How are symptoms of ovarian cancer managed?

BACKGROUND:

A study was undertaken to identify the diagnostic approaches that primary care physicians and gynecologists undertake in women with symptoms associated with ovarian cancer.

METHODS:

A vignette‐based survey was mailed to 3200 primary care physicians from the American Medical Association Physician Masterfile. The vignette described a 55‐year‐old woman with symptoms associated with ovarian cancer, although ovarian cancer was never mentioned. The authors evaluated patient, physician, and practice characteristics associated with a workup that could detect ovarian cancer.

RESULTS:

The survey response rate was 61.7%. After exclusions, 1532 physicians were included. Overall, 89.5% of physicians reported that they would recommend testing that can detect ovarian cancer (71.2% ultrasound; 25.4% pelvic computed tomography; 26.5% CA125). In adjusted analysis, the only patient factor associated with ovarian cancer testing was symptom type, genitourinary versus gastrointestinal (risk ratio, 1.07; 95% confidence interval, 1.03‐1.11). Physician and practice characteristics associated with recommending of ovarian cancer testing included specialty (gynecologists > family physicians and internists); type of practice (group > solo); clinical teaching (yes > no); and within Census division, location of practice, with all Central (East, West, North, and South) and Atlantic (Middle and South) areas having a lower likelihood than New England.

CONCLUSIONS:

On the basis of a vignette in which a woman reported symptoms associated with ovarian cancer, the majority of primary care physicians and gynecologists would not recommend CA125, but would recommend imaging of the pelvis. Gynecologists, physicians involved with clinical teaching, and those in group practices were significantly more likely to recommend testing that could lead to an ovarian cancer diagnosis. Cancer 2011;. © 2011 American Cancer Society.     

Are the symptoms of cancer and cancer treatment due to a shared biologic mechanism? A cytokine-immunologic model of cancer symptoms

BACKGROUND: Cancers and cancer treatments produce multiple symptoms that collectively cause a symptom burden for patients. These symptoms include pain, wasting, fatigue, cognitive impairment, anxiety, and depression, many of which co-occur. There is growing recognition that at least some of these symptoms may share common biologic mechanisms. METHODS: In November 2001, basic and clinical scientists met to consider evidence for a cytokine-immunologic model of symptom expression along with directions for future research. RESULTS: The characteristics of cytokine-induced sickness behavior in animal models have much in common with those of symptomatic cancer patients. Sickness behavior refers to a set of physiologic and behavioral responses observed in animals after the administration of infectious or inflammatory agents or certain proinflammatory cytokines. In some cases, these responses can be prevented by cytokine antagonists. A combination of animal and human research suggests that several cancer-related symptoms may involve the actions of proinflammatory cytokines. CONCLUSIONS: Based on the similarities between cancer symptoms and sickness behavior, the authors discussed approaches to further test the implications of the relationship between inflammatory cytokines and symptoms for both symptom treatment and symptom prevention.     

Declining cancer incidence at the oldest ages: Hallmark of aging or lower diagnostic activity?

BackgroundThe incidence of most cancers increases with age from early adulthood into old age but tends to level off or decrease at the highest ages. This decline may be caused by age-related mechanisms or due to lower diagnostic activity, leaving some cancers undiagnosed at the oldest ages.MethodsFor breast, colon, lung, and all sites except non-melanoma skin cancer, age-specific incidence rates of verified as well as suspected cancer were estimated up to ages 95+ years for a random sample of the Danish population, 1994–2011, based on nationwide health registers (40,008 verified and 9110 suspected cancers). Moreover, for cancers diagnosed in Denmark, 1978–2012 (613,384 cancers), age-specific percentages of tumors with microscopic verification (histological/cytological/hematological examination) were calculated.ResultsThe age-specific cancer incidence rates reached a peak between ages 65–89 years after which rates declined. The corresponding incidence pattern of suspected but not verified cancer was similar, with a trend of a slight absolute and relative decrease with age compared to verified cancer incidence. The proportion of cancers with microscopic verification decreased linearly from approximately 95% at ages 0–69 years all years to 70% (1978–1982) and to 80% (2010?2012) at ages 90+ years.ConclusionsThe lower diagnostic verification of cancer at the highest ages suggests a lower diagnostic activity among the oldest-old. However, the proportion of suspected but not verified cancers did not increase with age, possibly partially due to lack of registration. The declining cancer incidence at oldest ages is probably partly due to lower diagnostic activity.     

What is the role of neoadjuvant chemotherapy in the management of ovarian cancer?

