Transcript Ovarian CancerChallenges for Primary

Madhavi Venigalla, MD
Medical Oncology/Hematology
Lakeland Regional Cancer Center
OBJECTIVES
 Discuss screening/early detection practices
 Describe presenting symptoms
 Review current recommendations
Incidence: 1 in 55 women
ACS statistics for 2012:
22,280 new cases (stable since 1992)
15,500 deaths
Worldwide: Most common cancer in women
Rates highest in developed countries
Symptoms
 Nonspecific
 Persistent
Symptoms
 Bloating
 Pelvic or abdominal pain
 Difficulty eating or feeling full quickly
 Urgency or urinary frequency
 Most common is abdominal enlargement
Symptoms
Other symptoms commonly reported
 Fatigue
 Indigestion
 Back pain
 Pain with intercourse
 Constipation
 Menstrual irregularities
Risk Factors
 Genetic predisposition
 Family history is strongest risk
 Breast-ovarian cancer syndrome
 Lynch II syndrome
 Cancer of colon, breast, endometrium and HNPCC
Risk Factor (cont’d)
 Breast-ovarian syndrome
 Germline mutation in one of the breast cancer
susceptibility genes BRCA or BRCA2
 Prevalence


General population is 1 in 300
Ashkenazi Jewish is 2 in 100
Risk Factors (cont’d)
 Age
 Annual incidence in women age 50-75 is 50 per 100,000,
twice the rate in younger women
Risk Factors (cont’d)
 Decrease risk:
 Pregnancy
 OCP
 Breast feeding
 Tubal ligation
 Hysterectomy
 Increase risk:
 Infertility
 Endometriosis
 Peri or post menopausal
history of medications
Oral contraceptive Use
Duration of use
Never
3-6 months
7-11 months
1-4 years
5-9 years
>9 years
Relative Risk
1
.6
.7
.6
.4
.2
N England J Med 316:650 1987
Screening Tests
 There is no standardized test to detect ovarian cancer
at an early stage
 CA-125: most widely used screening method
 Specificity is limited
 False elevations in: endometriosis, fibroids, cirrhosis w/-
ascites, PID, cancers of breast, lung, pancreas, pleural or
peritoneal fluid due to any cancer
Clinical Trials
 Large studies in Sweden:
 Low positive predictive value of 3%
 Experts feel a screening protocol should have a PPV of at
least 10% (no more than 9 healthy women with false
positive screening would undergo unnecessary
procedures for each case of ovarian cancer detected)
Clinical Trials (cont’d)
 PLCO trial
 78,237 healthy women between 55 & 74
 Annual CA 125 and transvaginal ultrasound
 4 year follow up: PPV of 2.6%
UK Collaborative Trial of Ovarian
Cancer Screening
 Purpose

Evaluate a screening strategy using a risk of ovarian cancer
algorithm on the basis of age, CA 125 profile and transvaginal
ultrasound
 Method (control and screening group)
• Primary screening w/CA 125 – if abnormal
• Secondary screening w/CA 125 & TVUS
UK Trial (cont’d)
• Results:




6532 women were screened and assigned risk levels
1228 intermediate risk had repeat CA 125 and 53 were
classified as elevated risk
16 women had surgery
 11-benign pathology
 1 recurrent breast cancer in ovaries
 1 borderline and 3 with invasive epithelial ovarian cancer
Specificity and PPV for primary invasive epithelial ovarian
cancer were 99.8% and 19% respectively
JCO Vol 23(31) Nov 1 2005
Novel Tumor Marker
 HE4
 Human epididymis protein 4
 Only approved for monitoring women with ovarian
cancer for diagnosing recurrence or progression
Pelvic Ultrasonography
 Observer dependent
 UKC TOCS:
 48,230 women
 PPV was 5.3%
Multimodal Screening
CA 125 and ultrasound
PLCO
Usual Care
 13 year follow-up
 No difference in stage of ovarian cancer or mortality
Synthesis of Evidence
 Women at average risk
 Screening is not recommended
 Women at increased risk
 Counseling, genetic testing
 Women w/high risk family history
 NCCN recommends Q6 month CA 125 and TVUS
starting @age 30 or 5-10 yrs earlier than earliest age of 1st
diagnosis of ovarian cancer
Ovarian Cancer Follow up
 Monitor CA-125
 Physical Exam
 Including pelvic exam
 CT scan/PET scan as clinically indicated
 Consider family history evaluation if not done
previously
Key Points for the NP
 Identify at-risk patients
 Educate
 Intervene early
 Provide evidence based
care