Ovarian Cancer Awareness Month

September 13, 2021

Information

September 12, 2021

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

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00:00Funding for Yale Cancer Answers
00:02is provided by Smilow Cancer
00:04Hospital and AstraZeneca.
00:08Welcome to Yale Cancer Answers with
00:10your host doctor Anees Chagpar.
00:13Yale Cancer Answers features the latest
00:15information on cancer care by welcoming
00:17oncologists and specialists who are on the
00:19forefront of the battle to fight cancer.
00:21This week it's a conversation about ovarian
00:24cancer with Doctor Vaagn Andikyan.
00:26Doctor Vaagn Andikyan is assistant
00:28professor of obstetrics,
00:29gynecology and reproductive sciences
00:31at the Yale School of Medicine,
00:33where Doctor Chagpar is a
00:36professor of surgical oncology.
00:38Maybe you can tell us a little
00:41bit about how common is
00:43ovarian cancer and who gets it?
00:45This is a very common type of
00:47cancer in numbers, it is the
00:49fifth in cancer deaths among women in the US.
00:53Yearly, we diagnose about 25,000 patients
00:57with ovarian cancer and that leads to
01:0114,000 deaths annually.
01:04Often I see patients when they
01:07come for their well visit
01:09or other issues and
01:11they often ask me the question
01:13of what are their odds to develop
01:16ovarian cancer and a good number
01:18to quote is one in 80 lifetime
01:20risk of developing ovarian cancer.
01:23That sounds pretty
01:25good in the grand scheme of things,
01:28when you think about breast cancer being one
01:31in eight, ovarian cancer being one in 80,
01:34that's not bad.
01:35But still, ovarian cancer is a
01:38pretty serious condition.
01:39Tell us a little bit more about
01:42what are the risk factors.
01:44How does genetics play
01:46into ovarian cancer?
01:48You touch on a very important
01:50topic of breast cancer.
01:52A breast cancer, ovarian cancer,
01:54they measure some similarity.
01:57They are both reproductive organ cancers.
02:00However, ovarian cancer unfortunately
02:02has no screening and breast cancer,
02:05contrary to that,
02:07has a screening option and
02:09therefore we diagnosis ovarian cancer
02:11at a later stage most often.
02:13Genetics play a very important
02:16role in finding patients at risks.
02:20There was a large study
02:22done in UK that just published
02:25this year involving almost one
02:28million women and unfortunately
02:31demonstrated that with screening
02:33available in modern era, that includes
02:37ultrasound and the marker C 125,
02:40there was no reduction in the death rate.
02:43That was an unfortunate study and
02:46therefore very important to
02:48bring attention to your physician
02:51if you experiencing symptoms that
02:54could potentially be cancer.
02:57And we look at the symptoms
03:00whether they are specific or not,
03:03most of them are nonspecific,
03:05but symptoms such as weight loss,
03:09bloating, abdominal pain,
03:12changes in your bowel habits,
03:15those are concerning
03:17features and can be seen
03:19in many different conditions.
03:20Even benign conditions,
03:22bowel disease, but however they are
03:26not uncommon and can be seen mostly
03:28in patients in advanced disease.
03:31In early stage disease,
03:33unfortunately there's not a lot of
03:36symptoms and in an annual visit to OBGYN
03:39they may discover a cyst or mass in ovary
03:42that may trigger additional intervention.
03:48A large study was
03:51done in the last 10-20 years in molecular
03:55biology and discovered that the
03:57genes associated with ovarian cancer
04:00also related to breast cancer.
04:03BRCA 1 and BRCA 2,
04:05in patients with those gene
04:08mutations, we often see breast cancer, however,
04:11ovarian cancer is also on the rise.
04:14About 50% of patients with BRCA 1
04:17mutation may develop ovarian cancer
04:20and about 25 to 35% with BRCA 2.
04:26And fortunately there is a new
04:30group of drugs available especially
04:33for those patients.
