Ovarian Cancer: Treatment Options after Diagnosis


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Ovarian Cancer: Treatment Options after Diagnosis

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  • Use word optimal
  • Some will benefit from additional surgery (secondary cytoreduction), followed by further chemotherapy Some will not benefit from surgery and receive further chemotherapy Approach offered will depend on duration of remission (Disease-Free Period of time)
  • 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.
  • Ovarian Cancer: Treatment Options after Diagnosis

    1. 1. Ovarian Cancer: Treatment Options after Diagnosis Mildred R. Chernofsky, MD Sibley Center for Gynecologic Oncology and Advanced Pelvic Surgery Ovarian Health: Knowledge is Power Community Lecture Series 15 September 2009
    2. 2. Ovarian Cancer <ul><li>Second Most Common Gynecologic Cancer </li></ul><ul><ul><li>3% of all cancers diagnosed in women </li></ul></ul><ul><ul><ul><li>21,550 new ovarian cancers (2009) </li></ul></ul></ul><ul><ul><ul><li>14,600 deaths (2009) </li></ul></ul></ul><ul><ul><li>Leading Cause of Gynecologic Cancer Death </li></ul></ul><ul><ul><ul><li>More women die of ovarian cancer than cervical and endometrial cancer combined </li></ul></ul></ul><ul><ul><li>At presentation: </li></ul></ul><ul><ul><ul><li>About 3/4 will have Advanced Disease </li></ul></ul></ul><ul><ul><ul><li>Only ¼ will have Early Disease </li></ul></ul></ul>American Cancer Society, Cancer Facts and Figures 2009
    3. 3. Ovarian Cancer is a: <ul><li>Surgically Staged Disease: </li></ul><ul><ul><li>Extent of disease is determined at time of surgery by removal of specific organs and biopsies </li></ul></ul><ul><ul><li>Why is stage important? </li></ul></ul><ul><ul><ul><li>Prognosis </li></ul></ul></ul><ul><ul><ul><li>Need for additional treatment besides surgery: (chemotherapy) </li></ul></ul></ul>
    4. 4. Ovarian Cancer Staging: Surgery <ul><li>Peritoneal washings (Cytology) </li></ul><ul><li>Intact removal of the tumor (removal of both tubes and ovaries) + Hysterectomy </li></ul><ul><li>Inspection of all peritoneal surfaces + multiple biopsies </li></ul><ul><li>Lymph node assessment: (pelvic and aortic) </li></ul><ul><li>Removal of the omentum </li></ul>
    5. 6. Tumor Staging
    6. 7. Ovarian Cancer is a <ul><li>Surgically Treated Disease: </li></ul><ul><ul><li>In presence of extensive disease (surgical debulking/cytoreduction) </li></ul></ul><ul><ul><ul><li>Removing as much tumor as possible is critical: </li></ul></ul></ul><ul><ul><ul><ul><li>Best: no residual cancer (optimal) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Next best: remaining tumor nodules be very small (less than 1 cm) (optimal) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>This means we remove, if necessary, in addition to the uterus, tubes, ovaries and omentum,: sometimes the spleen, some bowel, some surface lining (peritoneal lining) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>When pts have large residual disease: suboptimal </li></ul></ul></ul></ul><ul><ul><ul><li>This approach confers a survival advantage </li></ul></ul></ul><ul><ul><ul><ul><li>Optimal versus suboptimal (11 months median survival improvement)* </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Optimal median survival 33.9 months </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Suboptimal medical survival 22.7 months </li></ul></ul></ul></ul></ul>*Bristow RE, JCO 2002;20:1248-1259
