encountering ovarian cancer in the primary care setting · uk familial ovarian cancer screening...

UW MEDICINE │ ONCOLOGY REGIONAL CARE ADVANCEMENT SYMPOSIUM (ORCA)

ENCOUNTERING OVARIAN CANCER

IN THE PRIMARY CARE SETTING

RENATA URBAN, MD MARCH 7, 2015

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

AUDIENCE RESPONSE QUESTION #1

2

URBAN Ovarian Cancer

URBAN

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


URBAN

Following the conclusion of treatment,

patients with ovarian cancer have less

depression, but more anxiety

Yes

No

Don’t Know


6


URBAN

DISCLOSURE

I am the PI of a research study that is

supported by Vermillion, Inc. I have no

other financial obligations to disclose

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

OBJECTIVES

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.

CASE PRESENTATION

Describe the patterns of care in treating

ovarian cancer

OBJECTIVES

ESTIMATED NEW CANCER CASES/DEATHS

UNITED STATES, 2014

Females Estimated

Deaths Site Estimated

New Cases

Genital System

— Uterine cervix

— Uterine corpus

— Ovary

— Vulva

— Vagina and other genital

91,370

12,360

52,630

21,980

4,850

3,170

28,080

4,020

8,590

14,270

1,030

880

All

Digestive System

Respiratory System

Skin (excluding basal/squamous)

Breast

805,500

129,450

114,450

34,110

232,340

273,430

61,870

73,290

4,090

39,620

Siegel R et al. CA 2014

OVARIAN CANCER

PATTERNS OF CARE

Incidence* Age-Adjusted Cancer

Death Rate

1999 2011 %

change 1990 2010

% change

Ovary 14.3 11.3 -20% 9.5 8.1 -14%

Breast 135.4 122.0 -10% 31.7 21.9 -31%

Colorectal** 48.4 34.9 -28% 24.7 13.3 -46%

Prostate 170.8 128.3 -25% 38.6 21.8 -44%

Siegel R et al. CA 2014

*Per 100,000 population **Female only

OVARIAN CANCER

PATTERNS OF CARE

Thrall MM et al. Gynecol Oncol 2011

Bristow RE et al. Obstet Gynecol 2013

Cliby W et al. Gynecol Oncol 2015

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

Review the indications and options

of screening for ovarian cancer in

the average and high-risk population

OBJECTIVES

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

Definition of High Risk

Personal History

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

BRCA 1 or 2 mutation

Lynch syndrome

Reproductive factors

History of infertility or endometriosis

Lifetime risk

estimated

at 5%

Lifetime risk

35-45% (BRCA1)

15-25% (BRCA2)

Lifetime risk

10-12%

Clear cell

& endometrioid

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


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

Race – black, white

Age – 35 vs 51

Insurance – private or Medicaid

Level of risk

Vignette: A woman presents for an annual exam

VARIABLES

High

Personal hx breast cancer age 30

Paternal grandmother ovarian cancer

Paternal 1st cousin breast ca premenopausal

Outcome: Referral to genetic counseling and/or offering

BRCA1/2 testing (almost never, sometimes,

almost always)

Mom had breast cancer age 70 Average

PATTERNS OF CARE

FOR HIGH RISK WOMEN

Referral for Genetic Counseling

Vignette

Risk for Ovarian Cancer

Physicians Average HIGH

Reported adherence to USPSTF guidelines

71% 41%

Correctly identified risk 61% 47%

OVARIAN CANCER

RISK REDUCTION

OCP’s

Tubal ligation

Weight reduction?

Education if history

of endometriosis

or infertility

Bilateral salpingectomy?

Definitive reduction

in risk with prophylactic

bilateral salpingo-oophorectomy

at 40 years or when childbearing

is complete

Shown to reduce both

ovarian and breast

cancer mortality

OCP’s, tubal ligation, bilateral

salpingectomy

High risk Average risk

Describe the symptoms associated

with ovarian cancer

OBJECTIVES

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

General checkup 25%

Mammogram 13%

Problem visits 62%

1,709 women in primary care clinic completed survey

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

OVARIAN CANCER SYMPTOMS

WOMEN WITH AND WITHOUT CANCER

Excluding patients presenting for routine checkup or mammogram only

Symptom Cancer vs. Clinic Patient Cancer vs. IBS Patients

Pelvic pain 2.2 (1.2-3.9) 2.6 (1.2-5.6)

Abdominal pain 2.3 (1.2-4.4) 0.7 (0.3-1.5)

