Role of Surgery in High-risk Ovarian Cancer

Transcript

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00:15 --> 00:17Welcome to Yale Cancer Answers with
00:17 --> 00:19your host doctor Anees Chagpar.
00:19 --> 00:21Yale Cancer Answers features the
00:21 --> 00:23latest information on cancer care by
00:23 --> 00:25welcoming oncologists and specialists
00:25 --> 00:27who are on the forefront of the
00:27 --> 00:29battle to fight cancer. This week,
00:29 --> 00:31it's a conversation about the role
00:31 --> 00:33of surgery in high risk ovarian
00:33 --> 00:35cancer with Doctor Mitchell Clark.
00:35 --> 00:37Doctor Clark is an assistant professor
00:37 --> 00:39of obstetrics and gynecology in the
00:39 --> 00:41division of Gynecological Oncology at
00:41 --> 00:43Yale University School of Medicine,
00:43 --> 00:45where Doctor Chagpar is
00:45 --> 00:47a professor of surgical oncology.
00:48 --> 00:50Dr. Clark, maybe we can start off by talking
00:50 --> 00:52a little bit about ovarian cancer.
00:52 --> 00:55Many people talk about this as
00:55 --> 00:58the cancer that whispers, tell us more about
00:58 --> 00:59that.
00:59 --> 01:01Although ovarian cancer is not the
01:01 --> 01:02most common gynecological cancer
01:02 --> 01:04that we encounter in our specialty,
01:04 --> 01:07it is unfortunately the cancer that
01:07 --> 01:08accounts for the greatest morbidity
01:08 --> 01:11as well as the greatest mortality
01:11 --> 01:13among the diseases that we do treat.
01:13 --> 01:15You're absolutely right in saying that
01:15 --> 01:17this is the cancer that whispers because
01:17 --> 01:19unlike a lot of the other
01:19 --> 01:21cancers we see in our practice,
01:21 --> 01:23the symptoms of ovarian cancer are
01:23 --> 01:25very nonspecific and often very vague.
01:25 --> 01:27Tell us more about
01:27 --> 01:29what those symptoms might be,
01:29 --> 01:31because I'm sure that there are
01:31 --> 01:32listeners out there going great,
01:32 --> 01:35so there's a cancer that is
01:35 --> 01:36potentially lethal that has
01:36 --> 01:39symptoms that are really vague.
01:39 --> 01:41How am I gonna know if I have this?
01:41 --> 01:42Absolutely, for
01:42 --> 01:45the most part, these symptoms occur as the
01:45 --> 01:47ovarian tumors grow and as you can imagine,
01:47 --> 01:50it starts off with a very small tumor
01:50 --> 01:51and progressives to something that
01:51 --> 01:54causes a lot of pressure in the pelvis.
01:54 --> 01:56So I tell women anytime you feel
01:56 --> 01:57that there's pain or pressure
01:57 --> 02:00in the pelvis or in the abdomen,
02:00 --> 02:01that's something that's concerning and should
02:01 --> 02:03be brought up with your gyencologist.
02:03 --> 02:06Beyond that, we do tell women to be
02:06 --> 02:08aware of any changes in their weight,
02:08 --> 02:09either weight loss or
02:09 --> 02:11weight gain, and sometimes it
02:11 --> 02:13can be as simple as something as
02:13 --> 02:15bloating or a bit of constipation
02:15 --> 02:17that is just out of characteristic from what
02:17 --> 02:20they have been experiencing in the past.
02:20 --> 02:22We do know that ovarian cancer tends
02:22 --> 02:24to occur in women as they get older,
02:24 --> 02:25particularly those who are
02:25 --> 02:26past menopause.
02:26 --> 02:27However,
02:27 --> 02:29there still can be many cases of
02:29 --> 02:31ovarian cancer in women that are
02:31 --> 02:32younger than the menopausal status,
02:32 --> 02:34and it's important to keep this in
02:34 --> 02:36mind when gynecologists as well as
02:36 --> 02:38primary care physicians are seeing
02:38 --> 02:40patients with these vague symptoms.
02:51 --> 02:54There are some rare
02:54 --> 02:57types of ovarian cancer that behave very
02:57 --> 02:59differently than the more common types
02:59 --> 03:02that we see in the older population,
03:02 --> 03:04and these can happen in young girls.
03:04 --> 03:07So it is important that mothers and young
03:07 --> 03:10daughters present to their pediatrician
03:10 --> 03:12with any of these similar complaints
03:12 --> 03:14related to increase in abdominal
03:14 --> 03:16pain or a bit of bloating,
03:16 --> 03:19or noticing something
03:19 --> 03:21uncharacteristic compared to what it has
03:21 --> 03:23perhaps been in the past as they were
03:23 --> 03:25developing as an adolescent.
03:25 --> 03:27Doctor Clark when we
03:27 --> 03:29think about all of these symptoms,
03:29 --> 03:31especially around
03:31 --> 03:32the holiday time, it's pretty
03:32 --> 03:35common to get a little
03:35 --> 03:37bit of weight gain or in some
03:37 --> 03:39of our cases a lot of weight gain,
03:39 --> 03:41a little bit of bloating,
03:41 --> 03:43a little bit of constipation.
