1. Roberta Ness, MD, MPH University of Pittsburgh Ovarian Cancer: Reproductive Factors and Beyond

2. Ovarian Cancer Descriptive Statistics Highlights Most frequent cause of death from gynecologic malignancy 40% five year survival 75% of patients have cancer spread beyond the ovary by the time of clinical detection Mortality has decreased only slightly in past 30 years Current guidelines do not support screening either pre- or post- menopausal women in whom there is no history of ovarian cancer

3. Prevention of Ovarian Cancer Secondary: Screening for early disease Primary: Preventing cancer development

4. Does Anything Prevent Ovarian Cancer? Oral contraceptives Pregnancies Breast feeding (long duration) Tubal ligation Oophorectomy and hysterectomy

5. Oral Contraceptives and Ovarian Cancer Risk 30-40%  Longer use, more protection Protection 20 or more years after last use New OCs protective

6. Pregnancies and Ovarian Cancer Whittemore 1992

7. Breast Feeding and Ovarian Cancer Whittemore 1992 0 6 12 18 24

8. Tubal Ligation

9. Oophorectomy Kauff ND, et al. N Engl J Med 2002;346:1609-15. 012243648607284 1.0 0.9 0.8 0.7 0.6 Salpingo-oophorectomy (n=98) Months Cumulative Proportion without Breast or BRCA-Related Gynecologic Cancer Surveillance (n=72)

10. Etiologic Hypotheses Ovulation hypothesis: Ovulation exposes ovarian epithelium to minor trauma which allows promotion of cells containing allele loss. Pituitary gonadotropin hormone hypothesis: High gonadotropin levels have direct toxic effect.

11. Gonadotropin Hypothesis Pro Parity Breastfeeding OC use Con HRT Fertility drugs Prospective measures

12. Fertility Drug Use VariableCasesControlsAdjusted OR (95% CI) Fertility Drugs (all) No91111371.0 Yes1492000.97 (0.76, 1.25) Fertility Drugs Never pregnant No1911471.0 Yes54221.60 (0.90, 2.87) Ever pregnant No7209901.0 Yes951780.82 (0.62, 1.09) Ness RB, Cramer DW, Goodman MT, et al. Infertility, fertility drugs and ovarian cancer: a pooled analysis of case-control studies. Am J Epid 2002:155:217-24.

13. Odds Ratios (95% CI) for Ovarian Cancer according to Estrogen Replacement (ERT), Estrogen + Progestin Sequential (HRT SP), and Estrogen + Progestin Continuous (HRT CP) CasesControlsOR (95%CI) ERT No5833531 Yes 59 2591.43(1.02-2.0) HRT SP No5503434 Yes 57 3481.54(1.15-2.05) HRT CP No5833494 Yes 55 2801.02(0.73-1.43) Riman T, et al. J Natl Cancer Inst 2002;94:497-504.

14. Relative Odds (95% CI) of Ovarian Cancer by Thirds of Serum Hormone Levels. Helzsouer KJ, Alberg AJ, Gordon GB, et al. Serum gonadotropins and steroid hormones and the development of ovarian cancer. JAMA 1995;274:1926-1930. HormoneLowMediumHighP (Trend) LH1.00.6 (0.1-2.8)0.4 (0.1-2.0).25 FSH1.00.5 (0.1-2.8)0.1 (0.0-1.0).02 Androstenedione1.02.3 (0.4-12.6)7.6 (1.2-48.7).008 Progesterone1.03.5 (0.4-31.5)5.8 (0.2-167.3).58 Estrone1.03.0 (0.9-10.3)1.7 (0.4-7.6)NA Estradiol1.02.1 (0.54-7.8)3.0 (0.6-14.9).26

15. Parity  Breastfeeding  Oral contraceptive use  ? Ovulation Involves Inflammation Reduced Ovarian Cancer Risk

16. Ovulation Elevates Inflammation Mediators TNF , IL-6, IL-1 Cell proliferation Oxidative stress Prostaglandins and leukotrienes Vascular permeability

17. Talc Use and Ovarian Cancer

18. Aspirin Use Risk 1.0 TzonouCramerRosenberg Tavani Akhmedkhanov Moysich 1984 1998 2000 2000 2001 2001 0.9 0.9 0.75 X X X 0.7 0.6 0.5 X X X

19. Host-invader Interactions Promote Carcinogenesis Treatment of ovarian ascites with TNF  promotes solid nodule formation in nude mice Nude mice with macrophages lacking gene for MMP-9 developed fewer ovarian tumors. Addition of macrophages with MMP-9 allowed ovarian neoplastic growth

