Ovarian Cancer Awareness Month

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:05Hospital and AstraZeneca.
00:07 --> 00:09Welcome to Yale Cancer Answers with
00:09 --> 00:12your host doctor Anees Chagpar.
00:12 --> 00:14Yale Cancer Answers features the latest
00:14 --> 00:16information on cancer care by welcoming
00:16 --> 00:19oncologists and specialists who are on the
00:19 --> 00:21forefront of the battle to fight cancer.
00:21 --> 00:23This week it's a conversation about ovarian
00:23 --> 00:26cancer with Doctor Vaagn Andikyan.
00:26 --> 00:28Doctor Vaagn Andikyan is assistant
00:28 --> 00:29professor of obstetrics,
00:29 --> 00:30gynecology and reproductive sciences
00:30 --> 00:33at the Yale School of Medicine,
00:33 --> 00:36where Doctor Chagpar is a
00:36 --> 00:38professor of surgical oncology.
00:38 --> 00:40Maybe you can tell us a little
00:40 --> 00:42bit about how common is
00:42 --> 00:44ovarian cancer and who gets it?
00:45 --> 00:47This is a very common type of
00:47 --> 00:48cancer in numbers, it is the
00:48 --> 00:52fifth in cancer deaths among women in the US.
00:52 --> 00:56Yearly, we diagnose about 25,000 patients
00:56 --> 01:01with ovarian cancer and that leads to
01:01 --> 01:0414,000 deaths annually.
01:04 --> 01:06Often I see patients when they
01:06 --> 01:09come for their well visit
01:09 --> 01:11or other issues and
01:11 --> 01:13they often ask me the question
01:13 --> 01:15of what are their odds to develop
01:15 --> 01:18ovarian cancer and a good number
01:18 --> 01:20to quote is one in 80 lifetime
01:20 --> 01:22risk of developing ovarian cancer.
01:22 --> 01:25That sounds pretty
01:25 --> 01:28good in the grand scheme of things,
01:28 --> 01:31when you think about breast cancer being one
01:31 --> 01:33in eight, ovarian cancer being one in 80,
01:33 --> 01:35that's not bad.
01:35 --> 01:37But still, ovarian cancer is a
01:37 --> 01:39pretty serious condition.
01:39 --> 01:41Tell us a little bit more about
01:41 --> 01:43what are the risk factors.
01:43 --> 01:45How does genetics play
01:45 --> 01:48into ovarian cancer?
01:48 --> 01:50You touch on a very important
01:50 --> 01:52topic of breast cancer.
01:52 --> 01:54A breast cancer, ovarian cancer,
01:54 --> 01:56they measure some similarity.
01:56 --> 02:00They are both reproductive organ cancers.
02:00 --> 02:02However, ovarian cancer unfortunately
02:02 --> 02:05has no screening and breast cancer,
02:05 --> 02:06contrary to that,
02:06 --> 02:09has a screening option and
02:09 --> 02:11therefore we diagnosis ovarian cancer
02:11 --> 02:13at a later stage most often.
02:13 --> 02:16Genetics play a very important
02:16 --> 02:19role in finding patients at risks.
02:19 --> 02:22There was a large study
02:22 --> 02:25done in UK that just published
02:25 --> 02:28this year involving almost one
02:28 --> 02:30million women and unfortunately
02:30 --> 02:33demonstrated that with screening
02:33 --> 02:37available in modern era, that includes
02:37 --> 02:40ultrasound and the marker C 125,
02:40 --> 02:43there was no reduction in the death rate.
02:43 --> 02:45That was an unfortunate study and
02:45 --> 02:48therefore very important to
02:48 --> 02:51bring attention to your physician
02:51 --> 02:54if you experiencing symptoms that
02:54 --> 02:57could potentially be cancer.
02:57 --> 03:00And we look at the symptoms
03:00 --> 03:02whether they are specific or not,
03:02 --> 03:04most of them are nonspecific,
03:04 --> 03:09but symptoms such as weight loss,
03:09 --> 03:12bloating, abdominal pain,
03:12 --> 03:15changes in your bowel habits,
03:15 --> 03:16those are concerning
03:16 --> 03:18features and can be seen
03:18 --> 03:20in many different conditions.
03:20 --> 03:22Even benign conditions,
03:22 --> 03:25bowel disease, but however they are
03:25 --> 03:28not uncommon and can be seen mostly
03:28 --> 03:30in patients in advanced disease.