04:35On one hand,
04:37you may consider that this is
04:39the unfortunate situation,
04:42however,
04:42on the other hand,
04:43we have a treatment available.
04:46Let's pick up on that.
04:48I mean the one thing that you mentioned
04:51which was interesting is that
04:53if you do have a BRCA mutation that
04:55tells you that you're at increased risk,
04:58that study that you quoted found
05:01that CA 125 vaginal ultrasounds,
05:03they really don't reduce mortality,
05:05but you mentioned that there
05:07are some drugs that may help in
05:09patients with these mutations.
05:10So tell us more.
05:12Of course, within the last five to ten years
05:15we discovered a new group of drugs,
05:18we call them PARP inhibitors.
05:20We learned more about the
05:22biology of ovarian cancer.
05:25And we realized that
05:27when
05:31our body repair double strand DNA
05:34breaks tumors that are
05:37deficient in those pathways have
05:40a harder time to repair themselves.
05:42So we're using tumor weaknesses
05:45and making it even worse by adding
05:49this enzyme blockers to help
05:52us to fight cancer cells.
05:55Several of the new drugs are available
05:57and approved by FDA to use in patients
06:00with ovarian cancer as a first line
06:02maintenance therapy and we use it
06:06as their therapy for later state disease.
06:10We use in combination with
06:13systemic cytotoxic chemotherapy
06:14there because as I mentioned,
06:18PARP inhibitors and there are several
06:20approved on the market,
06:22a new study has been done
06:25to discover in which sequence we
06:27should use them as a frontline or
06:30as a maintenance therapy versus
06:33reserved for recurrences.
06:35A lot to be discovered within
06:37the next 5-10 years,
06:38but we are on the right track.
06:40Just to be clear,
06:43the PARP inhibitors are really for
06:45treatment of people who have an
06:48ovarian cancer, particularly if
06:49they are also carriers of BRCA 1 or 2?
06:54If you've been diagnosed with a BRCA 1 or 2
06:57gene mutation,
06:59let's suppose somebody in your family was
07:01diagnosed with breast cancer and they
07:03were discovered to have the mutation,
07:06you were then tested,
07:07you now have a mutation,
07:09but you don't have ovarian cancer yet.
07:12At least you're aware of that.
07:14Are there any things that you
07:16could do to prevent ovarian cancer
07:18or to reduce your risk?
07:25We don't have medication that can
07:28potentially reverse the risks and
07:31we don't administer this PARP
07:33inhibition as a prophylactic therapy.
07:36The only approach we
07:38use is risk reducing surgeries.
07:41That entails a patient after completion
07:45of childbearing or after age of 35 to 40,
07:50we recommend to proceed with risk reducing
07:53surgery that includes the removal of the
07:56tubes and ovaries that will essentially
07:59eliminate the risk of ovarian cancer.
08:02It's not going to completely decrease
08:05the risk to zero because there's
08:07still a residual peritonei primary
08:09cancer, however,
08:11it will decrease the risk of
08:13ovarian cancer close to zero.
08:15That is the best strategy for
08:18patients with ovarian cancer
08:20and if you were to
08:23opt for that and say
08:25you've just been
08:27diagnosed with this mutation,
08:28you're worried about ovarian cancer,
08:31so you undergo a prophylactic bilateral mastectomy.
08:37They remove your tubes and
08:38your ovaries on both sides.
08:40What are the side effects of that
08:43surgery and how can you circumvent those?
08:46That's a great question,
08:48it depends on age.
08:50Obviously, the younger the patients are,
08:52they still have good performance
08:55and ovarian function and the
08:58unfortunate thing is this procedure will
09:01place a patient in a menopausal state.
09:04With side effects such as hot flashes,
09:07bone density problems,
09:10potentially cardiovascular disease, however,
09:14there have been studies demonstrating
09:18that risk reducing surgery actually
09:21helps patients live longer despite
09:23those side effects that may potentially
09:27compromise cardiovascular health,
09:29patients who undergo risk reducing
09:31surgery by eliminating risk of
09:33ovarian cancer and breast cancer,
09:35they can live potentially longer.
