ENCOUNTERING OVARIAN CANCER IN THE PRIMARY CARE SETTING RENATA - - PowerPoint PPT Presentation

UW MEDICINE │ ONCOLOGY REGIONAL CARE ADVANCEMENT SYMPOSIUM (ORCA)

ENCOUNTERING OVARIAN CANCER IN THE PRIMARY CARE SETTING

RENATA URBAN, MD

MARCH 7, 2015

A patient discloses that her sister has been diagnosed with ovarian cancer at the age of 52. I would recommend this patient undergo screening for breast and ovarian cancer.

True False

AUDIENCE RESPONSE QUESTION #1

2

URBAN Ovarian Cancer URBAN

A 57 yo patient presents with bloating and urinary problems. A pelvic ultrasound reveals free fluid and a complex adnexal mass. You consider referral to one of the following:

Ob/Gyn Surgical Oncology Gynecologic Oncology General Surgery Hematology/Oncology

AUDIENCE RESPONSE QUESTION #2

4

URBAN Ovarian Cancer URBAN

Following the conclusion of treatment, patients with ovarian cancer have less depression, but more anxiety

Yes No Don’t Know

AUDIENCE RESPONSE QUESTION #3

6

URBAN Ovarian Cancer URBAN

DISCLOSURE

I am the PI of a research study that is supported by Vermillion, Inc. I have no

• ther financial obligations to disclose

Describe the patterns of care in treating

• varian cancer

Review the indications and options for screening in the average and high-risk population Describe the symptoms associated with ovarian cancer List what tests to order when ovarian cancer is on your differential Discuss the surveillance and management

• f ovarian cancer patients after treatment

OBJECTIVES

60 yo teacher

Celiac disease, GERD Gallbladder polyps followed by US last few years Moderately obese with fatty liver, hyperlipidemia G2P2, C/S x1 No family history of GI, breast or gynecologic cancer; brother with testicular cancer

CASE PRESENTATION

6/26/14: Presents with a month of increasing bloating, without change in bowel. Has had persistent menses, irregular, followed by gynecologist and treated with progesterone 3 mos ago. Celiac disease was diagnosed 3 years ago & normally managed with diet. Symptoms initially felt like celiac, but progressed in spite of dietary change, and a trial of Gas-ex and Zantac. Bloating waking her at

• night. Acknowledges decreased food intake, no changes in urination

Exam: “Abdomen protuberant and slightly taut. Suprapubic tenderness

• n palpation.” Pelvic exam not performed.

Plan: Probiotic trial, CBC and pelvic US

7/7/14: Symptoms worsening. Now occasionally nauseated, more belching. Has not vomited, but eating very little. Symptoms now present for 6 weeks

Exam: Abdomen very distended and tympanic. Pelvic exam limited by distension, “uterus ill-defined, no focal mass.” Plan : Warning signs and symptoms of partial small bowel obstruction

• discussed. Orders for CT abdomen/pelvis, CBC, CMP, hCG, UA

CASE PRESENTATION

7/8/14: CT abdomen/pelvis

14 cm solid and cystic mass in mid-pelvis Abundant ascites, peritoneal stranding, and evidence of partial SBO Bilateral small pleural effusions

7/9/14: visit with PCP to review CT scan. Discusses plan to order CA 125 and possible need for paracentesis

CA 125 = 1411

7/10/14: Developing symptoms of partial SBO. Paracentesis performed, cytology reveals adenocarcinoma suspicious for gynecologic primary 7/15/14: Visit with SCCA Gynecologic Oncology.

CASE PRESENTATION

7/17/14: Undergoes ex-lap, hysterectomy, removal of tubes &

• varies, omentectomy, lymphadenectomy, cytoreduction and

intraperitoneal port placement

Pathology reveals IIIC high-grade serous carcinoma of the fallopian tube

Recommendations: IV & IP chemotherapy 12/29/14: Post-treatment visit at SCCA. Notes fatigue, numbness and tingling in fingertips. Intermittent constipation

CA 125 = 12 CT C/A/P shows small lymphocele, otherwise negative for recurrence Plan: discussed options for maintenance treatment & surveillance strategy. Schedule visit with Medical Genetics.

