future care plans. You can develop a survivorship plan along with your gynecologic oncologist and use this as an opportunity to evaluate and improve your overall health.

Back: What are the treatment options?

Photo courtesy of the Ovarian Cancer Alliance of Ohio

Voices

20  Nov  12

Ovarian Cancer

Ovarian Cancer Home | General information | Risk Factors | Symptoms
First Appointment | Diagnostic Tests | Stages | Treatment Options | Post-Treatment

What are the treatment options?

Your gynecologic oncologist will likely choose surgery first if they determine that you are healthy enough for surgery and that there is a high likelihood that they will be able to safely remove any tumor they can see in the abdomen during the surgery.

Surgery

Surgery may be performed via a traditional open incision in the abdomen or using a minimally invasive technique such as laparoscopy or robotic technology. If cancer is found during this surgery, your doctor will likely perform a complete hysterectomy, lymph node dissection, omentectomy (removal of an internal fat pad hanging down from the stomach and colon), pelvic washing (collection of sterile water that has been swished around the abdomen to pick up floating abnormal cells) and other biopsies of the lining of the abdomen. This is to determine whether it has spread beyond the ovary where it started, also known as staging.

In order to tell if you have cancer during the surgery, the doctor will send the tissue to the pathology lab for what is called a “frozen section.” This is when the pathology doctor gives a preliminary report to determine if there is concern for cancer. Most of the time this is a pretty accurate assessment of what the final report shows after they have had plenty of time to look all the way through the tumor. Occasionally, though, the diagnosis will change when the pathologist receives more information.

At surgery, if your gynecologic oncologist sees a tumor beyond the ovary, he or she will aim to remove all visible disease. If this is the case, your surgery may include removal of part of the bowel, the spleen, the diaphragm or even the liver in order to remove as much bulky tumor as possible. If your surgery is more extensive, you will need to prepare for a longer hospital stay and possibly some time spent in the intensive care unit.

Chemotherapy

If your doctor thinks that your tumor has spread to too many areas, he or she might decide that you would do better with surgery after a course of chemotherapy, since surgery is most successful if the doctor can remove all visible disease. If this is not possible, your treatment outcome will be the same if you get chemotherapy first; furthermore, this might help you to avoid a prolonged hospital stay.

Back: What are the stages of ovarian cancer?
Next: What happens after treatment?

Photo courtesy of the Ovarian Cancer Alliance of Ohio

Voices

20  Nov  12

Ovarian Cancer

Ovarian Cancer Home | General information | Risk Factors | Symptoms
First Appointment | Diagnostic Tests | Stages | Treatment Options | Post-Treatment

What tests might your gynecologic oncologist perform to determine treatment?

Most ovarian cancers are diagnosed at advanced stages (Stage III or IV). This means that at the time of diagnosis, the cancer has already spread beyond the female organs into the upper abdomen, lymph nodes or the chest. Despite this, the ability to surgically remove bulky tumors and the high likelihood that ovarian cancer will respond to chemotherapy means that most women with ovarian cancer will be in remission after their initial treatment. How long remission will last is impossible to predict.

If the cancer never comes back, that remission is considered a cure. However, most often, ovarian cancer does recur. The first two years after finishing initial treatment is the highest risk period. At the current time, recurrent ovarian cancer is not generally curable. The goals of treatment are to maximize quality of life while prolonging survival. Chemotherapy is the most common form of treatment for recurrent disease. Although this disease is known for its recurrent nature, there is increasing hope that a woman’s life may be extended with new treatments and lifestyle interventions.

If you have not already had the tests listed below, your gynecologist oncologist might order them prior to determining the appropriate treatment plan for your cancer.

Blood tests

Tumor markers (CA-125, CEA, CA 19-9, CA 27-29 and others): These tests give the doctor a better understanding of the likelihood that you have a cancer in your body. However, these tumor markers may be elevated even in the absence of a cancer, and some ovarian cancers do not have abnormal tumor markers. These tests may also help determine whether the cancer is coming from other parts of the body.

