Skip to Main Content

Role of Surgery in High-risk Ovarian Cancer

January 11, 2021
  • 00:00Support for Yale Cancer Answers
  • 00:02comes from AstraZeneca, a
  • 00:04biopharmaceutical business that is
  • 00:06pushing the boundaries of science
  • 00:09to deliver new cancer medicines.
  • 00:12More information at astrazeneca-us.com.
  • 00:15Welcome to Yale Cancer Answers with
  • 00:17your host doctor Anees Chagpar.
  • 00:20Yale Cancer Answers features the
  • 00:22latest information on cancer care by
  • 00:24welcoming oncologists and specialists
  • 00:25who are on the forefront of the
  • 00:28battle to fight cancer. This week,
  • 00:30it's a conversation about the role
  • 00:32of surgery in high risk ovarian
  • 00:34cancer with Doctor Mitchell Clark.
  • 00:36Doctor Clark is an assistant professor
  • 00:38of obstetrics and gynecology in the
  • 00:40division of Gynecological Oncology at
  • 00:42Yale University School of Medicine,
  • 00:43where Doctor Chagpar is
  • 00:45a professor of surgical oncology.
  • 00:48Dr. Clark, maybe we can start off by talking
  • 00:51a little bit about ovarian cancer.
  • 00:53Many people talk about this as
  • 00:56the cancer that whispers, tell us more about
  • 00:58that.
  • 00:59Although ovarian cancer is not the
  • 01:01most common gynecological cancer
  • 01:03that we encounter in our specialty,
  • 01:05it is unfortunately the cancer that
  • 01:07accounts for the greatest morbidity
  • 01:09as well as the greatest mortality
  • 01:11among the diseases that we do treat.
  • 01:13You're absolutely right in saying that
  • 01:15this is the cancer that whispers because
  • 01:18unlike a lot of the other
  • 01:20cancers we see in our practice,
  • 01:22the symptoms of ovarian cancer are
  • 01:23very nonspecific and often very vague.
  • 01:25Tell us more about
  • 01:28what those symptoms might be,
  • 01:29because I'm sure that there are
  • 01:31listeners out there going great,
  • 01:33so there's a cancer that is
  • 01:35potentially lethal that has
  • 01:37symptoms that are really vague.
  • 01:39How am I gonna know if I have this?
  • 01:41Absolutely, for
  • 01:43the most part, these symptoms occur as the
  • 01:46ovarian tumors grow and as you can imagine,
  • 01:48it starts off with a very small tumor
  • 01:50and progressives to something that
  • 01:52causes a lot of pressure in the pelvis.
  • 01:54So I tell women anytime you feel
  • 01:56that there's pain or pressure
  • 01:58in the pelvis or in the abdomen,
  • 02:00that's something that's concerning and should
  • 02:02be brought up with your gyencologist.
  • 02:04Beyond that, we do tell women to be
  • 02:06aware of any changes in their weight,
  • 02:09either weight loss or
  • 02:09weight gain, and sometimes it
  • 02:11can be as simple as something as
  • 02:13bloating or a bit of constipation
  • 02:15that is just out of characteristic from what
  • 02:18they have been experiencing in the past.
  • 02:20We do know that ovarian cancer tends
  • 02:22to occur in women as they get older,
  • 02:25particularly those who are
  • 02:26past menopause.
  • 02:27However,
  • 02:27there still can be many cases of
  • 02:29ovarian cancer in women that are
  • 02:31younger than the menopausal status,
  • 02:33and it's important to keep this in
  • 02:35mind when gynecologists as well as
  • 02:37primary care physicians are seeing
  • 02:39patients with these vague symptoms.
  • 02:52There are some rare
  • 02:54types of ovarian cancer that behave very
  • 02:57differently than the more common types
  • 03:00that we see in the older population,
  • 03:02and these can happen in young girls.
  • 03:05So it is important that mothers and young
  • 03:08daughters present to their pediatrician
  • 03:10with any of these similar complaints
  • 03:13related to increase in abdominal
  • 03:14pain or a bit of bloating,
  • 03:16or noticing something
  • 03:19uncharacteristic compared to what it has
  • 03:21perhaps been in the past as they were
  • 03:23developing as an adolescent.
  • 03:26Doctor Clark when we
  • 03:27think about all of these symptoms,
  • 03:29especially around
  • 03:31the holiday time, it's pretty
  • 03:33common to get a little
  • 03:35bit of weight gain or in some
  • 03:38of our cases a lot of weight gain,
  • 03:40a little bit of bloating,
  • 03:42a little bit of constipation.