03:43 --> 03:45When is there a trigger point at
03:45 --> 03:47which you say, this has
03:47 --> 03:49been going on for X amount of time,
03:49 --> 03:52I need to go and see the doctor,
03:52 --> 03:53or is it really
03:53 --> 03:55kinda see how it goes and if it gets
03:55 --> 03:57to a point that's concerning to you,
03:58 --> 04:00that's when you should see a doctor.
04:00 --> 04:02Can you give us a little bit of a clue?
04:02 --> 04:04Because some of these are so non specific,
04:04 --> 04:06I'm sure all of our listeners
04:06 --> 04:07are listening to this going,
04:07 --> 04:09yep, I've had weight gain,
04:09 --> 04:10I've had Constipation, I've had bloating.
04:10 --> 04:11Oh my God,
04:11 --> 04:13do I have an ovarian tumor?
04:14 --> 04:16This is something that we're hearing
04:16 --> 04:18very commonly or especially now
04:18 --> 04:20during Covid with many people at
04:20 --> 04:21home tending not to be as active,
04:21 --> 04:23perhaps as they were before Covid.
04:23 --> 04:26Many of the gyms and fitness regimens that
04:26 --> 04:28our listeners were probably more engaged
04:28 --> 04:30with pre covid are just not available,
04:30 --> 04:32so we are finding patients
04:32 --> 04:34coming in with these concerns,
04:34 --> 04:35especially related to the
04:35 --> 04:36bloating and weight gain.
04:36 --> 04:39I tend to tell women that if they experience
04:39 --> 04:41these symptoms that persist despite
04:41 --> 04:43changes in their diet or perhaps
04:43 --> 04:45their level of exercise that go
04:45 --> 04:47beyond a few weeks to a month,
04:47 --> 04:48these are things that should
04:48 --> 04:50be brought to the attention of
04:50 --> 04:51their primary care doctor,
04:51 --> 04:52or they're gynecologist
04:52 --> 04:54especially because these are very
04:54 --> 04:55vague symptoms and I don't want
04:55 --> 04:57to alarm our listeners and to say
04:57 --> 04:58that everyone with Constipation or
04:58 --> 05:00everyone with a bit of bloating is
05:00 --> 05:02likely to have an ovarian tumor,
05:02 --> 05:04but I think it is important for both
05:04 --> 05:06the patient and the provider to keep
05:06 --> 05:08these things in the back of their
05:08 --> 05:10head as we try to identify as many
05:10 --> 05:11women as possible in the early stages
05:11 --> 05:13of this very challenging disease.
05:14 --> 05:16And do you find that people with
05:16 --> 05:18ovarian tumors tend to present with
05:18 --> 05:20things that may signal
05:20 --> 05:22a loss of ovarian function?
05:22 --> 05:25Often times when we have tumors
05:25 --> 05:28in various parts of the body,
05:28 --> 05:29it'll affect the actual
05:29 --> 05:30functioning of that organ.
05:30 --> 05:33So when we think about ovaries and we
05:33 --> 05:35think about production of estrogen,
05:35 --> 05:37for example, people may
05:37 --> 05:40have hot flashes, and so on and so
05:40 --> 05:43forth as they go through menopause.
05:43 --> 05:45But with ovarian cancer, if you
05:45 --> 05:46don't have those symptoms,
05:46 --> 05:49does that mean that that's likely OK?
05:49 --> 05:51Or how often would you find
05:51 --> 05:53people presenting with an ovarian
05:53 --> 05:55tumor that actually presents with
05:55 --> 05:57things like hot flashes and vaginal
05:57 --> 05:59dryness and things like that?
06:02 --> 06:04For the most part, these tumors do occur in women
06:04 --> 06:05as they have exited menopause
06:05 --> 06:08and so the ovarian function is
06:08 --> 06:09already at baseline, quite low.
06:09 --> 06:12But even in those women who are still
06:12 --> 06:14having regular menstrual periods,
06:14 --> 06:16who are perhaps in their late
06:16 --> 06:1730s or early 40s?
06:17 --> 06:20We haven't seen as much of a
06:20 --> 06:21relationship between the hormonal
06:21 --> 06:23status in the hormonal symptoms
06:23 --> 06:26and a link between that in an
06:26 --> 06:27underlying ovarian pathology.
06:27 --> 06:30So so important for people
06:30 --> 06:32to recognize that because they
06:32 --> 06:34may be saying to themselves,
06:34 --> 06:36while I'm not having
06:36 --> 06:37hot flashes, I'm not
06:37 --> 06:39having tremendous pain,
06:39 --> 06:42but it really is a cancer that
06:42 --> 06:44whispers the other question that
06:44 --> 06:46our listeners may have is if you've
06:46 --> 06:49had a history of ovarian cysts,
06:49 --> 06:51often times people have gone
06:51 --> 06:53to the gynecologist and maybe
06:53 --> 06:55had an ultrasound or something,
06:55 --> 06:57and they've been told, oh
06:57 --> 06:59you've got ovarian cysts.
06:59 --> 07:01Does that increase their risk of
07:01 --> 07:03ovarian cancer?
07:03 --> 07:06So ovarian cysts are a very normal part of every woman's menstrual
07:06 --> 07:08history and reproductive history.
