Gynecological Cancer – 6
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for highlighting some very important points about ovary cancer. 1. A number of patients are detected with only a complex or solid ovary cyst, many times incidentally. They should be operated, without biopsy. And surgery should be done by involving a cancer or gyn cancer surgeon. There are no tests to rule out cancer with absolute certainty at this stage. 2. Goal of ovary cancer surgery is to remove all possible disease (optimal cytoreduction). Hence in many cases of stage 3, chemotherapy is given first to shrink disease and allow better more complete surgery. 3. Chemotherapy is possible in most stage 3 weak patients as well, when weakness is due to cancer. In fact, weakness improves as cancer is controlled and allows patients to regain strength, enough to undergo even a major surgery.
What about patients who are operable at diagnosis, do they need chemotherapy after surgery?
Answer: Yes. Many patients can be operated first, as they don’t have extensive disease. However, same as many other cancers, such as breast, colon…postoperative chemotherapy improves cure rates in ovary cancer too. Most stages, including stage 1 (with some specific features), stage 2, stage 3 benefit from adjuvant (postoperative) chemotherapy. A number of agents have been tried, but current standard of care is Carboplatin and Paclitaxel, given for six cycles, every 3 weeks. Various efforts to improve these results, including weekly paclitaxel, maintenance paclitaxel, adding a monoclonal antibody bevacizumab etc have not been successful, either due to lack of additional effectiveness, or toxicity. Only one variation with some improvement noted is using 2 weekly cycles, known as dose dense therapy. Giving chemotherapy every 2 weeks like this, has become possible due to availability of G-CSF, including its long acting form too. This is widely accepted way of giving postoperative chemotherapy in breast cancer.
Que: You mean none of the numerous new chemotherapy agents, targeted therapies, vaccines etc have been shown to improve results over the carboplatin paclitaxel combination which has been around for so long! Then where are they useful?
Ans: When it comes to postoperative chemotherapy, yes, you are right. Old is Gold. However, number of new agents are useful in stage 4 or recurrent ovary cancer. As discussed earlier, unfortunately, long term disease control is seen only in about 30% patients in India. That means, about 70% of women will either present in stage 4 or ultimately reach stage 4. And they benefit from these agents, in terms of improving symptoms, quality of life, prolonging life. Stage 4 patients cannot be cured in general however.
Que: You mean all stage 4 patients should be treated with new agents. What is the benefit ratio?
Ans: NO. All stage 4 patients should not be treated with anti cancer agents. Patients who present in stage 4, are very old, and have severe comorbidities may not benefit much. An important category unlikely to benefit much, are those who relapse within six months of completion of postoperative chemotherapy. They are known as Platinum Refractory Disease, meaning refractory to cisplatin/carboplatin type agents. This is a sign of very resistant disease, particularly if they have also received paclitaxel or docetaxel.
If possible, they should be enrolled in a clinical trial. If not available, consider only symptomatic care (especially if performance status is not good). If fitness is good, liposomal doxorubicin is one important choice, with one of the best efficacy in this setting, but also well tolerated and does not cause hair loss. Paclitaxel would be another very important option, if not given earlier. Overall survival however is only about one year, with all available options. Some people add bevacizumab, but overall survival remains same. If patient has BRCA germline mutation, PARP inhibitors, a new targeted therapy, is also an option, but approved for use after failure of 2-3 lines of chemotherapy. Olaparib, and Rucaparib are the currently available agents.
April 13th 2017.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com