03:30 --> 03:33In early stage disease,
03:33 --> 03:36unfortunately there's not a lot of
03:36 --> 03:39symptoms and in an annual visit to OBGYN
03:39 --> 03:42they may discover a cyst or mass in ovary
03:42 --> 03:45that may trigger additional intervention.
03:47 --> 03:51A large study was
03:51 --> 03:54done in the last 10-20 years in molecular
03:54 --> 03:57biology and discovered that the
03:57 --> 04:00genes associated with ovarian cancer
04:00 --> 04:02also related to breast cancer.
04:02 --> 04:05BRCA 1 and BRCA 2,
04:05 --> 04:07in patients with those gene
04:07 --> 04:11mutations, we often see breast cancer, however,
04:11 --> 04:14ovarian cancer is also on the rise.
04:14 --> 04:16About 50% of patients with BRCA 1
04:16 --> 04:19mutation may develop ovarian cancer
04:19 --> 04:23and about 25 to 35% with BRCA 2.
04:26 --> 04:30And fortunately there is a new
04:30 --> 04:33group of drugs available especially
04:33 --> 04:35for those patients.
04:35 --> 04:36On one hand,
04:36 --> 04:39you may consider that this is
04:39 --> 04:41the unfortunate situation,
04:41 --> 04:42however,
04:42 --> 04:43on the other hand,
04:43 --> 04:44we have a treatment available.
04:46 --> 04:48Let's pick up on that.
04:48 --> 04:50I mean the one thing that you mentioned
04:50 --> 04:52which was interesting is that
04:52 --> 04:55if you do have a BRCA mutation that
04:55 --> 04:58tells you that you're at increased risk,
04:58 --> 05:00that study that you quoted found
05:00 --> 05:03that CA 125 vaginal ultrasounds,
05:03 --> 05:05they really don't reduce mortality,
05:05 --> 05:06but you mentioned that there
05:06 --> 05:08are some drugs that may help in
05:08 --> 05:10patients with these mutations.
05:10 --> 05:11So tell us more.
05:11 --> 05:15Of course, within the last five to ten years
05:15 --> 05:18we discovered a new group of drugs,
05:18 --> 05:20we call them PARP inhibitors.
05:20 --> 05:22We learned more about the
05:22 --> 05:24biology of ovarian cancer.
05:24 --> 05:27And we realized that
05:27 --> 05:30when
05:30 --> 05:33our body repair double strand DNA
05:33 --> 05:37breaks tumors that are
05:37 --> 05:39deficient in those pathways have
05:39 --> 05:42a harder time to repair themselves.
05:42 --> 05:45So we're using tumor weaknesses
05:45 --> 05:49and making it even worse by adding
05:49 --> 05:51this enzyme blockers to help
05:51 --> 05:54us to fight cancer cells.
05:54 --> 05:57Several of the new drugs are available
05:57 --> 06:00and approved by FDA to use in patients
06:00 --> 06:02with ovarian cancer as a first line
06:02 --> 06:06maintenance therapy and we use it
06:06 --> 06:09as their therapy for later state disease.
06:09 --> 06:12We use in combination with
06:12 --> 06:14systemic cytotoxic chemotherapy
06:14 --> 06:17there because as I mentioned,
06:17 --> 06:20PARP inhibitors and there are several
06:20 --> 06:22approved on the market,
06:22 --> 06:24a new study has been done
06:24 --> 06:27to discover in which sequence we
06:27 --> 06:30should use them as a frontline or
06:30 --> 06:32as a maintenance therapy versus
06:32 --> 06:34reserved for recurrences.
06:34 --> 06:36A lot to be discovered within
06:36 --> 06:38the next 5-10 years,
06:38 --> 06:39but we are on the right track.
06:40 --> 06:42Just to be clear,
06:42 --> 06:45the PARP inhibitors are really for
06:45 --> 06:47treatment of people who have an
06:47 --> 06:49ovarian cancer, particularly if
06:49 --> 06:51they are also carriers of BRCA 1 or 2?
06:54 --> 06:57If you've been diagnosed with a BRCA 1 or 2
06:57 --> 06:58gene mutation,
06:58 --> 07:01let's suppose somebody in your family was
07:01 --> 07:03diagnosed with breast cancer and they
07:03 --> 07:05were discovered to have the mutation,
07:05 --> 07:07you were then tested,
07:07 --> 07:08you now have a mutation,
07:08 --> 07:11but you don't have ovarian cancer yet.