    7. 9. Ovarian Cancer Patient Populations <ul><li>Limited disease (resected) and low risk for recurrence </li></ul><ul><ul><li>Risk of recurrence: 10 % </li></ul></ul><ul><li>Limited disease (resected) and high risk for recurrence </li></ul><ul><ul><li>High risk: grade, high risk cell type (clear cell), surface ovarian disease, disease outside the ovary, ascites or positive washings) </li></ul></ul><ul><ul><li>Recurrence risk: 20-35% </li></ul></ul><ul><li>Small volume residual advanced disease ( optimal cytoreduction ) </li></ul><ul><ul><li>High risk for recurrence: 65-75% </li></ul></ul><ul><li>Large volume residual advanced disease ( suboptimal cytoreduction ) </li></ul><ul><ul><li>High risk for recurrence: 80-90% (  100%) </li></ul></ul>Thigpen JT, Clinical Ovarian Cancer 2008;1: 96-103
    8. 10. Ovarian Cancer: Early Stage Patients <ul><li>Low Risk (Disease confined to 1 or 2 ovaries, with no risk factors)  No additional treatment </li></ul><ul><li>High risk  Chemotherapy </li></ul><ul><ul><li>Paclitaxel + Carboplatin ( = Taxane + Platinum) </li></ul></ul>Taxane agents: Paclitaxel and docetaxel Platinum agents*: Carboplatin, Cisplatin Thigpen JT, Clinical Ovarian Cancer 2008;1: 96-103
    9. 11. Ovarian Cancer: Advanced Disease <ul><li>Small volume residual advanced disease (optimal cytoreduction) & </li></ul><ul><li>Large volume residual advanced disease (suboptimal cytoreduction) </li></ul><ul><ul><li>Both groups receive: Chemotherapy </li></ul></ul><ul><ul><li>Paclitaxel + Carboplatin ( = Taxane + Platinum) </li></ul></ul><ul><ul><li>80 % will respond to treatment and go on remission </li></ul></ul><ul><ul><ul><li>75 % will recur </li></ul></ul></ul><ul><ul><li>20 % will have chemoresistant disease and do poorly </li></ul></ul>Taxane agents: Paclitaxel and docetaxel Platinum agents: Carboplatin, Cisplatin
    10. 13. Ovarian Cancer: Small Volume Residual (Optimal), Advanced Disease Patients <ul><li>Intraperitoneal (IP) Chemotherapy: </li></ul><ul><ul><li>Delivery of chemotherapy to the abdominal cavity directly </li></ul></ul>
    11. 16. Ovarian Cancer: Small Volume Residual (Optimal), Advanced Disease Patients <ul><li>Intravenous (IV) & IP Paclitaxel and IP Cisplatin (GOG 172) versus IV Paclitaxel/Cisplatin </li></ul><ul><li>IP arm demonstrated the longest survival reported in the optimally debulked Stage III patients </li></ul><ul><ul><li>16 months improvement: 65.6 months median survival vs 49.7 months </li></ul></ul><ul><ul><li>An improvement in Progression free survival (PFS): period of time that patients are alive without disease returning: </li></ul></ul><ul><ul><ul><li>IV & IP Paclitaxel / IP Cisplatin: PFS: 23.8 months </li></ul></ul></ul><ul><ul><ul><li>IV Paclitaxel / IV Cisplatin: PFS 18.3 months </li></ul></ul></ul>Armstrong DK et al. NEJM 2006. 354: 34-43
    12. 19. Trends in Five-year Relative Survival (%)* Rates, US, 1975-2003 <ul><li>All sites 50 54 66 </li></ul><ul><li>Breast (female) 75 79 89 </li></ul><ul><li>Colon 51 59 65 </li></ul><ul><li>Leukemia 35 42 50 </li></ul><ul><li>Lung and bronchus 13 13 16 </li></ul><ul><li>Melanoma 82 87 92 </li></ul><ul><li>Non-Hodgkin lymphoma 48 53 64 </li></ul><ul><li>Ovary 37 40 45 </li></ul><ul><li>Pancreas 2 3 5 </li></ul><ul><li>Prostate 69 76 99 </li></ul><ul><li>Rectum 49 57 66 </li></ul><ul><li>Urinary bladder 74 78 81 </li></ul>* 5-year relative survival rates based on follow up of patients through 2004. Source: Surveillance, Epidemiology, and End Results Program, 1975-2004, Division of Cancer Control and Population Sciences, National Cancer Institute, 2007.       Site 1975-1977 1984-1986 1996-2003