  • 03:44When is there a trigger point at
  • 03:46which you say, this has
  • 03:48been going on for X amount of time,
  • 03:50I need to go and see the doctor,
  • 03:52or is it really
  • 03:54kinda see how it goes and if it gets
  • 03:56to a point that's concerning to you,
  • 03:58that's when you should see a doctor.
  • 04:00Can you give us a little bit of a clue?
  • 04:03Because some of these are so non specific,
  • 04:05I'm sure all of our listeners
  • 04:06are listening to this going,
  • 04:08yep, I've had weight gain,
  • 04:09I've had Constipation, I've had bloating.
  • 04:11Oh my God,
  • 04:12do I have an ovarian tumor?
  • 04:14This is something that we're hearing
  • 04:16very commonly or especially now
  • 04:18during Covid with many people at
  • 04:20home tending not to be as active,
  • 04:22perhaps as they were before Covid.
  • 04:24Many of the gyms and fitness regimens that
  • 04:26our listeners were probably more engaged
  • 04:28with pre covid are just not available,
  • 04:31so we are finding patients
  • 04:32coming in with these concerns,
  • 04:34especially related to the
  • 04:35bloating and weight gain.
  • 04:37I tend to tell women that if they experience
  • 04:39these symptoms that persist despite
  • 04:41changes in their diet or perhaps
  • 04:44their level of exercise that go
  • 04:45beyond a few weeks to a month,
  • 04:47these are things that should
  • 04:49be brought to the attention of
  • 04:50their primary care doctor,
  • 04:51or they're gynecologist
  • 04:53especially because these are very
  • 04:54vague symptoms and I don't want
  • 04:56to alarm our listeners and to say
  • 04:57that everyone with Constipation or
  • 04:59everyone with a bit of bloating is
  • 05:01likely to have an ovarian tumor,
  • 05:02but I think it is important for both
  • 05:04the patient and the provider to keep
  • 05:06these things in the back of their
  • 05:08head as we try to identify as many
  • 05:10women as possible in the early stages
  • 05:12of this very challenging disease.
  • 05:14And do you find that people with
  • 05:17ovarian tumors tend to present with
  • 05:19things that may signal
  • 05:21a loss of ovarian function?
  • 05:23Often times when we have tumors
  • 05:25in various parts of the body,
  • 05:28it'll affect the actual
  • 05:30functioning of that organ.
  • 05:31So when we think about ovaries and we
  • 05:34think about production of estrogen,
  • 05:36for example, people may
  • 05:38have hot flashes, and so on and so
  • 05:41forth as they go through menopause.
  • 05:43But with ovarian cancer, if you
  • 05:46don't have those symptoms,
  • 05:47does that mean that that's likely OK?
  • 05:49Or how often would you find
  • 05:52people presenting with an ovarian
  • 05:53tumor that actually presents with
  • 05:55things like hot flashes and vaginal
  • 05:57dryness and things like that?
  • 06:02For the most part, these tumors do occur in women
  • 06:04as they have exited menopause
  • 06:06and so the ovarian function is
  • 06:08already at baseline, quite low.
  • 06:10But even in those women who are still
  • 06:12having regular menstrual periods,
  • 06:14who are perhaps in their late
  • 06:1630s or early 40s?
  • 06:18We haven't seen as much of a
  • 06:20relationship between the hormonal
  • 06:22status in the hormonal symptoms
  • 06:24and a link between that in an
  • 06:27underlying ovarian pathology.
  • 06:28So so important for people
  • 06:30to recognize that because they
  • 06:32may be saying to themselves,
  • 06:34while I'm not having
  • 06:36hot flashes, I'm not
  • 06:38having tremendous pain,
  • 06:40but it really is a cancer that
  • 06:42whispers the other question that
  • 06:44our listeners may have is if you've
  • 06:47had a history of ovarian cysts,
  • 06:49often times people have gone
  • 06:51to the gynecologist and maybe
  • 06:53had an ultrasound or something,
  • 06:56and they've been told, oh
  • 06:57you've got ovarian cysts.
  • 06:59Does that increase their risk of
  • 07:01ovarian cancer?
  • 07:04So ovarian cysts are a very normal part of every woman's menstrual
  • 07:06history and reproductive history.
