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OVARIAN Cancer Awarness

September is Ovarian Cancer Awareness Month

The ancient Chinese philosopher Lao Tzu is credited with the inspirational words: “The thousand mile journey always begins with a single step.” This meaningful quotation is an apt description for progress that has been made and continues to be made in our national battle against ovarian cancer.

Given the moniker “silent killer” by generations of women and physicians, ovarian cancer now appears to be better understood than ever before. Though our victories often seem small and there is still much work to do, we are optimistic as we continue to push forward against ovarian cancer.

In 2001, President George W. Bush signed the executive order which declared the month of September “Ovarian Cancer Awareness month” in the U.S. Since that historic declaration of advocacy fifteen years ago, much has been learned and a clearer vision of the path forward has emerged.

Earlier this year, the Institute of Medicine released a seminal report called: “Ovarian Cancers: Evolving Paradigms in Research and Care.” This highly anticipated national document was the product of several years of collaboration and research by established thought leaders in the fields of gynecologic oncology, epidemiology, and patient advocacy, among others. This report has laid a new foundation in helping clinicians, patients, and researchers better understand different types of ovarian cancers at the cellular level and at the population level. It should have significant impact on research, care and advocacy in the years ahead.

The field of medical genetics has moved forward substantially over the past twenty years. It is now believed that perhaps 15 to 20% of all new cases of ovarian cancer are due to mutated genes that a woman inherits from her parents. It is now recommended that all women with ovarian cancer be tested for gene mutations. Ovary cancer patients who harbor certain gene mutations are now candidates of innovative new drugs that have been shown to be highly effective against ovarian cancer.

In family members discovered to be carrying gene mutations which cause ovarian cancer, the aim is to prevent the disease through medical and surgical interventions that significantly reduce the risk of developing ovarian cancer.

Over the past ten years, researchers and clinicians have discovered that many cases of ovarian cancer likely begin in the nearby fallopian tubes. Ongoing research in this area has led to widespread suggestion that prophylactic removal of the fallopian tubes in women undergoing other abdominal or pelvic operations may be an important way to prevent ovarian cancer.

The field of palliative care has grown dramatically in the U.S. over the past ten years. Patients and families battling serious illnesses such as ovarian cancer deserve the best supportive care, symptom control, communication and (when appropriate) end of life care. After years of being ignored, palliative care has finally captured the imagination of physicians and patients, alike. Women and families battling ovarian cancer can expect improvements in the quality of their lives now and in the future because of this realization.

I often tell my patients and their families facing a diagnosis of ovarian cancer that we have embarked on a journey that will (at times) seem like an uphill climb. It is my hope that the victories outlined here will provide some inspiration for each of us on the road.

Ovarian Cancer Screening and Controversies

Recently, the Food and Drug Administration issued a rare public health warning against ovarian cancer screening. To many people, this may seem confusing or contradictory. One might pose the following questions: Is it not the FDA’s job to protect the public against health threats? Is not ovarian cancer a lethal disease which kills thousands of American women each year? Why would the FDA issue such a disheartening message?

As an experienced gynecologic oncologist, hundreds of patients and family members have asked me over the years: “Why are most ovarian cancers diagnosed at such a late stage when it cannot be surgically cured?”

Ovarian cancer is a rare but very serious disease. In the United States, there are about 22,500 new cases each year. There are approximately 14,500 deaths each year from ovarian cancer in the US. The fundamental purpose of cancer screening tests (such as mammograms for breast cancer, pap smears for cervix cancer, and colonoscopy for colon/rectal cancer) is to lower the death rate from that cancer in the general population by catching the cancer before it grows and spreads.

Pap smears have proven to be one of the most effective public health screening tests in human history. In the developed world, death rates from cervix cancer (once a very common female cancer that killed tens of thousands of American women) have fallen by 75% over the past 75 years since physicians began screening for cervix cancer. Cervix cancer and deaths from cervix cancer are now very rare in the US due to widespread cervical cancer screening programs.

The “scientific proof” that screening the general population for ovarian cancer lowers death rates from this disease has been elusive. The main reason for this is that ovarian cancer is uncommon in the general population. Screening the general population for a rare disease has a distinct “down side.” The cancer screening test can falsely identify people as having a disease when they truly do not. These “false positive” screening results can lead individuals down a path toward unnecessary interventions and risks.

In 2011, the results of a large study of ovarian cancer screening here in the US were published. This study revealed that screening for ovarian cancer using blood tests and sonograms in the general population was not effective at saving lives.

Nine months ago, the initial results of a very important ovarian cancer screening study were published by Dr. Ian Jacobs and his team from the United Kingdom. This trial (called UKCTOCS) which began in 2001, involved over 200,000 women screened regularly over time for ovarian cancer using blood tests, sonograms, and physical examinations. The FDA and many other experts feel strongly that the results of the recently published UK trial do not prove that ovarian cancer screening is effective at saving lives.

For this reason, each woman should know the symptoms of ovarian cancer and be on the lookout for any of them in her body. These include persistent abdominal bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and/or urinary urgency or frequency. If you have suspicious symptoms lasting more than two to three weeks, talk to your doctor. This is the best chance for early detection.

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Ovarian Cancer: Get the Facts. Recognize the Signs.

Ovarian Cancer is one of the most deadly of women's cancers. In 2015, approximately 14,280 women will die in the United States from this disease. Many women don’t seek help until the disease has begun to spread; but if detected at its earliest stage, the five-year survival rate is more than 93%. The challenge is that the symptoms of ovarian cancer are often subtle and easily confused with ailments of less serious and more common health problems.

