ovarian cancer treatment – the latest and greatest

John K. ChanJohn K. Chan

Gynecologic Cancers

Ovarian Cancer Treatment – Ovarian Cancer Treatment –

The Latest and GreatestThe Latest and Greatest

John K. Chan, M.D.John K. Chan, M.D.Division of Gynecologic OncologyDivision of Gynecologic Oncology

UCSF University School of MedicineUCSF University School of Medicine


Gynecologic Cancers

No relevant financial disclosuresNo relevant financial disclosures


Gynecologic Cancers

OverviewOverview

• Ovarian cancerOvarian cancer– Awareness – symptoms?Awareness – symptoms?– Screening – blood test or ultrasound?Screening – blood test or ultrasound?– Treatment / prevention – surgery and chemotherapyTreatment / prevention – surgery and chemotherapy– Personalized novel therapy – are we there yet?Personalized novel therapy – are we there yet?

• Endometrial cancerEndometrial cancer– Robotic surgery – Man vs. machine?Robotic surgery – Man vs. machine?


Gynecologic Cancers

Ovarian CancerOvarian Cancer


Gynecologic Cancers

Ovarian Cancer – clinical presentationOvarian Cancer – clinical presentation


Gynecologic Cancers

Ovarian - benignOvarian - benign

fibromafibroma

cystadenomacystadenomateratomateratoma


Gynecologic Cancers

Ovarian mucinous cystadenomaOvarian mucinous cystadenoma


Gynecologic Cancers

Ovarian carcinomaOvarian carcinoma


Gynecologic Cancers

Symptoms of “silent killer”Symptoms of “silent killer”

72% of women had 72% of women had recurring symptoms - recurring symptoms - median of 2: median of 2:

• Back pain (45%)Back pain (45%)• Fatigue (34%)Fatigue (34%)• Bloating (27%)Bloating (27%)• Constipation (24%)Constipation (24%)• Urinary symptoms (16%)Urinary symptoms (16%)

Goff et al, JAMA 2004

Early stage (high risk) patientsEarly stage (high risk) patients

Over 70% had one or more Over 70% had one or more symptoms present 1-3 symptoms present 1-3 months before diagnosis:months before diagnosis:

• Abdomino-pelvic pain (38%)Abdomino-pelvic pain (38%)• Fullness / girth (27%)Fullness / girth (27%)• Abnormal bleeding (16%)Abnormal bleeding (16%)

Chan et al, SGO 2009


Gynecologic Cancers

Screening on ovarian cancer mortality: Screening on ovarian cancer mortality: Prostate, Lung, Colorectal and Ovarian (PLCO) TrialProstate, Lung, Colorectal and Ovarian (PLCO) Trial

Total 388 cancersTotal 388 cancers212 screened (5.7 / 10,000 212 screened (5.7 / 10,000 person years)person years)

176 unscreened (4.7 / 10,000 176 unscreened (4.7 / 10,000 person years)person years)

No reduction in ovarian No reduction in ovarian cancer mortality. cancer mortality.

False-positive screening test False-positive screening test result associated with result associated with complicationscomplications

Buys JAMA 2011

78,216postmenop

ausal women

aged 55 to 74 years

(1993-2001)Usual care(n=39,111)

Annual screening

CA-125 - 6 years

TV ultrasound - 4 years

(n=39,105)


Gynecologic Cancers

Ovarian cancerOvarian cancer

• 1 out of 70 U.S. women 1 out of 70 U.S. women • 25,000 cases annually25,000 cases annually• 14,000 deaths annually 14,000 deaths annually • 44thth in cancer related deaths among women in cancer related deaths among women• Mean age at diagnosis 59 yearsMean age at diagnosis 59 years


Gynecologic Cancers

Female Reproductive TractFemale Reproductive Tract New CasesNew Cases DeathsDeaths