07:11 --> 07:13At least you're aware of that.
07:13 --> 07:15Are there any things that you
07:15 --> 07:18could do to prevent ovarian cancer
07:18 --> 07:20or to reduce your risk?
07:25 --> 07:28We don't have medication that can
07:28 --> 07:30potentially reverse the risks and
07:30 --> 07:33we don't administer this PARP
07:33 --> 07:35inhibition as a prophylactic therapy.
07:35 --> 07:37The only approach we
07:37 --> 07:40use is risk reducing surgeries.
07:40 --> 07:45That entails a patient after completion
07:45 --> 07:49of childbearing or after age of 35 to 40,
07:49 --> 07:52we recommend to proceed with risk reducing
07:52 --> 07:55surgery that includes the removal of the
07:55 --> 07:58tubes and ovaries that will essentially
07:58 --> 08:01eliminate the risk of ovarian cancer.
08:01 --> 08:04It's not going to completely decrease
08:04 --> 08:06the risk to zero because there's
08:06 --> 08:09still a residual peritonei primary
08:09 --> 08:10cancer, however,
08:10 --> 08:13it will decrease the risk of
08:13 --> 08:15ovarian cancer close to zero.
08:15 --> 08:17That is the best strategy for
08:17 --> 08:19patients with ovarian cancer
08:20 --> 08:22and if you were to
08:22 --> 08:25opt for that and say
08:25 --> 08:26you've just been
08:26 --> 08:28diagnosed with this mutation,
08:28 --> 08:31you're worried about ovarian cancer,
08:31 --> 08:35so you undergo a prophylactic bilateral mastectomy.
08:36 --> 08:38They remove your tubes and
08:38 --> 08:40your ovaries on both sides.
08:40 --> 08:42What are the side effects of that
08:42 --> 08:45surgery and how can you circumvent those?
08:45 --> 08:47That's a great question,
08:47 --> 08:50it depends on age.
08:50 --> 08:52Obviously, the younger the patients are,
08:52 --> 08:54they still have good performance
08:54 --> 08:58and ovarian function and the
08:58 --> 09:01unfortunate thing is this procedure will
09:01 --> 09:04place a patient in a menopausal state.
09:04 --> 09:07With side effects such as hot flashes,
09:07 --> 09:10bone density problems,
09:10 --> 09:14potentially cardiovascular disease, however,
09:14 --> 09:17there have been studies demonstrating
09:17 --> 09:20that risk reducing surgery actually
09:20 --> 09:23helps patients live longer despite
09:23 --> 09:26those side effects that may potentially
09:26 --> 09:28compromise cardiovascular health,
09:28 --> 09:30patients who undergo risk reducing
09:30 --> 09:33surgery by eliminating risk of
09:33 --> 09:35ovarian cancer and breast cancer,
09:35 --> 09:39they can live potentially longer.
09:39 --> 09:41To alleviate the symptoms of menopause
09:41 --> 09:43we use a hormonal therapy.
09:43 --> 09:46Now we use non hormonal approaches
09:46 --> 09:50as well and the therapy is meant to
09:50 --> 09:53eleviate symptoms without interfering
09:53 --> 09:56with other hormonally active tumor
09:56 --> 09:59and without affect on the breast as such,
09:59 --> 10:02because the hormonal effect on
10:02 --> 10:06uterus and breast may be somewhat different,
10:06 --> 10:08we have to bear in mind we
10:08 --> 10:10potentially can help with symptoms,
10:10 --> 10:12but we also do not want to
10:12 --> 10:14hurt with breast cancer risk,
10:14 --> 10:16which as you mentioned,
10:16 --> 10:20is higher in BRCA mutation patients.
10:21 --> 10:24That's kind of a
10:24 --> 10:26tight rope to walk, to eliminate
10:26 --> 10:28symptoms as best you can while not
10:28 --> 10:30increasing the risk of other cancers.
10:31 --> 10:33That's correct when we do
10:33 --> 10:36this surgery after age of 50, the
10:36 --> 10:39average age of menopause in North America,
10:39 --> 10:41it's about 52.
10:41 --> 10:44When we do surgery at later age
10:44 --> 10:48those issues automatically are not there.
