Presentation is loading. Please wait.

Presentation is loading. Please wait.

Update on Ovarian Cancer

Similar presentations

Presentation on theme: "Update on Ovarian Cancer"— Presentation transcript:

1 Update on Ovarian Cancer
Robert E. Bristow, MD, MBA Professor and Director Division of Gynecologic Oncology University of California, Irvine – Medical Center

2 Ovarian Cancer Center Mission:
To provide exemplary and holistic clinical care to patients with ovarian cancer. To enhance community awareness of ovarian cancer regarding the importance of early diagnosis and the benefits of centralized expert care. To advance the science of the prevention and treatment of ovarian cancer in a meaningful way. Discover ▪ Teach ▪ Heal

3 Gynecologic Oncology Faculty Discover ▪ Teach ▪ Heal

4 Ovarian Cancer Center • Clinical Services
- coordination of multidisciplinary care - prevention, early detection, cancer survivorship - surgery and regional therapeutics - chemotherapy and clinical trials - ancillary services • Community Outreach and Education - web-based platform - virtual support group survivor network - conferences - international visiting scholar program • Research and Discovery - molecular biology and translational science - healthcare outcomes Discover ▪ Teach ▪ Heal

5 Screening, Early Detection, Cancer Survivorship
Ann’s Clinic Screening, Early Detection, Cancer Survivorship High-risk patients - genetic counseling & testing - surveillance programs - cancer prophylaxis Cancer survivors - programmatic plan - psycho-social wellness - management of treatment toxicities Discover ▪ Teach ▪ Heal

6 Peritoneal Surface Malignancies
 Disease confined to peritoneal cavity for much of natural history  Generally amenable to surgical resection  Positive survival impact of chemotherapy - varies by disease site Discover ▪ Teach ▪ Heal Discover ▪ Teach ▪ Heal

7 Radical Surgery for Ovarian Cancer
Sigmoid Tumor Left Ovary Right Ovary Uterus Bladder Tumor Discover ▪ Teach ▪ Heal

8 Radical Surgery for Ovarian Cancer
Uterus Bladder Tumor Cervix Distal Sigmoid Culdesac Tumor Discover ▪ Teach ▪ Heal

9 Radical Surgery for Ovarian Cancer
Rectosigmoid Colon Vaginal Cuff Discover ▪ Teach ▪ Heal

10 Development of Intra-Peritoneal (IP) Chemotherapy
1950’s: First use of intraperitoneal chemotherapy for malignant ascites 1968: Long-term peritoneal access device 1978: Demonstration of slow peritoneal clearance of some drugs 1984: Feasibility of intermittent large volume intraperitoneal therapy 1996: First report of a survival benefit for IP vs. IV chemotherapy in advanced ovarian cancer Discover ▪ Teach ▪ Heal

11 Armstrong DK et al. NEJM 2006; 354:34.
Discover ▪ Teach ▪ Heal

12 PFS: 18.3 vs 23.8 months OS: 49.7 vs 66.9 months
Armstrong DK et al. NEJM 2006; 354: 34. Discover ▪ Teach ▪ Heal

13 The ‘Evolution’ of Treatment for
Advanced Ovarian Cancer and Effect on Survival IP Rx Alkeran Cisplatin Paclitaxel (Optimal) Surgical & Chemotherapy Improvements (Suboptimal) Discover ▪ Teach ▪ Heal

14 Discover ▪ Teach ▪ Heal

15 IP Therapy Discover ▪ Teach ▪ Heal

16 IP Therapy Discover ▪ Teach ▪ Heal

17 IP Therapy Discover ▪ Teach ▪ Heal

18 IP Therapy Discover ▪ Teach ▪ Heal

19 Primary Cytoreductive Surgery Contemporary Survival Outcomes
Study Chemotherapy Residual Median Survival GOG152 IV-CDDP/IV-Taxol >1cm months GOG172 IV-CDDP/IV-Taxol <1cm months IP-CDDP/IV+IP-Taxol <1cm months 0.1–1.0cm months no gross months 0.1–1.0cm months no gross months Rose PG et al. N Eng J Med 2004; 351: 2489. Armstrong DK et al. N Eng J Med 2006; 354: 34. Discover ▪ Teach ▪ Heal

20 Hyperthermia and Neoplasia
Heat is…  Directly cytotoxic to cancer cells - disrupts microtubule system - induces primary protein damage - promotes vascular stasis  Synergistic with some chemotherapy agents Knox 1991, Stellar 1998 Discover ▪ Teach ▪ Heal Discover ▪ Teach ▪ Heal