09:39To alleviate the symptoms of menopause
09:42we use a hormonal therapy.
09:44Now we use non hormonal approaches
09:46as well and the therapy is meant to
09:51eleviate symptoms without interfering
09:53with other hormonally active tumor
09:56and without affect on the breast as such,
10:00because the hormonal effect on
10:03uterus and breast may be somewhat different,
10:06we have to bear in mind we
10:09potentially can help with symptoms,
10:10but we also do not want to
10:13hurt with breast cancer risk,
10:14which as you mentioned,
10:17is higher in BRCA mutation patients.
10:21That's kind of a
10:24tight rope to walk, to eliminate
10:26symptoms as best you can while not
10:29increasing the risk of other cancers.
10:31That's correct when we do
10:33this surgery after age of 50, the
10:36average age of menopause in North America,
10:39it's about 52.
10:41When we do surgery at later age
10:45those issues automatically are not there.
10:49However, when patient has an
10:52early onset of ovarian
10:54cancer and before age of 50,
10:57then we try to do this surgery early.
11:00In that circumstance, we
11:02do work with a patient without addressing
11:05her symptoms of surgical menopause.
11:08And I suppose in a BRCA patient
11:10the other way to reduce your risk of
11:13breast cancer even if you were going to
11:15take some sort of hormonal therapy to
11:17offset surgically induced menopause,
11:20is to have bilateral prophylactic
11:22mastectomies and reduce your
11:24risk of breast cancer as well.
11:26But that is another show,
11:28so getting back to ovarian cancer,
11:32you know you mentioned that this is
11:36often especially in the early stages,
11:39something that is not easily diagnosed.
11:41It's usually presenting late so
11:45what can women do if
11:47they want to catch this early?
11:50I mean should they be getting annual vaginal
11:53ulltrasounds?
11:55But the study showed that that
11:57really didn't improve survival.
11:59Or is it just a matter of being
12:00aware of your body and seeking
12:02medical advice when you have symptoms?
12:06Great question.
12:07I think the body sends us signals.
12:11So when we start connecting to our body,
12:15body and mind are interconnected
12:17and when you develop something new
12:20something changed over the course
12:22of the last couple of months,
12:24bring that to the attention of
12:26your physician and if you are not
12:29satisfied with the response,
12:32seek a second opinion and it is very
12:35important to know your family history.
12:38What did your aunt die from?
12:40What did your cousin die from.
12:46Find out whether it was genetically
12:48related and you potentially
12:50can get genetically tested.
12:52I think those two things, bringing attention
12:55to symptoms and finding your
12:57genetic background will help us
12:59to prevent some of the cancer,
13:01or at least diagnose early.
13:03That's so important and we are
13:05going to learn more about how to
13:08make a diagnosis of ovarian cancer,
13:11how to treat this, and what are the
13:14important advances that are going on
13:16in terms of clinical research regarding
13:18ovarian cancer right after we take
13:20a short break for medical minute.
13:22Please stay tuned to learn more
13:24about ovarian cancer with my
13:26guest Doctor Vaagn Andikyan.
13:28Support for Yale Cancer Answers
13:30comes from Smilow Cancer Hospital,
13:32where an individualized approach
13:34to prostate cancer
13:35screening is used to determine which men are
13:38eligible and would benefit from screening.
13:40To learn more, visit Yale Cancer
13:44Center dot org slash screening.
13:46Breast cancer is one of the most common
13:48cancers in women. In Connecticut alone,
13:50approximately 3500 women will be
13:53diagnosed with breast cancer this year,
13:55but there is hope,
13:57thanks to earlier detection,
13:58noninvasive treatments and the development
14:00of novel therapies to fight breast cancer.
14:03Women should schedule a baseline
14:05mammogram beginning at age 40 or
14:07earlier if they have risk factors
14:09associated with the disease.