Complete blood count and comprehensive metabolic panel: Prior to performing surgery or administering chemotherapy, these tests help to determine your nutritional status in addition to low blood counts (requiring blood transfusion) and your ability to tolerate anesthesia and surgery. They may also help predict your ability to recover.

Imaging and tests

Ultrasound (U/S), CT (CAT) scan, or MRI

  • To better understand the location of your mass, cyst or tumor
  • To better understand if your tumor has spread to other parts of your body
  • If your doctor is not concerned about distant spread of your disease, it is reasonable to only have an ultrasound prior to surgery.

Chest X-ray and EKG

These tests may be performed before surgery to help you anesthesiologist know that your heart and lungs are healthy.

Stress test, echocardiogram, pulmonary function tests

These tests may be performed before surgery if you have an abnormal chest X-ray and EKG, or if you have complaints of chest pain or shortness of breath.

Back: What information should you bring to your first appointment?
Next: What are the stages of ovarian cancer?

Photo courtesy of the Ovarian Cancer Alliance of Ohio

Voices

20  Nov  12

Ovarian Cancer

Ovarian Cancer Home | General information | Risk Factors | Symptoms
First Appointment | Diagnostic Tests | Stages | Treatment Options | Post-Treatment

What information should you bring to your first appointment?

When you go to your first appointment with your gynecologic oncologist, you may want to bring a friend or relative for moral support, to help you remember all your questions, and to take notes.

You should also bring:

  • Copies of any pertinent medical records that you have already had as part of your workup
    • Pathology reports of recent biopsies (lab tests from any biopsies you might have had). You may also go directly to the hospital lab and request the glass slides or tissue block from your biopsy.
    • Radiology reports including any X-rays, CT scans, ultrasounds, MRI and PET scans
    • Blood test results
    • Notes and records from other doctors and health care providers you have seen
  • A current list of all medications and supplements you are taking.
  • An updated list of your past medical and surgical history, including your gynecologic and obstetric history
  • Your family medical history, including a list of family members who have had cancer
  • A list of all doctors you are currently seeing for ongoing care
  • Your health insurance information
  • A list of any questions that you wish to ask the oncologist

Next: What tests might your gynecologic oncologist perform to determine treatment?

Photo courtesy of the Ovarian Cancer Alliance of Ohio

Voices

16  Nov  12

Ovarian Cancer

Ovarian cancer originates in the ovaries. The ovaries, located on each side of the uterus, are the pair of reproductive organs that produce eggs and are the main source of the primary female hormones, estrogen and progesterone. In 2015, the American Cancer Society estimated that 21,290 new cases of ovarian cancer would be diagnosed in the U.S. and 14,180 deaths would result. Ovarian cancer is the ninth most common cancer in women and is the most lethal of the gynecologic malignancies.

Role of the Gynecologic Oncologist

Gynecologic oncologists are trained in the comprehensive management of gynecologic cancer. As such, they coordinate care for women with ovarian cancer from diagnosis, to surgery, to chemotherapy, through survivorship and palliative care at the end of life. They serve as captain of the entire cancer care team of medical oncologists, pathologists, radiologists, physician assistants, nurse practitioners, registered nurses and genetic counselors, among others. Seek a specialist near you.

Patients, Caregivers and Survivors

As part of the overview section on ovarian cancer, learn general information, including risk factors and symptoms, and what to do if your doctor suspects you or your loved one has been diagnosed with ovarian cancer. SGO has a useful toolkit for ovarian cancer survivors, as well as a video and companion PDF booklet as a patient resource.

More information on ovarian cancer is available on the SGO genetics page. Both the SGO and the Society’s Foundation for Women’s Cancer (FWC) have endorsed the National Comprehensive Cancer Network (NCCN) guidelines for ovarian cancer patients. Additional resources have been developed to explain gynecologic cancer clinical trials and the phases involved.

