Presented July 9, 2016 at the Ovarian Cancer National Conference in Washington, DC

1. Decoding an
Ovarian Cancer
Diagnosis

2. Session Outline
• Introductions
• Process from diagnosis to follow-up
• ‘Doc, what should I be asking you?”
• Resources
• Questions and answers

3. Disclosures
 No financial disclosures.
 This is not medical advice.

4. Disclosures
 No financial disclosures.
 This is not medical advice
 I am a doctor.

5. Disclosures
 No financial disclosures.
 This is not medical advice
 I am a doctor.
 Stop me if I am using jargon or acronyms
 Interrupt and ask questions

6. Stephanie L. Wethington, MD
 Raised in Northern Virginia
 Medical training at Columbia University College of Physicians and
Surgeons, Magee Womens Hospital, New York Presbyterian
Hospital
 Gynecologic Oncology Fellowship at Memorial Sloan Kettering
Cancer Center
 Gynecologic Oncologist at Mid Atlantic Gynecologic Oncology and
Pelvic Surgery Associates

7. What do we mean by
Ovarian Cancer?
Cancer arising in the ovaries, fallopian tubes or peritoneum

8. What is a Gynecologic
Oncologist?
 Completed Ob/Gyn residency
 Additional 3-4 years of specialized training in the
care of women diagnosed with gynecologic cancers
 Fellowship training includes:
 Biology & pathology
 Diagnosis
 Treatment
 Surgery
 Chemotherapy
 Radiation
 Survivorship
 Research

9. Members of the treatment team
 Gynecologic oncologist
 Medical oncologist
 Radiation oncologist
 Palliative care provider
 Nurse navigator
 Chemotherapy infusion nurse
 Social worker
 “Housestaff”
 Nutritionist
 Physical and occupational therapists
 Acupuncturist
 Psychiatrist or psychologist
 Family and friends

10. The process:
From diagnosis to follow-up

11. Diagnosis
• Symptoms
• Incidental finding
• Tumor markers
• Imaging
• Biopsy
• Operation

12. What makes you unique?

13. Treatment
• Operation
• Chemotherapy
• (Biologic)
• (Targeted therapy)
• (Radiation)

14. Treatment
Surgery
• Laparotomy (open abdominal incision)
• Minimally invasive procedure
• Laparoscopy
• Robotic assisted laparoscopy
• Staging
• Where has the cancer spread?
• Debulking
• How can we remove all the visible tumor?

15. Treatment
Chemotherapy
• Intravenous
• In the vein
• Peripheral IV
• Mediport
• Intraperitoneal
• In the abdomen

16. Treatment
What is a cycle?
• Recurring group of chemotherapy doses
• Example: Dose dense paclitaxel and carboplatin
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1
Cycle#1
Carbo
Taxol
2 3 4 5 6 7
8
Taxol
9 10 11 12 13 14
15
Taxol
16 17 18 19 20 21
22
Cycle #2
Carbo
Taxol
23 24 25 26 27 28
29
Taxol
30 31

17. Treatment
• (Biologic)
• Avastin
• (Immunotherapy)
• (Targeted therapy)
• (PARP inhibitors)
• (Radiation)

18. Hot Topic Clinical Trials
 Geared to specific genomic abnormalities
 Tumor profiling
 Foundation One
 Precision Therapeutics
 Caris
 Immunotherapy
 Adoptive T cell therapy
 Vaccines
 PD-1, PD-L1
 Pembrolizumab

19. Follow-up
Components
• Symptoms
• Physical exam
• Tumor markers
• Imaging
Timeline
• Every 3 months
• Space out over time

20. “Doc, What should I be asking you?”
Know yourself

21. “Doc, What should I be asking you?
Understanding the diagnosis
• What type of ovarian cancer do I have?
• Histology
• Grade
• Stage
Understanding the treatment plan
• Will I have an operation or chemotherapy first?
• Why is that sequence recommended?
Who is my treatment team?

22. Understanding the operation
• What procedure did I have?
• One ovary or both?
• Uterus and cervix?
• Lymph nodes?
• Bowel?
• Other?
• Was it a staging procedure or a debulking
procedure?
“Doc, What should I be asking you?

23. “Doc, What should I be asking you?
Understanding the chemotherapy plan
 Which chemotherapy drugs will I receive?
 Will I receive chemotherapy through the vein (IV) or into the abdomen(IP)?
 Do I need a mediport?
 Are these chemotherapies standard of care?
 Are there other options?
 Am I eligible for any clinical trials?
 What are the expected side effects?
 Are there side effects about which I should call the office urgently?
 What are your recommendations to decrease side effects?
 Where will I receive chemotherapy?
 Will I receive a “chemo calendar”?
 Who do I call if I have a question about my chemotherapy treatment?
 How many chemotherapy treatments will I have?
 How often will I have an appointment with you?
 How often will I have blood drawn?
 Will I be able to work during the chemotherapy treatments? Limitations?
 Do I see my primary care doctor, cardiologist, other specialist while I am receiving
chemotherapy?