14:10With screening, early detection,
14:12and a healthy lifestyle,
14:14breast cancer can be defeated.
14:16Clinical trials are currently
14:18underway at federally designated
14:20Comprehensive cancer centers such
14:22as Yale Cancer Center and Smilow
14:24Cancer Hospital to make innovative
14:26new treatments available to patients.
14:28Digital breast tomosynthesis or 3D
14:31mammography is also transforming breast
14:33cancer screening by significantly
14:35reducing unnecessary procedures
14:37while picking up more cancers.
14:40More information is available at
14:43yalecancercenter.org. You're listening
14:44to Connecticut Public Radio.
14:47Welcome back to Yale Cancer Answers.
14:49This is doctor Anees Chagpar and I'm joined
14:51tonight by my guest Doctor Vaagn Andikyan.
14:53We're discussing the care of women with
14:56ovarian cancer and right before the break
14:59you were talking about how
15:01you know it's really important for
15:04women to know their family history and
15:07to really advocate for themselves.
15:09So if they have symptoms,
15:10even if they're non specific,
15:12a little bit of bloating, change in
15:14bowel habit, difficulty urinating,
15:15whatever it might be.
15:17A little bit of abdominal discomfort.
15:19Sometimes those might be the
15:21first signs of ovarian cancer,
15:23and it's so important to get it checked out
15:27so that we can find cancer at an early stage.
15:31I want to kind of pick
15:34up there and talk a little bit about
15:37diagnosis of ovarian cancer.
15:39How is it that people actually get diagnosed?
15:42So either they're going to come and
15:45present to you with some vague symptoms,
15:48and hopefully we find things early.
15:52But how is a diagnosis made?
15:59We grade ovarian cancer into two
16:02groups, early stage versus late stage,
16:04usually early stage it's
16:06an incidental finding of a cyst in the patient.
16:09They went to the emergency room for let's say
16:12gallbladder problem or pneumonia
16:15and they incidentally find a lesion
16:18that triggered additional work up.
16:30For patients who started experiencing symptoms
16:32they probably already have stage three
16:34and four disease.
16:36Unfortunately there is not a good
16:39symptom that can pick up
16:41an early stage ovarian cancer,
16:43unless the mass is so large and
16:46compressing on neighboring organs.
16:48We've seen often and not unusual to
16:51have a many centimeter mass in ovary
16:54and still have stage one disease.
16:57In those patients
16:58with early stage disease,
17:00we triage according their age.
17:03We often offer even fertility
17:05preservation for patients at younger
17:08age who desire future fertility
17:10and they have stage one disease.
17:13We can potentially save ovary and
17:16give them opportunity to become mothers.
17:19For those patients who are diagnosed late
17:21unfortunately,
17:22organ preservation is not an option.
17:25In that case we do a thorough work
17:28up to figure out whether patient is
17:31a candidate for surgery versus neoadjuvant
17:34chemotherapy.
17:36One approach focuses on upfront surgery.
17:40If patient comorbidity allows in
17:42cases when that type of surgery is not
17:46feasible due to disease distribution
17:49and or patient performance status,
17:52we proceed with neoadjuvant chemotherapy.
17:57Our organization historically
17:59had the focus on this approach,
18:02and we've demonstrated good
18:04results with that approach and
18:08national and International Studies
18:11demonstrated similarly good results
18:13with neoadjuvant chemotherapy in
18:15patients who are not a candidate
18:19for upfront debulking.
18:20The whole philosophy of surgical
18:22treatment of ovarian cancer
18:24to obtain,
18:25we call it no residual disease
18:27or optimal cytoreduction.
18:30When the volume of tumor is minimal,
18:32at least less than one centimeter,
18:34ideally no growth,
18:36or residual tumor following that surgery,
18:40we proceed with the systemic chemotherapy
18:44that includes administration
18:46of the cytotoxic drug, commonly
18:50we use carboplatin and paclitaxel
18:52with biologic agents such as Bevacizumab.