Clinical Practice Guidelines

SGO Position Statements

Choosing Wisely

In October 2013 Choosing Wisely®, an initiative of the ABIM Foundation, released SGO’s Five Things Physicians and Patients Should Question with specific tests or procedures that are commonly ordered but not always necessary in gynecologic oncology. SGO’s Choosing Wisely now has a number of patient resources and is mentioned in various online reference materials related to gynecologic oncology.

Photo courtesy of the Ovarian Cancer Alliance of Ohio

Voices

26  Oct  12

Use of CA125 for Monitoring Ovarian Cancer

June 2009

Results of a multi-institutional European trial on the utility of CA125 in monitoring ovarian cancer after completion of primary therapy have recently been reported at the annual meeting of the American Society of Clinical Oncology. The main conclusion was that women with relapsed ovarian cancer did not live longer if chemotherapy was started earlier based on a rising CA 125, as opposed to delaying treatment until symptoms developed. It was found that the group undergoing CA125 monitoring received five more months of chemotherapy overall, whereas quality of life measures were higher in women who were treated at the time of clinically evident recurrence. The results of this study have been featured in various professional and consumer media outlets, and physicians and patients will be seeking guidance regarding the implications.

The Society of Gynecologic Oncology commends the investigators of this study for contributing valuable data that further informs evidence-based management of ovarian cancer. The strength of this study is that it was a prospective randomized trial, but the study also had some significant limitations. The trial did not address the role of secondary cytoreduction in recurrent cases, participants were not stratified for residual disease after cytoreduction, remission was not consistently confirmed by imaging and treatment regimens at relapse were not standardized. The most pressing issue in the management of ovarian cancer is the development of new treatments that will further extend survival and cure more women.

Although there may not presently be a major survival advantage to the use of CA125 monitoring for earlier diagnosis of recurrence, patients and their physicians should still have the opportunity to choose this approach as integral to a philosophy of active management that includes participation in trials of novel therapies. Other patients, particularly those with a less robust performance status, might be more suitable for watchful waiting with an emphasis on quality of life. In practice, many have already been opting for such an approach without the support of data from clinical trials. The value of the present study is the confirmation that this is safe and reasonable. Patients and their physicians should be encouraged to actively discuss the pros and cons of CA125 monitoring and the implications for subsequent treatment and quality of life.

Voices

26  Oct  12

Use of CA125 in Screening for Ovarian Cancer

June 2010

Results of a multicenter screening trial using calculated algorithms based on age and trends in CA125 levels over time in women without familial risk of developing ovarian cancer have recently been reported at the annual meeting of the American Society of Clinical Oncology. Transvaginal ultrasound (TVUS) was not performed automatically but as indicated by the CA125 algorithm results. This study provides early evidence that incorporating a CA125 algorithm followed by TVUS may be a feasible strategy for screening low-risk women over 50 years of age. The results of this study have been featured in various professional and consumer media outlets, causing physicians and patients to seek guidance regarding the implications.

The Society of Gynecologic Oncology (SGO) commends the investigators of this study for contributing valuable data, and eagerly awaits the results of additional larger randomized controlled trials to confirm the usefulness of Risk of Ovarian Cancer Algorithm (ROCA) in screening women without familial risk of ovarian cancer. The positive predictive value noted in the study of 37.5% is superior to what has been reported from prior studies. However, as a screening strategy, that eventually could be applied to the general population, this figure is modest. There remains insufficient evidence to support routine CA125 +/- TVUS screening in low-risk women who are not part of a clinical trial. An additional limitation of this study was the lack of a control, observation-only arm, without which it is difficult to attribute any real benefit to the screening strategy. As with any prospective screening tool or treatment option, the impact of false positive and false negative screening results must be considered and balanced against the potential benefits of true positive and negative results. Finally, while the number of participants who needed more frequent CA125 monitoring, ultrasound, or referral to a specialist appeared small, a complete cost effectiveness analysis of this approach would be critical before adopting any universal screening program.

As specialists in women’s cancer care, gynecologic oncologists offer patients individualized treatment plans. Patients and their physicians are encouraged to discuss the pros and cons of CA125 and TVUS screening and the implications for subsequent treatment and quality of life.