  • 07:08Every time the cycle occurs,
  • 07:10a cyst develops on the ovary and should
  • 07:13regress after each menstrual cycle.
  • 07:15What's important to remember is that
  • 07:18as women exit menopause and are no
  • 07:20longer having regular menstrual periods,
  • 07:22cysys should not form
  • 07:24regularly, and they should certainly
  • 07:26not progress and become larger and
  • 07:28more complex appearing on ultrasound
  • 07:30or any sort of imaging.
  • 07:32So just because a woman has had this in
  • 07:34the past does not necessarily mean that
  • 07:37she will go on to develop an ovarian cancer,
  • 07:40but it is important for women who do
  • 07:43have cysts, that may have suspicious
  • 07:45findings on imaging that she follows
  • 07:47regularly with her gynecologist to
  • 07:49decide if and when it merits a referral
  • 07:51to an oncologist for a more specialized opinion.
  • 07:54Are there any women who
  • 07:56are particularly at risk of getting
  • 07:58ovarian cancer, or is this kind
  • 08:00of an equal opportunity killer?
  • 08:02There are a number of risk factors that
  • 08:05make a woman more likely to experience
  • 08:07an ovarian cancer in her lifetime.
  • 08:09One of the strongest is family history,
  • 08:12and when we think of family history,
  • 08:14it can be divided into those women
  • 08:16who have a known family history of a
  • 08:18genetic syndrome that may make them
  • 08:21more likely to experience a number of
  • 08:23different cancers and those who are
  • 08:25not necessarily related to a known
  • 08:27genetic syndrome,
  • 08:28but do have family members,
  • 08:31grandmothers, mothers perhaps who
  • 08:32did experience an ovarian cancer.
  • 08:35And the other category would be
  • 08:37those that do have a known genetic
  • 08:39predisposition so those who are
  • 08:42related to the BRCA gene and many
  • 08:44women are familiar with that genetic
  • 08:46syndrome as it relates to risk of
  • 08:49breast cancer and ovarian cancer.
  • 08:51But we are also understanding that
  • 08:53there are other hereditary cancer
  • 08:55syndromes like Lynch syndrome
  • 08:57that can also increase a woman's risk of
  • 08:59developing certain types of ovarian cancers,
  • 09:01so it is important in those women who have
  • 09:04strong family histories of cancers to
  • 09:06speak with their primary care doctor,
  • 09:08or if they do have an oncologist
  • 09:11to consider genetic testing
  • 09:12if it is indicated so that we can
  • 09:14identify those women whom perhaps
  • 09:16could benefit from some type of
  • 09:18prophylactic procedure to reduce their
  • 09:20risk of developing ovarian cancer
  • 09:22down the road.
  • 09:24What about women who don't have a family
  • 09:26history or genetic predisposition?
  • 09:28How common or uncommon is ovarian
  • 09:30cancer in those women?
  • 09:32In those who don't have those
  • 09:33strong family risk factors,
  • 09:35the risk is about 1 to 3% for their lifetime.
  • 09:38Now that's quite small in comparison
  • 09:40to some of the other cancers that
  • 09:42we see in the gynecological tract,
  • 09:45but the issue is that even though
  • 09:47it is rare, like I mentioned,
  • 09:49being that this disease does
  • 09:50account for so much morbidity,
  • 09:52and unfortunately,
  • 09:53survival rates are just not as good as
  • 09:56they are for the other cancers.
  • 10:02And when we talk about
  • 10:05high risk ovarian cancer,
  • 10:06what exactly is that?
  • 10:08Are there certain ovarian cancers
  • 10:10that are more likely to result in
  • 10:13morbidity and mortality than others?
  • 10:15So as you mentioned
  • 10:16regarding those cancers that do
  • 10:18occur in the very young women,
  • 10:21typically are less aggressive cancers and
  • 10:23those younger patients do experience
  • 10:28the more common type of ovarian
  • 10:30cancers that we see,
  • 10:32which we call high grade
  • 10:35serous and this is a subtype of ovarian
  • 10:37cancer that is quite bad behaving,
  • 10:40but unfortunately is the most common
  • 10:42type that we see and is the one that
  • 10:45does present at advanced stage.
  • 10:50I wanted to kind
  • 10:52of delve a little bit more into that,
  • 10:55so if women present with these kind
  • 10:57of vague symptoms and they've
  • 10:59listened to this show on Yale Cancer
  • 11:02Answers and they've decided to
  • 11:04go and talk to their primary
  • 11:06care physician or their gynecologist,
  • 11:08how is that worked up?