07:08 --> 07:10Every time the cycle occurs,
07:10 --> 07:13a cyst develops on the ovary and should
07:13 --> 07:15regress after each menstrual cycle.
07:15 --> 07:17What's important to remember is that
07:17 --> 07:20as women exit menopause and are no
07:20 --> 07:22longer having regular menstrual periods,
07:22 --> 07:24cysys should not form
07:24 --> 07:26regularly, and they should certainly
07:26 --> 07:28not progress and become larger and
07:28 --> 07:29more complex appearing on ultrasound
07:29 --> 07:31or any sort of imaging.
07:31 --> 07:34So just because a woman has had this in
07:34 --> 07:36the past does not necessarily mean that
07:36 --> 07:40she will go on to develop an ovarian cancer,
07:40 --> 07:42but it is important for women who do
07:42 --> 07:44have cysts, that may have suspicious
07:44 --> 07:46findings on imaging that she follows
07:46 --> 07:48regularly with her gynecologist to
07:48 --> 07:51decide if and when it merits a referral
07:51 --> 07:53to an oncologist for a more specialized opinion.
07:53 --> 07:56Are there any women who
07:56 --> 07:58are particularly at risk of getting
07:58 --> 08:00ovarian cancer, or is this kind
08:00 --> 08:02of an equal opportunity killer?
08:02 --> 08:04There are a number of risk factors that
08:04 --> 08:06make a woman more likely to experience
08:06 --> 08:09an ovarian cancer in her lifetime.
08:09 --> 08:11One of the strongest is family history,
08:11 --> 08:13and when we think of family history,
08:13 --> 08:15it can be divided into those women
08:15 --> 08:18who have a known family history of a
08:18 --> 08:20genetic syndrome that may make them
08:20 --> 08:23more likely to experience a number of
08:23 --> 08:25different cancers and those who are
08:25 --> 08:27not necessarily related to a known
08:27 --> 08:28genetic syndrome,
08:28 --> 08:30but do have family members,
08:30 --> 08:32grandmothers, mothers perhaps who
08:32 --> 08:34did experience an ovarian cancer.
08:34 --> 08:36And the other category would be
08:36 --> 08:39those that do have a known genetic
08:39 --> 08:41predisposition so those who are
08:41 --> 08:43related to the BRCA gene and many
08:43 --> 08:46women are familiar with that genetic
08:46 --> 08:48syndrome as it relates to risk of
08:48 --> 08:50breast cancer and ovarian cancer.
08:50 --> 08:52But we are also understanding that
08:52 --> 08:54there are other hereditary cancer
08:54 --> 08:56syndromes like Lynch syndrome
08:56 --> 08:59that can also increase a woman's risk of
08:59 --> 09:01developing certain types of ovarian cancers,
09:01 --> 09:03so it is important in those women who have
09:03 --> 09:06strong family histories of cancers to
09:06 --> 09:08speak with their primary care doctor,
09:08 --> 09:10or if they do have an oncologist
09:10 --> 09:12to consider genetic testing
09:12 --> 09:14if it is indicated so that we can
09:14 --> 09:15identify those women whom perhaps
09:15 --> 09:18could benefit from some type of
09:18 --> 09:20prophylactic procedure to reduce their
09:20 --> 09:21risk of developing ovarian cancer
09:21 --> 09:23down the road.
09:23 --> 09:25What about women who don't have a family
09:25 --> 09:27history or genetic predisposition?
09:27 --> 09:29How common or uncommon is ovarian
09:29 --> 09:31cancer in those women?
09:31 --> 09:33In those who don't have those
09:33 --> 09:34strong family risk factors,
09:34 --> 09:38the risk is about 1 to 3% for their lifetime.
09:38 --> 09:40Now that's quite small in comparison
09:40 --> 09:42to some of the other cancers that
09:42 --> 09:44we see in the gynecological tract,
09:44 --> 09:47but the issue is that even though
09:47 --> 09:49it is rare, like I mentioned,
09:49 --> 09:50being that this disease does
09:50 --> 09:52account for so much morbidity,
09:52 --> 09:52and unfortunately,
09:52 --> 09:55survival rates are just not as good as
09:55 --> 09:58they are for the other cancers.
10:02 --> 10:04And when we talk about
10:04 --> 10:06high risk ovarian cancer,
10:06 --> 10:08what exactly is that?
10:08 --> 10:10Are there certain ovarian cancers
10:10 --> 10:12that are more likely to result in
10:12 --> 10:14morbidity and mortality than others?
10:14 --> 10:16So as you mentioned
10:16 --> 10:18regarding those cancers that do
10:18 --> 10:21occur in the very young women,
10:21 --> 10:23typically are less aggressive cancers and
10:23 --> 10:25those younger patients do experience
10:28 --> 10:30the more common type of ovarian
10:30 --> 10:32cancers that we see,
10:32 --> 10:34which we call high grade
10:34 --> 10:37serous and this is a subtype of ovarian
10:37 --> 10:39cancer that is quite bad behaving,
10:39 --> 10:41but unfortunately is the most common
10:41 --> 10:44type that we see and is the one that
10:44 --> 10:46does present at advanced stage.