Difficulty eating 2.5 (1.3-5.0) 1.5 (0.7-3.7)

Bloating 3.6 (1.8-7.0) 3.0 (1.3-6.7)

Abdominal size 7.4 (3.8-14.2) 4.6 (2.1-10.1)

Urinary urgency 2.5 (1.3-4.8) 2.6 (1.2-5.7)

Constipation 1.6 (0.9-3.0) 1.0 (0.5-2.2)

Fatigue 1.4 (0.7-2.7) 1.1 (0.5-2.3)

Diarrhea 0.7 (0.1-0.4) 0.2 (0.1-0.5)

MEDIAN EPISODES SYMPTOMS/MONTH


Symptom Ovarian CA

(n=44) Primary Care Clinic

(n=1600) p

Pelvic pain 24 2 0.001

Abdominal pain 23 2 0.017

Bloating 30 2 0.004

Fatigue 30 8 0.001

Urinary symptoms 30 12 0.02

Constipation 12 2 0.001

Diarrhea 6 2 0.06

MEDIAN DURATION EACH SX IN MONTHS


Symptom Ovarian CA

(n=44) Primary Care Clinic

(n=1600) p

Pelvic pain 3 11 0.06

Abdominal pain 5 11 0.05

Bloating 3 12 0.04

Fatigue 3 12 0.08

Urinary symptoms 3 13 0.13

Constipation 3.5 12 0.001

Diarrhea 5 12 0.001

POSSIBILITIES FOR EARLIER DETECTION

DEVELOPMENT OF OVARIAN CANCER SYMPTOM INDEX

Prospective case-control study evaluated type and frequency

of symptoms

Subsequent development of symptom index

Index considered (+) if: Abdominal/pelvic pain, abdominal size/bloating,

difficulty eating or feeling full, urinary urgency/frequency

If present <1 year and occurred >12 days/mon

Specificity of 86.7% in women >50, sensitivity of 56.7%

for early stage disease

2.6% of general population screen (+)

Goff BA et al. Cancer 2007

SYMPTOM TRIGGERED SCREENING

FEASIBILITY & ACCEPTABILITY

Prospective study of women >40

1,261 patients screened if (+) referred for CA125 & TVS

Mean score of acceptability = 4.8 (1-5)

51 (4%) women had a positive SI

2 patients identified with ovarian cancer

All patients completed survey in <5 minutes

Goff BA et al. Gynecol Oncol 2012

USE OF SYMPTOM INDEX

TO TRIGGER EVALUATION

In a prospective study, 5,012 women were enrolled

to complete a symptom index (SI) assessment

SI

• Women >40 with at least one ovary and not pregnant

SI+

• Those with positive SI offered CA 125 and TVUS

• CA 125 >35 considered abnormal

SEER

• 12 months after study completion, all participants linked to Western Washington SEER to assess for diagnosis of ovarian cancer

SYMPTOM-TRIGGERED

DIAGNOSTIC EVALUATION

Of the study cohort, at baseline 8% had IBS and 20% had

GERD

241 (4.8%) had a positive SI

211 (88%) participated in additional testing with TVUS & CA 125

20 procedures were performed in study participants within

6 months of a positive SI

8 ovarian cancer cases detected

2 diagnosed within 6 months of the SI

1 had a positive SI and was diagnosed 31 days later with distant disease

1 had a negative SI; however she had a family history of ovarian cancer

and was undergoing evaluation for a pelvic mass at the time of study

participation

6 diagnosed 281-843 days after participation in the study

3 had early stage disease

Andersen MR et al. Obstet Gynecol 2014

SYMPTOM-TRIGGERED

DIAGNOSTIC EVALUATION

Evaluation resulted in 0.4% patients undergoing surgery

Very low number of ovarian cancer cases diagnosed

within 6 months of symptom index completion

Long-term follow-up identified 6 cancers

Possible that study participation provided women with education

about ovarian cancer symptoms, spurring them to seek evaluation

of subsequent symptoms

Real value may lie in its ability to act indirectly as an educational tool

Andersen MR et al. Obstet Gynecol 2014

SYMPTOM TRIGGERED SCREENING

COMBINATION WITH BIOMARKERS

The symptom index may have improved sensitivity

and specificity if combined with biomarkers

Prospective evaluation of 74 women with ovarian cancer

and 137 healthy controls

Symptom index (administered pre-diagnosis to cancer patients)

CA 125 & HE4

When symptom index plus CA125 or HE 4 was positive,

this yielded specificity of 98% for ovarian cancer

MR Andersen et al. Gynecol Oncol 2010

American Cancer Society now recommends that women

see their doctor if they experience symptoms of:

Abdominal swelling or bloating

Pelvic pressure or pain

Difficulty eating or feeling full

Problems with urination

Not all symptoms = ovarian cancer,

but consider it on your differential!