10:48 --> 10:51However, when patient has an
10:51 --> 10:53early onset of ovarian
10:53 --> 10:57cancer and before age of 50,
10:57 --> 10:59then we try to do this surgery early.
10:59 --> 11:02In that circumstance, we
11:02 --> 11:05do work with a patient without addressing
11:05 --> 11:07her symptoms of surgical menopause.
11:08 --> 11:10And I suppose in a BRCA patient
11:10 --> 11:12the other way to reduce your risk of
11:12 --> 11:14breast cancer even if you were going to
11:14 --> 11:17take some sort of hormonal therapy to
11:17 --> 11:19offset surgically induced menopause,
11:19 --> 11:22is to have bilateral prophylactic
11:22 --> 11:23mastectomies and reduce your
11:23 --> 11:25risk of breast cancer as well.
11:25 --> 11:28But that is another show,
11:28 --> 11:31so getting back to ovarian cancer,
11:31 --> 11:35you know you mentioned that this is
11:35 --> 11:38often especially in the early stages,
11:38 --> 11:41something that is not easily diagnosed.
11:41 --> 11:44It's usually presenting late so
11:44 --> 11:47what can women do if
11:47 --> 11:49they want to catch this early?
11:49 --> 11:53I mean should they be getting annual vaginal
11:53 --> 11:55ulltrasounds?
11:55 --> 11:57But the study showed that that
11:57 --> 11:58really didn't improve survival.
11:58 --> 12:00Or is it just a matter of being
12:00 --> 12:02aware of your body and seeking
12:02 --> 12:04medical advice when you have symptoms?
12:05 --> 12:06Great question.
12:06 --> 12:10I think the body sends us signals.
12:10 --> 12:14So when we start connecting to our body,
12:14 --> 12:17body and mind are interconnected
12:17 --> 12:19and when you develop something new
12:19 --> 12:21something changed over the course
12:21 --> 12:23of the last couple of months,
12:23 --> 12:26bring that to the attention of
12:26 --> 12:28your physician and if you are not
12:28 --> 12:30satisfied with the response,
12:32 --> 12:35seek a second opinion and it is very
12:35 --> 12:38important to know your family history.
12:38 --> 12:40What did your aunt die from?
12:40 --> 12:43What did your cousin die from.
12:45 --> 12:48Find out whether it was genetically
12:48 --> 12:50related and you potentially
12:50 --> 12:52can get genetically tested.
12:52 --> 12:54I think those two things, bringing attention
12:54 --> 12:56to symptoms and finding your
12:56 --> 12:58genetic background will help us
12:58 --> 13:00to prevent some of the cancer,
13:00 --> 13:02or at least diagnose early.
13:03 --> 13:05That's so important and we are
13:05 --> 13:08going to learn more about how to
13:08 --> 13:10make a diagnosis of ovarian cancer,
13:10 --> 13:13how to treat this, and what are the
13:13 --> 13:15important advances that are going on
13:15 --> 13:17in terms of clinical research regarding
13:18 --> 13:20ovarian cancer right after we take
13:20 --> 13:22a short break for medical minute.
13:22 --> 13:24Please stay tuned to learn more
13:24 --> 13:26about ovarian cancer with my
13:26 --> 13:27guest Doctor Vaagn Andikyan.
13:28 --> 13:30Support for Yale Cancer Answers
13:30 --> 13:32comes from Smilow Cancer Hospital,
13:32 --> 13:33where an individualized approach
13:33 --> 13:35to prostate cancer
13:35 --> 13:37screening is used to determine which men are
13:37 --> 13:40eligible and would benefit from screening.
13:40 --> 13:43To learn more, visit Yale Cancer
13:43 --> 13:45Center dot org slash screening.
13:45 --> 13:48Breast cancer is one of the most common
13:48 --> 13:50cancers in women. In Connecticut alone,
13:50 --> 13:52approximately 3500 women will be
13:52 --> 13:55diagnosed with breast cancer this year,
13:55 --> 13:56but there is hope,
13:56 --> 13:57thanks to earlier detection,
13:57 --> 13:59noninvasive treatments and the development
13:59 --> 14:02of novel therapies to fight breast cancer.
14:02 --> 14:04Women should schedule a baseline
14:04 --> 14:06mammogram beginning at age 40 or
14:06 --> 14:08earlier if they have risk factors
14:08 --> 14:10associated with the disease.