  • 11:10I mean, what should women expect
  • 11:12as they advocate for themselves
  • 11:13and making sure that if they have
  • 11:16an ovarian cancer it's found,
  • 11:18or at least that it's ruled out.
  • 11:21The thing I want to get across, and it's very
  • 11:24important is that we do not have any
  • 11:26screening test for ovarian cancer,
  • 11:28and so women who've had a pap
  • 11:30smear and a physical exam as
  • 11:32part of their annual assessment.
  • 11:34cannot necessarily be reassured that they
  • 11:36do not have an underlying ovarian cancer,
  • 11:39so women who have these symptoms that
  • 11:41we've talked about should expect their
  • 11:43doctor to perform a very thorough physical
  • 11:46exam that does include a pelvic exam,
  • 11:48and then usually this is
  • 11:50followed up with some imaging,
  • 11:52either by ultrasound or CT scan in
  • 11:54conjunction with some blood tests
  • 11:56that may help point their doctor in
  • 11:58the direction that this may be an
  • 12:00ovarian cancer that requires evaluation
  • 12:02by a gynecological oncologist, and
  • 12:04so women who are in
  • 12:05the High risk group,
  • 12:07so those women who have a
  • 12:09very strong family history,
  • 12:11the women who have a genetic predisposition,
  • 12:16people who are at very high risk,
  • 12:18there are some more advanced
  • 12:20screening techniques.
  • 12:21There's nothing for ovarian
  • 12:23cancer in terms of blood tests
  • 12:25or routine CT or ultrasound
  • 12:27evaluations
  • 12:28despite several large international trials,
  • 12:30we have not been able to identify a
  • 12:33modality of screening that has shown
  • 12:36to reduce the incidence of this cancer,
  • 12:38or to identify at a stage where
  • 12:40we could intervene and make a
  • 12:42significant difference in outcomes.
  • 12:44Having said that, however,
  • 12:45those women who do know that they harbor
  • 12:48an underlying genetic predisposition
  • 12:50to cancer like the BRCA gene,
  • 12:52or Lynch syndrome, should
  • 12:54follow regularly with a gynecologist
  • 12:56who can talk to them about some of the
  • 12:59increased surveillance that we can do,
  • 13:01or perhaps intervention through surgical
  • 13:03removal of the tubes and ovaries.
  • 13:06At a stage prior to the development of a
  • 13:08cancer that may be appropriate depending
  • 13:10on the person's underlying genetic mutation.
  • 13:14Yeah, so you're talking about
  • 13:16removing the ovaries and the tubes
  • 13:19before they get a cancer to reduce
  • 13:21the risk that they will get a cancer.
  • 13:24Does it reduce the risk to zero?
  • 13:34Unfortunately, it
  • 13:35is not absolutely 0, but it is quite close.
  • 13:38It does bring the risk down to a
  • 13:42below 4%. There are some
  • 13:44inherent risks
  • 13:46related to the lining
  • 13:48of the abdomen called the peritoneum.
  • 13:50This is an area of tissue that is near to
  • 13:53where the ovary and tube would have been,
  • 13:56but after removal of tubes and ovaries
  • 13:58in a woman that's very high risk
  • 14:01given her genetic predisposition,
  • 14:02her risk is significantly reduced compared
  • 14:04to what it would have been if she had not
  • 14:08undergone that prophylactic procedure.
  • 14:09Well, that's great information
  • 14:10for people to know. We're going to
  • 14:13learn much more about the surgical
  • 14:15management of high risk ovarian cancer
  • 14:17after we take a short break for a
  • 14:21medical minute, please stay tuned to
  • 14:24learn more with my guest
  • 14:26Doctor Mitchell Clark.
  • 14:27Support for Yale Cancer Answers
  • 14:29comes from AstraZeneca, dedicated
  • 14:31to providing innovative treatment
  • 14:33options for people living with
  • 14:36cancer. Learn more at astrazeneca-us.com.
  • 14:37This is a medical minute about Melanoma.
  • 14:40While Melanoma accounts for only
  • 14:41about 4% of skin cancer cases,
  • 14:44it causes the most skin cancer
  • 14:46deaths. When detected early
  • 14:48however, Melanoma is easily treated
  • 14:50and highly curable. Clinical trials
  • 14:52are currently underway to test
  • 14:54innovative new treatments for Melanoma.