Breast Breast 192,200 192,200 40,20040,200

Colorectal 68,100 Colorectal 68,100 29,00029,000

Lung/Bronchus 78,800 Lung/Bronchus 78,800 67,30067,300

Endometrium 38,300 Endometrium 38,300 6,6006,600

OvaryOvary 23,400 23,400 13,90013,900

CervixCervix 13,900 13,900 4,4004,400

Vulva 3,600 800Vulva 3,600 800

American Cancer Society


Gynecologic Cancers

Reproductive factorsReproductive factors

• Increased risk - Increased risk - • NulliparityNulliparity• InfertilityInfertility

• Decreases risk -Decreases risk -• Oral contraceptives Oral contraceptives

protective - 50% decrease protective - 50% decrease with 5 or more years of use.with 5 or more years of use.

• MultiparityMultiparity• LactationLactation


Gynecologic Cancers

Primary Therapy – ovarian cancerPrimary Therapy – ovarian cancer

• Goals of SurgeryGoals of Surgery– DiagnosisDiagnosis

– Staging (early stage disease)Staging (early stage disease)

– Cytoreduction (advanced disease)Cytoreduction (advanced disease)

• Adjuvant ChemotherapyAdjuvant Chemotherapy– Except stage IA or IB and grade I or II or clear cell histologyExcept stage IA or IB and grade I or II or clear cell histology


Gynecologic Cancers

Platinum + Taxane ChemotherapyPlatinum + Taxane Chemotherapy(Carboplatin + Paclitaxel)(Carboplatin + Paclitaxel)

Surgery with maximum Surgery with maximum cytoreduction effortcytoreduction effort


Gynecologic Cancers

• Significant survival advantage for Significant survival advantage for women optimally cytoreducedwomen optimally cytoreduced

• Procedures may include:Procedures may include:– En blocEn bloc resection of uterus, resection of uterus,

ovaries and pelvic tumorovaries and pelvic tumor– OmentectomyOmentectomy– Selective lymphadenectomySelective lymphadenectomy– Bowel resectionBowel resection– Removal of diaphragmatic Removal of diaphragmatic

and peritoneal implants and peritoneal implants – Splenectomy, appendectomySplenectomy, appendectomy

20

22

24

26

28

30

32

34

36

38

40

0 10 20 30 40 50 60 70 80 90 100

% Cytoreduction

Med

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Mo

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Bristow, J., Clin. Oncol. 20: 1248, 2002


Gynecologic Cancers

US News and World ReportUS News and World Report

Liou, Chan J. Surg Onc 2005Tewari, Chan SGO 2013

Intraperitoneal vs. IV therapyLong- term Survival

• Median PFS25.0 vs 20.0 mo,

p=0.02

• Median OS62.0 vs 51.0 mo,

p=0.048

Tewari, Chan SGO 2013

Gross vs Microscopic Disease

• IP therapy– Advantages in both

microscopic and macroscopic residual disease

– 65% vs 58% microscopic– 44% vs 35% gross

residualGross residual 1.82-fold

increase in risk for death


Gynecologic Cancers

BevacizumabBevacizumab (rhuMAB VEGF) (rhuMAB VEGF)

• Recombinant humanized Recombinant humanized monoclonal IgGmonoclonal IgG11 antibody antibody11

• Recognizes all isoforms of VEGF-ARecognizes all isoforms of VEGF-A22

• Estimated half-life Estimated half-life is approximately 20 days (range, 11-is approximately 20 days (range, 11-50 days)50 days)11

• Randomized trials establish efficacy Randomized trials establish efficacy in colon, breast, lung, and renal in colon, breast, lung, and renal cancercancer

1. Avastin [package insert]. South San Francisco, CA: Genentech, Inc.; 2007; 2. Presta, et al. Cancer Res. 1997;57:4593.


Gynecologic Cancers

Mechanism of action of anti-angiogenic agentsMechanism of action of anti-angiogenic agents