10:49 --> 10:52I wanted to kind
10:52 --> 10:55of delve a little bit more into that,
10:55 --> 10:57so if women present with these kind
10:57 --> 10:59of vague symptoms and they've
10:59 --> 11:01listened to this show on Yale Cancer
11:01 --> 11:03Answers and they've decided to
11:03 --> 11:06go and talk to their primary
11:06 --> 11:08care physician or their gynecologist,
11:08 --> 11:09how is that worked up?
11:09 --> 11:11I mean, what should women expect
11:11 --> 11:13as they advocate for themselves
11:13 --> 11:15and making sure that if they have
11:15 --> 11:17an ovarian cancer it's found,
11:17 --> 11:19or at least that it's ruled out.
11:20 --> 11:23The thing I want to get across, and it's very
11:23 --> 11:26important is that we do not have any
11:26 --> 11:28screening test for ovarian cancer,
11:28 --> 11:30and so women who've had a pap
11:30 --> 11:32smear and a physical exam as
11:32 --> 11:34part of their annual assessment.
11:34 --> 11:36cannot necessarily be reassured that they
11:36 --> 11:38do not have an underlying ovarian cancer,
11:38 --> 11:41so women who have these symptoms that
11:41 --> 11:43we've talked about should expect their
11:43 --> 11:45doctor to perform a very thorough physical
11:45 --> 11:48exam that does include a pelvic exam,
11:48 --> 11:49and then usually this is
11:49 --> 11:51followed up with some imaging,
11:51 --> 11:54either by ultrasound or CT scan in
11:54 --> 11:55conjunction with some blood tests
11:55 --> 11:57that may help point their doctor in
11:57 --> 12:00the direction that this may be an
12:00 --> 12:02ovarian cancer that requires evaluation
12:02 --> 12:03by a gynecological oncologist, and
12:03 --> 12:05so women who are in
12:05 --> 12:07the High risk group,
12:07 --> 12:09so those women who have a
12:09 --> 12:10very strong family history,
12:10 --> 12:13the women who have a genetic predisposition,
12:15 --> 12:18people who are at very high risk,
12:18 --> 12:20there are some more advanced
12:20 --> 12:21screening techniques.
12:21 --> 12:22There's nothing for ovarian
12:22 --> 12:25cancer in terms of blood tests
12:25 --> 12:27or routine CT or ultrasound
12:27 --> 12:27evaluations
12:27 --> 12:29despite several large international trials,
12:29 --> 12:32we have not been able to identify a
12:32 --> 12:35modality of screening that has shown
12:35 --> 12:38to reduce the incidence of this cancer,
12:38 --> 12:40or to identify at a stage where
12:40 --> 12:42we could intervene and make a
12:42 --> 12:44significant difference in outcomes.
12:44 --> 12:45Having said that, however,
12:45 --> 12:48those women who do know that they harbor
12:48 --> 12:49an underlying genetic predisposition
12:49 --> 12:52to cancer like the BRCA gene,
12:52 --> 12:54or Lynch syndrome, should
12:54 --> 12:55follow regularly with a gynecologist
12:55 --> 12:59who can talk to them about some of the
12:59 --> 13:01increased surveillance that we can do,
13:01 --> 13:03or perhaps intervention through surgical
13:03 --> 13:05removal of the tubes and ovaries.
13:05 --> 13:07At a stage prior to the development of a
13:07 --> 13:10cancer that may be appropriate depending
13:10 --> 13:12on the person's underlying genetic mutation.
13:13 --> 13:16Yeah, so you're talking about
13:16 --> 13:18removing the ovaries and the tubes
13:18 --> 13:21before they get a cancer to reduce
13:21 --> 13:24the risk that they will get a cancer.
13:24 --> 13:26Does it reduce the risk to zero?
13:34 --> 13:35Unfortunately, it
13:35 --> 13:38is not absolutely 0, but it is quite close.
13:38 --> 13:41It does bring the risk down to a
13:41 --> 13:43below 4%. There are some
13:43 --> 13:45inherent risks
13:45 --> 13:47related to the lining
13:47 --> 13:50of the abdomen called the peritoneum.
13:50 --> 13:53This is an area of tissue that is near to
13:53 --> 13:56where the ovary and tube would have been,
13:56 --> 13:58but after removal of tubes and ovaries
13:58 --> 14:00in a woman that's very high risk
14:00 --> 14:02given her genetic predisposition,
14:02 --> 14:04her risk is significantly reduced compared
14:04 --> 14:07to what it would have been if she had not
14:07 --> 14:08undergone that prophylactic procedure.
14:08 --> 14:10Well, that's great information
14:10 --> 14:12for people to know. We're going to
14:12 --> 14:14learn much more about the surgical
14:14 --> 14:16management of high risk ovarian cancer
14:16 --> 14:20after we take a short break for a
14:20 --> 14:23medical minute, please stay tuned to
14:23 --> 14:25learn more with my guest
14:25 --> 14:27Doctor Mitchell Clark.
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15:14 --> 15:18You're listening to Connecticut Public Radio.
15:18 --> 15:18Welcome
15:18 --> 15:20back to Yale Cancer Answers.
15:20 --> 15:23This is doctor Anees Chagpar
15:23 --> 15:25and I'm joined tonight by my
15:25 --> 15:27guest doctor Mitchell Clark.