  • 14:56The goal of the specialized
  • 14:58programs of research excellence
  • 15:00in skin cancer or SPORE grant is
  • 15:02to better understand the biology
  • 15:04of skin cancer with a focus on
  • 15:07discovering targets that will lead
  • 15:09to improved diagnosis and treatment.
  • 15:11More information is available
  • 15:13at yalecancercenter.org.
  • 15:14You're listening to Connecticut Public Radio.
  • 15:19Welcome
  • 15:19back to Yale Cancer Answers.
  • 15:21This is doctor Anees Chagpar
  • 15:23and I'm joined tonight by my
  • 15:26guest doctor Mitchell Clark.
  • 15:27We're talking about the role of surgery
  • 15:30in high risk ovarian cancer and
  • 15:32right before the break Mitchell
  • 15:35you talked about the fact that in
  • 15:37women with a genetic predisposition,
  • 15:39even though you can remove
  • 15:41the tubes and ovaries,
  • 15:43it doesn't reduce their risk down to zero.
  • 15:46You can still get cancer on the peritoneum.
  • 15:49That lining of the abdominal cavity.
  • 15:51Although it does reduce your
  • 15:53risk quite substantially,
  • 15:55so my next question is in women
  • 15:58who have been found to have ovarian cancer,
  • 16:01we talked a little bit about the fact
  • 16:04that this is a cancer that really
  • 16:07presents with very nonspecific symptoms.
  • 16:09You go to your gynecologist,
  • 16:11or to your family physician,
  • 16:13they do a thorough physical exam and
  • 16:16then maybe an ultrasound or a CT scan.
  • 16:19What happens next in terms of
  • 16:22making the diagnosis?
  • 16:24So after the results of these tests,
  • 16:26many patients will refer to meet
  • 16:28with myself or one of my colleagues
  • 16:31to discuss whether or not all of
  • 16:33the different aspects of the work
  • 16:35up are pointing in the direction
  • 16:37of an ovarian cancer. Typically,
  • 16:39most women will come with the CA 125,
  • 16:42which is a blood test that helps
  • 16:44us understand if the findings
  • 16:45on the CAT scan are consistent
  • 16:47with the possible ovarian cancer.
  • 16:49However, I do want to clarify
  • 16:52for our listeners that this is
  • 16:54not a test for ovarian cancer.
  • 16:56It is really just one piece of the
  • 16:59diagnostic evaluation that we undertake
  • 17:00to help understand if the symptoms
  • 17:02are related to an ovarian cancer.
  • 17:04So once patients are referred to meet
  • 17:07with us and these results are pointing
  • 17:09us in the direction of an ovarian cancer,
  • 17:12then we have to decide whether or not this
  • 17:15patient is best suited by starting with us,
  • 17:18an operation or a surgical
  • 17:19removal of her ovarian cancer,
  • 17:21or whether or not we need to
  • 17:23consider starting with treatments
  • 17:25such as chemotherapy.
  • 17:26And we've really evolved over the last
  • 17:29five to 10 years in understanding how
  • 17:31to triage women to the appropriate
  • 17:33first step in their cancer treatment.
  • 17:36And how is that decision made?
  • 17:38So we historically would take all
  • 17:40women to surgery initially and there
  • 17:43was significant morbidity associated
  • 17:45with these very complex operations that
  • 17:48involve removing all of the different
  • 17:50areas of the abdomen and pelvis where
  • 17:53we found these cancerous tumors.
  • 17:55However,
  • 17:56now we understand through rigorous
  • 17:58international trials that there
  • 18:00are women who actually benefit
  • 18:02from starting with chemotherapy.
  • 18:04Ovarian cancer is a very
  • 18:06chemosensitive disease, as we call it.
  • 18:08In that these cancer cells do
  • 18:10respond to that systemic treatment
  • 18:12and shrink the tumors down.
  • 18:15In order for surgery to be
  • 18:17accomplished with less morbidity
  • 18:19and then perhaps in the past,
  • 18:21just like in systemic treatment like
  • 18:23immunotherapy and PARP inhibition,
  • 18:25we're trying to do that same type of
  • 18:28precision medicine in surgery as well.