Regression1,2 Inhibition1Normalisation2

Reduces tumor mass

Enhances activity of concomitant therapies

Prevents growth of micrometastases

Efficacy of continued therapy

Continued effects

1. Baluk et al. Curr Opin Genet Dev 20052. Willett et al. Nat Med 2004

Early effects


Gynecologic Cancers

GOG-0218 study schemaGOG-0218 study schema

Previously untreated epithelial ovarian, primary

peritoneal, or fallopian tube cancer

• Stage III optimal (macroscopic)• Stage III suboptimal• Stage IV

n=1800 (planned)

Stratification variables:• GOG performance status• Stage/debulking status

1:1:1

15 months

Paclitaxel 175 mg/m2

Carboplatin AUC 6

Placebo

IArm

Cytotoxic (6 cycles)

Maintenance(16 cycles)

(CP + PLA → PLA)

Carboplatin AUC 6

Paclitaxel 175 mg/m2

PlaceboBevacizumab

15 mg/kg

II(CP + BEV→ PLA)

Bevacizumab 15 mg/kg

Carboplatin AUC 6

Paclitaxel 175 mg/m2III

(CP + BEV BEV)

Burger et al. J Clin Oncol 2010;28(18S): Abstr LBA1


Gynecologic Cancers

GOG-0218: Investigator-GOG-0218: Investigator-Assessed PFSAssessed PFS

Arm I Arm I CP CP

(n=625)(n=625)

Arm IIArm IICP + BEVCP + BEV(n=625)(n=625)

Patients with event, n (%)Patients with event, n (%)423 423

(67.7)(67.7)418 418

(66.9)(66.9)

Median PFS, monthsMedian PFS, months 10.310.3 11.211.2

Stratified analysis HR Stratified analysis HR (95% CI)(95% CI)

0.9080.908(0.759(0.759––1.040)1.040)

One-sided p-value (log rank)One-sided p-value (log rank) 0.080*0.080*

+ BEV (Arm II)+ BEV (Arm II)CP (Arm I)CP (Arm I)

*p-value boundary = 0.0116*p-value boundary = 0.0116

+ BEV + BEV → BEV maintenance (Arm III)→ BEV maintenance (Arm III)

Pro

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fre

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pro

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Months since randomizationMonths since randomization

1.01.0

0.90.9

0.80.8

0.70.7

0.60.6

0.50.5

0.40.4

0.30.3

0.20.2

0.10.1

00 00 1212 2424 3636

Arm IIIArm IIICP + BEV CP + BEV BEV BEV

(n=623)(n=623)

360 360 (57.8)(57.8)

14.114.1

0.717 0.717 (0.625(0.625––0.824)0.824)

<0.0001*<0.0001*

2323


Gynecologic Cancers

GOG-0218: Overall Survival GOG-0218: Overall Survival Analysis Analysis

At time of final PFS analysis (January 2010)At time of final PFS analysis (January 2010)

+ BEV (Arm II)+ BEV (Arm II)CP (Arm I)CP (Arm I)

+ BEV + BEV → BEV maintenance (Arm III)→ BEV maintenance (Arm III)

Arm IArm ICPCP

(n=625)(n=625)

Arm IIArm IICP + BEVCP + BEV(n=625)(n=625)

Arm IIIArm IIICP + BEV CP + BEV

BEVBEV(n=623)(n=623)

Patients with events, n (%)Patients with events, n (%) 156 (25.0)156 (25.0) 150 (24.0)150 (24.0) 138 (22.2)138 (22.2)

Median OS, monthsMedian OS, months 39.339.3 38.738.7 39.739.7

Stratified analysisStratified analysisHR (95% CI)HR (95% CI)

1.0361.036(0.827(0.827––1.297)1.297)

0.9150.915(0.727(0.727––1.152)1.152)

One-sided p-valueOne-sided p-value 0.3610.361 0.2520.252

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Months since randomizationMonths since randomization