CASE PRESENTATION

Describe the patterns of care in treating

• varian cancer

OBJECTIVES

ESTIMATED NEW CANCER CASES/DEATHS UNITED STATES, 2014

Females

Estimated Deaths

Site

Estimated New Cases

Genital System — Uterine cervix — Uterine corpus — Ovary — Vulva — Vagina and other genital All Digestive System Respiratory System Skin (excluding basal/squamous) Breast 8 1 1 2

Siegel R et al. CA 2014

OVARIAN CANCER PATTERNS OF CARE

Incidence* Age-Adjusted Cancer Death Rate 1999 2011 % change 1990 2010 % change

Ovary

14.3 11.3

• 20%

9.5 8.1

• 14%

Breast

135.4 122.0

• 10%

31.7 21.9

• 31%

Colorectal**

48.4 34.9

• 28%

24.7 13.3

• 46%

Prostate

170.8 128.3

• 25%

38.6 21.8

• 44%

Siegel R et al. CA 2014

*Per 100,000 population **Female only

OVARIAN CANCER PATTERNS OF CARE

Thrall MM et al. Gynecol Oncol 2011 Bristow RE et al. Obstet Gynecol 2013 Cliby W et al. Gynecol Oncol 2015

Overall five-year survival rates for ovarian cancer have improved from 36% to 44%

This is not consistent for all patients Three large population-based studies have now shown that less than 50% of women with ovarian cancer in the US receive guideline therapy

Review the indications and options

• f screening for ovarian cancer in

the average and high-risk population OBJECTIVES

OVARIAN CANCER SCREENING CHALLENGES

Debatable precursor or in situ lesion Major surgical procedure required for diagnosis Even if only 1% of tests are false-positive, 25 women would require surgery for each diagnosed cancer Lifetime probability of developing ovarian cancer is <2%

USPSTF, ACOG & SGO do not recommend routine screening for ovarian cancer in an average risk patient

OVARIAN CANCER ESTIMATION OF RISK

The importance of identifying patients at high risk cannot be overemphasized Vignette-based survey of Ob/Gyns, internal medicine and family medicine physicians found that 2/3 of physicians underestimated the risk of ovarian cancer in a patient at much higher risk than the general population

Baldwin LM et al. J Gen Intern Med 2013

SCREENING FOR OVARIAN CANCER HIGH-RISK PATIENT

Definition of High Risk

Personal History

Premenopausal breast cancer

Family History

1st or 2nd degree relative with ovarian cancer at any age 1st degree relative with breast cancer <50, bilateral breast cancer or male breast cancer 1st degree relative with colon or uterine cancer <50

Genetic syndrome

BRCA 1 or 2 mutation Lynch syndrome

Reproductive factors

History of infertility or endometriosis

Lifetime risk estimated at 5% Lifetime risk 35-45% (BRCA1) 15-25% (BRCA2) Lifetime risk 10-12% Clear cell & endometrioid

• varian cancer

SCREENING FOR OVARIAN CANCER HIGH-RISK PATIENTS

For patients with an identified hereditary ovarian cancer syndrome, consider TVUS & CA 125 every 6-12 months starting at age 30-35 or 5-10 years before the earliest cancer diagnosis in a family member

SCREENING FOR OVARIAN CANCER HIGH-RISK PATIENTS

■ UK Familial Ovarian Cancer Screening Study ■ 3,563 women with ≥10% lifetime risk of ovarian cancer recruited for study ■ Screening every 4 months with CA 125 and TVUS ■ Of cancers detected, 30.8% stage I/II ■ Sensitivity of 75%, PPV 25.5%, NPV 99.9% ■ Risk-reducing salpingo-oophorectomy remains the standard of care

Rosenthal AN et al. J Clin Oncol 2013

PATTERNS OF CARE FOR HIGH RISK WOMEN

Trivers KF et al. Cancer 201

PATTERNS OF CARE FOR HIGH RISK WOMEN

Race – black, white Age – 35 vs 51 Insurance – private or Medicaid Level of risk

Vignette: A woman presents for an annual exam

VARIABLES

High Personal hx breast cancer age 30 Paternal grandmother ovarian cancer Paternal 1st cousin breast ca premenopausal Outcome: Referral to genetic counseling and/or offering BRCA1/2 testing (almost never, sometimes, almost always) Mom had breast cancer age 70 Average

