Ovarian Cancer

Is your treatment what more than 1,100 Oncologists recommend?

The information provided below is meant to help you understand the role of your ovarian cancer biology treatment decisions, as well as the role of other tools used in determining your ability to receive chemotherapy or targeted therapy (precision medicine).

In 2016, it is estimated that 22,280 new cases of ovarian cancer diagnosed in the United States (CA Cancer J Clin 2016; 66(1):7-30). Ovarian cancer is the leading cause of gynecologic cancer death in the United States with more than 70% of patients present with advanced disease (SEER cancer statistics review 1975-2012). It is estimated that one in 70 women will develop ovarian cancer during their lifetime. Currently there are no reliable methods for early detection. Thus, the 5 – year survival rates of ovarian cancer has remained about 30-44%.

Risk Factors

Common causes are older age, family history of ovarian cancer (5% risk of developing ovarian cancer), having cancer gene BRCA1/2 or HNPCC (Lynch syndrome), and prolonged period of ovulation in childless women, early first menstrual period (menarche), late menopause and infertility. Less common causes are white race and diets high in animal fat. Women, who use oral contraceptives for more than 5 years, do have less ovarian cancer risk.

Treatment

Three different approaches to treating cancer are available. Treatment recommendations will vary based on the type of cancer you have and could include a combination of all three options listed below:

• Surgery (to remove tumor): the standard approach is to debulk the tumor (cytoreduction surgery) that include hysteretomy (removal of the uterus), removal of both ovaries and surrounding lymph nodes, biopsy the pelvic tissue areas and washing of the pelvic. The ultimate goal is to have optimal debulking surgery (defined as <1cm residual disease) or no residual disease. If you have too large of the tumor for surgery, chemotherapy is given prior to surgery and patients tend to have better outcomes with this approach
• Radiation (if indicated)
• Chemotherapy with or without targeted therapy (precision medicine)

This website is designed to outline in detail your chemotherapy and/or targeted therapy options and offer you personalized information about the best options to yield optimal survival and quality of life. Multiple factors affect your treatment options including:

• Cancer is recurring (you have had ovarian cancer before) or your cancer is a first time diagnosis: The treatment for recurrence is determined by what type of treatment you received for your first diagnosis. Certain chemotherapies can only be given once in your lifetime, so if you have already received one type of chemotherapy with your first cancer, then that chemotherapy will not be recommended for you again.
• The particular ovarian cell types of the tumor will greatly affect treatment decisions: Ovarian carcinoma comes from the surface cells of the ovary with four histologic subtypes (serous, endometrioid, mucinous, clear cell), 70% of patients have serous histology (CA Cancer J Clin 2011;61:183).
• Cancer stage at the time of the diagnosis: Your treating physicians will do imaging tests (CT, bone scan or PET/CT) to determine your stage. Early stage lung cancer (tumor only in the lung) is mainly treated with surgery. If the cancer has spread outside the chest, it is considered advanced lung cancer and treatment is mainly with chemotherapy and targeted therapy.

Ovarian cancer stages (made by surgical exploration by the surgeon)

• Stage I: tumor limited to one (IA) or both ovaries (IB) with capsule rupture and malignant cells in ascites or peritoneal washings (IC)
• Stage II: tumor involves one or both ovaries with extension on uterus or Fallopian tubes (IIA) or on pelvic tissues (IIB) and malignant cells in ascites or peritoneal washings (IIC)
• Stage III: tumor involves one or both ovaries with microscopic peritoneal metastasis outside the pelvis (IIIA) or <2cm peritoneal metastasis outside the pelvis (IIIB) or >2cm peritoneal metastasis outside the pelvis or node positive (IIIC)
• Stage IV: tumor spreads to other parts of body

Targeted therapy (precision medicine) for ovarian cancer include:

• Vascular endothelial growth factor (VEGF): is a protein normally made by tumor cells and it is responsible for increasing the blood flow to the tumor in order to facilitate the growth of the tumor.  Targeted drug that targets VEGF such as bevacizumab blocks this protein path from stimulating new blood vessels formation to stop cancer growth.
• BRCA1/2 gene mutation: BRCA1/2 genes are tumor suppressor genes and are responsible for DNA repair among other functions. If you have this mutation, a newer drug called PARP (poly ADP ribose polymerase) inhibitor (olaparib) was recently available for ovarian cancer patients. PARP1 is a protein that works to repair single-strand DNA breaks (‘nicks’ in the DNA), this process is important for cell division.

Chemotherapy drugs in ovarian cancer include carboplatin, paclitaxel, doxil, topotecan, gemcitabine. Some hormonal drugs such as letrozole and tamoxifen are sometimes used as well. Even though the personalized ovarian cancer treatment report is generated for you, your individual tolerability to each treatment will depend on your overall health, i.e. whether you have other illness (diabetes, heart disease, liver disease, arthritis, or kidney disease). All personalized ovarian cancer treatment plans are recommended based on expertise ‘s opinions from multiple national guidelines (NCCN, ASCO, ESMO, ASTRO).

Another assessment that your treating physicians may use to determine your ability to tolerate treatment includes a tool called ECOG performance status described as below:

ECOG PERFORMANCE STATUS

Grade 0: Fully active, able to carry on all activity
Grade 1: Restricted in physically strenuous activity but ambulatory and able to carry out light house work, office work
Grade 2: Ambulatory and capable of all self-care but unable to carry out any work activities
Grade 3: Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
Grade 4: Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair

(Am J Clin Oncol 1982: 5: 649-655)

This computer program only will cover about 85% of ovarian cancer cases. If your cancer is primary peritoneal cancer or Fallopian tube then the treatment plan is more involved and complicated, we recommend that you discuss with your treating physicians. Other ovarian cancer with less common pathology like germ cell or carcino-sarcoma or sex-cord stromal cell are not discussed here. Your treating physicians will confirm your diagnosis of ovarian cancer and pathology.

Finally, chemotherapy and targeted therapies can result in unpleasant side effects such as hair loss, numbness of fingers or toes, cardiac toxicity, nausea, vomiting, diarrhea, abnormal liver function or low white blood cell count that could cause infection, and fatigue. However, advances in the oncology field have led to numerous supportive measures, such as white blood cell growth support (i.e. Neulasta) or anti-nausea medications (such as Zofran, Emend), that help to control most side effects when used as prescribed.

The best time to use this service (based on more than 1,100 cancer experts) is after you have learned the details of your cancer and treatment plan from your treating physicians, and would like to clarify and confirm that your treatment is the best option for your cancer. This questionnaire is used mainly for drug treatment in medical oncology.