1.01.0

0.90.9

0.80.8

0.70.7

0.60.6

0.50.5

0.40.4

0.30.3

0.20.2

0.10.1

00 00 1212 2424 3636 4848

2424


Gynecologic Cancers

1021041061081010

1012

0 2 4 6 8 10 12 14 16 18 20

Conventional chemotherapyConventional chemotherapy

1012

1010

108

106

104

102

1

Dose-dense chemotherapyDose-dense chemotherapy

0 2 4 6 8 10 12 14 16 18 20Larry Norton, The Oncologist 2001;6(suppl 3):30


Gynecologic Cancers

Ovarian Epithelial, Primary Peritoneal, or Ovarian Epithelial, Primary Peritoneal, or Fallopian Tube cancerFallopian Tube cancer

FIGO Stage II-IVFIGO Stage II-IV

Ovarian Epithelial, Primary Peritoneal, or Ovarian Epithelial, Primary Peritoneal, or Fallopian Tube cancerFallopian Tube cancer

FIGO Stage II-IVFIGO Stage II-IV

Conventional TC (c-TC)Conventional TC (c-TC)　　 Paclitaxel 180mg/mPaclitaxel 180mg/m22, day 1, day 1　　 Carboplatin AUC 6.0, day 1Carboplatin AUC 6.0, day 1　　 every 21 days for 6-9 cyclesevery 21 days for 6-9 cycles

Conventional TC (c-TC)Conventional TC (c-TC)　　 Paclitaxel 180mg/mPaclitaxel 180mg/m22, day 1, day 1　　 Carboplatin AUC 6.0, day 1Carboplatin AUC 6.0, day 1　　 every 21 days for 6-9 cyclesevery 21 days for 6-9 cycles

Dose-dense weekly TC (dd-TC)Dose-dense weekly TC (dd-TC)　　 Paclitaxel 80mg/mPaclitaxel 80mg/m22, days 1,8,15, days 1,8,15　　 Carboplatin AUC 6.0, day 1Carboplatin AUC 6.0, day 1　　 every 21 days for 6-9 cyclesevery 21 days for 6-9 cycles

Dose-dense weekly TC (dd-TC)Dose-dense weekly TC (dd-TC)　　 Paclitaxel 80mg/mPaclitaxel 80mg/m22, days 1,8,15, days 1,8,15　　 Carboplatin AUC 6.0, day 1Carboplatin AUC 6.0, day 1　　 every 21 days for 6-9 cyclesevery 21 days for 6-9 cycles

RandomizationRandomizationStratification; Stratification;

Residual disease: Residual disease: <<1cm, > 1cm1cm, > 1cmFIGO StageFIGO Stage ：： II vs. III vs. IVII vs. III vs. IVHistologyHistology ：： clear cell/mucinous vs.serous/others clear cell/mucinous vs.serous/others

N. Katsumata, Lancet 2009


Gynecologic Cancers

Treatment n Event 3-yr　survival P　value HR　 95%CI　

c-TC 319　 124 65.1%

dd-TC 312　 96 72.1% 0.0325 0.749 0.574-0.976

0 6 12 18 24 30 36 42 48 54 60

0.0

0.2

0.4

0.6

0.8

1.0

Months from randomization

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Overall survival


Gynecologic Cancers

ConclusionsConclusions

• Dose-dense paclitaxel with 3 weekly carboplatin should be a Dose-dense paclitaxel with 3 weekly carboplatin should be a new standard chemotherapy for ovarian cancernew standard chemotherapy for ovarian cancer