18:56New data came up actually
18:59two years ago, a
19:01large study in Europe demonstrated the
19:04benefit of heated chemotherapy that
19:07can be administered during the surgery.
19:10That whole approach, called HIPC,
19:13heated intraperitoneal chemotherapy
19:15is done during surgery for
19:18patients who
19:19received neo adjuvant chemotherapy and
19:23underwent successful debulking surgery,
19:26receive heated chemotherapy during
19:28their procedure and they follow
19:31on their regular therapy after
19:34surgery and recovery from HIPC.
19:38This approach is slowly picking up
19:41the pace and the study
19:44in Europe demonstrated one year
19:47survival benefit in those patients
19:49who underwent this type of therapy.
19:52Another approach is organ
19:56preservation and we work closely
19:59with our colleagues in reproductive
20:02endocrinology ovacyt preservation
20:04and the patient even may opt for her
20:09ovacyt to be collected prior
20:12to proceeding with surgery.
20:23Just to back up,
20:28you know when you talk about
20:30ovarian cancer as either being
20:32early stage versus advanced,
20:34how exactly do you determine that?
20:37So say somebody presents to
20:38you and they've got some,
20:40you know, vague symptoms.
20:41What are the tests that you
20:44will do to first of all,
20:45find out if this is in fact ovarian cancer,
20:49and second,
20:50whether this falls into the early stage
20:54bucket or the late stage bucket.
20:57Great question.
20:58And honestly, unfortunately
21:00as of today we do not have any
21:03definitive tool to know for sure
21:06whether this is ovarian cancer.
21:08So diagnostic imaging is broadly used today
21:13CT, PET scans, MRI.
21:16They are not very specific
21:20in the ovary.
21:23Ovarian surface itself may attract
21:25tumor from other areas.
21:27For example, stomach cancer may travel
21:30to ovary and when you see ovarian mass
21:34but that initial cancer was originated
21:37from a GI tract from colon cancer,
21:41it's very important to do a thorough work up,
21:44and the imaging is number one.
21:46We use oncomarkers to tailor
21:50other possible diagnosis,
21:52such as colon cancer,
21:53pancreatic cancer,
21:54breast cancer.
21:57The markers
22:02depend on the patient age.
22:06We may include additional oncomarkers.
22:09Very interesting that ovarian cancer
22:12has family of three cancer in one.
22:16One derives from lining of the
22:18ovary and those give rise to
22:21epithelial ovarian cancer.
22:23The second family derives from
22:26hormonally active tumors.
22:28And those tumors may secrete
22:30certain chemicals that we can
22:32pick up on a blood test.
22:36And the third group of tumors
22:40derived from germ cells.
22:45And those three cancers
22:46may have different
22:48biology and different tests we
22:50use to diagnose before surgery,
22:53but ultimately our diagnosis heavily
22:56relies on histologic evaluation.
22:59What that means
23:01is we perform some kind of a
23:04biopsy or surgery to take a sample to
23:07find out what type of cancer it is.
23:16It sounds like the therapies
23:19for advanced cancers are very different
23:21from the surgery for local cancer,
23:23whereas local cancers you might
23:25even get to spare part of the ovary.
23:28In advanced cancers we're talking about,
23:31you know, big surgeries taking
23:34out multiple organs,
23:36potentially adding in hipec and so on.
23:39So in other cancers
23:40that we talked about doing
23:43a core needle biopsy to get
23:46a preoperative diagnosis.
23:47But in ovarian cancer,
23:48is that the case or is that something
23:51that is diagnosed at the time of surgery?
23:55If the imaging demsonstrate advanced
23:59disease and patient performance status does not
24:02allow us to perform debulking surgery,
24:05in that case we proceed
24:08with neoadjuvant chemotherapy.
24:10In that case scenario we
24:13proceed with core needle biopsy.
