Gynecological Cancer – 5
(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. It is a common cancer among Indian women, but cure rates are half that of USA, mainly due to late detection. 2. Lifestyle changes is an important risk factor. About 10% cases are hereditary. 3. No one test or a combination of tests is approved for screening i.e. for early detection. In spite of such claims for few tests, no good test exists. Hence we need to advise women about the risks and limitations of such tests.
Lastly you had mentioned that in early operable cases, biopsy is not required before surgery. But in more advance cases, like those with ascites, you would prefer to give chemotherapy first, then surgery. Can you elaborate more?
Answer: Yes. Let us talk about the treatment of ovary cancer. In early stages, i.e. stage 1 or 2, a cancer is suspected based on findings on sonography or on CT scan and CA 125. These patients typically have mild symptoms or even incidental finding of an ovary cyst. If the cyst is solid or complex, suspicion for ovary cancer is high. In older age groups, risk is significantly high. However, even in young women, one may have ovary ca but with alternate histology such as germ cell tumor.
It is better to operate without biopsy in such patients, as rupturing capsule of ovary cyst may upstage the patient i.e. increase stage from 1 to 2. This obviously worsens patient’s prognosis.
On the other hand, patients with several peritoneal nodules, or large ascites, or large omental involvement etc, direct optimal surgery is generally not feasible. Goal of ovary cancer surgery is to remove all disease (complete cytoreduction), but if not feasible, at least not leave any tumor over 1 cm. This is known as optimal cytoreduction. Achieving optimal cytoreduction clearly gives better survival, compared to suboptimal cytoreduction. Even the best of chemotherapy or other therapies cannot compensate for inadequate or suboptimal surgery. This knowledge has led to the concept of preoperative chemotherapy. That means, if direct optimal surgery is not feasible, one should start with chemotherapy. Chemotherapy will shrink the tumor and will allow better surgery, thus improving overall survival. Prior to this knowledge, patients frequently underwent two surgeries i.e. one at diagnosis, and second after few chemotherapy cycles. This understanding, better chemotherapy treatments, and multidisciplinary team work is now able to save patients from unnecessary two surgeries, with equal or better results.
Que: Ok. So what you are saying is that there are patients who have a complex cyst or an ovary mass with minimal or no symptoms in some cases. And such patients should not be ignored. Even if there CA 125 tumor marker, and all other blood tests are normal, they should still be operated.
Ans: Yes not all of these patients will turn out to be cancer, but removal of these suspicious adnexal masses or ovary cyst will lead to a significant number of early cancers being treated. Hence it is important. Unfortunately, there are no tests to rule out cancer or diagnose cancer with absolute certainty without surgery. Whenever possible, a suspected ovary cancer, even if it seems stage 1, should be operated by a cancer surgeon, preferably a Gynec cancer surgeon. This is an established practice in USA/Europe for decades. Such site specific surgical training concept is comparatively new in India, but many centers do practice it for many years.
Que: So, Dr Chiragbhai, a good surgery (complete or at least optimal cytoreduction) is the main foundation of ovary cancer surgery, with maximum impact on survival, right! However we do have many advance cancer patients with poor fitness due to cancer or age, where an extensive surgery may not be safe. And weak patients cannot undergo chemotherapy as well. What do you recommend in such cases?
Ans: Very good question. However you will be surprised to know that patients who are weak due to cancer or very old, are actually perfect candidates for chemotherapy. Single agent chemotherapy or chemotherapy divided in weekly doses is very well tolerated by such patients. It improves there fitness by controlling cancer. Then such patients can safely undergo surgery and obtain better results.
It is actually a wrong concept that all weak patients cannot tolerate chemotherapy. In most cases where advance cancer is the reason for weakness, chemotherapy (of course with some basic planning of dose and schedule and type of drug to be used) in fact improves fitness substantially. If marked weakness is due to other reasons, such as other major illness, chemotherapy should probably be avoided altogether.
Studies show that preoperative chemotherapy improves optimal cytoreduction rate, less surgical complications, early discharge. However overall survival remains the same, probably due to the underlying more aggressive biology of the disease, as seen by more advance stage at diagnosis.
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