PATTERNS OF CARE FOR HIGH RISK WOMEN

Referral for Genetic Counseling

Vignette Risk for Ovarian Cancer

Physicians

Average HIGH

Reported adherence to USPSTF guidelines

71% 41%

Correctly identified risk

61% 47%

OVARIAN CANCER RISK REDUCTION

OCP’s Tubal ligation Weight reduction? Education if history

• f endometriosis
• r infertility

Bilateral salpingectomy? Definitive reduction in risk with prophylactic bilateral salpingo-oophorectomy at 40 years or when childbearing is complete Shown to reduce both

• varian and breast

cancer mortality OCP’s, tubal ligation, bilateral salpingectomy

High risk Average risk

Describe the symptoms associated with ovarian cancer OBJECTIVES

When (and why) should ovarian cancer be on your differential?

SYMPTOMS AS SCREEN?

Previous survey of 1,725 women with ovarian cancer demonstrated prevalence of symptoms even in women with early stage disease

Abdominal/GI symptoms most common

Subsequent case-control study performed to assess symptoms

Preoperative survey given to 128 patients undergoing surgery for a pelvic mass 44 women within this group found to have ovarian cancer Identical survey given to 1709 women presenting to primary care clinic

Goff BA et al. Cancer 2000 Goff BA et al. JAMA 2004

RESULTS — PRIMARY CARE CLINICS SYMPTOMS OF OVARIAN CANCER

General checkup 25% Mammogram 13% Problem visits 62% 1,709 women in primary care clinic completed survey 95% reported at least 1 symptom in past year Back pain 60% Fatigue 52% Indigestion 37% Urinary symptoms 35% Constipation 33% Median number reported symptoms was 4 Median severity 2-3

OVARIAN CANCER SYMPTOMS WOMEN WITH AND WITHOUT CANCER

Excluding patients presenting for routine checkup or mammogram only

Symptom Cancer vs. Clinic Patient Cancer vs. IBS Patients Pelvic pain 2.2 (1.2-3.9) 2.6 (1.2-5.6) Abdominal pain 2.3 (1.2-4.4) 0.7 (0.3-1.5) Difficulty eating 2.5 (1.3-5.0) 1.5 (0.7-3.7) Bloating 3.6 (1.8-7.0) 3.0 (1.3-6.7) Abdominal size 7.4 (3.8-14.2) 4.6 (2.1-10.1) Urinary urgency 2.5 (1.3-4.8) 2.6 (1.2-5.7) Constipation 1.6 (0.9-3.0) 1.0 (0.5-2.2) Fatigue 1.4 (0.7-2.7) 1.1 (0.5-2.3) Diarrhea 0.7 (0.1-0.4) 0.2 (0.1-0.5)

MEDIAN EPISODES SYMPTOMS/MONTH SYMPTOMS OF OVARIAN CANCER

Symptom Ovarian CA (n=44) Primary Care Clinic (n=1600) p Pelvic pain 24 2 0.001 Abdominal pain 23 2 0.017 Bloating 30 2 0.004 Fatigue 30 8 0.001 Urinary symptoms 30 12 0.02 Constipation 12 2 0.001 Diarrhea 6 2 0.06

MEDIAN DURATION EACH SX IN MONTHS SYMPTOMS OF OVARIAN CANCER

Symptom Ovarian CA (n=44) Primary Care Clinic (n=1600) p Pelvic pain 3 11 0.06 Abdominal pain 5 11 0.05 Bloating 3 12 0.04 Fatigue 3 12 0.08 Urinary symptoms 3 13 0.13 Constipation 3.5 12 0.001 Diarrhea 5 12 0.001

POSSIBILITIES FOR EARLIER DETECTION DEVELOPMENT OF OVARIAN CANCER SYMPTOM INDEX

Prospective case-control study evaluated type and frequency

• f symptoms

Subsequent development of symptom index

Index considered (+) if: Abdominal/pelvic pain, abdominal size/bloating, difficulty eating or feeling full, urinary urgency/frequency If present <1 year and occurred >12 days/mon