Aggressive cytoreductive surgery followed by aggressive chemotherapy is the standard of care for advanced-stage ovarian cancer patients, among whom the greatest survival benefit is seen in those with no gross disease left after the initial surgical cytoreduction. Since this represents only 23% of stage III patients and 8% of stage IV patients, alternative strategies for patients who do not appear to be surgically cytoreducible to no macroscopic residual disease need to be identified. Neoadjuvant chemotherapy, which may offer a variety of benefits in this population, is one such strategy that is being evaluated in prospective randomized trials. This article reviews the current status of neoadjuvant chemotherapy for the management of women with advanced-stage ovarian cancer.     

Molecular aspects of ovarian cancer. Is gene therapy the solution?

Genetic abnormalities of cancer cells are complex and usually nonspecific. Genetic anomalies specific to ovarian cancer have not been reported. This article focuses on what molecular anomalies are known in ovarian cancer and describes the first trials that have used transfer of genes to reestablish a normal cellular function in this disease. Suicide gene therapy has been the prototype of this new therapeutic approach.     

Is there place for radiotherapy in the treatment of advanced ovarian cancer?

BACKGROUND AND PURPOSE: Irradiation of advanced ovarian cancer has been performed during the years 1976-1984 with six-field technique. Results of this treatment in a long follow-up have never before been evaluated. MATERIAL AND METHODS: Seventy-five patients with stage IIb-IV of invasive ovarian cancer have been treated with a combination of surgery, radiotherapy and chemotherapy. The results of the treatment were compared with 98 patients treated during the year 1991-1992 with surgery and chemotherapy only. RESULTS: After controlling for the differences in background factors between the groups considered, there was still a significantly better survival rate for the patients treated with radiotherapy. CONCLUSION: The results suggest that the role of radiotherapy in advanced ovarian cancer should be investigated in a prospective randomized trial.     

What is the role of ovarian ablation in the management of primary and metastatic breast cancer today?

Ovarian ablation has been used for more than a century in the treatment of breast cancer. Methods of irreversible ovarian ablation include surgical oophorectomy and ovarian irradiation. Potentially reversible castration can be accomplished medically using luteinizing hormone releasing hormone (LHRH) analogues. In addition, cytotoxic chemotherapy unpredictably produces amenorrhea and primary ovarian failure in 10%-95% of premenopausal women as a function of patient age, cumulative dose, and the specific agents used. In the metastatic setting, ovarian ablation and tamoxifen monotherapies produce comparable outcomes and may be more effective when used together. While many early adjuvant trials of ovarian ablation were methodologically flawed, a more recent meta-analysis by the Early Breast Cancer Trialists' Collaborative Group of 12 properly designed randomized trials found significantly greater disease-free and overall survival rates for women under the age of 50, regardless of nodal status, receiving ovarian ablation as a single adjuvant therapy. Several important issues regarding the role of ovarian ablation in the treatment of breast cancer remain unresolved. Data suggest that ovarian ablation followed by some years of tamoxifen produces similar results to those seen with adjuvant chemotherapy in women with hormone-receptor positive breast cancer; however, the value of combining these modalities is still unclear. Other areas of ongoing investigation include the appropriate duration of therapy with LHRH analogues in the adjuvant setting, the long-term sequelae of ovarian suppression among young breast cancer survivors, and refinement of the population most likely to benefit from ovarian ablation or suppression.     

Prophylactic salpingectomy for the prevention of ovarian cancer: Who should we target?

Ovarian cancer is the most fatal gynecologic malignancy (50% 5-year survival) due to a typically advanced stage at diagnosis and a high rate of recurrence. Chemoprevention options are limited, and few interventions have been shown to reduce cancer risk or mortality. Emerging data support the model that fallopian tubes are the site of origin for a proportion of high-grade serous cancers. This implies that a subset of cancers may be prevented by removing the fallopian tubes while leaving the ovaries intact. Accordingly, there has been shift in clinical practice for average risk women; some now recommend removal of both the fallopian tubes only instead of tubal ligation for sterilization or at the time of benign gynecologic surgery. This has been termed opportunistic salpingectomy and represents a means of decreasing the burden of ovarian cancer by preventing cancers that arise in the fallopian tubes. There have been no detailed, prospective reports that have estimated ovarian cancer risk reduction with opportunistic salpingectomy, neither among women at baseline population risk nor among women at a high risk of developing the disease. The situation is complicated for women with a BRCA mutation—bilateral salpingo-oophorectomy is a proven means of risk reduction and salpingectomy alone is not the standard of care. Based on the existing data, salpingectomy alone should only be reserved for women with a lifetime risk of ovarian cancer of less than 5%.     

Intraperitoneal chemotherapy for frontline ovarian cancer therapy: Vindicated or vilified?

Conclusions A regimen of IV paclitaxel plus IP cisplatin and paclitaxel improves both PFS and OS in patients with optimally cytoreduced stage III ovarian cancer relative to IV cisplatin and paclitaxel.