Turning the big C into the little c: Resources and Reassurance

Decoding an Ovarian Cancer Diagnosis

Session OutlineIntroductions

Process from diagnosis to follow-up

Doc, what should I be asking you?

Resources

Questions and answers

Disclosures

No financial disclosures.This is not medical advice.

Disclosures

No financial disclosures.This is not medical adviceI am a doctor.

Disclosures

No financial disclosures.This is not medical adviceI am a doctor.Stop me if I am using jargon or acronymsInterrupt and ask questions

Stephanie L. Wethington, MD

Raised in Northern Virginia

Medical training at Columbia University College of Physicians and Surgeons, Magee Womens Hospital, New York Presbyterian Hospital

Gynecologic Oncology Fellowship at Memorial Sloan Kettering Cancer Center

Gynecologic Oncologist at Mid Atlantic Gynecologic Oncology and Pelvic Surgery Associates

What do we mean by Ovarian Cancer?Cancer arising in the ovaries, fallopian tubes or peritoneum

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What is a Gynecologic Oncologist?Completed Ob/Gyn residencyAdditional 3-4 years of specialized training in the care of women diagnosed with gynecologic cancers Fellowship training includes:Biology & pathologyDiagnosisTreatmentSurgeryChemotherapyRadiationSurvivorshipResearch

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Members of the treatment team

Gynecologic oncologistMedical oncologistRadiation oncologistPalliative care providerNurse navigatorChemotherapy infusion nurseSocial workerHousestaffNutritionistPhysical and occupational therapistsAcupuncturistPsychiatrist or psychologistFamily and friends

The process: From diagnosis to follow-up

Diagnosis

SymptomsIncidental finding

Tumor markersImaging

BiopsyOperation

What makes you unique?

TreatmentOperation

Chemotherapy

(Biologic)

(Targeted therapy)

(Radiation)

TreatmentSurgeryLaparotomy (open abdominal incision)Minimally invasive procedureLaparoscopyRobotic assisted laparoscopyStagingWhere has the cancer spread?DebulkingHow can we remove all the visible tumor?

TreatmentChemotherapyIntravenousIn the veinPeripheral IVMediportIntraperitonealIn the abdomen

TreatmentWhat is a cycle?Recurring group of chemotherapy dosesExample: Dose dense paclitaxel and carboplatin

MondayTuesdayWednesdayThursdayFridaySaturdaySunday1 Cycle#1CarboTaxol2345678Taxol9101112131415Taxol16171819202122Cycle #2CarboTaxol23242526272829Taxol3031

Treatment

(Biologic)Avastin(Immunotherapy)

(Targeted therapy)(PARP inhibitors)

(Radiation)

Hot Topic Clinical TrialsGeared to specific genomic abnormalities

Tumor profiling Foundation OnePrecision TherapeuticsCaris

ImmunotherapyAdoptive T cell therapyVaccinesPD-1, PD-L1Pembrolizumab

Almost 600 trials18

Follow-up

ComponentsSymptomsPhysical examTumor markersImaging

TimelineEvery 3 monthsSpace out over time

Doc, What should I be asking you?

Know yourself

Doc, What should I be asking you?

Understanding the diagnosis

What type of ovarian cancer do I have?HistologyGradeStage

Understanding the treatment plan

Will I have an operation or chemotherapy first?Why is that sequence recommended?

Who is my treatment team?

Understanding the operation

What procedure did I have?One ovary or both?Uterus and cervix?Lymph nodes?Bowel?Other?

Was it a staging procedure or a debulking procedure?

Doc, What should I be asking you?

Doc, What should I be asking you? Understanding the chemotherapy plan

Which chemotherapy drugs will I receive?Will I receive chemotherapy through the vein (IV) or into the abdomen(IP)?Do I need a mediport? Are these chemotherapies standard of care? Are there other options?Am I eligible for any clinical trials? What are the expected side effects?Are there side effects about which I should call the office urgently? What are your recommendations to decrease side effects?Where will I receive chemotherapy? Will I receive a chemo calendar?Who do I call if I have a question about my chemotherapy treatment?How many chemotherapy treatments will I have? How often will I have an appointment with you?How often will I have blood drawn?Will I be able to work during the chemotherapy treatments? Limitations?Do I see my primary care doctor, cardiologist, other specialist while I am receiving chemotherapy?