• Limitations – Limitations –

Pharmacogenetic and tumor difference – asians vs. non-asiansPharmacogenetic and tumor difference – asians vs. non-asians

toxicity and efficacytoxicity and efficacy

less convenientless convenient

more toxicmore toxic

global implicationsglobal implications


Gynecologic Cancers

GOG 262GOG 262

3-weekly IV paclitaxel 175 mg/m2

IV carboplatin AUC 6 q3w

Bevacizumab 15 mg/kg q3w Suboptimal stage III/IV epithelial

ovarian, PP or FT cancer

Bevacizumab 15 mg/kg q3w

Weekly IV paclitaxel 80 mg/m2

IV carboplatin AUC 6 q3w

Open: SEPT 2010Open: SEPT 2010Target Accrual:Target Accrual: 625 pts625 pts Optional* bevacizumab on cycle 2 x 6 then maintenance Optional* bevacizumab on cycle 2 x 6 then maintenance

bevacizumab 15 mg/kg IV day 1 every 21 days until bevacizumab 15 mg/kg IV day 1 every 21 days until progression or adverse effects preclude further treatment.progression or adverse effects preclude further treatment.

Chan J PIChan J PI


Gynecologic Cancers

Recurrent Ovarian Cancer - Recurrent Ovarian Cancer - What is the Optimal Agent, Optimal Dose, & ScheduleWhat is the Optimal Agent, Optimal Dose, & Schedule


Gynecologic Cancers

Ovarian Carcinoma: Natural HistoryOvarian Carcinoma: Natural History

SymptomsSymptomsSymptomsSymptoms

DiagnosisDiagnosis

Chemotherapy #1Chemotherapy #1Chemotherapy #1Chemotherapy #1

Surgical EvaluationSurgical Evaluation

EvaluationEvaluation? SLL? SLL

ProgressionProgression

Chemo #2Chemo #2Chemo #2Chemo #2 Chemo #3+Chemo #3+Chemo #3+Chemo #3+

SupportiveSupportiveCareCare

DeathDeath

ConsolidationConsolidationConsolidationConsolidation

Curative intentCurative intent Palliative intentPalliative intent

SecondarySecondarySurgerySurgery


Gynecologic Cancers

Molecular therapyMolecular therapy– block receptorblock receptor– inhibit tyrosine kinaseinhibit tyrosine kinase– conjugate ligandconjugate ligand– anti-sense ligandanti-sense ligand

Signal transduction

Celldeath

MAbsToxin

conjugates Antisense

Proteinsynthesis

KKKK

Ligand

KK

Signal transduction

TKIs

TKIKK

Ligand Ligand Ligand

Small MoleculesSmall Molecules


Gynecologic Cancers

mRNAExpressionArray CGH Mutations

SensitivityPredictor

Predicting Sensitivity: An Integrated Approach


Gynecologic Cancers

• 13,321 women with ovarian cancer in California.

• Only a third of patients received the best possible care by NCCN

• More experienced surgeons (>10 ovarian cancer and hospitals that treated >20 year) associated with better outcomes


Gynecologic Cancers

The Role of the physicians in Early DetectionThe Role of the physicians in Early Detection

• Consider referral or consultation - Gynecologic OncologistConsider referral or consultation - Gynecologic Oncologist

– Postmenopausal and one of the following:Postmenopausal and one of the following:

• elevated CA125, ascites, nodular or fixed mass, metastasis, elevated CA125, ascites, nodular or fixed mass, metastasis,

or family history of breast or ovarian canceror family history of breast or ovarian cancer

– Premenopausal and one of the following: Premenopausal and one of the following:

• elevated CA125 (>200), ascites, metastasis, or family elevated CA125 (>200), ascites, metastasis, or family

history of breast or ovarian cancerhistory of breast or ovarian cancer

ACOG Committee Opinion #280, December 2002


Gynecologic Cancers

Kaplan-Meier 5 yr disease-specific survival - gynecologic oncologist careKaplan-Meier 5 yr disease-specific survival - gynecologic oncologist care

Gynecologic oncologist Gynecologic oncologist 39% 39% (p<0.001)(p<0.001)No gynecologic oncologist No gynecologic oncologist 30% 30%

Gyn Onc (n=509)

No Gyn Onc (n=982)

Northern CaliforniaNorthern CaliforniaCalifornia Cancer California Cancer RegistryRegistry

