Transcript OVARIAN CANCER - hillingdongp.org.uk

OVARIAN CANCER:
Recognition & initial
management / where are we
now
Mr. Panos Sarhanis MD FRCOG
Gynaecology Cancer Lead
NWLH London
Aims & objectives
 Present new disease data
 Focus on new developments in
recognition & initial management
 Present local data
 Highlight patient centered care
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Key message – NCIN
November 2010
 23% of newly diagnosed cancer
patients came through as emergency
presentations. For almost all cancer
types, one-year survival rates were
much lower for patients presenting as
emergencies than for those
presenting via other routes.
Tumour biology – current
targets
 Targeted therapies
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Small molecules vs biologics
Anti-angiogenic
PARP Inhibitors
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Introduction (NICE 2010)
 Ovarian cancer is the leading cause of
death from gynaecological cancer in
the UK, and its incidence is rising.
 It is the fifth most common cancer in
women, with a lifetime risk of about 2%
in England and Wales.
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Background – ovarian cancer
statistics UK 2006 (Cancer Res. UK
2009)
ENGLAND
WALES SCOT.
NI
UK
CASES
5528
380
500
188
6596
Per
100000
21.4
25
18.9
21.2
21.4
Age
standardi
sed
17.1
18.6
14
19.1
16.9
/ 100000
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In the USA
 Ovarian cancer is the leading cause of
deaths form Gyn. Malignancies
 5th commonest cause of Cancer deaths
 In 2010 there will be 21,900 new cases
and an estimated 13,900 deaths
 Less than 40% of women are cured
 70% of patients present with advanced
disease (NCCN Guidelines 2011)
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Background (NICE 2010)
 The outcome for women with ovarian
cancer is generally poor, with an overall
5-year survival rate of less than 35%.
 This is because most women who have
ovarian cancer present with advanced
disease.
 The stage of the disease is the most
important factor affecting outcome.
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Stage
 Epithelial ovarian cancer, which is the most
common type of ovarian cancer, spreads mainly
by tumour shedding from the diseased
ovaries. These tumour cells are then carried
over to the neighbouring organs, mainly the
large and small intestines by a clockwise
physiological current.
 To determine the stage, the patient undergoes
surgery for a thorough exploration the
abdomen and pelvis.
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STAGE: 5 Year Survival
STAGE 1
STAGE 2
STAGE 3
STAGE 4
90%
70%
23%
N/A
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Risk factors
 Nulliparity
 Early menarche & late menopause
 Prolonged ovulation induction
 BRCA 1& 2
 HRT use (Morch LS et al Hormone
therapy and ovarian cancer JAMA
2009;302:298-305)
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Protective factors
 Early parity, breastfeeding
 Hysterectomy
 Tubal ligation
 COCP
These factors can reduce the incidence by
30-60%!
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Screening
 Preliminary results of UKCTOCS
encouraging, full results awaited
 SGO recommends NOT to use ROCA,
OVA-1 test, OVASURE as screening
tests
 In the meantime there is NO
EFFECTIVE screening
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Patient centered care
 This presentation takes into account
NICE Guideline 2010 – Draft
 Women with ovarian cancer should have
the opportunity to make informed
decisions about their care and treatment,
in partnership with their healthcare
professionals.
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Communication
 Good communication between healthcare professionals and
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patients is essential. It should be supported by evidence-based
written information tailored to the patient’s needs.
Treatment and care, and the information patients are given
about it, should be culturally appropriate. It should also be
accessible to people with additional needs such as physical,
sensory or learning disabilities, and to people who do not speak
or read English.
If the patient agrees, families and carers should have the
opportunity to be involved in decisions about treatment and
care.
Families and carers should also be given the information and
support they need.
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NICE 2010
 Most women have had symptoms for
months before presentation, and there
are often delays between presentation
and specialist referral.
 There is a need for greater awareness of
the disease and also for initial
investigations in primary and secondary
care that enable earlier referral
and maximisation of treatment options.
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Key priorities
 Carry out tests in primary care if a woman
(especially if 50 or over) reports having any of
the following symptoms on a persistent or
frequent basis – particularly more than 12 times
per month:
– persistent abdominal distension (women often refer to this as
‘bloating’)
– difficulty eating and/or feeling full (early satiety)
– pelvic or abdominal pain
– increased urinary urgency and/or frequency.
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Key priorities
 Carry out appropriate assessments for
ovarian cancer in any woman of 50 or
over who has symptoms that suggest
irritable bowel syndrome (IBS) because
IBS rarely presents for the first time in
women of this age.
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Key priorities – first tests
 Measure serum CA125 in primary care in
women with symptoms that suggest ovarian
cancer
 If serum CA125 is greater than 35 IU/ml,
arrange an ultrasound scan of the abdomen
and pelvis.
 Advise any woman who has normal serum
CA125, or CA125 greater than 35 IU/ml but a
normal ultrasound, to return to her GP for reassessment if her symptoms persist
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Malignancy indices
 Calculate a risk of malignancy index I
(RMI I) score (after performing an
ultrasound) and refer all women with an
RMI I score of 200 or greater to a
specialist multidisciplinary team.