    13. 20. Recurrent Ovarian Cancer
    14. 21. Recurrent Ovarian Cancer <ul><li>Patients free of disease 6 months or greater and then recur: Platinum sensitive. Options depend on: </li></ul><ul><ul><ul><li>amount of tumor that recurs - isolated versus multifocal </li></ul></ul></ul><ul><ul><ul><ul><li>Can it be all removed surgically </li></ul></ul></ul></ul><ul><ul><ul><li>functional status of patients - healthy versus unwell </li></ul></ul></ul><ul><ul><ul><li>For some: Surgery  chemotherapy (Platinum + Taxane) (Paclitaxel + Carboplatin) </li></ul></ul></ul><ul><ul><ul><li>Majority  Chemotherapy (Platinum + Taxane) (Paclitaxel + Carboplatin) </li></ul></ul></ul><ul><ul><ul><ul><li>The response to the chemotherapy will be better the longer beyond 6 months that they were free of disease </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Treat until progression, or unacceptable toxicity or complete response </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If become resistant: change to a new drug, and repeat… </li></ul></ul></ul></ul><ul><li>Patients free of disease less than 6 months and then recur: Platinum resistant. </li></ul><ul><ul><li>Chemotherapy: Response rate is low (7-26 %) </li></ul></ul><ul><ul><li>Start with a nonplatinum single agent </li></ul></ul><ul><ul><li>Do poorly </li></ul></ul>Thigpen JT, Clinical Ovarian Cancer 2008;1: 96-103
    15. 22. Chemotherapy Agents Used in Recurrent Ovarian Cancer <ul><li>carboplatin </li></ul><ul><li>cisplatin </li></ul><ul><li>pegylated liposomal doxorubicin </li></ul><ul><li>topotecan </li></ul><ul><li>gemcitabine </li></ul><ul><li>oral etoposide </li></ul><ul><li>vinorelbine </li></ul><ul><li>weekly paclitaxel </li></ul><ul><li>docetaxel </li></ul><ul><li>permetrexed </li></ul><ul><li>tamoxifen </li></ul><ul><li>oxaliplatin </li></ul><ul><li>5-fluorouracil </li></ul>Thigpen JT, Clinical Ovarian Cancer 2008;1: 96-103
    16. 23. What’s new and hot: Targeted Therapies or Biologics!! agents that block a necessary pathway for cancer cells
    17. 24. What’s new and hot <ul><li>Bevacizumab: </li></ul>
    18. 25. Future Directions
    19. 27. Future Directions in Advanced Ovarian Cancer GOG 212 GOG 252 Trying to find a more tolerable IP regimen Maintenance Chemotherapy
    20. 28. (Many agents being tested) :Better tolerated regimen, role of IP Carboplatin (Paclitaxel or bevacizumab)
    21. 29. Questions ?? <ul><li>Panel session for questions. Submit your questions. </li></ul><ul><li>Acknowledge & Thank: GynecoLogic Cancer Collaborative: Society of Gynecologic Oncologists (SGO): slides </li></ul><ul><li>Mildred R. Chernofsky, MD </li></ul><ul><li>Sibley Center for Gynecologic Oncology and Advanced Pelvic Surgery </li></ul><ul><li>202-243-5295 </li></ul>
    22. 30. <ul><li>November 6-8, 2009 </li></ul><ul><li>Washington, DC </li></ul><ul><li>Half marathon/5K /1 mile </li></ul><ul><li>walk </li></ul><ul><li>gcfrace.com </li></ul><ul><li>Free concurrent Survivor’s </li></ul><ul><li>Courses </li></ul><ul><ul><li>Cervical Cancer, </li></ul></ul><ul><ul><li>Endometrial Cancer </li></ul></ul><ul><ul><li>Ovarian Cancer </li></ul></ul><ul><li>To register: </li></ul><ul><li>http://www.wcn.org/courses/ </li></ul><ul><li>CME Course for Physicians </li></ul><ul><li>To register: </li></ul><ul><li>www.sgo.org/content.aspx?id=2760 </li></ul>