15:27 --> 15:29We're talking about the role of surgery
15:29 --> 15:32in high risk ovarian cancer and
15:32 --> 15:34right before the break Mitchell
15:34 --> 15:36you talked about the fact that in
15:36 --> 15:39women with a genetic predisposition,
15:39 --> 15:41even though you can remove
15:41 --> 15:42the tubes and ovaries,
15:42 --> 15:45it doesn't reduce their risk down to zero.
15:45 --> 15:49You can still get cancer on the peritoneum.
15:49 --> 15:51That lining of the abdominal cavity.
15:51 --> 15:53Although it does reduce your
15:53 --> 15:54risk quite substantially,
15:54 --> 15:57so my next question is in women
15:57 --> 16:01who have been found to have ovarian cancer,
16:01 --> 16:04we talked a little bit about the fact
16:04 --> 16:07that this is a cancer that really
16:07 --> 16:09presents with very nonspecific symptoms.
16:09 --> 16:11You go to your gynecologist,
16:11 --> 16:13or to your family physician,
16:13 --> 16:16they do a thorough physical exam and
16:16 --> 16:19then maybe an ultrasound or a CT scan.
16:19 --> 16:21What happens next in terms of
16:21 --> 16:22making the diagnosis?
16:23 --> 16:26So after the results of these tests,
16:26 --> 16:28many patients will refer to meet
16:28 --> 16:30with myself or one of my colleagues
16:30 --> 16:32to discuss whether or not all of
16:32 --> 16:35the different aspects of the work
16:35 --> 16:37up are pointing in the direction
16:37 --> 16:38of an ovarian cancer. Typically,
16:38 --> 16:41most women will come with the CA 125,
16:41 --> 16:43which is a blood test that helps
16:43 --> 16:45us understand if the findings
16:45 --> 16:47on the CAT scan are consistent
16:47 --> 16:49with the possible ovarian cancer.
16:49 --> 16:51However, I do want to clarify
16:51 --> 16:53for our listeners that this is
16:53 --> 16:55not a test for ovarian cancer.
16:55 --> 16:58It is really just one piece of the
16:58 --> 17:00diagnostic evaluation that we undertake
17:00 --> 17:02to help understand if the symptoms
17:02 --> 17:04are related to an ovarian cancer.
17:04 --> 17:06So once patients are referred to meet
17:06 --> 17:08with us and these results are pointing
17:08 --> 17:11us in the direction of an ovarian cancer,
17:11 --> 17:14then we have to decide whether or not this
17:14 --> 17:17patient is best suited by starting with us,
17:17 --> 17:19an operation or a surgical
17:19 --> 17:20removal of her ovarian cancer,
17:20 --> 17:23or whether or not we need to
17:23 --> 17:24consider starting with treatments
17:24 --> 17:26such as chemotherapy.
17:26 --> 17:28And we've really evolved over the last
17:28 --> 17:31five to 10 years in understanding how
17:31 --> 17:33to triage women to the appropriate
17:33 --> 17:35first step in their cancer treatment.
17:35 --> 17:38And how is that decision made?
17:38 --> 17:40So we historically would take all
17:40 --> 17:42women to surgery initially and there
17:42 --> 17:44was significant morbidity associated
17:44 --> 17:47with these very complex operations that
17:47 --> 17:50involve removing all of the different
17:50 --> 17:53areas of the abdomen and pelvis where
17:53 --> 17:55we found these cancerous tumors.
17:55 --> 17:55However,
17:55 --> 17:57now we understand through rigorous
17:57 --> 17:59international trials that there
17:59 --> 18:01are women who actually benefit
18:01 --> 18:03from starting with chemotherapy.
18:03 --> 18:05Ovarian cancer is a very
18:05 --> 18:08chemosensitive disease, as we call it.
18:08 --> 18:10In that these cancer cells do
18:10 --> 18:12respond to that systemic treatment
18:12 --> 18:14and shrink the tumors down.
18:14 --> 18:17In order for surgery to be
18:17 --> 18:18accomplished with less morbidity
18:18 --> 18:20and then perhaps in the past,
18:20 --> 18:23just like in systemic treatment like
18:23 --> 18:24immunotherapy and PARP inhibition,
18:24 --> 18:27we're trying to do that same type of
18:27 --> 18:30precision medicine in surgery as well.
18:30 --> 18:32We want to look at each patient
18:32 --> 18:34very individually and assess her
18:34 --> 18:36underlying risk factors or underlying
18:36 --> 18:38health status in order to decide,
18:38 --> 18:41is this a patient who should
18:41 --> 18:42be initially operated on,
18:42 --> 18:45or is this a patient who for other
18:45 --> 18:47reasons should start with chemotherapy
18:47 --> 18:50and both of those options have been
18:50 --> 18:52found to be equally efficacious.
18:52 --> 18:55But oftentimes when we talk
18:55 --> 18:57about treating people with chemotherapy,
18:57 --> 18:58especially targeted
18:58 --> 18:59therapy and immunotherapy,
18:59 --> 19:01oftentimes there is a biopsy done
19:01 --> 19:04that'll look at the tumor and tell
19:04 --> 19:06us whether it has certain receptors.