REVIEWING THE SYMPTOMS…

List what tests to order when ovarian cancer

is on your differential

OBJECTIVES

WHEN CONSIDERING OVARIAN CANCER ON YOUR

DIFFERENTIAL FOR THE PATIENT WITH SYMPTOMS

Labs

CA 125

Consider poor specificity of this test

in premenopausal women!

Presence of other conditions

that can increase CA 125

HE4

Increased sensitivity for ovarian cancer

compared with CA 125

More often expressed in endometrioid

and clear cell tumors compared

with CA 125

Clarke-Pearson DL. N Engl J Med 2009

Endometriosis

Uterine leiomyoma

Cirrhosis (with

or without ascites)

Pelvic inflammatory

disease

Cancer of the

endometrium

or pancreas

Presence of pleural

or peritoneal fluid

from any cause

(e.g. CHF)


DIFFERENTIAL FOR THE PATIENT WITH SYMPTOMS

Pelvic exam?

Evidence does not support the use of a pelvic exam to screen patients

for ovarian cancer

However, exam may reveal findings that impact diagnostic evaluation

(e.g. pelvic mass, lymphadenopathy, ascites) or identify other cause of

symptoms

Transvaginal ultrasound Presence of mass?

Free fluid in pelvis, ascites

Solid component

Thick septations

Peritoneal masses

Bloomfield HE et al. Ann Intern Med 2014

Myers ER et al. AHRQ Publication No. 06-E004


DIFFERENTIAL… FOR THE PATIENT WITH A PELVIC MASS

CA 125

Consider poor sensitivity of this test in a premenopausal woman

HE4

FDA approved to be performed in combination with pelvic US & CA 125

in the Risk of Ovarian Malignancy Algorithm (ROMA)

OVA-1

Multivariate serum assay

FDA approved to assess risk of malignancy in a patient

with a pelvic mass


DIFFERENTIAL… FOR THE PATIENT WITH A PELVIC MASS

Transvaginal ultrasound

Most cost-effective

No exposure to radiation

CT abdomen/pelvis

Presence of ascites

CONSIDERATION FOR REFERRAL OF A PATIENT

WITH AN ADNEXAL MASS TO GYNECOLOGIC ONCOLOGY

Premenopausal (<50)

CA 125 > 200 U/mL

Ascites

Evidence of abdominal or

distant metastasis (by results

of exam or imaging study)

Family history of breast

or ovarian cancer in a first

degree relative

ACOG Practice Bulletin No. 83, July 2007 (Reaffirmed 2013)

Postmenopausal

Elevated CA 125 levels

Ascites

Nodular or fixed pelvic mass

Evidence of abdominal or

distant metastasis (by results

of exam or imaging study)

Family history of breast

or ovarian cancer

in a first-degree relative

Treatments associated with improved survival

in ovarian cancer

Optimal surgical cytoreduction

Platinum-based chemotherapy

Care of ovarian cancer patients by gynecologic oncologists is

associated with improved survival

Patients treated by gynecologic oncologists more likely

to undergo primary surgery and chemotherapy

ROLE OF THE GYNECOLOGIC ONCOLOGIST

Earle CC et al. J Natl Cancer Inst 2006

Chan JK et al. Obstet Gynecol 2007

SURGICAL OUTCOMES AS A PROGNOSTIC FACTOR

99 months

36 months

29.6 months

0%

25%

50%

75%

100%

0 12 24 36 48 60 72 84 96 108 120 132 144

0%

25%

50%

75%

100%

0 12 24 36 48 60 72 84 96 108 120 132 144

0 mm

1-10 mm

>10 mm

0 mm

1-10mm

>10 mm

Progression-Free

Survival

Overall Survival

% P

FS

Months

% O

S

Months

29.6 months

36 months

99 months

1-10 mm vs. 0 mm:

>10 mm vs. 1-10 mm:

log-rank: P < 0.0001

HR (95%CI)

2.52 (2.26-2.81)

1.36 (1.24-1.50)

1-10 mm vs. 0 mm:

>10 mm vs. 1-10 mm:

log-rank: P < 0.0001

HR (95%CI)

2.70 (2.37-3.07)