21 HIPEC Schematic Discover ▪ Teach ▪ Heal Discover ▪ Teach ▪ Heal

22 HIPEC Techniques  Open (colisuem)  Closed Discover ▪ Teach ▪ Heal

23 Role of HIPEC in Ovarian Cancer
 Retrospective study design ( )  Advanced ovarian cancer (n=43)  Up-front HIPEC cisplatin + IV chemotherapy  Morbidity – 13.9%; mortality – 2.3%  Median OS = 53 months - complete initial resection = 131 months  Median PFS = 39 months Melis A et al. Bull Cancer 2011, doi Discover ▪ Teach ▪ Heal Discover ▪ Teach ▪ Heal

24 Burger RA et al. NEJM 2011; 365: 2473. Discover ▪ Teach ▪ Heal

25 PFS: +3.8 month maintenance Rx OS: no significant effect
Burger RA et al. NEJM 2011; 365: 2473. Discover ▪ Teach ▪ Heal

26 Fertility Preservation
• Ovarian cancer - conservative surgery - young patients - early stage disease, atypical tumor types - chemotherapy with ovarian suppression Discover ▪ Teach ▪ Heal

27 Robotic Surgery ● daVinci surgical platform Advantages
- patient-side robot - vision cart - robotic master console Advantages Improved visualization Finer instrument control and dexterity Ergonomic design Autonomous surgical environment Discover ▪ Teach ▪ Heal

28 da Vinci® – Robotic Surgery Technology
Script: “So what makes da Vinci Surgery different from conventional open surgery and laparoscopy? The da Vinci System’s seamless integration of …Intuitive motion, 3D high definition (HD) visualization and fully articulating instruments (called EndoWrist Instruments)… provides surgeons with unparalleled precision, dexterity and control formerly achievable only in open surgery. These enabling features allow surgeons to perform complex surgery using a minimally invasive approach, with even more precision, dexterity and control than with an open approach -- thus improving patient outcomes and satisfaction. Comparison of lap vs. da Vinci: “Conventional laparoscopy has had limited adoption for complex procedures due to its technological limitations, not a deficiency in surgeon capabilities: Here is how da Vinci addresses and overcomes these limitations: Intuitive® Motion: “With laparoscopic surgery, the surgeon had to learn to overcome the fulcrum effect, where if the surgeon moved his/her hand to the right, the instrument went to the left. da Vinci maintains a corresponding eye-hand instrument tip alignment, allowing for intuitive instrument control, which helps to replicate the experience of open surgery. The surgeon’s hand movements are scaled, filtered and seamlessly translated to the robotic arms and instruments at the patient’s side.” 3D HD Vision: “With conventional laparoscopic visualization on a standard video monitor, there was no depth perception available, which made complex suturing and dissection difficult. The da Vinci System’s three-dimensional, high definition vision with up to 10x magnification offers surgeons an immersive view of the operative field superior to any other surgical approach, including traditional open surgery and laparoscopy. EndoWrist® Instrumentation: “With conventional laparoscopy, the surgeon lost the natural dexterity of his/her hand and wrist because it was replaced by straight, rigid instruments. EndoWrist Instruments are designed to provide surgeons with natural dexterity and a range of motion far greater than even the human hand. EndoWrist instruments come in a wide array of tips designed to facilitate procedures ranging from mitral valve repair to hysterectomy. These multi-use instruments are available in 8mm and 5mm diameters.” Dual Console Capability: “An optional second console with the da Vinci® Si™ system allows an additional surgeon to provide an assist, and facilitates teaching and proctoring. By emulating the teaching environment of open surgery, dual console functionality maximizes the efficiency and effectiveness of da Vinci training for new surgeons.” “Bottom line: patients can now benefit from a minimally invasive option for many complex procedures. Now, let me show you some features of the new da Vinci Si system that distinguish it from our previous two generations of da Vinci systems: The Standard and the S.” *Note: Magnification varies as a function of distance of scope from tissue. Discover ▪ Teach ▪ Heal

29 Research and Discovery
Clinical Trials • Ovarian cancer - intraperitoneal chemotherapy / HIPEC - molecular profiling - quality of life / cancer survivorship - developmental therapeutics / biologic agents Discover ▪ Teach ▪ Heal

30 Research and Discovery QOH Ovarian Cancer Research Laboratory
• PhD recruitment underway • Collaborative effort • Genetic screening and early detection • Molecular basis of disease - characteristics of long-term survivors - circumventing chemo-resistance Discover ▪ Teach ▪ Heal

31 Research and Discovery
• Surgical techniques • Advanced imaging techniques / onco-imaging • Clinical trials of new chemotherapeutic agents • Biological therapies • Public health applications Discover ▪ Teach ▪ Heal