14:10 --> 14:12With screening, early detection,
14:12 --> 14:13and a healthy lifestyle,
14:13 --> 14:16breast cancer can be defeated.
14:16 --> 14:17Clinical trials are currently
14:17 --> 14:19underway at federally designated
14:19 --> 14:21Comprehensive cancer centers such
14:21 --> 14:23as Yale Cancer Center and Smilow
14:23 --> 14:25Cancer Hospital to make innovative
14:25 --> 14:28new treatments available to patients.
14:28 --> 14:30Digital breast tomosynthesis or 3D
14:30 --> 14:33mammography is also transforming breast
14:33 --> 14:35cancer screening by significantly
14:35 --> 14:36reducing unnecessary procedures
14:36 --> 14:39while picking up more cancers.
14:39 --> 14:42More information is available at
14:42 --> 14:43yalecancercenter.org. You're listening
14:43 --> 14:45to Connecticut Public Radio.
14:46 --> 14:48Welcome back to Yale Cancer Answers.
14:48 --> 14:51This is doctor Anees Chagpar and I'm joined
14:51 --> 14:53tonight by my guest Doctor Vaagn Andikyan.
14:53 --> 14:56We're discussing the care of women with
14:56 --> 14:58ovarian cancer and right before the break
14:58 --> 15:01you were talking about how
15:01 --> 15:03you know it's really important for
15:03 --> 15:06women to know their family history and
15:06 --> 15:08to really advocate for themselves.
15:08 --> 15:10So if they have symptoms,
15:10 --> 15:11even if they're non specific,
15:11 --> 15:13a little bit of bloating, change in
15:13 --> 15:15bowel habit, difficulty urinating,
15:15 --> 15:17whatever it might be.
15:17 --> 15:19A little bit of abdominal discomfort.
15:19 --> 15:21Sometimes those might be the
15:21 --> 15:23first signs of ovarian cancer,
15:23 --> 15:26and it's so important to get it checked out
15:26 --> 15:30so that we can find cancer at an early stage.
15:30 --> 15:33I want to kind of pick
15:33 --> 15:37up there and talk a little bit about
15:37 --> 15:39diagnosis of ovarian cancer.
15:39 --> 15:42How is it that people actually get diagnosed?
15:42 --> 15:44So either they're going to come and
15:44 --> 15:47present to you with some vague symptoms,
15:48 --> 15:52and hopefully we find things early.
15:52 --> 15:54But how is a diagnosis made?
15:58 --> 16:01We grade ovarian cancer into two
16:01 --> 16:04groups, early stage versus late stage,
16:04 --> 16:05usually early stage it's
16:05 --> 16:09an incidental finding of a cyst in the patient.
16:09 --> 16:12They went to the emergency room for let's say
16:12 --> 16:14gallbladder problem or pneumonia
16:14 --> 16:18and they incidentally find a lesion
16:18 --> 16:20that triggered additional work up.
16:29 --> 16:32For patients who started experiencing symptoms
16:32 --> 16:34they probably already have stage three
16:34 --> 16:35and four disease.
16:35 --> 16:38Unfortunately there is not a good
16:38 --> 16:41symptom that can pick up
16:41 --> 16:43an early stage ovarian cancer,
16:43 --> 16:46unless the mass is so large and
16:46 --> 16:48compressing on neighboring organs.
16:48 --> 16:50We've seen often and not unusual to
16:50 --> 16:53have a many centimeter mass in ovary
16:53 --> 16:56and still have stage one disease.
16:56 --> 16:58In those patients
16:58 --> 17:00with early stage disease,
17:00 --> 17:02we triage according their age.
17:02 --> 17:05We often offer even fertility
17:05 --> 17:07preservation for patients at younger
17:08 --> 17:10age who desire future fertility
17:10 --> 17:13and they have stage one disease.
17:13 --> 17:16We can potentially save ovary and
17:16 --> 17:18give them opportunity to become mothers.
17:18 --> 17:21For those patients who are diagnosed late
17:21 --> 17:21unfortunately,
17:21 --> 17:24organ preservation is not an option.
17:24 --> 17:27In that case we do a thorough work
17:27 --> 17:31up to figure out whether patient is
17:31 --> 17:33a candidate for surgery versus neoadjuvant
17:33 --> 17:35chemotherapy.
17:35 --> 17:39One approach focuses on upfront surgery.