1994 and 1996 1994 and 1996 1,491 women1,491 womenstage IC-IV ovarian stage IC-IV ovarian cancercancer

Chan et al Obgyn 2007


Gynecologic Cancers

Early-stage:Early-stage: Late-stage:Late-stage:Gynecologic oncologist Gynecologic oncologist 66% 66% Gynecologic oncologist Gynecologic oncologist 31% 31%No gynecologic oncologist No gynecologic oncologist 61% 61% No gynecologic oncologist No gynecologic oncologist 23% 23%(p=0.157)(p=0.157) (p<0.001)(p<0.001)

Gyn Onc (n=398)

No Gyn Onc (n=692)

Kaplan-Meier five-year disease-specific survival based on Kaplan-Meier five-year disease-specific survival based on gynecologic oncologist caregynecologic oncologist care

Gyn Onc (n=100)

No Gyn Onc (n=211)

Chan et al Obgyn 2007


Gynecologic Cancers

Chronic stress promotes tumor growth and angiogenesis

Thaker, Sood Nat Med 2006Thaker, Sood Nat Med 2006

Animals showed markedly Animals showed markedly increased vascularization andincreased vascularization andtumor growth via cAMP–PKA tumor growth via cAMP–PKA signaling pathwaysignaling pathway

Mouse model of ovarian cancerMouse model of ovarian cancerTumors in stressedTumors in stressed


Gynecologic Cancers

Cervical Cancer Cervical Cancer


Gynecologic Cancers

The Global Burden of Cancer to Women WorldwideThe Global Burden of Cancer to Women Worldwide

Parkin DM et al CA Cancer J Clin 2005;55;74-108

John K. Chan, M.D.John K. Chan, M.D.

Screening Guidelines - Review

Initiate

Screening interval

DiscontAge 21-29 Age >30

ACS / ASCCP / ASCP (2012)

21 Cytology every three years

Co-testing HPV and cytology every five years (preferred)Cytology every three years (acceptable)

65

US Preventive Services Task Force (2012)


Cytology every three yearsAlternative: co-testing HPV and cytology every five years¥

65

ACOG (2012)


Co-testing HPV and cytology every five years (preferred)Cytology every three years

65


Gynecologic Cancers

Biology of HPV Infection: High-Grade LesionsBiology of HPV Infection: High-Grade Lesions11–3–3

*CIN = cervical intraepithelial neoplasia; ICC = invasive cervical cancer1. Goodman A, Wilbur DC. N Engl J Med. 2003;349:1555–1564. Adapted with permission from the Massachusetts Medical Society. 2. Doorbar J. J Clin Virol. 2005;32(suppl):S7–S15. 3. Bonnez W. In: Richman DD, Whitley RJ, Hayden FJ, eds. Washington, DC: American Society for Microbiology Press; 2002:557–596.

Normal Normal CervixCervix

HPV Infection HPV Infection (CIN* 2) (CIN* 3)(CIN* 2) (CIN* 3)

Cervical Cancer Cervical Cancer (Invasive)(Invasive)

Infectious Viral Particles

Episome

Perinuclear Clearing (Koilocytosis)

Basal cell layer


Gynecologic Cancers


Gynecologic Cancers

Yeast Cell (or Yeast Cell (or Baculovirus Expression System)

L1 gene L1 gene on HPV on HPV

DNADNA

L1 gene inserted L1 gene inserted into genome of into genome of

yeast cellyeast cell

Yeast cell DNAYeast cell DNA

mRNAmRNAtRNAtRNA

rRNArRNA

TranscriptionTranscription

TranslationTranslation

Capsid proteinsCapsid proteins

Empty viral capsids

Elicits Elicits immune immune

response in response in hosthost

HPV L1 VLP Vaccine SynthesisHPV L1 VLP Vaccine Synthesis


Gynecologic Cancers

Chan, Berek JCO 2007


Gynecologic Cancers

Prophylactic HPV VaccinesProphylactic HPV Vaccines

• Quadra-valent (Merck)Quadra-valent (Merck)– Recombinant L1 proteins using yeastRecombinant L1 proteins using yeast– 100% effective in preventing 100% effective in preventing

persistent HPV infectionpersistent HPV infection– Phase III Study completedPhase III Study completed