  • 18:30We want to look at each patient
  • 18:32very individually and assess her
  • 18:34underlying risk factors or underlying
  • 18:37health status in order to decide,
  • 18:39is this a patient who should
  • 18:41be initially operated on,
  • 18:43or is this a patient who for other
  • 18:46reasons should start with chemotherapy
  • 18:48and both of those options have been
  • 18:51found to be equally efficacious.
  • 18:53But oftentimes when we talk
  • 18:55about treating people with chemotherapy,
  • 18:57especially targeted
  • 18:58therapy and immunotherapy,
  • 18:59oftentimes there is a biopsy done
  • 19:02that'll look at the tumor and tell
  • 19:05us whether it has certain receptors.
  • 19:07For example, in breast cancer,
  • 19:09we talk about HER 2
  • 19:11which is also found in other cancers.
  • 19:14For immunotherapy we often look at
  • 19:16checkpoint inhibitors PD one PDL1
  • 19:18and so on, but thus far in the work
  • 19:21up we haven't heard about a biopsy.
  • 19:24So how do you make that decision of,
  • 19:27we're going to treat
  • 19:29with chemotherapy versus surgery
  • 19:31or immunotherapy versus surgery?
  • 19:32And what kind of systemic therapy to use?
  • 19:35That's a great
  • 19:37point. So when patients are first considered,
  • 19:39whether or not they should
  • 19:41go down the route of surgery.
  • 19:43Or whether they should go down
  • 19:45the road of chemotherapy.
  • 19:47If chemotherapy is felt to be
  • 19:48the best option for that woman,
  • 19:50we do get a biopsy.
  • 19:52As we mentioned, most ovarian
  • 19:54cancers do present at advanced stage,
  • 19:55unfortunately,
  • 19:56but this does allow us to obtain
  • 19:58a biopsy of one of these
  • 20:00metastatic lesions somewhere
  • 20:01in the abdomen and pelvis.
  • 20:03In order to ensure that we do
  • 20:05have the correct diagnosis,
  • 20:06this also allows us to begin the
  • 20:08process of undertaking genetic
  • 20:10testing of the tumor so that we can
  • 20:12understand what types of targeted
  • 20:14therapies may benefit this patient.
  • 20:15For women who go to surgery,
  • 20:17that tumor will be sent to our expert
  • 20:20pathologist during the operation so
  • 20:21that they can have a look under the
  • 20:24microscope while the patient is asleep
  • 20:26in order to confirm that this
  • 20:28is an ovarian cancer.
  • 20:29By the time the patient sees us in the
  • 20:32office with the combination of CA 125,
  • 20:34the CT scan images as well as
  • 20:36the distribution and location
  • 20:38of the disease on the imaging,
  • 20:40most times we are able to make a
  • 20:42presumptive diagnosis of ovarian cancer,
  • 20:44but you're very correct in saying
  • 20:46before we initiate any type
  • 20:48of systemic treatment,
  • 20:49we do ensure that we have confirmation
  • 20:51of the type of cancer that this is.
  • 20:55I want to look at both of
  • 20:58those arms of the tree individually.
  • 21:00For patients who go to surgery,
  • 21:02one of the things that you said was that
  • 21:05the surgery tends to be quite extensive.
  • 21:09And so walk us through what
  • 21:12that surgery actually looks like.
  • 21:14I mean, do you start by by doing a
  • 21:16kind of surgical biopsy of the tumor
  • 21:19and sending that to your pathologist?
  • 21:21Do you take out the whole ovary
  • 21:23and then what are all of these
  • 21:26surfaces that you were talking
  • 21:28about that are actually removed
  • 21:30if the diagnosis of ovarian
  • 21:31cancer is confirmed?
  • 21:33So when women are taken to surgery,
  • 21:35we are trying to make the decision of
  • 21:38whether or not the disease can be removed
  • 21:41in its entirety and what I mean by that
  • 21:44is the goal of surgery in ovarian cancer,
  • 21:47whether or not that surgery happens
  • 21:48at the beginning of her cancer journey
  • 21:51or whether it happens after some
  • 21:53chemotherapy is to remove all of
  • 21:55the visible ovarian cancer tumors.