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RMI
 RMI I combines three pre-surgical
features:
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serum CA125 (CA125),
menopausal status (M)
and ultrasound score (U).
 The RMI is a product of the ultrasound
scan score, the menopausal status and
the serum CA125 level (IU/ml).
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RMI
 RMI = U x M x CA125
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The ultrasound result is scored 1 point for each of the
following characteristics: multilocular cysts, solid areas,
metastases, ascites and bilateral lesions. U = 0 (for an
ultrasound score of 0), U = 1 (for an ultrasound score of 1),
U = 3 (for an ultrasound score of 2–5).
The menopausal status is scored as 1 = pre-menopausal
and 3 = postmenopausal
The classification of ‘post-menopausal’ is a woman who has
had no period for more than 1 year or a woman over 50 who
has had a hysterectomy.
Serum CA125 is measured in IU/ml and can vary between 0
and hundreds or even thousands of units
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RMI & referrals
 refer all women with an RMI I
score of 200 or greater to a specialist
multidisciplinary team
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Workload & outcomes
 2 WW referrals
 Confirmed cancers 09-
10
NPH/CMH
NPH/CMH
April 08 to Mar 09
April 09 to Mar 10
1453
1730
endometrial
45
28 2ww,
17 non 2ww
Ovarian
36
15 2ww, 21
non 2ww
Cervical
14
6 2ww, 8
non 2ww
Unknown
6
6 non 2ww
Peritoneal
3
2 2ww, 1
non 2ww
Vulva
5
2 2ww, 3
non 2ww
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Gynaecology
total
109
KPI
 The Gynaecology team has achieved the 100%
target for the 2-week wait standard.
 The MDT has also achieved the 31-day
standard and the 62-day standard.
 Breach analysis has shown that breeches occur
in patients with a complex diagnostic pathway
and more than one biopsy procedure.
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Surgery
 Optimal surgical staging constitutes: midline laparotomy
to allow thorough assessment of the abdomen and pelvis;
a total abdominal hysterectomy, bilateral salpingooophorectomy and infracolic omentectomy;
 biopsies of any peritoneal deposits;
 random biopsies of the pelvic and abdominal peritoneum;
and retroperitoneal lymph node assessment
 [Winter Roach BA, Kitchener HC, Dickinson HO (2009)
Adjuvant (post-surgery) chemotherapy for early stage
epithelial ovarian cancer. Cochrane Database of
Systematic Reviews issue 3: CD004706]
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LOS- Towards Enhanced
recovery
Average LOS
10
9
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Average LOS
4
3
2
1
0
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Chemotherapy regimens
 It is recommended that paclitaxel in combination with a
platinumbased compound or platinum-based therapy
alone (cisplatin or carboplatin) are offered as alternatives
for first-line chemotherapy (usually following surgery) in
the treatment of ovarian cancer.
 The choice of treatment for first-line chemotherapy for
ovarian cancer should be made after discussion between
the responsible clinician and the patient about the risks
and benefits of the options available.
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Patients expect
 To be respected and kept informed
 A comprehensive explanation through
their journey
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Ensure that information is
available about:
 the stage of the disease, treatment options and prognosis
 how to manage the side effects of both the disease and its
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treatments in order to maximise wellbeing
sexuality and sexual activity
fertility and hormone treatment
symptoms and signs of disease recurrence
genetics, including the chances of family members developing
ovarian cancer
self-help strategies to optimise independence and coping
where to go for support, including support groups, how to deal
with emotions such as sadness, depression, anxiety and a
feeling of a lack of control over the outcome of the disease and
treatment.
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Patient satisfaction (09-10)
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100% of patients who responded received their diagnosis in person.
75% of patients who responded were given their diagnosis by a
consultant
93% felt waiting time were average or good
87% felt the space of the clinic was average or good
87% felt cleanliness was average or good
93% felt there was respect for privacy was good
87% felt attitude and friendliness of reception staff was good
75% of patient felt they understood the explanation of their diagnosis.
80% did receive written information at time of diagnosis,81% found it
useful
79% responded yes to being offered a copy of their GP letter at
diagnosis.
100% were introduced to a generic clinical nurse specialist at diagnosis.
100% felt they were adequately involved in decision regarding their
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treatment.
When you had surgery, did you feel that
you were given enough information about
the following?
yes
no
Reason for needing an operation
(n=13)
13 (100%)
0 (0%)
What the operation entailed and any
complications/side effects (n=13)
10 (77%)
3 (23%)
Recovery and what to expect after surgery
(n=13)
10 (77%)
3 (23%)
Advice as to who to contact if you developed
problems following discharge from hospital
(n=13)
8 (62%)
5 (38%)
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GPs expect
 Timely & comprehensive
communication
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Audit on timely GP notification of
cancer diagnosis 09-10
 88% patients had proof that the
confirmation form was faxed to the GP
 2 patients had wrong GP recorded
 3 were in patient outliers _coordinator
not informed
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Research- largest recruitment in
Network!
Hospital Accrual Apr 09 to 31 Mar
10
Trial Name
NSECG
NP
10
UKFOCSS
NP
39
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THANK YOU!
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