Doc, What should I be asking you? Understanding the follow-up

How often do I need a physical exam?How often do I need to check tumor markers?How often do I need to have an imaging study?

What other cancer screening do I need?

Do I need to see my primary care doctor or other specialists?

Is there anything I can do to reduce my risk of recurrence?

Should I schedule an appointment with a genetic counselor?

This process is very lonely. Help?Will I be able to have children after my treatment?My son is getting married in two months. Will I be able to attend?I dont want anyone to know I have been diagnosed with cancer. How do I keep my diagnosis private?What do I tell my children?I have been married for 30 years and we have a wonderful intimate relationship? Will this be affected?I am so tired. What can I do about the fatigue I am feeling?Doc, What should I be asking you?

Resources

General oncology

American Cancer Society, www.cancer.orgNational Cancer Institute, www.cancer.govNational Comprehensive Cancer Network, www.nccn.orgNRG Oncology, www.nrgoncology.orgPatient Advocate Foundation, www.patientadvocate.org

ResourcesGynecologic oncology specificEyes on the Prize, www.eyesontheprize.orgFoundation for Womens Cancer, www.foundationforwomenscancer.orgGilda Radner Familial Ovarian Cancer Registry, www.ovariancancer.comNational Ovarian Cancer Coalition, www.ovarian.orgOvarian Cancer Research Fund Alliance, www.ovariancancer.org Ovations for the Cure of Cancer, www.ovationsforthecure.orgSociety of Gynecologic Oncology, www.sgo.org

Resources

Support Networks

Cancer Care, www.cancercare.orgCancer Support Community, www.cancersupportcommunity.orgNational Coalition for Cancer Survivorship, www.canceradvocacy.orgSHARE: Self-help for Women with Breast or Ovarian Cancer, www.sharecancersupport.org

Resources

Questions and Answers

If I could only share one piece of information, it would be..

Extra material in case time or questions

Terminology

Key TerminologyHistologyEpithelial Germ cellSex cord stromal tumor

Germ cell---start in the cells that form eggsSex cord stromal tumors start in the cells that hold the ovary together and release hormones34

Key TerminologyGrade

How abnormal are the tumor cells under the microscope?

Grade 1 = Well differentiatedGrade 2 = moderately differentiatedGrade 3 = poorly differentiated

Low gradeHigh grade

Key TerminologyStage = Spread

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Key Terminology

Tumor Markers

ExamplesCA-125HE4InhibinAFPLDH

How are they used?Monitor response to treatmentDetect recurrence

Word of Caution

Ca125 glycoprotein37

Key TerminologyImaging StudiesCT (computed tomography) ScanSeries of xray imagesCombined by a computerIntravenous or oral contrastStructure

Key TerminologyImaging Studies

MRI (Magnetic resonance imaging)Magnetic field and radio wavesCombined by a computerIntravenous contrastStructure

Key TerminologyImaging StudiesPET (positron emission tomography) ScanRadioactive tracerDye collects in areas of the body with high metabolic activityMetabolism

PETCTFused

Clinical Trials

Clinical Trials

Goal: Identify better ways to treat ovarian cancer

Who leads? Principal investigator, MDResearch team

Who sponsors?Academic medical centersPharmaceutical companiesNonprofit organizationsNRG oncologyFederal agencies

Clinical Trials

StructurePhase ISafetyDosagePhase IISafetyEffectivenessPhase IIIEffectiveness

Clinical TrialsExample questions to ask:What are the possible interventions I might receive during the trial? Why do researchers believe the intervention being tested might be effective? Has it been tested before?Does everyone receive the study drug?When do I find out which intervention I will receive?How do the possible risks, side effects, and benefits of this trial compare with those of my current treatment?What will I have to do?How long will the study last?Who will pay for my participation? Reimbursed for other expenses?What type of long-term follow-up care is part of this trial? If I benefit from the intervention, will I be allowed to continue receiving it after the trial ends?Will results of the study be provided to me?Who will oversee my medical care while I am in the trial?

Tumor Testing

Tumor TestingCaris Life Sciences

Multiple tumor profiling technologiesIHC, FISH/CISH, Next-Generation Sequencing, PCR

Tumor Testing

Precision Therapeutics

Tumor cells are grown in the lab, treated with various chemotherapy drugs, and response measured

Clinical TrialsFoundationOne

Sequences more than 200 cancer-related genes

Genetic Counseling??

SGO Recommendations