19:06 --> 19:08For example, in breast cancer,
19:08 --> 19:11we talk about HER 2
19:11 --> 19:13which is also found in other cancers.
19:13 --> 19:16For immunotherapy we often look at
19:16 --> 19:17checkpoint inhibitors PD one PDL1
19:17 --> 19:21and so on, but thus far in the work
19:21 --> 19:24up we haven't heard about a biopsy.
19:24 --> 19:27So how do you make that decision of,
19:27 --> 19:29we're going to treat
19:29 --> 19:30with chemotherapy versus surgery
19:30 --> 19:32or immunotherapy versus surgery?
19:32 --> 19:35And what kind of systemic therapy to use?
19:35 --> 19:36That's a great
19:36 --> 19:39point. So when patients are first considered,
19:39 --> 19:40whether or not they should
19:40 --> 19:43go down the route of surgery.
19:43 --> 19:45Or whether they should go down
19:45 --> 19:46the road of chemotherapy.
19:46 --> 19:48If chemotherapy is felt to be
19:48 --> 19:50the best option for that woman,
19:50 --> 19:52we do get a biopsy.
19:52 --> 19:53As we mentioned, most ovarian
19:53 --> 19:55cancers do present at advanced stage,
19:55 --> 19:55unfortunately,
19:55 --> 19:58but this does allow us to obtain
19:58 --> 20:00a biopsy of one of these
20:00 --> 20:01metastatic lesions somewhere
20:01 --> 20:02in the abdomen and pelvis.
20:02 --> 20:04In order to ensure that we do
20:04 --> 20:06have the correct diagnosis,
20:06 --> 20:08this also allows us to begin the
20:08 --> 20:09process of undertaking genetic
20:09 --> 20:11testing of the tumor so that we can
20:11 --> 20:13understand what types of targeted
20:13 --> 20:15therapies may benefit this patient.
20:15 --> 20:17For women who go to surgery,
20:17 --> 20:19that tumor will be sent to our expert
20:19 --> 20:21pathologist during the operation so
20:21 --> 20:23that they can have a look under the
20:23 --> 20:25microscope while the patient is asleep
20:25 --> 20:27in order to confirm that this
20:27 --> 20:28is an ovarian cancer.
20:28 --> 20:31By the time the patient sees us in the
20:31 --> 20:34office with the combination of CA 125,
20:34 --> 20:36the CT scan images as well as
20:36 --> 20:37the distribution and location
20:37 --> 20:39of the disease on the imaging,
20:39 --> 20:42most times we are able to make a
20:42 --> 20:44presumptive diagnosis of ovarian cancer,
20:44 --> 20:45but you're very correct in saying
20:45 --> 20:47before we initiate any type
20:47 --> 20:48of systemic treatment,
20:48 --> 20:51we do ensure that we have confirmation
20:51 --> 20:53of the type of cancer that this is.
20:55 --> 20:57I want to look at both of
20:57 --> 21:00those arms of the tree individually.
21:00 --> 21:02For patients who go to surgery,
21:02 --> 21:05one of the things that you said was that
21:05 --> 21:09the surgery tends to be quite extensive.
21:09 --> 21:11And so walk us through what
21:11 --> 21:13that surgery actually looks like.
21:13 --> 21:16I mean, do you start by by doing a
21:16 --> 21:18kind of surgical biopsy of the tumor
21:18 --> 21:21and sending that to your pathologist?
21:21 --> 21:23Do you take out the whole ovary
21:23 --> 21:25and then what are all of these
21:25 --> 21:27surfaces that you were talking
21:27 --> 21:29about that are actually removed
21:29 --> 21:31if the diagnosis of ovarian
21:31 --> 21:32cancer is confirmed?
21:32 --> 21:34So when women are taken to surgery,
21:34 --> 21:37we are trying to make the decision of
21:37 --> 21:40whether or not the disease can be removed
21:40 --> 21:43in its entirety and what I mean by that
21:43 --> 21:46is the goal of surgery in ovarian cancer,
21:46 --> 21:48whether or not that surgery happens
21:48 --> 21:50at the beginning of her cancer journey
21:50 --> 21:52or whether it happens after some
21:52 --> 21:54chemotherapy is to remove all of
21:54 --> 21:56the visible ovarian cancer tumors.
21:56 --> 21:58Now the ovary is open to the abdomen
21:58 --> 22:00and pelvis inside a woman's body,
22:00 --> 22:03and so these cancer cells have a
22:03 --> 22:05tendency to try to get out and escape
22:05 --> 22:07and attach to that peritoneum that
22:07 --> 22:10I talked about before that can land
22:10 --> 22:11on various surfaces
22:11 --> 22:14working throughout the abdomen and
22:14 --> 22:16pelvis and so it's important that we
22:16 --> 22:18review those images prior to taking
22:18 --> 22:20one with the surgery so that it helps
22:20 --> 22:22us understand how extensive an
22:22 --> 22:24operation might be. For some women
22:24 --> 22:26their surgery might include removing
22:26 --> 22:28the ovaries, the uterus, cervix,
22:28 --> 22:29as well as the omentum,
22:29 --> 22:32which is a fat pad that lays over the bowel,
22:33 --> 22:34but for some women their
22:34 --> 22:36surgery may be more extensive,
22:36 --> 22:38including removal of perhaps the spleen,
22:38 --> 22:41a segment of the bowel,
22:41 --> 22:43every woman's cancer surgery
22:43 --> 22:46is very individualized to her disease.