But we do know that ovarian cancer is NOT a silent disease. If you have the symptoms listed here—lasting more than two to three weeks—talk to your doctor to first rule out the more common causes of them. If there is no clear reason for your symptoms, however, your doctor needs to consider the possibility of ovarian cancer. This is the best chance for early detection. Unfortunately, there is no adequate screening test of ovarian cancer at this time which is one of the reasons that this cancer is often discovered in later stages. You are your best advocate.

Four common symptoms of ovarian cancer:

• Persistent abdominal bloating
• Pelvic or abdominal pain
• Difficulty eating or feeling full quickly
• Urinary urgency or frequency
Other symptoms may include:
• Nausea, indigestion, gas, constipation or diarrhea
• Extreme fatigue
• Shortness of breath
• Backaches
• Weight Gain

Be aware; but don’t worry yourself sick
Most women with the above symptoms will not have ovarian cancer. Your doctor should first rule out more common causes of these symptoms, but if there is no clear reason for them, your doctor needs to consider the possibility of ovarian cancer.

Reducing your risk
While there is no proven screening method for early-stage ovarian cancer and detection is difficult, certain risk factors can increase a woman’s chance of developing the disease.

Risk factors for developing ovarian cancer
Age: Ovarian cancer is most common in women over age 50 and in women who have stopped menstruating (have been through menopause), and the risk increases with age. But ovarian cancer can affect women of all ages.

Genetics and family history: If a woman has two or more relatives from the same side of her family affected by ovarian, colorectal or breast cancer, her risk of developing ovarian cancer may be increased. This tends to be a result of an inherited faulty gene (BRCA1 or BRCA2 mutation) that increase a woman’s risk of developing ovarian and breast cancer. Genetics and family history are responsible for at least 15% of ovarian cancers. Women who are descended from Ashkenazi Jewish populations are more likely to carry this faulty gene. All women diagnosed with ovarian cancer are recommended to consider genetic testing.

Child-bearing history: Women who have not had children, are unable to have children, have never used oral contraceptives or became pregnant over the age of 30, may be slightly more at risk. This is due to the ovaries not having a “rest” from the break and repair of the surface of the ovary when women ovulate each month.

Endometriosis: This condition is when the tissue lining the uterus (endometrium) is also found outside of the uterus.

Lifestyle factors: Examples include smoking tobacco, being overweight or eating a high fat diet.

Hormonal factors: Including early puberty (menstruating before age 12) or late menopause (onset after 50).

Modern Approaches to Care

In 2001, President George W. Bush signed an executive order which declared the month of September “Ovarian Cancer Awareness Month.” This was a historic moment for patients, families, nurses, caregivers and physicians who care for people affected by this disease. Ovarian cancer is a relatively rare cancer, statistically speaking; however, it remains a significant cause of cancer mortality for women in the United States and worldwide.

Over the past two decades, much progress has been made in the fight against this disease. Some of this progress will be discussed in this report. Ovarian cancer is often called “the silent killer” due to the fact that its symptoms are often vague and the disease is usually diagnosed at an advanced stage which renders it difficult to cure in many cases. Given this reality, much effort has been put forward into developing screening tests for ovarian cancer. There is presently no screening test for ovarian cancer.

It is well known that if cancers can be caught earlier (i.e., before they spread) then they can be more readily cured. Last year, a large study from the United Kingdom was published. This study, led by Dr. Ian Jacobs, followed women with serial blood test measurements of a chemical called CA125. This “tumor maker” is well known to be elevated in many cases of ovarian cancer. The initially released results of this large trial indicate that in some cases it is indeed possible to detect ovarian cancer “earlier.” Dr. Jacobs and his colleagues caution us that more analysis of their data is needed. This international group will be publishing follow up reports to better inform physicians, patients and the public in the near future.

For many women already affected by ovarian cancer, the last year or two has been an exciting and hopeful time. Our understanding of the genetic and molecular basis for ovarian cancer is evolving and improving rapidly. It is now believed that up to 20% of all ovarian cancers are “familial” in nature. Testing patients with ovarian cancer for genetic mutations that they may have been born with is now considered standard practice in the United States. The widespread adoption of this practice will allow us to identify more patients who may significantly benefit from a newer class of drugs called PARP inhibitors. These oral medications have been shown in recent studies to provide significant improvements in survival for women who have experienced a recurrence of their ovarian cancer.

Genetic testing also allows us to identify other family members (siblings, children) who may also carry a genetic mutation which predisposes to ovarian cancer (or other cancers). When an affected family member is identified, physicians may then intervene in these cases to prevent cancer before it develops.

On a related front, many physicians are also now routinely examining the “molecular fingerprint” of each patient’s cancer to assist in decision making for therapies that may work better than others. Understanding the potential “biomarkers” and “drug targets” in each cancer case helps physicians and patients make smarter decisions with novel drugs that were not widely available just a few years ago. This is the general notion of “personalized medicine” that has captured the imagination of physicians and the public in recent times. One can now imagine a future where the “site of origin” of a person’s cancer is less relevant for decision making than the “molecular fingerprint” that the cancer reveals to us when it is carefully studied with modern molecular technologies.

When I meet a new patient and family affected by ovarian cancer, I often tell them that we are about to make an uphill journey together in the years ahead. With recent developments and ongoing research, I am now optimistic that the future is brighter for these courageous women and their families with whom I have been invited to climb.