1.34 (1.21-1.49)

du Bois AI et al. Cancer. 2009

Involvement of Gynecologic Oncologists in Treatment of Patients with Suspicious Ovarian Mass

3,200 physicians surveyed in 2009

Vignette-based survey of a 57 year old with pain,

bloating, suspicious right adnexal mass and ascites

Referral to Gyn Onc: FP 39.3%

IM 51.0%

Ob/Gyns 66.3%

Among Ob/Gyns, 33.7% performed the primary surgery

Factors associated with not referring

Medicaid insurance

Weekly average of 90+ patients

Rural or solo practice

ROLE OF THE GYNECOLOGIC ONCOLOGIST

Goff et al. Gynecol Oncol 2011

Discuss the surveillance and management

of ovarian cancer patients after treatment

OBJECTIVES

WHAT HAPPENED IN BETWEEN?

Cytoreductive surgery

Bowel resection

Risk for infection following

splenectomy

Postoperative pain

Surgical menopause

Complications?

VTE

Wound issues

Chemotherapy

Neuropathy

Fatigue

Gastrointestinal issues

Bone marrow suppression

Depression

WHAT HAPPENS NOW?

Maintenance

Surveillance

Performance

MAINTENANCE

Refers to prolonged therapy to increase the probability

of remaining in remission

Options

Additional chemotherapy

Biologic agents

Clinical trial

Please encourage patients to speak to their oncologist

regarding any options for maintenance treatment

SURVEILLANCE

NCCN recommendations for surveillance

Visit and physical exam

Tumor markers

CA 125 if initially elevated

HE4 also FDA approved for monitoring for recurrent

or progressive disease

Imaging as clinically indicated

Salani et al. Am J Obstet Gynecol 2011

SURVEILLANCE PATTERNS OF RECURRENCE

26-50% of recurrences

occur in the pelvis

Other common sites

Retroperitoneal lymph nodes

Upper abdomen

Lungs

Rare sites of metastases

Brain

Cutaneous

Symptoms

Can be similar as initial

presentation

Bowel obstruction

Shortness of breath

SURVEILLANCE

Referral of ALL patients with epithelial ovarian cancer

for genetic counseling and testing

In a study of Canadian patients with high-grade serous ovarian

cancer, referral for genetic counseling based on family history

alone would have missed 35% of mutation carriers

Schrader KA et al. Obstet Gynecol 2011

PERFORMANCE

WHAT ARE PATIENTS EXPERIENCING?

Survey of 100 patients with ovarian cancer

Symptoms with highest frequency and severity

Emotional symptoms

Negative feelings about treatment or prognosis

Fatigue

Pain

Frequent symptoms (variable severity)

Dyspareunia

Neurologic symptoms (cognitive impairment, neuropathy)

Less frequent, more severe symptoms

Socio-economic concerns

Negative body image

Insomnia

Stavraka C et al. Gynecol Oncol 2012

PERFORMANCE

SYMPTOM MANAGEMENT

Fatigue

Neurotoxicity

Most often due to chemotherapy

Numbness & weakness in hands, discomfort in feet, muscle cramps

GI toxicity

Can be due to both surgery and chemotherapy

Risk of bowel obstruction

May be herald of recurrent disease

Abdominal pain, diarrhea and/or constipation

Lymphedema

Gynecologic

Menopause

Sexual dysfunction

Mirabeau-Beale KL et al. Gynecol Oncol 2009

PERFORMANCE

SYMPTOM MANAGEMENT

Neurotoxicity

Gabapentin

CAM: Vitamin B6 complex, L-glutamine

Lymphedema

Compression stockings

Physical therapy, manual decompression treatment

Gynecologic

Consider either systemic or local estrogen replacement therapy

Venlafaxine for vasomotor symptoms

Mirabeau-Beale KL et al. Gynecol Oncol 2009

Ibeanu O et al. Gynecol Oncol 2011

PERFORMANCE

SURVIVORSHIP AND PHYSICAL HEALTH

Fatigue

Estimated to occur in 70-100% of patients with cancer

Can be due to anemia, malnutrition, medications, depression, insomnia

May also contribute to cognitive dysfunction

Encourage exercise!

Participating in physical activity has been associated with a lower risk

of ovarian cancer mortality

Zhou Y et al. Gynecol Oncol 2014

PERFORMANCE

SURVIVORSHIP – MENTAL AND EMOTIONAL HEALTH

“Chemo brain”

Studies have shown variable rates of cognitive dysfunction following

therapy for ovarian cancer

Consider relaxation techniques, physical exercise programs,

“brain training”

Avoid continuing benzodiazepines!