Specificity of 86.7% in women >50, sensitivity of 56.7% for early stage disease

2.6% of general population screen (+)

Goff BA et al. Cancer 2007

SYMPTOM TRIGGERED SCREENING FEASIBILITY & ACCEPTABILITY

Prospective study of women >40

1,261 patients screened  if (+) referred for CA125 & TVS

Mean score of acceptability = 4.8 (1-5) 51 (4%) women had a positive SI

2 patients identified with ovarian cancer

All patients completed survey in <5 minutes

Goff BA et al. Gynecol Oncol 2012

USE OF SYMPTOM INDEX TO TRIGGER EVALUATION

In a prospective study, 5,012 women were enrolled to complete a symptom index (SI) assessment

SI

• Women >40 with at least one ovary

and not pregnant

SI+

• Those with positive SI offered CA 125

and TVUS

• CA 125 >35 considered abnormal

SEER

• 12 months after study completion, all participants

linked to Western Washington SEER to assess for diagnosis of ovarian cancer

SYMPTOM-TRIGGERED DIAGNOSTIC EVALUATION

Of the study cohort, at baseline 8% had IBS and 20% had GERD 241 (4.8%) had a positive SI

211 (88%) participated in additional testing with TVUS & CA 125 20 procedures were performed in study participants within 6 months of a positive SI

8 ovarian cancer cases detected

2 diagnosed within 6 months of the SI

1 had a positive SI and was diagnosed 31 days later with distant disease 1 had a negative SI; however she had a family history of ovarian cancer and was undergoing evaluation for a pelvic mass at the time of study participation

6 diagnosed 281-843 days after participation in the study

3 had early stage disease

Andersen MR et al. Obstet Gynecol 2014

SYMPTOM-TRIGGERED DIAGNOSTIC EVALUATION

Evaluation resulted in 0.4% patients undergoing surgery Very low number of ovarian cancer cases diagnosed within 6 months of symptom index completion Long-term follow-up identified 6 cancers

Possible that study participation provided women with education about ovarian cancer symptoms, spurring them to seek evaluation

• f subsequent symptoms

Real value may lie in its ability to act indirectly as an educational tool

Andersen MR et al. Obstet Gynecol 2014

SYMPTOM TRIGGERED SCREENING COMBINATION WITH BIOMARKERS

The symptom index may have improved sensitivity and specificity if combined with biomarkers Prospective evaluation of 74 women with ovarian cancer and 137 healthy controls

Symptom index (administered pre-diagnosis to cancer patients) CA 125 & HE4

When symptom index plus CA125 or HE 4 was positive, this yielded specificity of 98% for ovarian cancer

MR Andersen et al. Gynecol Oncol 2010

American Cancer Society now recommends that women see their doctor if they experience symptoms of:

Abdominal swelling or bloating Pelvic pressure or pain Difficulty eating or feeling full Problems with urination

Not all symptoms = ovarian cancer, but consider it on your differential!

REVIEWING THE SYMPTOMS…

List what tests to order when ovarian cancer is on your differential OBJECTIVES

WHEN CONSIDERING OVARIAN CANCER ON YOUR DIFFERENTIAL FOR THE PATIENT WITH SYMPTOMS

Labs

CA 125

Consider poor specificity of this test in premenopausal women! Presence of other conditions that can increase CA 125

HE4

Increased sensitivity for ovarian cancer compared with CA 125 More often expressed in endometrioid and clear cell tumors compared with CA 125

Clarke-Pearson DL. N Engl J Med 2009

Endometriosis Uterine leiomyoma Cirrhosis (with

• r without ascites)

Pelvic inflammatory disease Cancer of the endometrium

• r pancreas

Presence of pleural

• r peritoneal fluid

from any cause (e.g. CHF)

WHEN CONSIDERING OVARIAN CANCER ON YOUR DIFFERENTIAL FOR THE PATIENT WITH SYMPTOMS

Pelvic exam?

