Malcolm Padwick MD FRCOG Gynaecology Cancer Surgeon gynaecology.me.uk Malcolm Padwick MD FRCOG Gynaecology Cancer Surgeon Ovarian cancer

Overview 6900 cases per year in UK 1 in 75 women 5th most common cancer in women Half are over 65 75% mortality

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symptoms Bloated abdomen Full after starting to eat Weight loss Nausea and indigestion Pelvic pain Change in bowel habit Frequency of urine Backache Swollen ankles Abdominal mass Vaginal bleeding

NICE guidelines 2011 Primary care : 2 week wait referral if physical examination identifies ascites and/or pelvic mass not caused by known fibroids. No need to wait for investigations.

NICE guidelines 2011 Primary care : investigate women, especially if over 50 yrs, if they report any of the following symptoms on a persistent or frequent basis.

NICE guidelines 2011 Persistent abdominal distention (bloating) Feeling full – early satiety and/or loss of appetite Pelvic or abdominal pain Increased urinary frequency and/or urgency Unexplained weight loss fatigue or change in bowel habit Women over 50 yrs with new diagnosis of IBS

NICE guidelines 2011 Primary care : First tests Serum CA125 If CA125 > 35 IU/ml Pelvic and abdominal ultrasound If CA125 or USS negative investigate for other causes and ask patient to return if symptoms become more frequent or persistent

misdiagnosis Gastric or peptic ulcers (GI referral) Gallstones (surgeons) Diverticulitis (colorectal) Cystitis (urology) SOB pleural effusion/ PE (chest physician)

prognosis Survival rate by Stage 1 90% 2 60% to 70% 3 15% to 35% 1 90% 2 60% to 70% 3 15% to 35% 4 5% to 15% Latest data shows 50 % women alive at 5 yrs with stage 3 or 4 disease

Screening Ca125 85% of women with cancer have a raised CA125 But only 50% of women with early stage cancer have a raised CA125 Ca125 is raised in benign conditions

Screening USS Vaginal ultrasound Accurate but high rate of false positives Relatively expensive

screening No general screening available in UK Selective screening for high risk individuals – more than two affected direct relatives BRAC 1 and 2 High risk screening not officially recommended but has acceptance Consider preventative surgery

Making a diagnosis New symptoms in otherwise fit women Postmenopausal – especially > 65 yrs A large mass in a woman with minimal or new symptoms is likely to be ovary/uterus New diagnosis of IBS after 40 yrs is rarely correct ! USS is single most useful investigation

USS Good quality community based service ?? Wait to select correct specialty service – getting this wrong can generate major delays What is the danger in finding coincidental benign disease ?

BSO can be day surgery

Ovplex 362 plasma samples from women with ovarian cancer (n=150) and healthy controls (n=212) were used to develop a multivariate classification model incorporating five plasma biomarkers associated with ovarian cancer. Based upon the measurement of these 5 markers, the model calculates the likelihood that a patient has ovarian cancer

news Do not use Ca125 for follow up patients

news HRT increases risk of epithelial ovarian cancer

news Delayed surgery now accepted

news Intraperitoneal chemotherapy

news Science News Personalized Treatment for Ovarian Cancer ScienceDaily (Nov. 17, 2010) — Researchers have shown that point mutations -- mis-spellings in a single letter of genetic code -- that drive the onset and growth of cancer cells can be detected successfully in advanced ovarian cancer using a technique called OncoMap. The finding opens the way for personalised medicine in which every patient could have their tumour screened, specific mutations identified, and the appropriate drug chosen to target the mutation and halt the growth of their cancer.

news Ultra radical cyto-reductive surgery Diaphragmatic stripping Liver resection Splenectomy Coeliac axis lymph node dissection

The message Treatment is effective but only if we can catch the disease early enough Treatment is more about living a good quality of life with the disease rather than cure