22:46 --> 22:48And we take a great deal of time in ensuring
22:49 --> 22:51that we select patients to take to surgery
22:51 --> 22:53who are good candidates to have
22:53 --> 22:55all of the visible tumors removed.
22:55 --> 22:57We know from decades of research
22:57 --> 22:59that the only value in surgery in
22:59 --> 23:02ovarian cancer is when we can remove
23:02 --> 23:04all of the visible disease if not
23:04 --> 23:05down to a very tiny amount.
23:05 --> 23:07If we don't feel that that
23:07 --> 23:09can be achieved upfront,
23:09 --> 23:10women will be triaged to that
23:10 --> 23:12chemotherapy arm of the decision-making
23:12 --> 23:15tree so that we can shrink down
23:15 --> 23:16the disease at the outset.
23:16 --> 23:18And then perform an operation at a later
23:18 --> 23:21date that removes all their visible cancer.
23:21 --> 23:24You know when you put it that way
23:24 --> 23:26Doctor Clark, it sounds like the best
23:26 --> 23:28option for the majority of women would be
23:28 --> 23:31to have systemic therapy first, because
23:31 --> 23:33if the cancer was resectable,
23:33 --> 23:36having the chemotherapy first would shrink
23:36 --> 23:40it down and still make it resectable,
23:40 --> 23:41if not more resectable.
23:41 --> 23:45And if the tumor was quite extensive,
23:45 --> 23:47having chemotherapy or systemic therapy
23:47 --> 23:51first would shrink that and make that
23:51 --> 23:54option of surgery more attainable so
23:54 --> 23:56it would seem to me that the
23:56 --> 23:59patients in whom surgery first was a
23:59 --> 24:01recommendation would be quite small.
24:01 --> 24:04Is that right?
24:04 --> 24:07Yeah, size is one of the characteristics that we look at in
24:07 --> 24:08helping decide which patients will
24:08 --> 24:11benefit from surgery at the outset.
24:11 --> 24:13For patients who have disease that
24:13 --> 24:15is beyond a certain size or located
24:15 --> 24:17in multiple different places,
24:17 --> 24:19we do know from research that those
24:19 --> 24:21patients do benefit from this
24:21 --> 24:23pre treatment with chemotherapy
24:23 --> 24:24in order to reduce
24:24 --> 24:26the size of their ovarian cancers,
24:26 --> 24:29and as we've been discussing a lot today,
24:29 --> 24:31most women do unfortunately present
24:31 --> 24:33with this metastatic picture,
24:33 --> 24:35and so we are finding more and more
24:35 --> 24:37utility in using the chemotherapy at the
24:37 --> 24:40outset of a patient's cancer journey.
24:40 --> 24:41But I just want every listener to
24:41 --> 24:44know if they do encounter a personal
24:44 --> 24:46experience with ovarian cancer,
24:46 --> 24:48that both options should be considered,
24:48 --> 24:50and that's why it's so important that
24:50 --> 24:51gynecological oncologist is involved
24:51 --> 24:54in that decision making at the very
24:54 --> 24:55beginning of her cancer journey.
24:57 --> 24:58Is there a disadvantage to
24:58 --> 25:00pursuing systemic therapy first,
25:00 --> 25:03even if you have a small tumor
25:03 --> 25:06and it's confined to the ovary?
25:06 --> 25:08Would there be a disadvantage
25:08 --> 25:10to doing systemic therapy first,
25:10 --> 25:12could you avoid systemic therapy
25:12 --> 25:15if you had surgery first?
25:15 --> 25:17Ovarian cancer treatment is really a
25:17 --> 25:20medley of chemotherapy and surgery,
25:20 --> 25:22and the question is what
25:22 --> 25:24combination and in what order?
25:24 --> 25:27We do know for women that
25:27 --> 25:28have smaller disease burden,
25:28 --> 25:31that's typically confined to the ovary,
25:31 --> 25:32or perhaps in locations,
25:32 --> 25:35that would not require
25:35 --> 25:36multiple surgical procedures,
25:36 --> 25:39that they do actually have a survival
25:39 --> 25:41benefit to initiating their treatment
25:41 --> 25:43with surgery followed by chemotherapy.
25:43 --> 25:45On the flip side,
25:45 --> 25:47as we have mentioned,
25:47 --> 25:48those with significant amount
25:48 --> 25:50of disease in various locations
25:50 --> 25:53have been shown to benefit from
25:53 --> 25:54receiving the chemotherapy first.
25:54 --> 25:56We almost never treat with
25:56 --> 25:58one without the other,
25:58 --> 26:00and this disease has been something
26:00 --> 26:02that has been traditionally
26:02 --> 26:04treated with both a combination of
26:04 --> 26:07those two of those two options.
26:07 --> 26:09And so where do you see
26:09 --> 26:11therapy moving in the future?
26:11 --> 26:13What are the exciting
26:13 --> 26:14developments that you've seen,
26:14 --> 26:17say in the last year or so?
