1. Ovarian Cancer Gloria S. Huang, M.D. Assistant Professor Department of Obstetrics & Gynecology and Women ’ s Health Division of Gynecologic Oncology Albert Einstein College of Medicine Montefiore Medical Center Albert Einstein Cancer Center

2. Who gets it? What are the signs and symptoms? How do you work it up? How do you treat it? What are the chances of survival? Ovarian Cancer

3. Ovarian Cancer: U.S. Epidemiology Eighth most common cancer among women –Estimated 20,180 new cases in 2006 Lifetime risk of getting ovarian cancer is approximately 1 in 67 (1.5%) Accounts for 3% of cancers in women American Cancer Society 2006

4. Ovarian cancer: U.S. Epidemiology 5th most common cause of cancer death in women Estimated 15,310 deaths in 2006 Lifetime risk of dying from ovarian cancer is 1 in 95 (1%)

5. Histology 85% Epithelial –Serous carcinoma-most common –Endometrioid –Mucinous carcinoma –Clear cell carcinoma 5% Germ Cell 10% Sex cord Stromal

6. Ovarian Cancer

7. Ovarian Cancer: Risk Factors IncreaseDecrease AgeOCPs Family historyPregnancy Infertility/low parity Tubal ligation Personal cancer history Breast-feeding

8. Hereditary factors BRCA 1 and BRCA 2 –10% of ovarian cancers –Lifetime risk 40-50% HNPCC –1% of ovarian cancers

9. Who gets it? What are the signs and symptoms? How do you work it up? How do you treat it? What are the chances of survival? Ovarian Cancer

10. Ovarian Cancer: Symptoms 95% of women DO report symptoms. Symptoms can be vague and not gynecologic: –Abdominal bloating, increased girth –Fatigue –Gastrointestinal disturbances –Urinary symptoms –Abdominal/pelvic pain –Menstrual irregularities –Increased flatulence

11. Who gets it? What are the signs and symptoms? How do you work it up? How do you treat it? What are the chances of survival? Ovarian Cancer

12. Ovarian Cancer: Diagnostic Modalities Rectovaginal pelvic exam TVS and/or CT scan or MRI CA-125 If diagnosis uncertain, laparoscopy may be useful diagnostic tool Surgical exploration

13. Normal Ovary

14. Ovarian Cancer

16. Who gets it? What are the signs and symptoms? How do you work it up? How do you treat it? What are the chances of survival? Ovarian Cancer

17. Ovarian Cancer: Surgical Rx for Early Stage Disease Optimal therapy: TAH BSO + staging (including pelvic and PALN) In younger women, reproductive conservation may be appropriate Approximately 30% will have histologic evidence of metastatic disease

18. Ovarian Cancer: Staging by Surgical Specialty Evaluation of completeness of surgical staging Nearly half of women with early ovarian cancer were inadequately staged by general Ob/Gyns or General Surgeons SurgeonComplete Staging Gyn/Onc97% Ob/Gyn52% Surgeon35% Source: McGowen et al. Ob/Gyn 1985

19. Ovarian Cancer: Surgical Treatment for Advanced Disease Significant survival advantage for women optimally cytoreduced Procedures may include: –En bloc resection of uterus, ovaries and pelvic tumor –Omentectomy –Bowel resection –Removal of diaphragmatic and peritoneal implants –Splenectomy, appendectomy

20. Ovarian Cancer: Survival by Residual Disease GOG Protocols (PR) 52 and 97

21. Ovarian Cancer: Chemotherapy Almost all patients should receive adjuvant chemotherapy with platinum and a taxane >70% response rate I.P. chemo in optimally debulked pts Many new agents being tested Encourage clinical trial participation

22. Taxol and ovarian cancer McGuire W.P. et al. New Engl J of Med, 334 (1996)

23. Who gets it? What are the signs and symptoms? How do you work it up? How do you treat it? What are the chances of survival? Ovarian Cancer

24. Ovarian Cancer: Follow-up Healthcare RV pelvic exam and CA-125 q 3-4 mo x 2 years, q 6 mo for years 3-5 CT scan for symptoms General health maintenance (mammography, Pap smear, bone density, colon-rectal screening, cholesterol, etc.) Discuss HRT, diet, exercise

25. Ovarian Cancer: Recurrence 75% of patients relapse Treatment options include: –Secondary cytoreduction –Retreatment with platinum/taxane –Second-line therapies, including chemo, radiation, immunologic, gene therapies –Encourage clinical trials

26. Ovarian Cancer: U.S. Patterns of Care Stage Appropriate Treatment I10% II15% III71% IV53% 785 women with ovarian cancer studied Munoz JCO 1997

27. Ovarian Cancer: Importance of Surgeon 1,866 women with ovarian cancer Significant advantage for those women managed by Gynecologic Oncologist –More likely to have optimal cytoreduction –Reduction in death by 25% (p= 0.005) compared to Ob/Gyn and General Surgeons Junor et al, Brit J Ob/Gyn, 11/99

28. Ovarian Cancer: Stage Distribution and 5-year Survival StagePercentSurvival I24%95%95% II6%65% III55%15-30% IV15%0-20% Overall50% American Cancer Society 2002

29. Relative Survival: Ovarian & Breast Cancers Five-Year Relative Survival Rates by Stage at Diagnosis StageOvaryBreast Local93%97% Regional55%76% Distant25%21% All Stages50%84%

30. Ovarian Cancer: Future Directions Cost-effective screening Early detection Prevention Reversing chemoresistance Targeted therapies Immunotherapy Gene therapy