Update on Gynecological Cancers: Prevention, Diagnosis and Treatment Webcast January 28, 2009 pptx

Introduction Andrew Schorr: Find out how you have the best chance of a cure or longer life if you're diagnosed with ovarian cancer.. One of the areas that women think about of course is

Update on Gynecological Cancers: Prevention, Diagnosis and Treatment

Webcast

January 28, 2009

Barbara Goff, M.D

Jane VanVoorst

Please remember the opinions expressed on Patient Power are not necessarily the views of Seattle

Cancer Care Alliance, its medical staff or Patient Power Our discussions are not a substitute for

seeking medical advice or care from your own doctor That’s how you’ll get care that’s most

appropriate for you

Introduction

Andrew Schorr:

Find out how you have the best chance of a cure or longer life if you're diagnosed

with ovarian cancer Hear about how being overweight increases your risk of

endometrial cancer and learn how the HPV vaccine continues to be a cancer

breakthrough for women It's all next on Patient Power

Andrew Schorr:

Hello This is Andrew Schorr with another one of our Patient Power programs

sponsored by the Seattle Cancer Care Alliance Thank you for being with us

One of the areas that women think about of course is a whole range of

gynecological cancers: Ovarian cancer, uterine or endometrial cancer, cervical

cancer There are other types as well And so we're going to discuss that in our

program, how to you get the best care, certainly what are things that raise your

risk, and how can you prevent these cancers at all or certainly also prevent a

recurrence if you are diagnosed

I want to introduce you to someone who has faced one of the scariest cancers, but

I guess I'd say as a leukemia survivor that all cancers are scary, and that's Jane

VanVoorst Jane is 56 years old She works in the banking field in Bellingham,

Washington, where she lives She has two grown sons But two years ago about

she was diagnosed with ovarian cancer, and she learned a lot along the way

Happily she's doing well, but we wanted to share that story And then we'll

introduce you to her doctor, who is one of the leading gynecological cancer experts

in the world, and we'll be with her in just a minute

But, Jane, welcome to Patient Power Tell us about the symptoms you were having

that made you think maybe things weren't quite right

Jane’s Story

Jane:

Thank you, Andrew It's a pleasure to be here My initial symptoms were early on,

and it was blooding, rare but occasional At the time however I didn't know it was

a symptom, so what took me to the doctor was a had a general sense of not feeling

well, not doing well I'm a runner, I ate well, I exercise, I took good care of myself,

and something just felt off It was time for my annual checkup, so I went to my

GP, general practitioner, and told him what was going on, and he did a little bit

deeper analysis and said, I think there might be something going on, simply

because I mentioned the bloating He sent me in for the ultrasound, and there I

had to get several because coincidentally I had an infection that arose at the same

time in my abdomen where I had a high fever

And bottom line is after looking at that the radiologist up here thought that perhaps

was simply the residuals of an infection, let's wait six months But my GP, because

he knew me and knew that normally I do quite well said, no, I don't think so, and

got me to a local gynecologist here in town in Bellingham who did an exam and said

pretty much, I think I know what you have and then referred me to either Seattle

Cancer Care Alliance or Swedish, and I let her pick She was very familiar with Dr

Goff and her work, and so she got me to Seattle Cancer Care, and the rest I guess

is history

Andrew Schorr:

And the history is that then you did have surgery and then six months of chemo

starting in the fall of 2006 with the surgery And you go in for checkups, but you're

doing really well

Jane:

I'm doing very well Thank you

Andrew Schorr:

Oh, that is so good Now, you mentioned Dr Goff, and let's bring her on That is

Dr Barbara Goff, who has been on Patient Power before She is a professor at the

University of Washington and director of gynecologic oncology at the University of

Washington Medical Center and the Seattle Cancer Care Alliance

Dr Goff, I understand in ovarian cancer where you go, now studies show, really

makes a difference in how well you may do Help us understand that

Ovarian Cancer Studies

Dr Goff:

Ovarian cancer is a complex disease, and unfortunately most of the time when

women get to the doctor the cancer has already spread beyond the ovaries So the

surgery when you go in and you try to remove the cancer it's very important that

you go to a center where there's experts in dealing with the surgical procedures

that need to be done when you make that initial diagnosis of ovarian cancer

Oftentimes a bowel resection needs to be done, extensive dissection

But what's really key in ovarian cancer is getting all the cancer out, and there have

been now numerous studies, probably about 30 studies both here and in Europe

and in Asia which show that when women are treated by gynecologic oncologists or

treated in centers that specialize in gynecologic cancers, specifically ovarian cancer,

that their cure rates are significantly higher than women who are not So I think

it's very important if someone even suggests that you have ovarian cancer that you

really seek out a consultation with someone who has expertise in ovarian cancer

Andrew Schorr:

Now, let's talk about the problem of ovarian cancer, and then we're going to move

on to others as well But in ovarian cancer typically it's found late, and maybe

there were warning signs, maybe there weren't I know you have been an author

of research related to are there sort of a group of subtle symptom that could

suggest it Jane referred to some bloating and didn't feel quite right Help us

understand what we know today that could give a woman a clue that she should be

checked further

Dr Goff:

That's a great question Historically ovarian cancer was always called the silent

killer because people thought that symptoms weren't supposed to develop until

advanced stages when there was really no chance of cure But really through some

partnering with some patients of mine and the Ovarian Cancer National Alliance I

started doing some research about what are the symptoms that women present

with Is it true that it's silent, or is it not true that it's silent? And through a

number of research publications we've really sort of narrowed it down to a set of

key symptoms that if women have these symptoms they're still very unlikely to

have ovarian cancer but they should have it checked out

The symptoms that are most important include bloating, increased abdominal size,

abdominal pain, pelvic pain, difficulty eating, feeling full quickly, and having some

urinary symptoms It's not just having these symptoms occasionally, once or

twice, but it's that these symptoms occur fairly consistently, every day or every

other day, and that these symptoms are new to patients So similar to what Jane

said is that, you know, I've always been normal and all of a sudden now why am I

getting bloating now And a lot of women just sort of pass it off as going through

menopause or getting older, but it's very key that if you have these symptoms that

you at least go in and get yourself checked out It's unlikely you'll have ovarian

cancer, but those are the early warning signs of ovarian cancer

Types of Gynecological Cancers

Andrew Schorr:

All right Let's understand some of the other gynecologic cancers We know about

cervical cancer, and hopefully women are getting pap smears, and you'll help us

understand about that And younger women now it's recommended that they have

this HPV vaccine, and you and I will talk about that before and we'll talk about that

as we go And then there's uterine or endometrial cancer, and I know there's some

others as well And I know there's some thinking now that related to cancer are

epidemic, if you will, of obesity, and obesity among women could be a factor So

help us understand the thinking about a connection between obesity and either

cancer the first time or a recurrence

Dr Goff:

Yeah, well, I think that's another great question Certainly obesity is probably the

number one risk factor for development of uterine or endometrial cancer

Endometrial cancer is actually the most common gynecologic malignancy, and a lot

of women don't realize that, but it is the most common GYN cancer that women

get, and it is related to obesity And the reason for that is that the fat cells in our

body will convert some of the steroids that are made by other organs in our body

into estrogens, and so women who are obese have very, very high levels of

estrogen that they actually make on their own So for example if a woman is 50

pounds overweight her risk of getting endometrial cancer is about 10 times greater

than a woman who is of normal weight

So what we are seeing as GYN oncologists is that there are increasing numbers of

women who are getting endometrial cancer And what's a little bit scary is that

we're seeing it in younger and younger women as we're seeing the obesity

epidemic start to hit children and start to hit women in their younger ages This

used to be a disease that we only saw after women went through menopause, but

we're seeing greater numbers of women even in their 30s and 40s now developing

endometrial cancer because of their obesity Obesity is also linked to breast

cancer, and we're not really talking about breast cancer today, but it is a risk factor

for breast cancer again because of the elevated levels of estrogen

I think the other thing that's really important in terms of recurrence is that there

have now been a number of studies that show that people in who engage in

moderate amounts of exercise following their cancer diagnosis can actually

significantly reduce their risk of recurrence And there have been some studies

specifically looking at women in breast cancer and in colon cancer, and women who

engage in moderate amounts of activity after their cancer diagnosis can have up to

a 30 percent reduction in their risk of recurrence if they sustain that moderate

amount of exercise

Andrew Schorr:

All right I just want to recap some of this, put it in perspective So going back to

ovarian for a minute, there are some subtle symptom that if a woman experiences,

and you listed those, she should at least be checked Related to cervical cancer,

that's what the pap smear is all about, right?