17:39 --> 17:42If patient comorbidity allows in
17:42 --> 17:46cases when that type of surgery is not
17:46 --> 17:48feasible due to disease distribution
17:48 --> 17:52and or patient performance status,
17:52 --> 17:55we proceed with neoadjuvant chemotherapy.
17:56 --> 17:59Our organization historically
17:59 --> 18:01had the focus on this approach,
18:01 --> 18:04and we've demonstrated good
18:04 --> 18:07results with that approach and
18:07 --> 18:10national and International Studies
18:10 --> 18:13demonstrated similarly good results
18:13 --> 18:15with neoadjuvant chemotherapy in
18:15 --> 18:18patients who are not a candidate
18:18 --> 18:19for upfront debulking.
18:19 --> 18:22The whole philosophy of surgical
18:22 --> 18:23treatment of ovarian cancer
18:23 --> 18:24to obtain,
18:24 --> 18:27we call it no residual disease
18:27 --> 18:29or optimal cytoreduction.
18:29 --> 18:32When the volume of tumor is minimal,
18:32 --> 18:34at least less than one centimeter,
18:34 --> 18:36ideally no growth,
18:36 --> 18:39or residual tumor following that surgery,
18:39 --> 18:43we proceed with the systemic chemotherapy
18:43 --> 18:46that includes administration
18:46 --> 18:49of the cytotoxic drug, commonly
18:49 --> 18:52we use carboplatin and paclitaxel
18:52 --> 18:55with biologic agents such as Bevacizumab.
18:55 --> 18:59New data came up actually
18:59 --> 19:01two years ago, a
19:01 --> 19:04large study in Europe demonstrated the
19:04 --> 19:07benefit of heated chemotherapy that
19:07 --> 19:09can be administered during the surgery.
19:09 --> 19:13That whole approach, called HIPC,
19:13 --> 19:14heated intraperitoneal chemotherapy
19:14 --> 19:17is done during surgery for
19:17 --> 19:19patients who
19:19 --> 19:22received neo adjuvant chemotherapy and
19:22 --> 19:25underwent successful debulking surgery,
19:25 --> 19:28receive heated chemotherapy during
19:28 --> 19:31their procedure and they follow
19:31 --> 19:34on their regular therapy after
19:34 --> 19:38surgery and recovery from HIPC.
19:38 --> 19:40This approach is slowly picking up
19:40 --> 19:43the pace and the study
19:43 --> 19:46in Europe demonstrated one year
19:46 --> 19:49survival benefit in those patients
19:49 --> 19:51who underwent this type of therapy.
19:51 --> 19:55Another approach is organ
19:55 --> 19:58preservation and we work closely
19:58 --> 20:01with our colleagues in reproductive
20:01 --> 20:04endocrinology ovacyt preservation
20:04 --> 20:09and the patient even may opt for her
20:09 --> 20:11ovacyt to be collected prior
20:11 --> 20:13to proceeding with surgery.
20:23 --> 20:27Just to back up,
20:27 --> 20:30you know when you talk about
20:30 --> 20:32ovarian cancer as either being
20:32 --> 20:34early stage versus advanced,
20:34 --> 20:36how exactly do you determine that?
20:36 --> 20:38So say somebody presents to
20:38 --> 20:39you and they've got some,
20:39 --> 20:41you know, vague symptoms.
20:41 --> 20:43What are the tests that you
20:43 --> 20:45will do to first of all,
20:45 --> 20:49find out if this is in fact ovarian cancer,
20:49 --> 20:50and second,
20:50 --> 20:53whether this falls into the early stage
20:53 --> 20:56bucket or the late stage bucket.
20:57 --> 20:58Great question.
20:58 --> 21:00And honestly, unfortunately
21:00 --> 21:03as of today we do not have any
21:03 --> 21:05definitive tool to know for sure
21:05 --> 21:07whether this is ovarian cancer.
21:07 --> 21:12So diagnostic imaging is broadly used today
21:12 --> 21:16CT, PET scans, MRI.
21:16 --> 21:19They are not very specific
21:19 --> 21:22in the ovary.
21:22 --> 21:25Ovarian surface itself may attract
21:25 --> 21:26tumor from other areas.
21:26 --> 21:29For example, stomach cancer may travel
21:29 --> 21:33to ovary and when you see ovarian mass
21:33 --> 21:36but that initial cancer was originated
21:37 --> 21:41from a GI tract from colon cancer,
21:41 --> 21:43it's very important to do a thorough work up,
21:43 --> 21:46and the imaging is number one.