• HPV L1 Types 6, 11, 16 & 18 vs. HPV L1 Types 6, 11, 16 & 18 vs. adjuvantadjuvant

• Endpoint CIN2+Endpoint CIN2+

• Bi-valent (GSK)Bi-valent (GSK)– Recombinant L1 proteins using Recombinant L1 proteins using

baculovirusbaculovirus

– 100% effective in preventing persistent 100% effective in preventing persistent HPV infectionHPV infection

– Phase III study ongoingPhase III study ongoing• HPV L1 Types 16 & 18 vs. Hepatitis AHPV L1 Types 16 & 18 vs. Hepatitis A• Endpoint CIN 2+Endpoint CIN 2+

Villa LL et al Lancet Oncol. 2005 May;6(5):271-8.

Harper DM et alLancet. 2004 Nov 13-19;364(9447):1757-65.


Gynecologic Cancers

Advisory Committee on Immunization Practices —(Pediatric, gynecologic, and family practice)

females aged 11 to 12 (as young as age 9)Catch-up vaccination 13 to 26 years (Bivalent or quadrivalent)

males aged 11 or 12 years (as young as 9)Catch-up 13 to 21 years (Quadrivalent)


Gynecologic Cancers

ConclusionsConclusions

• The incidence of cervical cancer is decreasingThe incidence of cervical cancer is decreasing• Vaccines will eliminate this disease in a generationVaccines will eliminate this disease in a generation• Multimodality therapy in almost every scenario of invasive Multimodality therapy in almost every scenario of invasive

diseasedisease• Clinical and translational trials ongoing investigating new Clinical and translational trials ongoing investigating new

agentsagents


Gynecologic Cancers

Uterine CancerUterine Cancer


Gynecologic Cancers

Robotic Surgical SystemRobotic Surgical System

• Unparalleled Precision Dexterity and Unparalleled Precision Dexterity and ControlControl– High resolution 3D visualizationHigh resolution 3D visualization– Fully articulating Fully articulating EndoWristEndoWrist®® instruments instruments– Intuitive movement, motion scaling, Intuitive movement, motion scaling,

tremor reductiontremor reduction


Gynecologic Cancers

Robotic surgery – public perceptionRobotic surgery – public perception


Gynecologic Cancers

Robotic surgery vs. laparoscopic Robotic surgery vs. laparoscopic surgery surgery

Safe and feasible. ?better than Safe and feasible. ?better than laparoscopylaparoscopyAdvantages - Decreases physician Advantages - Decreases physician tremor, fatiguetremor, fatigueDisadvantages - Increase OR time, Disadvantages - Increase OR time, cost, bulky, no tactile feedbackcost, bulky, no tactile feedbackTransition from open to laparoscopic Transition from open to laparoscopic surgery, Market pressuressurgery, Market pressures

Evidence based practice vs. state of Evidence based practice vs. state of art (novel technologies)art (novel technologies)

Venkat, Chan et al, Gyn Onc 2011


Gynecologic Cancers

ReviewReview

• Ovarian cancerOvarian cancer– Surgery – optimal surgery – high volume surgeonsSurgery – optimal surgery – high volume surgeons– Adjuvant chemotherapy – intraperitoneal & weekly therapyAdjuvant chemotherapy – intraperitoneal & weekly therapy

• Cervix cancerCervix cancer– Prevention – New screening & HPV vaccine Prevention – New screening & HPV vaccine

• Endometrial cancer Endometrial cancer – Robotic LaparoscopyRobotic Laparoscopy


Gynecologic Cancers

[email protected](415) 306-4668(415) 306-4668

ovarian cancer treatment – the latest and greatest

Health & Medicine

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