Transcript ANN`S CLINIC – (powerpoint presentation)
Update on Ovarian Cancer
Robert E. Bristow, MD, MBA Professor and Director Division of Gynecologic Oncology University of California, Irvine – Medical Center
Ovarian Cancer Center
Mission: •To provide exemplary and holistic clinical care to patients with ovarian cancer.
•To enhance community awareness of ovarian cancer regarding the importance of early diagnosis and the benefits of centralized expert care.
•To advance the science of the prevention and treatment of ovarian cancer in a meaningful way.
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Gynecologic Oncology
Faculty Discover ▪ Teach ▪ Heal
Ovarian Cancer Center
• Clinical Services - coordination of multidisciplinary care - prevention, early detection, cancer survivorship - surgery and regional therapeutics - chemotherapy and clinical trials - ancillary services • Community Outreach and Education - web-based platform - virtual support group survivor network - conferences - international visiting scholar program • Research and Discovery - molecular biology and translational science - healthcare outcomes Discover ▪ Teach ▪ Heal
Ann’s Clinic
Screening, Early Detection, Cancer Survivorship
High-risk patients - genetic counseling & testing - surveillance programs - cancer prophylaxis Cancer survivors - programmatic plan - psycho-social wellness - management of treatment toxicities Discover ▪ Teach ▪ Heal
Peritoneal Surface Malignancies
Disease confined to peritoneal cavity for much of natural history
Generally amenable to surgical resection
Positive survival impact of chemotherapy - varies by disease site Discover ▪ Teach ▪ Heal
Radical Surgery for Ovarian Cancer
Uterus Bladder Tumor Right Ovary Sigmoid Tumor Left Ovary Discover ▪ Teach ▪ Heal
Radical Surgery for Ovarian Cancer
Uterus Bladder Tumor Cervix Distal Sigmoid Culdesac Tumor Discover ▪ Teach ▪ Heal
Radical Surgery for Ovarian Cancer
Vaginal Cuff Rectosigmoid Colon Discover ▪ Teach ▪ Heal
Development of Intra-Peritoneal (IP)
•
Chemotherapy
1950’s: First use of intraperitoneal chemotherapy for malignant ascites
• •
1968: Long-term peritoneal access device 1978: Demonstration of slow peritoneal clearance of some drugs
•
1984: Feasibility of intermittent large volume intraperitoneal therapy
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1996: First report of a survival benefit for IP vs. IV chemotherapy in advanced ovarian cancer Discover ▪ Teach ▪ Heal
Armstrong DK et al. NEJM 2006; 354:34.
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PFS: 18.3 vs 23.8 months
Armstrong DK et al. NEJM 2006; 354: 34.
OS: 49.7 vs 66.9 months Discover ▪ Teach ▪ Heal
The ‘Evolution’ of Treatment for Advanced Ovarian Cancer and Effect on Survival
80 60 40 20 0 12 1975 Alkeran Surgical & Chemotherapy Improvements 57.4
(Optimal) 66.9
(Optimal) 52 24 37 (Suboptimal) 14 1983 1986 1996 Cisplatin Paclitaxel 1998 2003 2006 IP Rx Discover ▪ Teach ▪ Heal
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IP Therapy
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IP Therapy
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IP Therapy
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IP Therapy
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Primary Cytoreductive Surgery Contemporary Survival Outcomes
Study Chemotherapy Residual Median Survival GOG152 IV-CDDP/IV-Taxol GOG172 IV-CDDP/IV-Taxol IP-CDDP/IV+IP-Taxol >1cm 36 months 0.1
–1.0cm <1cm no gross 0.1
–1.0cm <1cm no gross 39 months 50 months 78 months 53 months 67 months 127 months
Rose PG et al. N Eng J Med 2004; 351: 2489.
Armstrong DK et al. N Eng J Med 2006; 354: 34.
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Hyperthermia and Neoplasia
Heat is…
Directly cytotoxic to cancer cells - disrupts microtubule system - induces primary protein damage - promotes vascular stasis
Synergistic with some chemotherapy agents
Knox 1991, Stellar 1998
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HIPEC Schematic
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HIPEC Techniques
Open (colisuem)
Closed Discover ▪ Teach ▪ Heal
Role of HIPEC in Ovarian Cancer
Retrospective study design (1995-2005) Advanced ovarian cancer (n=43) Up-front HIPEC cisplatin + IV chemotherapy Morbidity – 13.9%; mortality – 2.3% Median OS = 53 months - complete initial resection = 131 months
Median PFS = 39 months
Melis A et al. Bull Cancer 2011, doi 21659062.
