Ovarian cancer represents about 25% of all malignant tumors of the female genital organs. However, more deaths from this form of cancer occur in the United States each year than with endometrial cancer and cervical cancer. The life risk of developing spontaneous ovarian cancer is about 1.7%. It is expected that in 2008 epithelial ovarian cancer will occur, which will lead to 15,520 deaths. The average age of diagnosis is 60 years. Significant improvement in survival rate for 5 years in patients with ovarian cancer. This is probably a combination of the best surgery for the removal of tumors and the best option for chemotherapy.
Most patients with this type of ovarian cancer do not have signs or symptoms until the disease spreads to the upper abdomen. 70% of patients with progressive disease. Symptoms of early ovarian cancer may include nonspecific discomfort in the pelvic region, frequency of urination, and constipation caused by an increase in the mass of the pelvis. With progressive disease, patients experience abdominal pain, bloating, anorexia, nausea, and constipation.
The best tumor marker for ovarian cancer is CA 125. Small increases in CA 125 can also be observed with endometriosis, benign tumors, fibroids and pregnant and postpartum women. In addition, a moderate increase in CA 125 can be observed in other adnocarcinoma, such as breast and endometrial cancer. The sensitivity of CA 125 ranges from 70% to 80%, and specificity ranges from 98.6% to 99.4%. However, in the middle risk group with low prevalence of ovarian cancer, a false positive can be unacceptably high.
The National Cancer Institute recommends screening for ovarian cancer with known genetic syndromes associated with this disease, and women with a strong family history. Recommended screening for women without a family history of ovarian cancer is not recommended. Known genetic syndromes include hereditary breast cancer and ovarian cancer associated with BRCA 1, BRCA 2 and the inherited colorectal inheritance cancer syndrome (HNPCC). The absolute risk of developing ovarian cancer in the presence of a BRCA 1 or BRCA 2 mutation is between 16% and 60%. For patients with HNPCC syndrome, the risk of developing ovarian cancer over a lifetime is between 9% and 12%.
Epithelial cancer accounts for about 90% of ovarian cancer cases. Common histologies include serous, mucin, endometroid, transient and clear cell types. Germ cell tumors include dysgerminoma, endodermal sinus tumor, malignant embryonic carcinoma of the taratoma, or primary choriocarcinoma. Stromal tumors include granulose tumor or Sertoli-Leydig tumor.
At initial presentation, the operation is used to confirm and stage the cancer. Stage I disease is limited to one or both ovaries. Stage II includes one or both of the contract with the expansion of the pelvic internal organs. Phase III is associated with implants on the abdominal cavity or serous surface of the liver, or includes the small intestine or omentum. Stage IV disease includes distant metastases. 5-year survival for stage IA-disease and histology of 1 or 2 degrees above 90%. For patients with a high level of risk of stage I and stage II, the 5-year survival rate is 80%. For patients with stage III after optimal debulation, 5-year survival ranges from 20% to 30%. This is reduced to less than 10% for stage III patients with suboptimal debulping and stage IV disease.
Stage I ovarian cancer with favorable prognostic features can only be treated with surgery. For women with a high risk of early stage (stage I stage 3 or stage II), adjuvant chemotherapy with platinum-based agents shows an 11% improvement in progression-free survival and an 8% improvement in overall survival. For patients with stage III and IV, the current standard of treatment includes the maximum attempt at surgical cytoreduction followed by chemotherapy with platinum-based agents.
Optimal debulaking is an important part of ovarian cancer treatment. Retrospective data have shown that survival is better for women receiving chemotherapy in the presence of a disease with a low volume. In conditions where optimal surgical cytoreduction cannot be achieved, an alternative approach is for the patient to receive chemotherapy in front. For patients who have a partial response to neoadjuvant chemotherapy, it may be advisable to undergo a surgical removal of a macroscopic disease at that time.
Regarding the standard of care for chemotherapy for advanced ovarian cancer, studies have shown that the combination of paclitaxel / cisplatin is superior to the combination of cyclophosphamide / cisplatin. Later studies have shown that carboplatin / paclitaxel is at least as effective as cisplatin / paclitaxel.
Intra-pitoneal chemotherapy is an attractive approach to the treatment of a disease that is very limited in the area of the peritoneum. GOG 172, which was a clinical trial of phase III, showed that this regional approach led to excellent survival and overall survival compared with intravenous administration. The disadvantage of this approach is local toxicity and the need for an intraperitoneal catheter.
Due to the high recurrence rate in patients with advanced ovarian cancer, the question of whether consolidation chemotherapy can improve the time to progress, and overall survival was considered in a phase III study that compared 3 and 12 cycles of taxol. Progressive survival contributed to the 12th cycle. However, the overall survival between the two shoulders was not different. Therefore, the oncologist should discuss with the patient and give them the opportunity to decide whether improved survival rates justify progress, toxicity, including peripheral neuropathy and alopecia.
For many patients with advanced ovarian cancer who have an initial response to treatment, the disease recurs at a later time. The treatment of patients with recurrent disease or resistant disease must be individualized. For people with a long period of treatment, a free interval, many similar drugs are reused. There are also a number of disposable drugs with ovarian cancer activity. These include altretamine, bevacizumab, docetaxel, etoposide, gemcitabine, liposomal doxorubicin, paclitaxel, tamoxifen, topotecan and vinorelbine.
Radiation may also play a role in weakening some patients with recurrent ovarian cancer. Symptoms, such as pain from the growth of pelvic mass or bone metastases, can be alleviated. Very rarely can cerebral metastases develop, which can also be treated with radiation.
A better treatment for ovarian cancer requires a team approach between a primary care physician, a gynecological oncological surgeon, medical oncologists and radiation oncologists. As chemotherapeutic agents become available, and as we continue to understand the biology of ovarian cancer, we hope to further improve the overall survival and quality of life of our patients.