24:15But if the imaging shows us
24:20high suspicion
24:22for ovarian cancer
24:24in that case, we do not
24:25obtain preoperative core biopsy with
24:28concern of potential side effects,
24:30infection and in anticipation of major
24:34surgery in patients with what
24:38looks like ovarian cyst and we are not
24:41sure 100% whether it's cancerous or not,
24:43we proceed with laparoscopic surgery.
24:46Remove that cyst in the obtained
24:49frozen section and for our
24:52listeners, frozen section
24:53is a tool when patients
24:56sleep under anesthesia.
24:57We perform surgery and we ask our
25:00pathological colleagues within 20 minutes to give
25:02us an answer whether it's cancer or not,
25:05and according to that diagnosis,
25:07we decide whether the removal of
25:09cyst is enough or we should proceed
25:12with more staging type of surgery
25:15that includes removal of lymph nodes.
25:21And so as we talk about the different
25:23kinds of therapies for ovarian cancer,
25:26depending on the stage,
25:28we've talked about surgery,
25:29we've talked about systemic chemotherapy,
25:32the two modalities that
25:33we haven't talked about,
25:35that we do talk about a lot on this show,
25:37one is radiation therapy,
25:40and the other is immunotherapy.
25:43Is there a role for either
25:44of these modalities in the
25:46treatment of ovarian cancer?
25:54In the US we performed a study in the 80s
26:00and we compared the whole abdominal
26:03radiation versus systemic chemotherapy
26:05and we demonstrated that systemic
26:08chemotherapy works better. Less toxicity,
26:10less concern for bowel side effects,
26:14and we stay away from radiation
26:16in ovarian cancer.
26:18Select patients may
26:20benefit from radiation therapy
26:22for palliative purposes.
26:24If there is a small recurrence in a
26:26bone or small pelvic recurrence and
26:29patient is not surgical candidate,
26:32we may contemplate radiation therapy,
26:34but it's esoteric use.
26:37We don't use a radiation therapy
26:40to treat ovarian cancer.
26:41What about immunotherapy?
26:44It's a great question.
26:48Unfortunately, it is not really primetime
26:50yet for ovarian cancer.
26:53Current therapies demonstrated modest effect.
26:57We are still working on a biomarker
27:00for ovarian cancer.
27:02As I mentioned,
27:04there are three large families
27:06of ovarian cancer, epithelial, germ
27:09cell and sex cord stromal tumor.
27:12But within those groups there
27:14is also subdivision into high
27:16grade serous, low grade serous,
27:18clear cell, endometrial, etc.
27:20so there are some groups of ovarian cancer
27:23they may potentially
27:25benefit from immunotherapy,
27:27but that research is still ongoing.
27:29Which brings me to probably my last
27:32question, which is what are the
27:34most exciting advances in terms of
27:36clinical research in ovarian cancer?
27:38What do we have to look forward to?
27:42So the large ones are using PARP
27:46inhibition and in a large number of patients
27:49with this mutation we discovered several
27:52other new genes that may be also affected
27:56in patients with ovarian cancer.
27:58We're trying to understand which group
28:01of patients should receive this
28:05therapy upfront versus a recurrence.
28:08So the other group of the new drugs
28:11are used for molecular targeted therapy.
28:16We use molecular studies to demonstrate
28:19sudden receptors and we can potentially
28:22attach cytotoxic agents or use those
28:25molecular targets to a new group of drugs.
28:29Doctor Vaagn Andikyan is an
28:31assistant professor of obstetrics,
28:33gynecology and reproductive sciences
28:34at the Yale School of Medicine.
28:37If you have questions,
28:38the address is cancer answers at
28:41yale.edu and past editions of the
28:43program are available in audio and
28:45written form at Yale Cancer Center dot Org.
28:48We hope you'll join us next week to
28:50learn more about the fight against
28:52cancer here on Connecticut Public
28:54radio funding for Yale Cancer
28:55Answers is provided by Smilow
28:57Cancer Hospital and AstraZeneca.