21:46 --> 21:49We use oncomarkers to tailor
21:49 --> 21:51other possible diagnosis,
21:51 --> 21:53such as colon cancer,
21:53 --> 21:54pancreatic cancer,
21:54 --> 21:57breast cancer.
21:57 --> 22:02The markers
22:02 --> 22:05depend on the patient age.
22:05 --> 22:09We may include additional oncomarkers.
22:09 --> 22:12Very interesting that ovarian cancer
22:12 --> 22:15has family of three cancer in one.
22:15 --> 22:18One derives from lining of the
22:18 --> 22:21ovary and those give rise to
22:21 --> 22:22epithelial ovarian cancer.
22:22 --> 22:25The second family derives from
22:25 --> 22:27hormonally active tumors.
22:27 --> 22:29And those tumors may secrete
22:29 --> 22:31certain chemicals that we can
22:31 --> 22:34pick up on a blood test.
22:36 --> 22:39And the third group of tumors
22:39 --> 22:41derived from germ cells.
22:44 --> 22:46And those three cancers
22:46 --> 22:48may have different
22:48 --> 22:50biology and different tests we
22:50 --> 22:52use to diagnose before surgery,
22:52 --> 22:56but ultimately our diagnosis heavily
22:56 --> 22:59relies on histologic evaluation.
22:59 --> 23:00What that means
23:00 --> 23:03is we perform some kind of a
23:03 --> 23:06biopsy or surgery to take a sample to
23:06 --> 23:09find out what type of cancer it is.
23:15 --> 23:18It sounds like the therapies
23:18 --> 23:21for advanced cancers are very different
23:21 --> 23:23from the surgery for local cancer,
23:23 --> 23:25whereas local cancers you might
23:25 --> 23:28even get to spare part of the ovary.
23:28 --> 23:30In advanced cancers we're talking about,
23:30 --> 23:33you know, big surgeries taking
23:33 --> 23:35out multiple organs,
23:35 --> 23:38potentially adding in hipec and so on.
23:38 --> 23:40So in other cancers
23:40 --> 23:42that we talked about doing
23:42 --> 23:45a core needle biopsy to get
23:45 --> 23:47a preoperative diagnosis.
23:47 --> 23:48But in ovarian cancer,
23:48 --> 23:50is that the case or is that something
23:50 --> 23:53that is diagnosed at the time of surgery?
23:55 --> 23:58If the imaging demsonstrate advanced
23:58 --> 24:01disease and patient performance status does not
24:01 --> 24:05allow us to perform debulking surgery,
24:05 --> 24:08in that case we proceed
24:08 --> 24:10with neoadjuvant chemotherapy.
24:10 --> 24:12In that case scenario we
24:12 --> 24:14proceed with core needle biopsy.
24:14 --> 24:17But if the imaging shows us
24:19 --> 24:22high suspicion
24:22 --> 24:23for ovarian cancer
24:23 --> 24:25in that case, we do not
24:25 --> 24:27obtain preoperative core biopsy with
24:27 --> 24:30concern of potential side effects,
24:30 --> 24:34infection and in anticipation of major
24:34 --> 24:37surgery in patients with what
24:37 --> 24:40looks like ovarian cyst and we are not
24:40 --> 24:43sure 100% whether it's cancerous or not,
24:43 --> 24:46we proceed with laparoscopic surgery.
24:46 --> 24:49Remove that cyst in the obtained
24:49 --> 24:51frozen section and for our
24:51 --> 24:53listeners, frozen section
24:53 --> 24:55is a tool when patients
24:55 --> 24:56sleep under anesthesia.
24:56 --> 24:59We perform surgery and we ask our
24:59 --> 25:01pathological colleagues within 20 minutes to give
25:01 --> 25:04us an answer whether it's cancer or not,
25:04 --> 25:07and according to that diagnosis,
25:07 --> 25:09we decide whether the removal of
25:09 --> 25:12cyst is enough or we should proceed
25:12 --> 25:14with more staging type of surgery
25:14 --> 25:17that includes removal of lymph nodes.
25:20 --> 25:23And so as we talk about the different
25:23 --> 25:26kinds of therapies for ovarian cancer,
25:26 --> 25:27depending on the stage,
25:27 --> 25:29we've talked about surgery,
25:29 --> 25:32we've talked about systemic chemotherapy,
25:32 --> 25:33the two modalities that
25:33 --> 25:34we haven't talked about,
25:34 --> 25:37that we do talk about a lot on this show,
25:37 --> 25:39one is radiation therapy,
25:39 --> 25:42and the other is immunotherapy.