Evidence does not support the use of a pelvic exam to screen patients for ovarian cancer However, exam may reveal findings that impact diagnostic evaluation (e.g. pelvic mass, lymphadenopathy, ascites) or identify other cause of symptoms

Transvaginal ultrasound  Presence of mass?

Free fluid in pelvis, ascites Solid component Thick septations Peritoneal masses

Bloomfield HE et al. Ann Intern Med 2014 Myers ER et al. AHRQ Publication No. 06-E004

WHEN CONSIDERING OVARIAN CANCER ON YOUR DIFFERENTIAL… FOR THE PATIENT WITH A PELVIC MASS

CA 125

Consider poor sensitivity of this test in a premenopausal woman

HE4

FDA approved to be performed in combination with pelvic US & CA 125 in the Risk of Ovarian Malignancy Algorithm (ROMA)

OVA-1

Multivariate serum assay FDA approved to assess risk of malignancy in a patient with a pelvic mass

WHEN CONSIDERING OVARIAN CANCER ON YOUR DIFFERENTIAL… FOR THE PATIENT WITH A PELVIC MASS Transvaginal ultrasound

Most cost-effective No exposure to radiation

CT abdomen/pelvis

Presence of ascites

CONSIDERATION FOR REFERRAL OF A PATIENT WITH AN ADNEXAL MASS TO GYNECOLOGIC ONCOLOGY

Premenopausal (<50)

CA 125 > 200 U/mL Ascites Evidence of abdominal or distant metastasis (by results

• f exam or imaging study)

Family history of breast

• r ovarian cancer in a first

degree relative

ACOG Practice Bulletin No. 83, July 2007 (Reaffirmed 2013)

Postmenopausal

Elevated CA 125 levels Ascites Nodular or fixed pelvic mass Evidence of abdominal or distant metastasis (by results

• f exam or imaging study)

Family history of breast

• r ovarian cancer

in a first-degree relative

Treatments associated with improved survival in ovarian cancer

Optimal surgical cytoreduction Platinum-based chemotherapy

Care of ovarian cancer patients by gynecologic oncologists is associated with improved survival Patients treated by gynecologic oncologists more likely to undergo primary surgery and chemotherapy

ROLE OF THE GYNECOLOGIC ONCOLOGIST

Earle CC et al. J Natl Cancer Inst 2006 Chan JK et al. Obstet Gynecol 2007

SURGICAL OUTCOMES AS A PROGNOSTIC FACTOR

99 months 36 months 29.6 months

0% 25% 50% 75% 1 00% 1 2 24 36 48 60 72 84 96 1 08 1 20 1 32 1 44 0% 25% 50% 75% 1 00% 1 2 24 36 48 60 72 84 96 1 08 1 20 1 32 1 44

0 mm 1-10 mm >10 mm 0 mm 1-10mm >10 mm

Progression-Free Survival Overall Survival

% PFS Months % OS Months 29.6 months 36 months 99 months

1-10 mm vs. 0 mm: >10 mm vs. 1-10 mm: log-rank: P < 0.0001 HR (95%CI) 2.52 (2.26-2.81) 1.36 (1.24-1.50) 1-10 mm vs. 0 mm: >10 mm vs. 1-10 mm: log-rank: P < 0.0001 HR (95%CI) 2.70 (2.37-3.07) 1.34 (1.21-1.49)

du Bois AI et al. Cancer. 2009

Involvement of Gynecologic Oncologists in Treatment of Patients with Suspicious Ovarian Mass

3,200 physicians surveyed in 2009 Vignette-based survey of a 57 year old with pain, bloating, suspicious right adnexal mass and ascites Referral to Gyn Onc: FP 39.3% IM 51.0% Ob/Gyns 66.3% Among Ob/Gyns, 33.7% performed the primary surgery Factors associated with not referring

Medicaid insurance Weekly average of 90+ patients Rural or solo practice

ROLE OF THE GYNECOLOGIC ONCOLOGIST

Goff et al. Gynecol Oncol 2011

Discuss the surveillance and management

• f ovarian cancer patients after treatment

OBJECTIVES

WHAT HAPPENED IN BETWEEN?

Cytoreductive surgery

Bowel resection Risk for infection following splenectomy Postoperative pain Surgical menopause Complications?

