ovarian cancer challenges for primary care
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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Ovarian CancerChallenges for Primary Care
Madhavi Venigalla, MDMedical Oncology/Hematology
Lakeland Regional Cancer Center
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OBJECTIVES
Discuss screening/early detection practices Describe presenting symptoms Review current recommendations
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Ovarian Cancer
Incidence: 1 in 55 womenACS statistics for 2012:22,280 new cases (stable since 1992)15,500 deathsWorldwide: Most common cancer in womenRates highest in developed countries
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SymptomsNonspecificPersistent
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SymptomsBloatingPelvic or abdominal painDifficulty eating or feeling full quicklyUrgency or urinary frequencyMost common is abdominal enlargement
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SymptomsOther symptoms commonly reported
FatigueIndigestionBack painPain with intercourseConstipationMenstrual irregularities
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Risk FactorsGenetic predisposition
Family history is strongest riskBreast-ovarian cancer syndromeLynch II syndrome
Cancer of colon, breast, endometrium and HNPCC
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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
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Risk Factors (cont’d)Age
Annual incidence in women age 50-75 is 50 per 100,000, twice the rate in younger women
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Risk Factors (cont’d)Decrease risk:
PregnancyOCPBreast feedingTubal ligationHysterectomy
Increase risk:InfertilityEndometriosisPeri or post
menopausal history of medications
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Oral contraceptive UseDuration of use Relative Risk Never 13-6 months .67-11 months .71-4 years .65-9 years .4>9 years .2 N England J Med 316:650 1987
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Screening TestsThere is no standardized test to detect
ovarian cancer at an early stageCA-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
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Clinical TrialsLarge 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)
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Clinical Trials (cont’d)PLCO trial
78,237 healthy women between 55 & 74Annual CA 125 and transvaginal ultrasound4 year follow up: PPV of 2.6%
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UK Collaborative Trial of Ovarian Cancer ScreeningPurpose
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
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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
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Novel Tumor MarkerHE4
Human epididymis protein 4Only approved for monitoring women with
ovarian cancer for diagnosing recurrence or progression
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Pelvic UltrasonographyObserver dependentUKC TOCS:
48,230 womenPPV was 5.3%
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Multimodal Screening
CA 125 and ultrasoundPLCO Usual Care13 year follow-upNo difference in stage of ovarian cancer or
mortality
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Synthesis of EvidenceWomen at average risk
Screening is not recommendedWomen at increased risk
Counseling, genetic testingWomen 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
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Ovarian Cancer Follow upMonitor CA-125Physical Exam
Including pelvic examCT scan/PET scan as clinically indicatedConsider family history evaluation if not done
previously
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Key Points for the NPIdentify at-risk
patientsEducate Intervene earlyProvide evidence
based care