  • 21:56Now the ovary is open to the abdomen
  • 21:59and pelvis inside a woman's body,
  • 22:01and so these cancer cells have a
  • 22:03tendency to try to get out and escape
  • 22:06and attach to that peritoneum that
  • 22:08I talked about before that can land
  • 22:10on various surfaces
  • 22:12working throughout the abdomen and
  • 22:14pelvis and so it's important that we
  • 22:17review those images prior to taking
  • 22:19one with the surgery so that it helps
  • 22:21us understand how extensive an
  • 22:23operation might be. For some women
  • 22:25their surgery might include removing
  • 22:26the ovaries, the uterus, cervix,
  • 22:28as well as the omentum,
  • 22:30which is a fat pad that lays over the bowel,
  • 22:33but for some women their
  • 22:35surgery may be more extensive,
  • 22:37including removal of perhaps the spleen,
  • 22:39a segment of the bowel,
  • 22:41every woman's cancer surgery
  • 22:43is very individualized to her disease.
  • 22:46And we take a great deal of time in ensuring
  • 22:49that we select patients to take to surgery
  • 22:52who are good candidates to have
  • 22:54all of the visible tumors removed.
  • 22:56We know from decades of research
  • 22:58that the only value in surgery in
  • 23:00ovarian cancer is when we can remove
  • 23:02all of the visible disease if not
  • 23:04down to a very tiny amount.
  • 23:06If we don't feel that that
  • 23:08can be achieved upfront,
  • 23:09women will be triaged to that
  • 23:11chemotherapy arm of the decision-making
  • 23:13tree so that we can shrink down
  • 23:15the disease at the outset.
  • 23:17And then perform an operation at a later
  • 23:19date that removes all their visible cancer.
  • 23:22You know when you put it that way
  • 23:24Doctor Clark, it sounds like the best
  • 23:26option for the majority of women would be
  • 23:29to have systemic therapy first, because
  • 23:31if the cancer was resectable,
  • 23:34having the chemotherapy first would shrink
  • 23:37it down and still make it resectable,
  • 23:40if not more resectable.
  • 23:42And if the tumor was quite extensive,
  • 23:45having chemotherapy or systemic therapy
  • 23:48first would shrink that and make that
  • 23:52option of surgery more attainable so
  • 23:55it would seem to me that the
  • 23:57patients in whom surgery first was a
  • 24:00recommendation would be quite small.
  • 24:02Is that right?
  • 24:05Yeah, size is one of the characteristics that we look at in
  • 24:07helping decide which patients will
  • 24:09benefit from surgery at the outset.
  • 24:11For patients who have disease that
  • 24:13is beyond a certain size or located
  • 24:16in multiple different places,
  • 24:17we do know from research that those
  • 24:20patients do benefit from this
  • 24:22pre treatment with chemotherapy
  • 24:23in order to reduce
  • 24:25the size of their ovarian cancers,
  • 24:27and as we've been discussing a lot today,
  • 24:30most women do unfortunately present
  • 24:31with this metastatic picture,
  • 24:33and so we are finding more and more
  • 24:35utility in using the chemotherapy at the
  • 24:38outset of a patient's cancer journey.
  • 24:40But I just want every listener to
  • 24:42know if they do encounter a personal
  • 24:44experience with ovarian cancer,
  • 24:46that both options should be considered,
  • 24:48and that's why it's so important that
  • 24:50gynecological oncologist is involved
  • 24:52in that decision making at the very
  • 24:54beginning of her cancer journey.
  • 24:57Is there a disadvantage to
  • 24:59pursuing systemic therapy first,
  • 25:00even if you have a small tumor
  • 25:03and it's confined to the ovary?
  • 25:06Would there be a disadvantage
  • 25:09to doing systemic therapy first,
  • 25:11could you avoid systemic therapy
  • 25:13if you had surgery first?
  • 25:16Ovarian cancer treatment is really a
  • 25:18medley of chemotherapy and surgery,
  • 25:20and the question is what
  • 25:22combination and in what order?
  • 25:24We do know for women that
  • 25:27have smaller disease burden,
  • 25:29that's typically confined to the ovary,
  • 25:31or perhaps in locations,
  • 25:33that would not require
  • 25:35multiple surgical procedures,
  • 25:37that they do actually have a survival
  • 25:39benefit to initiating their treatment
  • 25:41with surgery followed by chemotherapy.
  • 25:44On the flip side,
  • 25:45as we have mentioned,
  • 25:47those with significant amount
  • 25:49of disease in various locations
  • 25:51have been shown to benefit from
  • 25:53receiving the chemotherapy first.
  • 25:55We almost never treat with
  • 25:57one without the other,
  • 25:58and this disease has been something
  • 26:01that has been traditionally
  • 26:03treated with both a combination of
  • 26:05those two of those two options.