VTE Wound issues

Chemotherapy

Neuropathy Fatigue Gastrointestinal issues Bone marrow suppression Depression

WHAT HAPPENS NOW?

Maintenance Surveillance Performance

MAINTENANCE

Refers to prolonged therapy to increase the probability

• f remaining in remission

Options

Additional chemotherapy Biologic agents Clinical trial

Please encourage patients to speak to their oncologist regarding any options for maintenance treatment

SURVEILLANCE NCCN recommendations for surveillance

Visit and physical exam Tumor markers

CA 125 if initially elevated HE4  also FDA approved for monitoring for recurrent

• r progressive disease

Imaging as clinically indicated

Salani et al. Am J Obstet Gynecol 2011

SURVEILLANCE

PATTERNS OF RECURRENCE

26-50% of recurrences

• ccur in the pelvis

Other common sites

Retroperitoneal lymph nodes Upper abdomen Lungs

Rare sites of metastases

Brain Cutaneous

Symptoms

Can be similar as initial presentation Bowel obstruction Shortness of breath

SURVEILLANCE

Referral of ALL patients with epithelial ovarian cancer for genetic counseling and testing In a study of Canadian patients with high-grade serous ovarian cancer, referral for genetic counseling based on family history alone would have missed 35% of mutation carriers

Schrader KA et al. Obstet Gynecol 2011

PERFORMANCE WHAT ARE PATIENTS EXPERIENCING?

Survey of 100 patients with ovarian cancer

Symptoms with highest frequency and severity

Emotional symptoms Negative feelings about treatment or prognosis Fatigue Pain

Frequent symptoms (variable severity)

Dyspareunia Neurologic symptoms (cognitive impairment, neuropathy)

Less frequent, more severe symptoms

Socio-economic concerns Negative body image Insomnia

Stavraka C et al. Gynecol Oncol 2012

PERFORMANCE SYMPTOM MANAGEMENT

Fatigue Neurotoxicity

Most often due to chemotherapy Numbness & weakness in hands, discomfort in feet, muscle cramps

GI toxicity

Can be due to both surgery and chemotherapy Risk of bowel obstruction

May be herald of recurrent disease

Abdominal pain, diarrhea and/or constipation

Lymphedema Gynecologic

Menopause Sexual dysfunction

Mirabeau-Beale KL et al. Gynecol Oncol 2009

PERFORMANCE SYMPTOM MANAGEMENT

Neurotoxicity

Gabapentin CAM: Vitamin B6 complex, L-glutamine

Lymphedema

Compression stockings Physical therapy, manual decompression treatment

Gynecologic

Consider either systemic or local estrogen replacement therapy Venlafaxine for vasomotor symptoms

Mirabeau-Beale KL et al. Gynecol Oncol 2009 Ibeanu O et al. Gynecol Oncol 2011

PERFORMANCE SURVIVORSHIP AND PHYSICAL HEALTH

Fatigue

Estimated to occur in 70-100% of patients with cancer Can be due to anemia, malnutrition, medications, depression, insomnia May also contribute to cognitive dysfunction Encourage exercise!

Participating in physical activity has been associated with a lower risk

• f ovarian cancer mortality

Zhou Y et al. Gynecol Oncol 2014

PERFORMANCE SURVIVORSHIP – MENTAL AND EMOTIONAL HEALTH

“Chemo brain”

Studies have shown variable rates of cognitive dysfunction following therapy for ovarian cancer Consider relaxation techniques, physical exercise programs, “brain training” Avoid continuing benzodiazepines!