Cervical Cancer and HPV

Dr Goff:

Yeah, and the HPV vaccine I think it's really important to emphasize that currently

the HPV vaccine, it's FDA approved for women age 26 and under, and I think

anyone who is, any girl in her teens or a woman who is 26 or younger really should

get the HPV vaccine because it has over a 90 percent ability to reduce the HPV

infections which are the direct cause of cervical cancer

Andrew Schorr:

Okay And then we talked about obesity and then exercise for women That's good

any time but also certainly if you've been diagnosed as well Now, what about also

the signs of endometrial cancer, uterine cancer? What are the signs there? We

talked about it being seen unfortunately often later in ovarian, but are there some

more direct clues when it comes to either premenopausal or postmenopausal, which

I know it's more common, endometrial cancer?

Dr Goff:

Endometrial cancer is actually usually diagnosed in early stages, and that's because

there are some early warning symptoms that most women recognize as not normal

and they get themselves in to the doctor So for postmenopausal women, and the

majority of endometrial cancers do occur in women who are postmenopausal, about

75 percent will, and so for them the most common warning sign or the early

symptom would be postmenopausal bleeding So any woman who has any bleeding

after the menopause should go right in to their gynecologist and get checked out

Usually that results in a woman getting a biopsy of the lining of the uterus or

sometimes an ultrasound of the uterine to look at how thick the lining of the uterus

is

For premenopausal women the symptoms of endometrial cancer would be irregular

bleeding, bleeding heavier than normal, bleeding longer than normal, passing large

amounts of clots or bleeding in between the menses So any time you have an

abnormality with your menses it's important to go and get that checked out by your

doctor because it could be a sign of cancer Now, in most premenopausal women,

particularly if you are of normal weight, abnormal bleeding is not going to be

related to cancer So again we don't want to scare anyone, but it is important to

have abnormal menses or abnormal bleeding definitely checked out by a

gynecologist

Endometriosis and Endometrial Cancer

Andrew Schorr:

Dr Goff, some women experience endometriosis Is there any connection between

that and later developing endometrial cancer?

Dr Goff:

No, there doesn't appear to be a connection between endometriosis and

endometrial cancer There have been a couple of studies that suggest that

endometriosis may increase the risk of ovarian cancer, but that's a very weak

association, so I don't think anyone, if they've had endometriosis, that's a very

common disease, I don't think that they should be too concerned that later on

they're at elevated risk for cancer

Andrew Schorr:

What if they had nonmalignant fibroid tumors?

Dr Goff:

No, those do not appear to increase a woman's risk of either uterine cancer or

cervical cancer or ovarian cancer

Andrew Schorr:

Well, that's all good to know Now let's talk about treatment Now, Jane, you had

surgery, and I imagine with ovarian cancer it's fairly extensive How long did it

take to recover?

Jane:

I was in the hospital 13 days

Andrew Schorr:

Wow

Jane:

Which was unusually long It usually isn't quite that long, but I was in there for at

least that And then I was probably quite weakened for another month or so

Andrew Schorr:

Now, Dr Goff, I know there are some new techniques related to surgery and even

robots being used Help us understand where you are now with surgical

techniques I know they vary by patient, but what's being offered at the SCCA?

Dr Goff:

You know, I think the robotic surgery is one of the most exciting things that we are

now offering patients because it allows women to have fairly extensive cancer

surgical procedures through generally four or five very tiny, maybe less than an

inch incisions in their abdomen, and oftentimes these women can actually go home

the next day So the cancers that are best treated with robotic surgery are the

endometrial cancers and the cervix cancers Unfortunately with ovarian cancer

because there tends to be so much extensive spread, those still need to be treated

sort of the old fashioned, big abdominal incision And what's key in that case is

getting all the cancer out, and so cosmetics and time in the hospital sort of take a

back seat to trying to get the best cure rate that you can because ovarian cancer is

the deadliest of the gynecologic cancers that we treat

When we do surgery for ovarian cancer we often use a lot of fancy lasers and other

techniques to ablate cancer We do a lot of bowel resections, so we have very

special staplers and all sorts of other sort of high-tech instruments that we have to

make the surgery faster and more successful, things we have that reduce blood

loss that really allow us to be much more aggressive in the operating room than we

used to be to really improve those cure rates Because that's really the goal with

ovarian cancer is giving that patient the absolute best cure rate that you can

Andrew Schorr:

Right Now, of course in ovarian cancer as an example but maybe some more

advanced endometrial cancers and others, then often there's drug therapy and

maybe in some cases radiation too So help us understand, take in like Jane's case,

Jane we mentioned had six months of chemotherapy Where are we now with

improvements in the drug therapies and the delivery?