20. Parity  Breastfeeding  Oral contraceptive use  ? Reduced Unopposed Estrogen Reduced Ovarian Cancer Risk

21. Unopposed Estrogen: Epidemiology of Risk Early menarche, short cycle length Reduced exercise ERT, but not necessarily HRT

22. Cottreau CM, Ness RB, Kriska AM. Physical activity and reduced risk of ovarian cancer. Obstet Gynecol 2000;96:609-14. Odds Ratios and 95% Confidence Intervals of Ovarian Cancer Risk in Relation to Lifetime Leisure Physical Activity. Physical activity LevelCasesControlsOR (95% CI) Low2894441.00 Moderate 3215760.85 (0.69, 1.06) High1543440.73 (0.56, 0.94) P for Trend.01

23. Unopposed Estrogens Estrogen receptors in normal ovarian epithelium, ovarian cancer cells Estrogen stimulates ovarian cancer in vitro Elevated local and serum estrogen levels in ovarian cancer Ovulation may elevate serum estradiol levels

24. Progesterone Rodriguez G. Ovarian cancer and high risk women: implications of prevention, screening and early detection. May, 2002, Pittsburgh, PA. Apoptotic Effect of Hormonal Treatment on Macaque Ovarian Epithelium Median percent of Range of percent of Study groupNumber apoptic cell counts apoptotic cell counts Control 20 3.9% 0.1-33.0 % Hormone treated Ethinyl – Estradiol 20 1.8% 0.1-28.6 % Combination pill 1714.5% 3.0-61.0 % Levonogestrel 1824.9% 3.5-61.8 %

25. Adjusted Odds Ratios for Ovarian Cancer According to Oral Contraceptive (OC) Potency Schindkraut JM, Calingert B, Marchbanks PA, et al. Impact of progestin and estrogen potency in oral contraceptives on ovarian cancer risk. JNCI 2002;94:32-8. Progesterone/Estrogen Cases Controls Adjusted OR(95%CI) High/High22 3341.0 High/Low0 170.0 (0.0-n/e) Low/High49 4972.1(1.2-3.7) Low/Low33 3061.6(0.9-3.0) Nonusers28617112.9(1.8-4.5)

26. Barriers to Understanding the Pathophysiology of Ovarian Cancer Lack of a relevant animal model Absence of a recognized premalignant lesion

27. Endometriosis Endometrial implants (ectopic)/outside the endometrium Occurs in 3-8% of reproductive age women Thought to arise from retrograde menstruation Almost all women have retrograde menstruation

28. Epidemiology: Brinton, et al. 20,686 women hospitalized for endometriosis 11.4 Years OvarianBreastNon-Hodgkin’s CancerCancerLymphoma SIR 1.9SIR 1.3SIR 1.8 SIR 4.2 for longstanding ovarian disease

29. Epidemiology: Ness et al. SHARE analysis: 767 cases, 1367 controls Pooled analysis: 5207 cases, 7705 controls

30. Endometriosis Risk 1.0 1.9 X 1.7 X Brinton Ness Ness 2000 2002

31. Ovarian Cancer Studies Endometriosis among 20-50% of endometrioid and clear cell tumors Endometriosis among 3-9% of serous, mucinous, and other histologic subtypes

32. Immune Abnormalities in Endometriosis Reduced peritoneal NK activity Elevated numbers and activity of peripheral/ peritoneal macrophage and T cell activity TGF    NK activity MMP-9, VEGF   extracellular matrix and  angiogenesis

33. Endometriosis Estradiol Prostaglandins Cytokines Estrone Genetics Macrophages, T cells, NK cells Cytokines  TGF   NK activity  VEGF  MMPs Androstenedione Progesterone X Aromatase 17  HSD-1 X Estrogens COX-2

34. Estrogen-Related Risk Factors for Ovarian Cancer and Endometriosis Association to VariableOvarian CancerEndometriosis Nulliparity++++ Lack of oral contraception+++ Lack of breast feeding+++? Early age at menarche+++ Short or long menstrual cycles++ Body Mass Index-+? Height++ Caffeine use++ Alcohol use-+? Lack of exercise+?++

35. Endometriosis Estradiol Prostaglandins Cytokines Estrone Genetics Macrophages, T cells, NK cells Cytokines  TGF   NK activity  VEGF  MMPs Androstenedione Progesterone X Aromatase 17  HSD-1 X Estrogens COX-2

36. Synthesis Retrograde Menstruation EndometriosisOvarian Cancer Androgens Estrogens  Progesterone Cytokines Prostaglandins MMP-9