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Burger RA et al. NEJM 2011; 365: 2473.
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PFS: +3.8 month maintenance Rx
Burger RA et al. NEJM 2011; 365: 2473.
OS: no significant effect Discover ▪ Teach ▪ Heal
Fertility Preservation
• Ovarian cancer - conservative surgery - young patients - early stage disease, atypical tumor types - chemotherapy with ovarian suppression Discover ▪ Teach ▪ Heal
Robotic Surgery
● daVinci surgical platform - patient-side robot - vision cart - robotic master console Advantages Improved visualization Finer instrument control and dexterity Ergonomic design Autonomous surgical environment Discover ▪ Teach ▪ Heal
da Vinci ®
– Robotic Surgery Technology Discover ▪ Teach ▪ Heal
Research and Discovery
Clinical Trials
• Ovarian cancer - intraperitoneal chemotherapy / HIPEC - molecular profiling - quality of life / cancer survivorship - developmental therapeutics / biologic agents Discover ▪ Teach ▪ Heal
Research and Discovery
QOH Ovarian Cancer Research Laboratory
• PhD recruitment underway • Collaborative effort • Genetic screening and early detection • Molecular basis of disease - characteristics of long-term survivors - circumventing chemo-resistance Discover ▪ Teach ▪ Heal
Research and Discovery
• Surgical techniques • Advanced imaging techniques / onco-imaging • Clinical trials of new chemotherapeutic agents • Biological therapies • Public health applications Discover ▪ Teach ▪ Heal
Research and Discovery
Modern Approach to Cancer Therapeutics
Pathways Analysis Patient Metabolism Mutations Genes Downregulated Genes Upregulated Discover ▪ Teach ▪ Heal
OVA1
Qualitative serum test – 5 immunoassays - Apolipoprotein A -
2 Microglobulin - Transthyretin - Transferrin - CA125 II
Single numerical result: 0 - 10 FDA approved September 2009 Ovarian mass, > 18y/o, planned surgery Triage tool for surgical decision-making Not a screening or independent diagnostic test Category Premenopausal Postmenopausal Low Risk <5.0
<4.4
High Risk ≥5.0
≥4.4
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OVA1
Sensitivity vs CA125
Subjects All cancers (n=161) All epithelial ovarian cancers (n=96) Early stage EOC (n=41) Premenopausal women w/ early stage EOC (n=14) OVA1 92.5% 99.0% 97.6% 92.9% CA125-II 68.9% 82.3% 65.9% 35.7% Performance Sensitivity % Specificity % NPV % PPV %
Overall Performance
Preoperative Assessment 75 79 87 62 Assessment + OVA1
96
35
95
40
Ueland F. et al. Int Gyn Cancer Soc Annual Meeting, 2010, Prague.
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Disparities in Epithelial Ovarian Cancer Quality of Care and Survival According to Race and Socioeconomic Status: a Study of 47,160 Patients from the National Cancer Data Base
Robert E. Bristow a , Matthew A. Powell b , Noor Al-Hammadi c , Ling Chen c , J. Phillip Miller c , Phillip Y. Roland d , David G. Mutch b , William A. Cliby e a Division of Gynecologic Oncology, Department of Obstetrics and Gynecology University of California, Irvine School of Medicine b Division of Gynecologic Oncology, Department of Obstetrics and Gynecology c Department of Biostatistics Washington University in St. Louis School of Medicine d Gynecologic Oncology, Department of Gynecology and Obstetrics Saint Francis Francis Hospital and Medical Center e Division of Gynecologic Surgery, Department of Obstetrics and Gynecology Mayo Clinic Discover ▪ Teach ▪ Heal
Adherence to NCCN Guidelines Race
61.5% 51.3% 65.6% 56.4% * 43.9% 35.6% * * *p<0.0001
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Adherence to NCCN Guidelines Payer
* * * *p<0.0001
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Adherent/Non-Adherent Care by Race
5-year Overall Survival Non-adherent White Adherent African-American Non-adherent African-American p<0.0001
41.4% 37.8% 33.3% 22.5% Discover ▪ Teach ▪ Heal
Outreach and Education
Public Community - Education and Awareness - Virtual support network Resource for Professionals - Education and Awareness - Expedited referral system - Partnering in patient care Discover ▪ Teach ▪ Heal
Thank you!
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