Drug Therapies and Treatment Delivery

Dr Goff:

Ovarian cancer, this is a disease that requires both a surgical phase of treatment

and a chemotherapy phase of treatment When you have been able to successfully

remove all of the cancer then you can offer the patient the opportunity of having

chemotherapy directly delivered into the abdominal cavity And that has been

associated with a significant improvement in survival for women So now that, it

used to be the average length of time that women survived was about three years,

and there was about a 20 percent chance of cure With appropriate, with an

optimal surgery where you get out all the cancer and giving women intraperitoneal

chemotherapy we can push that cure rate very close to about 50 percent We'd

love to have it a hundred, but that's a lot better than 20 percent if we're looking at

50 percent And the average length of time even if you don't survive is over five

years So we've really made a substantial improvement in the treatment of ovarian

cancer through direct delivery of the chemotherapy into the abdomen

I think one of the other really exciting areas in cancer treatment, not only for

gynecologic cancers but really for all cancers, is the development of these very new

and novel biologic agents where we have new chemotherapies that directly target

specific enzymes or specific antibodies that are on the cancer And so you go in

and with almost surgical precision you can knock out a certain enzyme in a cell

which then kills the cell and results in quite a bit less toxicity Because I think Jane

will tell you what she went through was quite toxic, but some of the newer drugs

that we have are actually quite a bit less toxic They're all in different phases of

development, but I think it's a very exciting time to be a cancer physician because

of all of these new drugs that are coming out and that are available

Andrew Schorr:

Yeah, I have to tell my story briefly So I'm a leukemia survivor, diagnosed more

than 12, almost 13 years ago, and then I was in a clinical trial, a phase II clinical

trial just at a single center And then it was really neat to be at one of the big

cancer conventions a couple of months ago, and there were now two big phase III

trials that studied the drugs I had eight years before, and it validated it, and now

it's the world standard

So that brings me to a discussion of trials At the SCCA, in these areas that are

fast changing, because you talked about changes from just when Jane had

treatment two years ago, tell us about the trials in gynecologic oncology Are you

excited about those? You mentioned these new drugs, and it seems like you're

refining your surgical techniques as well

Dr Goff:

Yeah We participate in a number of large group trials through the Gynecologic

Oncology Group, which is an NCI-sponsored cooperative group trial, which NCI is

National Cancer Institute We also have our own investigator-initiated trials, and

there is a lot of excitement in terms of these new drugs There are new methods of

delivering drugs There are new surgical techniques that we are trialing And so I

think it's really important for patients to understand the importance of participating

in clinical trials like you did because it's the only way that we can advance our

knowledge and figure out what should be the standard of care, what is going to be

better And so that's very important

You know, when Jane came through we actually didn't have a clinical trial that

matched where she was, and so she didn't end up going on a clinical trial, but she

benefited from a clinical trial that had just closed right prior to her being diagnosed,

which we were able to use that information and sort of change the standard of care,

which used to be just giving chemotherapy intravenously to giving chemotherapy

intraabdominally But whenever possible we do try to offer a menu of clinical trials

for our patients if they will qualify and if it seems to be appropriate So I think it's

important for patients not to be afraid of clinical trials but understand that they

have help advance science and advance knowledge for the people coming

sometimes just right behind them in terms of what is the best way to treat these

cancers

Andrew Schorr:

I know that doctors, researchers don't like to promote it that way, but I feel that I

got today's medicine yesterday, or if it's a trial now, maybe tomorrow's medicine

today

Dr Goff:

Yes

Andrew Schorr:

So that's something from the patient's point of view to consider

One last area I wanted to ask you about, Dr Goff, and I want to hear more from

Jane too, so any of us who are diagnosed with cancer, men or women, say do we

have to worry about our kids Is there a genetic connection? So in the gynecologic

cancers, what about that?