24. “Doc, What should I be asking you?
Understanding the follow-up
• How often do I need a physical exam?
• How often do I need to check tumor markers?
• How often do I need to have an imaging study?
• What other cancer screening do I need?
• Do I need to see my primary care doctor or other specialists?
• Is there anything I can do to reduce my risk of recurrence?
• Should I schedule an appointment with a genetic
counselor?

25. • This process is very lonely. Help?
• Will I be able to have children after my treatment?
• My son is getting married in two months. Will I be able to
attend?
• I don’t want anyone to know I have been diagnosed with
cancer. How do I keep my diagnosis private?
• What do I tell my children?
• I have been married for 30 years and we have a wonderful
intimate relationship? Will this be affected?
• I am so tired. What can I do about the fatigue I am feeling?
“Doc, What should I be asking you?

26. Resources
General oncology
 American Cancer Society, www.cancer.org
 National Cancer Institute, www.cancer.gov
 National Comprehensive Cancer Network,
www.nccn.org
 NRG Oncology, www.nrgoncology.org
 Patient Advocate Foundation,
www.patientadvocate.org

27. Resources
Gynecologic oncology specific
o Eyes on the Prize, www.eyesontheprize.org
o Foundation for Womens Cancer,
www.foundationforwomenscancer.org
o Gilda Radner Familial Ovarian Cancer Registry,
www.ovariancancer.com
o National Ovarian Cancer Coalition, www.ovarian.org
o Ovarian Cancer Research Fund Alliance,
www.ovariancancer.org
o Ovations for the Cure of Cancer,
www.ovationsforthecure.org
o Society of Gynecologic Oncology, www.sgo.org

28. Resources
Support Networks
 Cancer Care, www.cancercare.org
 Cancer Support Community,
www.cancersupportcommunity.org
 National Coalition for Cancer Survivorship,
www.canceradvocacy.org
 SHARE: Self-help for Women with Breast or Ovarian
Cancer, www.sharecancersupport.org

29. Resources

30. Questions and Answers

31. If I could only share one
piece of information,
it would be…..

32. Extra material in case time or
questions

33. Terminology

34. Key Terminology
Histology
 Epithelial
 Germ cell
 Sex cord stromal tumor

35. Key Terminology
Grade
How abnormal are the tumor cells under the microscope?
• Grade 1 = Well differentiated
• Grade 2 = moderately differentiated
• Grade 3 = poorly differentiated
• Low grade
• High grade

36. Key Terminology
Stage = Spread
0

37. Key Terminology
Tumor Markers
Examples
• CA-125
• HE4
• Inhibin
• AFP
• LDH
How are they used?
• Monitor response to treatment
• Detect recurrence
Word of Caution

38. Key Terminology
Imaging Studies
CT (computed tomography) Scan
• Series of xray images
• Combined by a computer
• Intravenous or oral contrast
• Structure

39. Key Terminology
Imaging Studies
MRI (Magnetic resonance imaging)
• Magnetic field and radio waves
• Combined by a computer
• Intravenous contrast
• Structure

40. Key Terminology
Imaging Studies
PET (positron emission tomography) Scan
• Radioactive tracer
• Dye collects in areas of the body with high metabolic activity
• Metabolism
PET CT Fused

41. Clinical Trials

42. Clinical Trials
 Goal: Identify better ways to treat ovarian cancer
 Who leads?
• Principal investigator, MD
• Research team
 Who sponsors?
• Academic medical centers
• Pharmaceutical companies
• Nonprofit organizations
• NRG oncology
• Federal agencies

43. Clinical Trials
Structure
• Phase I
• Safety
• Dosage
• Phase II
• Safety
• Effectiveness
• Phase III
• Effectiveness

44. Clinical Trials
Example questions to ask:
• What are the possible interventions I might receive during the trial?
• Why do researchers believe the intervention being tested might be effective? Has
it been tested before?
• Does everyone receive the study drug?
• When do I find out which intervention I will receive?
• How do the possible risks, side effects, and benefits of this trial compare with
those of my current treatment?
• What will I have to do?
• How long will the study last?
• Who will pay for my participation? Reimbursed for other expenses?
• What type of long-term follow-up care is part of this trial?
• If I benefit from the intervention, will I be allowed to continue receiving it after the
trial ends?
• Will results of the study be provided to me?
• Who will oversee my medical care while I am in the trial?

45. Tumor Testing

46. Tumor Testing
 Caris Life Sciences
 Multiple tumor profiling technologies
• IHC, FISH/CISH, Next-Generation Sequencing,
PCR

47. Tumor Testing
 Precision Therapeutics
 Tumor cells are grown in the lab, treated with various
chemotherapy drugs, and response measured

48. Clinical Trials
 FoundationOne
 Sequences more than 200 cancer-related genes

49. Genetic Counseling??

50. SGO Recommendations