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Knowledge is Power: ovarian cancer
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  • The survival rates for all cancers combined and for certain site-specific cancers have improved significantly since the 1970s, due, in part, to both earlier detection and advances in treatment. Survival rates markedly increased for cancers of the prostate, breast, colon, rectum, and for leukemia. With new treatment techniques and increased utilization of screening, there is hope for even greater improvements in the not-too-distant future.

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  • 1. Epithelial Ovarian Cancer: Bevacizumab and GOG 218 Mildred R. Chernofsky, MD Associate Clinical Professor Department of Obstetrics and Gynecology George Washington University Sibley Center for Gynecologic Oncology and Advanced Pelvic Surgery 29 September 2010
  • 2. Ovarian Cancer
    • Second Most Common Gynecologic Cancer
      • 3% of all cancers diagnosed in women
        • 21,880 new ovarian cancers (2010)
        • 13,850 deaths (2010)
      • Leading Cause of Gynecologic Cancer Death
        • More women die of ovarian cancer than cervical and endometrial cancer combined
      • At presentation:
        • About 3/4 will have Advanced Disease
        • Only ¼ will have Early Disease
    American Cancer Society, Cancer Facts and Figures 2010
  • 3. Tumor Staging
    • Peritoneal washings abdomen/pelvis (Cytology)
    • Exploration of the abdomen
    • Intact removal of the tumor (removal of both tubes and ovaries) + Total Abdominal Hysterectomy
    • Inspection of all peritoneal surfaces + multiple biopsies
    • Lymph node assessment: pelvic and aortic nodes
    • Removal of the omentum
  • 4.  
  • 5. Tumor Debulking Optimal tumor debulking confers an 11 month median survival advantage over the median survival of suboptimal patients
  • 6.  
  • 7. Following Surgery  Chemotherapy for Advanced Ovarian Cancer
    • intravenous paclitaxel and carboplatin
    • Intravenous/intraperitoneal paclitaxel and intraperitoneal cisplatin
  • 8. Trends in Five-year Relative Survival (%)# Rates, US, 1975-2005
    • All sites 50 54 68*
    • Breast (female) 75 79 90*
    • Colon 52 59 66*
    • Leukemia 35 42 54*
    • Lung and bronchus 13 13 16*
    • Melanoma 82 87 93*
    • Non-Hodgkin lymphoma 48 53 69*
    • Ovary 37 40 46*
    • Pancreas 3 3 6*
    • Rectum 49 57 69*
    • Urinary bladder 74 78 82*
    # 5-year relative survival rates based on follow up of patients through 2006. Source: Horner et al, SEER Cancer Statistics Review, 1975-2006, NCI, Bethesda, MD, seer.cancer.gov/csr/1975_2006/,2009.       Site 1975-1977 1984-1986 1999-2005 * The difference in rates between 1975-1977 and 1999-2005 is statistically significant, (p < 0.05%)
  • 9. Can we make survival better in ovarian cancer ? Is the answer biologics?
  • 10. Biologics
    • Medications/agents that are trying to target unique elements such as receptors or proteins that may be expressed by cancer cells or unique processes in diseases, such as rheumatoid arthritis, Crohn’s disease and psoriasis.
  • 11. Angiogenesis
      • Formation of new blood vessels
      • Healthy versus disease states
      • Angiogenic switch = VEGF=vascular endothelial growth factor
  • 12. Eskens FA and Verweij J. The clinical toxicity profile of vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor (VEGFR) targeting angiogenesis inhibitors; A review. Eur J Cancer 2006; 42: 3127-3139. Blood vessel formation
  • 13.  
  • 14. Bevacizumab (Avastin © )
    • Blocks blood vessel formation in cancers
    • FDA approval for use in
      • Metastatic colorectal cancer
      • Non-small cell lung cancer
      • Metastatic breast cancer
      • Glioblastoma
      • Metastatic renal cancer
    Avastin© is manufactured by Genentech/Roche
  • 15. Frumovitz F and Sood AK. Vascular endothelial growth factor (VEGF) pathway as a therapeutic target in gynecologic malignancies. Gynecol Oncol 2007; 104:768-778. Bevacizumab in Recurrent Ovarian Cancer
  • 16. Definitions
    • Progression free survival: The length of time during and after treatment in which a patient is living with a disease that does not get worse.
    • Median survival: The time from either diagnosis or treatment at which half of the patients with a given disease are found to be, or expected to be, still alive
    cancer.gov
  • 17.  
  • 18. GOG 218: Phase III Trial of Bevacizumab in the Primary Treatment of Advanced Epithelial Ovarian, Primary Peritoneal, or Fallopian Tube Cancer: A Gynecologic Oncology Group (GOG) Study Slide courtesy of the Gynecologic Oncology Group (GOG) and provided by Dr. Robert A. Burger, ASCO 2010
  • 19. Phase III Trial of Bevacizumab in the Primary Treatment of Advanced Epithelial Ovarian, Primary Peritoneal, or Fallopian Tube Cancer: A Gynecologic Oncology Group (GOG) Study
    • Results:
      • 3 month improvement in progression free survival in Arm III (chemotherapy + upfront bevacizumab +maintenance bevacizumab compared to chemotherapy alone- Arm I)
      • PFS Improvement of arm III was noted in all subgroups analyzed: Stage III optimal, Stage III suboptimal, Stage IV, all performance status groups (0, 1-2), all age groups (less than 60 y/o, 60-69 y/o and 70 y/o or greater)
      • Side effects were well tolerated.
      • At time of this initial analysis- no difference in overall survival
    Burger et al, ASCO 2010
  • 20. Phase III Trial of Bevacizumab in the Primary Treatment of Advanced Epithelial Ovarian, Primary Peritoneal, or Fallopian Tube Cancer: A Gynecologic Oncology Group (GOG) Study
    • Conclusions
      • Primary study objective was met
      • Bevacizumab with chemotherapy (paclitaxel/carboplatin) provided a progression free survival that was statistically superior to chemotherapy alone (paclitaxel/carboplatin)
      • Bevacizumab is first molecular targeted and first antiangiogenic agent to demonstrate benefit in the ovarian cancer population in upfront treatment.
    Burger et al, ASCO 2010
  • 21. ICON 7
    • Results soon to be presented at European Society for Medical Oncology 2010.
  • 22. Future research
    • Optimal dosing schedule of bevacizumab
    • Duration of treatment
  • 23. Conclusions
    • There has been an improvement in the survival of patients with ovarian cancer as a result of better chemotherapy drugs compared to the 1970’s.
    • Ovarian cancer is still a very lethal disease.
    • More research is needed with new promising agents, like Bevacizumab and other targeted agents, which may hold the key to further improvement in survival.
  • 24. Questions / Acknowledgements
    • Panel session for questions
    • Acknowledge & Thank: GynecoLogic Cancer Collaborative: Society of Gynecologic Oncologists (SGO), IMER (Institute for Medical Education and Research): slides
    • Dr. Robert Burger and Gynecologic Oncology Group (and statisticians): GOG 218 data slides
    • Mildred R. Chernofsky
    • Sibley Center for Gynecologic Oncology and Advanced Pelvic Surgery
    • 202-243-5295