Genetics and Gynecologic Cancers

Dr Goff:

Certainly for ovarian cancer there is a genetic link with that type of cancer With

endometrial cancer there is a small percentage of cancers that are genetically

linked With ovarian cancer about 15 percent of them do have a genetic

component Most of those cancers are seen in families that have premenopausal

breast cancer and ovarian cancers associated together, and there are some other

more rare cancers that you can sometimes see These would be fallopian tube

cancers; male breast cancer; primary peritoneal cancers, which are cancers of the

lining of the abdomen Those also constitute part of that syndrome So we

strongly encourage our patients at SCCA who have been diagnosed with ovarian

cancer to at least speak with a genetic counselor, have their family history taken,

and see whether or not it makes sense for them to go ahead and get genetic

testing to see whether or not they have one of these genes which predispose them

to developing ovarian cancer and breast cancer And then other families members

can choose whether or not they would also like to undergo genetic testing, because

any family member who is directly related to that woman, if it be a sister or a

brother, a mother or a daughter, they would have a 50 percent chance of inheriting

that gene

Andrew Schorr:

So, Jane, you have two sons Do you have any daughters-in-law yet?

Jane:

Not yet

Andrew Schorr:

Okay Well, hopefully some day you will or even granddaughters So you've lived

it, and now we've gotten a lot of education from Dr Goff related to cancers in

women, gynecologic ones So what would you say to somebody listening? You

went the extra mile with advice from a doctor as well, and I think it's made a big

difference, and you went to a key center and a leading gynecologic oncology

specialist to help you with treatment, with her team What would you say to

women listening either related to being proactive, the prevention things we heard,

or just getting to the right place for care?

Jane:

If I was talking to someone, just women in general, as I do now, I'd tell them two

things: Get fit and know the symptoms And if you've got any of the symptoms go

to the doctor The likelihood you've got the disease is small, but at least you won't

have it diagnosed late stage like I did They'll catch it early if in fact you do have it

When I talk to women who are currently ill or have just been diagnosed I tell them,

almost echo what Dr Goff said, I tell them all that your best chance of survival is

getting to a gynecological oncologist who is at a specialty care clinic And we are

very fortunate in the Northwest I tell anyone in the Northwest, go to Seattle

Cancer Care, because from a patient's perspective as important as it is that you

have that survival, when you're in treatment you're so inside your head and you're

so, since you've been through it you know You have that natural fear What you

also need is a clinic that does nothing but deal with women or men like you so that

they know what you're going through, they can anticipate what you're feeling, and

give you total care, not just healthcare And I think the U-Dub excelled at knowing

how to treat patients and knowing how to make us feel like we were their only

concern when we were there

And then I also tell people when they're going through treatment to find another

woman who has had the disease before them That would have benefited me

greatly when I was going through it because for me everything was new, and with

new everything is a little bit fearful But once I got to talk to people who had been

through it they could tell me what to expect, and they gave me tips So that's what

I try to do now is to provide that service to women

And then post treatment I tell them to avoid worrying, because until someone tells

me it is a cure for cancer or a preventive measure of getting cancer I'm not going

to do it Spend that energy finding a way to last Spend that energy finding a way

to find hope And then get fit, exercise, eat right and count your blessings

Andrew Schorr:

Absolutely And that's all great advice One thing I would just like to say, my

perspective too, and, Dr Goff, I'm sure you feel this way too, it's very helpful to

have support from people who have sort of walked in your shoes ahead of you, but

know that everybody's cancer situation is different In all the cancer programs I've

done we keep seeing subtypes and different situations People react to drugs

differently or recover from surgery differently So you need to know that And also

even in situations where the statistics have not been great, and ovarian cancer,

thank goodness, is improving, you're not a statistic Any comments on that sort of

individualization and the statistics, applying it to one person, Dr Goff?

Dr Goff:

Well, I think that's absolutely right What I say to every single patient who I treat,

and particularly with ovarian cancer where you're not giving people statistics of a

90 percent chance of cure, I think it's very important to understand that statistics

apply to the 100 people over there They never apply to an individual And you

will either live or die from the cancer, and our job is to do everything we can to get

you cured from this cancer And that's really how I approach every patient as an

individual, and every individual has to approach their cancer that way

You also have to be very careful about what you read on the internet because it

may not apply to you As you said, every cancer is a little bit different There are

different grades, there are different histologies, and not all ovarian cancers are the

same And so you can go and look up all of these horrible statistics on the internet,

but they may not completely apply to you at all So I think you need to be very

careful

The other thing I think is very important is you have to feel like your doctor is a

member of your team, and so you should not be afraid to get a second opinion and

to see if there is somebody else who you would make a better team with because I

think that that's really important The patient and the physician have to work

together It has to be a team effort It can't just be the patient, it can't just be the

doctor, but it has to be the two of you together deciding that you're going to treat

this cancer and you're going to do what you can to get that cure