32 Modern Approach to Cancer Therapeutics
Research and Discovery Modern Approach to Cancer Therapeutics Pathways Analysis Patient Metabolism Mutations The contemporary approach to guiding the choice of therapeutics, and even drug development, is based largely on molecular targeting. Comprehensive pathway analysis, mutational status, up and down gene regulation, and patient metabolism are all critical components of personalized medicine. Designing therapeutics with these molecular targets in mind will ultimately increase drug efficacy in select patient populations as well as reduce the cost of drug development. Genes Downregulated Genes Upregulated Discover ▪ Teach ▪ Heal

33 OVA1  Qualitative serum test – 5 immunoassays
- Apolipoprotein A - Transthyretin - 2 Microglobulin - Transferrin - CA125 II  Single numerical result:  FDA approved September 2009  Ovarian mass, > 18y/o, planned surgery  Triage tool for surgical decision-making  Not a screening or independent diagnostic test Category Low Risk High Risk Premenopausal < ≥5.0 Postmenopausal < ≥4.4 Discover ▪ Teach ▪ Heal

34 Preoperative Assessment
OVA1 Sensitivity vs CA125 Subjects OVA1 CA125-II All cancers (n=161) 92.5% 68.9% All epithelial ovarian cancers (n=96) 99.0% 82.3% Early stage EOC (n=41) 97.6% 65.9% Premenopausal women w/ early stage EOC (n=14) 92.9% 35.7% Overall Performance Performance Preoperative Assessment Assessment + OVA1 Sensitivity % 75 96 Specificity % 79 35 NPV % 87 95 PPV % 62 40 Ueland F. et al. Int Gyn Cancer Soc Annual Meeting, 2010, Prague. Discover ▪ Teach ▪ Heal

35 Disparities in Epithelial Ovarian Cancer
Quality of Care and Survival According to Race and Socioeconomic Status: a Study of 47,160 Patients from the National Cancer Data Base Robert E. Bristowa, Matthew A. Powellb, Noor Al-Hammadic, Ling Chenc, J. Phillip Millerc, Phillip Y. Rolandd, David G. Mutchb, William A. Clibye aDivision of Gynecologic Oncology, Department of Obstetrics and Gynecology University of California, Irvine School of Medicine bDivision of Gynecologic Oncology, Department of Obstetrics and Gynecology cDepartment of Biostatistics Washington University in St. Louis School of Medicine dGynecologic Oncology, Department of Gynecology and Obstetrics Saint Francis Francis Hospital and Medical Center eDivision of Gynecologic Surgery, Department of Obstetrics and Gynecology Mayo Clinic Good morning, on behalf of my co-authors and the SGO Quality and Outcomes Committee, I would like to thank you Dr, McMeekin, Dr. Curtin, members of the program committee, and members and guests of the Society for the opportunity to present our research on disparities in ovarian cancer care and survival according to race and socioeconomic status. Discover ▪ Teach ▪ Heal

36 Adherence to NCCN Guidelines
Race 65.6% 61.5% 56.4% 51.3% 43.9% The distribution of subjects according to the different components of care revealed that African American ovarian cancer patients were significantly less likely to receive proper surgery and chemotherapy compared to White patients. Overall, African American patients received NCCN guideline therapy in just 36% of cases, compared to 44% of White patients. 35.6% * *p<0.0001 * * Discover ▪ Teach ▪ Heal

37 Adherence to NCCN Guidelines
Payer Unadjusted for other factors, the distribution of subjects by elements of care stratified by payer status revealed that patients with Medicare payer status were less likely to receive guideline care due to the higher proportion of elderly patients in this subset. These data also show that patients with Medicaid and those who were Not Insured were significantly less likely to receive proper surgery and overall care compared to patients with Private insurance or Managed Care. * * * *p<0.0001 Discover ▪ Teach ▪ Heal

38 Adherent/Non-Adherent Care by Race
5-year Overall Survival Adherent White % Non-adherent White 37.8% Adherent African-American 33.3% Non-adherent African-American 22.5% p<0.0001 N=47,160 A significant difference was observed in 5-year overall survival stratified by race and NCCN guideline adherent care. As you can see, the 5-year survival for White patients receiving both adherent and non-adherent care were significantly better compared to African American patients in either category. White patients receiving NCCN guideline adherent care survived almost twice as long as African American patients receiving substandard care. The directionality and significance of these trends in survival were unaffected by either facility type or annual ovarian cancer case volume. Discover ▪ Teach ▪ Heal

39 Outreach and Education
Public Community - Education and Awareness - Virtual support network Resource for Professionals - Expedited referral system - Partnering in patient care Discover ▪ Teach ▪ Heal

40 Thank you! Discover ▪ Teach ▪ Heal

Download ppt "Update on Ovarian Cancer"

Similar presentations

Ads by Google