Psychological effects

In a prospective study of ovarian cancer patients, depression levels were found to decrease 3 months after chemotherapy, however levels

• f anxiety were found to increase

Cognitive behavioral therapy, antidepressant/antianxiety medication

Hipkins J et al. Br J Health Psychol 2004

SURVIVORSHIP PLAN

In 2006, the Institute of Medicine (IOM) met to review the challenge of the growing number of cancer survivors

• utstripping capacity of providers

IOM recommended that cancer patients should have a treatment summary and follow-up care plan  the survivorship care plan Unclear if these plans impact care

Prospective study in patients with gynecologic cancers found no difference in evaluation of health services and satisfaction

Institute of Medicine of the National Academies: Cancer Survivorship Care Planning Brothers BM et al. Gynecol Oncol 2013

A patient discloses that her sister has been diagnosed with ovarian cancer at the age of 52. I would consider screening this patient for breast cancer and ovarian cancer

True False

AUDIENCE RESPONSE QUESTION #1

64

A 57 yo patient presents with bloating and urinary problems. A pelvic ultrasound reveals free fluid and a complex adnexal mass. You consider referral to one of the following:

Ob/Gyn Surgical Oncology Gynecologic Oncology General Surgery Hematology/Oncology

AUDIENCE RESPONSE QUESTION #2

65

Following the conclusion of treatment, patients with ovarian cancer have less depression, but more anxiety

Yes No Don’t Know

AUDIENCE RESPONSE QUESTION #3

66

Primary care providers are crucial to both the diagnosis and management of ovarian cancer patients

Identification of patients at high risk for ovarian cancer Recognize symptoms that may indicate ovarian cancer on a differential Evaluation & diagnosis of a patient with possible

• varian cancer

Referring patient with concerning history and/or findings to a gynecologic oncologist Discussing genetic counseling with patients with a concerning medical history and/or diagnosis of

• varian cancer

SUMMARY

67

PROVIDER AND PATIENT RESOURCES

Survivorship Clinic at the Seattle Cancer Care Alliance Society for Gynecologist Oncologists

www.sgo.org

National Cancer Comprehensive Network Marsha Rivkin Center for Ovarian Cancer Research Foundation for Women’s Cancer

www.foundationforwomenscancer.org

Ovarian Cancer Together

http://www.ovariancancertogether.org/Pages/FriendsTOGETHERWA.aspx

Schrader KA et al. Obstet Gynecol 2011

DIVISION OF GYNECOLOGIC ONCOLOGY UNIVERSITY OF WASHINGTON

Barbara Goff, MD Heidi Gray, MD Benjamin Greer, MD Hisham Tamimi, MD Elizabeth Swisher, MD John Liao, MD, PhD Renata Urban, MD Barbara Norquist, MD Barbara Silko, ARNP Listya Shah, PA-C

Questions? We are available 24-7 through MedCon (206) 520-5000 or 1 (877) 520-5000 Referrals? (206) 288-7155

QUESTIONS?

Renata Urban, MD

urbanr@uw.edu (206) 543-3669 or (206) 288-2025

71

Annual transvaginal ultrasound scan (TVS) and CA125 screening.

Adam N. Rosenthal et al. JCO 2013;31:49-57

RISK OF OVARIAN CA IN WOMEN WITH SYMPTOMS IN PRIMARY CARE

212 ovarian cancer patients with 1,060 matched controls Charts photocopied and anonymously scored for symptoms 85% of cancer cases and 15% of controls had one

• f 7 symptoms

Abdominal distension, urinary frequency and abdominal pain were significantly associated with ovarian cancer, even at 6 months prior to diagnosis

Hamilton W et al. BMJ 2009

Population-Based Case-Control Study

Pilot project involving public dissemination of information regarding ovarian cancer symptoms 1455 Canadian patients underwent CA 125, followed by TVUS

16% had abnormal initial test result Only one patient underwent surgery who was found to have benign disease 72% patients with ovarian cancer had complete resection

OPEN ACCESS SYMPTOMS SCREENING

The DOvE Study

Gilbert et al. Lancet Oncol 2012.

REFERRALS/CONSULTS FOR OVARIAN CANCER BY FPS OR IMS MULTIVARIATE REGRESSION

Goff BA et al. Obstet Gynecol 2011.

Other vs Solo Group vs Solo Int Med vs Fam Med Female vs Male MD Urban vs Rural Practice 61–90 vs ≥91 1–60 vs ≥91 Private Ins vs Medicaid Afr Amer vs Cauc

Practice Type: Average # Patients/wk:

1 2

Risk Ratio (95% Confidence Interval)

URBAN Ovarian Cancer URBAN

URBAN Ovarian Cancer URBAN

URBAN Ovarian Cancer URBAN