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Ovarian Cancer Challenges for Primary Care

Ovarian Cancer Challenges for Primary Care. Madhavi Venigalla, MD Medical Oncology/Hematology Lakeland Regional Cancer Center. OBJECTIVES Discuss screening/early detection practices Describe presenting symptoms Review current recommendations. Ovarian Cancer. Incidence: 1 in 55 women

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Ovarian Cancer Challenges for Primary Care

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  1. Ovarian CancerChallenges for Primary Care Madhavi Venigalla, MD Medical Oncology/Hematology Lakeland Regional Cancer Center

  2. OBJECTIVES • Discuss screening/early detection practices • Describe presenting symptoms • Review current recommendations

  3. Ovarian Cancer Incidence: 1 in 55 women ACS statistics for 2012: 22,280 new cases (stable since 1992) 15,500 deaths Worldwide: Most common cancer in women Rates highest in developed countries

  4. Symptoms • Nonspecific • Persistent

  5. Symptoms • Bloating • Pelvic or abdominal pain • Difficulty eating or feeling full quickly • Urgency or urinary frequency • Most common is abdominal enlargement

  6. Symptoms Other symptoms commonly reported • Fatigue • Indigestion • Back pain • Pain with intercourse • Constipation • Menstrual irregularities

  7. Risk Factors • Genetic predisposition • Family history is strongest risk • Breast-ovarian cancer syndrome • Lynch II syndrome • Cancer of colon, breast, endometrium and HNPCC

  8. Risk Factor (cont’d) • Breast-ovarian syndrome • Germline mutation in one of the breast cancer susceptibility genes BRCA or BRCA2 • Prevalence • General population is 1 in 300 • Ashkenazi Jewish is 2 in 100

  9. Risk Factors (cont’d) • Age • Annual incidence in women age 50-75 is 50 per 100,000, twice the rate in younger women

  10. Risk Factors (cont’d) • Decrease risk: • Pregnancy • OCP • Breast feeding • Tubal ligation • Hysterectomy • Increase risk: • Infertility • Endometriosis • Peri or post menopausal history of medications

  11. Oral contraceptive Use Duration of use Relative Risk Never 1 3-6 months .6 7-11 months .7 1-4 years .6 5-9 years .4 >9 years .2 N England J Med 316:650 1987

  12. Screening Tests • There is no standardized test to detect ovarian cancer at an early stage • CA-125: most widely used screening method • Specificity is limited • False elevations in: endometriosis, fibroids, cirrhosis w/- ascites, PID, cancers of breast, lung, pancreas, pleural or peritoneal fluid due to any cancer

  13. Clinical Trials • Large studies in Sweden: • Low positive predictive value of 3% • Experts feel a screening protocol should have a PPV of at least 10% (no more than 9 healthy women with false positive screening would undergo unnecessary procedures for each case of ovarian cancer detected)

  14. Clinical Trials (cont’d) • PLCO trial • 78,237 healthy women between 55 & 74 • Annual CA 125 and transvaginal ultrasound • 4 year follow up: PPV of 2.6%

  15. UK Collaborative Trial of Ovarian Cancer Screening • Purpose • Evaluate a screening strategy using a risk of ovarian cancer algorithm on the basis of age, CA 125 profile and transvaginal ultrasound • Method (control and screening group) • Primary screening w/CA 125 – if abnormal • Secondary screening w/CA 125 & TVUS

  16. UK Trial (cont’d) • Results: • 6532 women were screened and assigned risk levels • 1228 intermediate risk had repeat CA 125 and 53 were classified as elevated risk • 16 women had surgery • 11-benign pathology • 1 recurrent breast cancer in ovaries • 1 borderline and 3 with invasive epithelial ovarian cancer • Specificity and PPV for primary invasive epithelial ovarian cancer were 99.8% and 19% respectively JCO Vol 23(31) Nov 1 2005

  17. Novel Tumor Marker • HE4 • Human epididymis protein 4 • Only approved for monitoring women with ovarian cancer for diagnosing recurrence or progression

  18. Pelvic Ultrasonography • Observer dependent • UKC TOCS: • 48,230 women • PPV was 5.3%

  19. Multimodal Screening CA 125 and ultrasound PLCO Usual Care • 13 year follow-up • No difference in stage of ovarian cancer or mortality

  20. Synthesis of Evidence • Women at average risk • Screening is not recommended • Women at increased risk • Counseling, genetic testing • Women w/high risk family history • NCCN recommends Q6 month CA 125 and TVUS starting @age 30 or 5-10 yrs earlier than earliest age of 1st diagnosis of ovarian cancer

  21. Ovarian Cancer Follow up • Monitor CA-125 • Physical Exam • Including pelvic exam • CT scan/PET scan as clinically indicated • Consider family history evaluation if not done previously

  22. Key Points for the NP • Identify at-risk patients • Educate • Intervene early • Provide evidence based care

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