26:17 --> 26:19What are the exciting things
26:19 --> 26:21that are coming down the pike
26:21 --> 26:23that women who may be facing
26:23 --> 26:24ovarian cancer should know about?
26:25 --> 26:28Well, our dream in ovarian cancer is
26:28 --> 26:30to see this disease detected at its
26:30 --> 26:33preclinical or very early stages and
26:33 --> 26:35the ability to detect this through a
26:35 --> 26:38simple blood test or screening test
26:38 --> 26:39would really revolutionize ovarian
26:39 --> 26:41cancer treatment and the experience
26:41 --> 26:43for patients who do face this disease.
26:43 --> 26:46There are many groups who are working
26:46 --> 26:48on developing tests like this,
26:48 --> 26:50but they really are in the research
26:50 --> 26:53setting only and until then we need to
26:53 --> 26:56focus on how best to manage patients
26:56 --> 26:57who present with advanced disease.
26:57 --> 27:00We've seen a number of approvals and
27:00 --> 27:02new drugs and new therapies in ovarian
27:02 --> 27:05cancer just in the last one to two years.
27:05 --> 27:08And when we think back to 10 years ago,
27:08 --> 27:09the number of different treatments
27:09 --> 27:12that a patient would have open to
27:12 --> 27:13her are significantly increased,
27:13 --> 27:16and we're excited to be able to
27:16 --> 27:18offer patients treatment that can
27:18 --> 27:20even be taken of an oral tablet once
27:20 --> 27:22or twice a day at home.
27:22 --> 27:24That may help reduce their risk
27:24 --> 27:26of ovarian cancer coming back,
27:26 --> 27:28we even see patients who
27:28 --> 27:30experience ovarian cancer survival as
27:30 --> 27:33a chronic disease and until we can
27:33 --> 27:35develop a reliable screening tests
27:35 --> 27:37that can detect this very early,
27:37 --> 27:39we hope to improve outcomes and
27:39 --> 27:42extend survival as long as possible,
27:42 --> 27:44perhaps even until the next
27:45 --> 27:48best thing comes down the pipeline.
27:48 --> 27:49I mean,
27:49 --> 27:50it certainly sounds exciting,
27:50 --> 27:52especially when you think about
27:52 --> 27:55where we started this conversation,
27:55 --> 27:58which was talking about how ovarian cancer
27:58 --> 28:00is a disproportionate killer of
28:00 --> 28:03women with cancer as opposed to
28:03 --> 28:04other gynecologic malignancies
28:04 --> 28:07but the concept of finding it
28:07 --> 28:09early and finding new treatments,
28:09 --> 28:10especially oral treatments,
28:10 --> 28:12is certainly exciting.
28:12 --> 28:15Which brings me to my last question,
28:15 --> 28:16which is,
28:16 --> 28:21this era of Covid has made us all think
28:21 --> 28:24a little bit more creatively about
28:24 --> 28:27how we treat patients with cancer.
28:27 --> 28:29Trying to avoid having them in
28:29 --> 28:31hospital settings and so on.
28:31 --> 28:33How has this affected your practice
28:33 --> 28:35in terms of treating patients
28:35 --> 28:37with ovarian cancer and what are
28:37 --> 28:39some of the options that women
28:39 --> 28:41have availed themselves of
28:41 --> 28:43that they may not have
28:43 --> 28:46previously?
28:46 --> 28:48I have to say, one of the saddest things to see in the covid
28:48 --> 28:51era is women who come in with delayed
28:51 --> 28:54diagnosis and I know that that stems
28:54 --> 28:56from personal concern of exposure and
28:56 --> 28:58going into their health care providers.
28:58 --> 29:00But I would encourage all women to reach
29:00 --> 29:02out to their practitioners in order
29:02 --> 29:05to establish either a telephone or a
29:05 --> 29:07video visit so that they can have some
29:07 --> 29:09time to meet with their practitioner
29:09 --> 29:10and discuss some of the symptoms
29:10 --> 29:12that we've been talking about today.
29:12 --> 29:14We have really revolutionized our
29:14 --> 29:16ability to access patients in their
29:16 --> 29:17home environment or in an environment
29:17 --> 29:19that is most convenient for them,
29:19 --> 29:21and I hope the telephone and video
29:21 --> 29:23video visits will be something that
29:23 --> 29:25we can continue to use as we move
29:25 --> 29:27forward outside of the covered
29:27 --> 29:29area so that we can provide
29:30 --> 29:32really meaningful and convenient care
29:32 --> 29:35to people when they need it most.
29:35 --> 29:35Doctor
29:35 --> 29:37Mitchell Clark is an assistant professor
29:37 --> 29:40of obstetrics and gynecology in the
29:40 --> 29:41division of Gynecological Oncology
29:41 --> 29:43at the Yale School of Medicine.
29:43 --> 29:45If you have questions,
29:45 --> 29:46the address is canceranswers@yale.edu
29:46 --> 29:48and past editions of the program
29:48 --> 29:50are available in audio and written
29:50 --> 29:52form at yalecancercenter.org.
29:52 --> 29:55We hope you'll join us next week to
29:55 --> 29:58learn more about the fight against
29:58 --> 30:00cancer here on Connecticut Public Radio.

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January 10, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

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