  • 26:08And so where do you see
  • 26:10therapy moving in the future?
  • 26:12What are the exciting
  • 26:14developments that you've seen,
  • 26:15say in the last year or so?
  • 26:18What are the exciting things
  • 26:19that are coming down the pike
  • 26:21that women who may be facing
  • 26:23ovarian cancer should know about?
  • 26:26Well, our dream in ovarian cancer is
  • 26:28to see this disease detected at its
  • 26:31preclinical or very early stages and
  • 26:33the ability to detect this through a
  • 26:36simple blood test or screening test
  • 26:38would really revolutionize ovarian
  • 26:40cancer treatment and the experience
  • 26:42for patients who do face this disease.
  • 26:44There are many groups who are working
  • 26:46on developing tests like this,
  • 26:48but they really are in the research
  • 26:51setting only and until then we need to
  • 26:53focus on how best to manage patients
  • 26:56who present with advanced disease.
  • 26:58We've seen a number of approvals and
  • 27:00new drugs and new therapies in ovarian
  • 27:02cancer just in the last one to two years.
  • 27:05And when we think back to 10 years ago,
  • 27:08the number of different treatments
  • 27:10that a patient would have open to
  • 27:12her are significantly increased,
  • 27:14and we're excited to be able to
  • 27:16offer patients treatment that can
  • 27:18even be taken of an oral tablet once
  • 27:21or twice a day at home.
  • 27:22That may help reduce their risk
  • 27:24of ovarian cancer coming back,
  • 27:26we even see patients who
  • 27:28experience ovarian cancer survival as
  • 27:30a chronic disease and until we can
  • 27:33develop a reliable screening tests
  • 27:35that can detect this very early,
  • 27:37we hope to improve outcomes and
  • 27:40extend survival as long as possible,
  • 27:42perhaps even until the next
  • 27:46best thing comes down the pipeline.
  • 27:48I mean,
  • 27:49it certainly sounds exciting,
  • 27:51especially when you think about
  • 27:53where we started this conversation,
  • 27:55which was talking about how ovarian cancer
  • 27:59is a disproportionate killer of
  • 28:01women with cancer as opposed to
  • 28:03other gynecologic malignancies
  • 28:05but the concept of finding it
  • 28:07early and finding new treatments,
  • 28:10especially oral treatments,
  • 28:11is certainly exciting.
  • 28:12Which brings me to my last question,
  • 28:15which is,
  • 28:17this era of Covid has made us all think
  • 28:21a little bit more creatively about
  • 28:24how we treat patients with cancer.
  • 28:28Trying to avoid having them in
  • 28:30hospital settings and so on.
  • 28:31How has this affected your practice
  • 28:34in terms of treating patients
  • 28:35with ovarian cancer and what are
  • 28:37some of the options that women
  • 28:40have availed themselves of
  • 28:41that they may not have
  • 28:43previously?
  • 28:46I have to say, one of the saddest things to see in the covid
  • 28:49era is women who come in with delayed
  • 28:51diagnosis and I know that that stems
  • 28:54from personal concern of exposure and
  • 28:56going into their health care providers.
  • 28:59But I would encourage all women to reach
  • 29:01out to their practitioners in order
  • 29:03to establish either a telephone or a
  • 29:05video visit so that they can have some
  • 29:07time to meet with their practitioner
  • 29:09and discuss some of the symptoms
  • 29:11that we've been talking about today.
  • 29:13We have really revolutionized our
  • 29:14ability to access patients in their
  • 29:16home environment or in an environment
  • 29:18that is most convenient for them,
  • 29:20and I hope the telephone and video
  • 29:22video visits will be something that
  • 29:24we can continue to use as we move
  • 29:26forward outside of the covered
  • 29:27area so that we can provide
  • 29:30really meaningful and convenient care
  • 29:32to people when they need it most.
  • 29:35Doctor
  • 29:35Mitchell Clark is an assistant professor
  • 29:38of obstetrics and gynecology in the
  • 29:40division of Gynecological Oncology
  • 29:42at the Yale School of Medicine.
  • 29:44If you have questions,
  • 29:45the address is canceranswers@yale.edu
  • 29:47and past editions of the program
  • 29:49are available in audio and written
  • 29:51form at yalecancercenter.org.
  • 29:53We hope you'll join us next week to
  • 29:55learn more about the fight against
  • 29:58cancer here on Connecticut Public Radio.