UW MEDICINE │ ONCOLOGY REGIONAL CARE ADVANCEMENT SYMPOSIUM (ORCA) ENCOUNTERING OVARIAN CANCER IN THE PRIMARY CARE SETTING RENATA URBAN, MD MARCH 7, 2015
AUDIENCE RESPONSE QUESTION #1 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 2
Ovarian Cancer URBAN URBAN
AUDIENCE RESPONSE QUESTION #2 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 4
Ovarian Cancer URBAN URBAN
AUDIENCE RESPONSE QUESTION #3 Following the conclusion of treatment, patients with ovarian cancer have less depression, but more anxiety Yes No Don’t Know 6
Ovarian Cancer URBAN URBAN
DISCLOSURE I am the PI of a research study that is supported by Vermillion, Inc. I have no other financial obligations to disclose
OBJECTIVES Describe the patterns of care in treating ovarian 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 of ovarian cancer patients after treatment
CASE PRESENTATION 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 on 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 & ovaries, 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.
OBJECTIVES Describe the patterns of care in treating ovarian cancer
ESTIMATED NEW CANCER CASES/DEATHS UNITED STATES, 2014 Females Estimated Estimated Site New Cases Deaths All 8 Digestive System 1 Respiratory System 1 Skin (excluding basal/squamous) Breast 2 Genital System — Uterine cervix — Uterine corpus — Ovary — Vulva — Vagina and other genital Siegel R et al. CA 2014
OVARIAN CANCER PATTERNS OF CARE Age-Adjusted Cancer Incidence* Death Rate % % 1999 2011 1990 2010 change change 14.3 11.3 -20% 9.5 8.1 -14% Ovary 135.4 122.0 -10% 31.7 21.9 -31% Breast 48.4 34.9 -28% 24.7 13.3 -46% Colorectal** 170.8 128.3 -25% 38.6 21.8 -44% Prostate *Per 100,000 population **Female only Siegel R et al. CA 2014
OVARIAN CANCER PATTERNS OF CARE 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 Thrall MM et al. Gynecol Oncol 2011 Bristow RE et al. Obstet Gynecol 2013 Cliby W et al. Gynecol Oncol 2015
OBJECTIVES Review the indications and options of screening for ovarian cancer in the average and high-risk population
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 Lifetime risk Definition of High Risk estimated Personal History at 5% 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 Lifetime risk BRCA 1 or 2 mutation 35-45% (BRCA1) Lynch syndrome 15-25% (BRCA2) Reproductive factors History of infertility or endometriosis Lifetime risk 10-12% Clear cell & endometrioid ovarian 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 Vignette: A woman presents for an annual exam VARIABLES Race – black, white Age – 35 vs 51 Insurance – private or Medicaid Level of risk Average Mom had breast cancer age 70 Personal hx breast cancer age 30 Paternal grandmother ovarian cancer High Paternal 1st cousin breast ca premenopausal Outcome: Referral to genetic counseling and/or offering BRCA1/2 testing (almost never, sometimes, almost always)
PATTERNS OF CARE FOR HIGH RISK WOMEN Referral for Genetic Counseling Vignette Risk for Ovarian Cancer Average HIGH Physicians Reported adherence 71% 41% to USPSTF guidelines 61% 47% Correctly identified risk
OVARIAN CANCER RISK REDUCTION Average risk High risk OCP’s Definitive reduction in risk with prophylactic Tubal ligation bilateral salpingo-oophorectomy Weight reduction? at 40 years or when childbearing Education if history is complete of endometriosis Shown to reduce both or infertility ovarian and breast Bilateral salpingectomy? cancer mortality OCP’s, tubal ligation, bilateral salpingectomy
OBJECTIVES Describe the symptoms associated with ovarian cancer 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 1,709 women in primary care clinic completed survey General checkup 25% Mammogram 13% Problem visits 62% 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
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