Psychological effects

In a prospective study of ovarian cancer patients, depression levels

were found to decrease 3 months after chemotherapy, however levels

of anxiety were found to increase

Cognitive behavioral therapy, antidepressant/antianxiety medication

Hipkins J et al. Br J Health Psychol 2004

SURVIVORSHIP PLAN

In 2006, the Institute of Medicine (IOM) met to review the

challenge of the growing number of cancer survivors

outstripping capacity of providers

IOM recommended that cancer patients should have a

treatment summary and follow-up care plan the survivorship

care plan

Unclear if these plans impact care

Prospective study in patients with gynecologic cancers found

no difference in evaluation of health services and satisfaction

Institute of Medicine of the National Academies:

Cancer Survivorship Care Planning

Brothers BM et al. Gynecol Oncol 2013

A patient discloses that her sister has

been diagnosed with ovarian cancer at

the age of 52. I would consider

screening this patient for breast cancer

and ovarian cancer

True

False


64

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


65

Following the conclusion of treatment,

patients with ovarian cancer have less

depression, but more anxiety

Yes

No

Don’t Know


66

Primary care providers are crucial to both the diagnosis and management of ovarian cancer patients

Identification of patients at high risk for ovarian cancer

Recognize symptoms that may indicate ovarian cancer on a differential

Evaluation & diagnosis of a patient with possible ovarian cancer

Referring patient with concerning history and/or findings to a gynecologic oncologist

Discussing genetic counseling with patients with a concerning medical history and/or diagnosis of ovarian cancer

SUMMARY

67

PROVIDER AND PATIENT RESOURCES

Survivorship Clinic at the Seattle Cancer Care Alliance

Society for Gynecologist Oncologists

www.sgo.org

National Cancer Comprehensive Network

Marsha Rivkin Center for Ovarian Cancer Research

Foundation for Women’s Cancer

www.foundationforwomenscancer.org

Ovarian Cancer Together

http://www.ovariancancertogether.org/Pages/FriendsTOGETHERWA.aspx

Schrader KA et al. Obstet Gynecol 2011

http://www.foundation

DIVISION OF GYNECOLOGIC ONCOLOGY

UNIVERSITY OF WASHINGTON

Barbara Goff, MD Heidi Gray, MD

Benjamin Greer, MD

Hisham Tamimi, MD Elizabeth Swisher, MD John Liao, MD, PhD

Renata Urban, MD Barbara Norquist, MD Barbara Silko, ARNP Listya Shah, PA-C

Questions? We are available 24-7 through MedCon (206) 520-5000 or 1 (877) 520-5000

Referrals? (206) 288-7155

QUESTIONS?

Renata Urban, MD

[email protected]

(206) 543-3669 or (206) 288-2025

71

Annual transvaginal ultrasound scan (TVS) and CA125 screening.

Adam N. Rosenthal et al. JCO 2013;31:49-57

©2013 by American Society of Clinical Oncology

RISK OF OVARIAN CA IN WOMEN

WITH SYMPTOMS IN PRIMARY CARE

212 ovarian cancer patients with 1,060 matched controls

Charts photocopied and anonymously scored for symptoms

85% of cancer cases and 15% of controls had one

of 7 symptoms

Abdominal distension, urinary frequency and abdominal pain

were significantly associated with ovarian cancer,

even at 6 months prior to diagnosis

Hamilton W et al. BMJ 2009

Population-Based Case-Control Study

Pilot project involving public dissemination of

information regarding ovarian cancer symptoms

1455 Canadian patients underwent CA 125,

followed by TVUS

16% had abnormal initial test result

Only one patient underwent surgery who was found

to have benign disease

72% patients with ovarian cancer had complete

resection

OPEN ACCESS SYMPTOMS SCREENING

The DOvE Study

Gilbert et al. Lancet Oncol 2012.

REFERRALS/CONSULTS FOR OVARIAN CANCER

BY FPS OR IMS MULTIVARIATE REGRESSION

Goff BA et al. Obstet Gynecol 2011.

Other vs Solo

Group vs Solo

Int Med vs Fam Med

Female vs Male MD

Urban vs Rural Practice

61–90 vs ≥91

1–60 vs ≥91

Private Ins vs Medicaid

Afr Amer vs Cauc

Practice Type:

Average # Patients/wk:

0 1 2 Risk Ratio (95% Confidence Interval)


URBAN

encountering ovarian cancer in the primary care setting · uk familial ovarian cancer screening...

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