25:42 --> 25:44Is there a role for either
25:44 --> 25:45of these modalities in the
25:45 --> 25:47treatment of ovarian cancer?
25:54 --> 26:00In the US we performed a study in the 80s
26:00 --> 26:02and we compared the whole abdominal
26:02 --> 26:04radiation versus systemic chemotherapy
26:04 --> 26:07and we demonstrated that systemic
26:07 --> 26:10chemotherapy works better. Less toxicity,
26:10 --> 26:13less concern for bowel side effects,
26:13 --> 26:15and we stay away from radiation
26:15 --> 26:18in ovarian cancer.
26:18 --> 26:19Select patients may
26:19 --> 26:21benefit from radiation therapy
26:21 --> 26:23for palliative purposes.
26:23 --> 26:26If there is a small recurrence in a
26:26 --> 26:28bone or small pelvic recurrence and
26:28 --> 26:31patient is not surgical candidate,
26:31 --> 26:34we may contemplate radiation therapy,
26:34 --> 26:36but it's esoteric use.
26:36 --> 26:39We don't use a radiation therapy
26:39 --> 26:41to treat ovarian cancer.
26:41 --> 26:44What about immunotherapy?
26:44 --> 26:47It's a great question.
26:47 --> 26:49Unfortunately, it is not really primetime
26:49 --> 26:52yet for ovarian cancer.
26:52 --> 26:56Current therapies demonstrated modest effect.
26:56 --> 27:00We are still working on a biomarker
27:00 --> 27:01for ovarian cancer.
27:01 --> 27:03As I mentioned,
27:03 --> 27:06there are three large families
27:06 --> 27:08of ovarian cancer, epithelial, germ
27:08 --> 27:11cell and sex cord stromal tumor.
27:11 --> 27:13But within those groups there
27:13 --> 27:15is also subdivision into high
27:15 --> 27:17grade serous, low grade serous,
27:17 --> 27:20clear cell, endometrial, etc.
27:20 --> 27:23so there are some groups of ovarian cancer
27:23 --> 27:25they may potentially
27:25 --> 27:26benefit from immunotherapy,
27:26 --> 27:28but that research is still ongoing.
27:29 --> 27:32Which brings me to probably my last
27:32 --> 27:34question, which is what are the
27:34 --> 27:36most exciting advances in terms of
27:36 --> 27:38clinical research in ovarian cancer?
27:38 --> 27:39What do we have to look forward to?
27:41 --> 27:45So the large ones are using PARP
27:45 --> 27:49inhibition and in a large number of patients
27:49 --> 27:51with this mutation we discovered several
27:51 --> 27:55other new genes that may be also affected
27:55 --> 27:57in patients with ovarian cancer.
27:57 --> 28:01We're trying to understand which group
28:01 --> 28:04of patients should receive this
28:04 --> 28:07therapy upfront versus a recurrence.
28:07 --> 28:11So the other group of the new drugs
28:11 --> 28:15are used for molecular targeted therapy.
28:15 --> 28:18We use molecular studies to demonstrate
28:18 --> 28:22sudden receptors and we can potentially
28:22 --> 28:25attach cytotoxic agents or use those
28:25 --> 28:28molecular targets to a new group of drugs.
28:29 --> 28:31Doctor Vaagn Andikyan is an
28:31 --> 28:32assistant professor of obstetrics,
28:32 --> 28:34gynecology and reproductive sciences
28:34 --> 28:36at the Yale School of Medicine.
28:36 --> 28:38If you have questions,
28:38 --> 28:40the address is cancer answers at
28:40 --> 28:42yale.edu and past editions of the
28:42 --> 28:45program are available in audio and
28:45 --> 28:47written form at Yale Cancer Center dot Org.
28:47 --> 28:49We hope you'll join us next week to
28:49 --> 28:51learn more about the fight against
28:51 --> 28:53cancer here on Connecticut Public
28:53 --> 28:55radio funding for Yale Cancer
28:55 --> 28:57Answers is provided by Smilow
28:57 --> 28:59Cancer Hospital and AstraZeneca.

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September 12, 2021

Yale Cancer Center

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