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

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Presentation on theme: "Robert E. Bristow, MD, MBA Professor and Director Division of Gynecologic Oncology University of California, Irvine – Medical Center Update on Ovarian."— Presentation transcript:

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

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

6 Discover Teach Heal 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

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

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

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

10 Development of Intra-Peritoneal (IP) Chemotherapy 1950s: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 Armstrong DK et al. NEJM 2006; 354: 34. PFS: 18.3 vs 23.8 monthsOS: 49.7 vs 66.9 months Discover Teach Heal

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

14

15 IP Therapy Discover Teach Heal

16 IP Therapy Discover Teach Heal

17 IP Therapy Discover Teach Heal

18 IP Therapy

19 Study Chemotherapy Residual Median Survival GOG152IV-CDDP/IV-Taxol >1cm 36 months GOG172IV-CDDP/IV-Taxol <1cm 50 months IP-CDDP/IV+IP-Taxol <1cm 67 months Primary Cytoreductive Surgery Contemporary Survival Outcomes 0.1–1.0cm 39 months no gross 78 months 0.1–1.0cm 53 months no gross 127 months Rose PG et al. N Eng J Med 2004; 351: Armstrong DK et al. N Eng J Med 2006; 354: 34. Discover Teach Heal

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

21 HIPEC Schematic Discover Teach Heal

22 HIPEC Techniques Open (colisuem) Closed Discover Teach Heal

23 Role of HIPEC in Ovarian Cancer Melis A et al. Bull Cancer 2011, doi 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 Discover Teach Heal

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

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

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 - 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 Discover Teach Heal

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

30 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 QOH Ovarian Cancer Research Laboratory

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 Patient Metabolism Pathways Analysis Mutations Genes Upregulated Genes Downregulated Research and Discovery 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 CategoryLow RiskHigh Risk Premenopausal < Postmenopausal < Discover Teach Heal

34 Performance Preoperative Assessment Assessment + OVA1 Sensitivity %7596 Specificity %7935 NPV %8795 PPV %6240 SubjectsOVA1CA125-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% OVA1 Ueland F. et al. Int Gyn Cancer Soc Annual Meeting, 2010, Prague. Sensitivity vs CA125 Overall Performance 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. Bristow a, Matthew A. Powell b, Noor Al-Hammadi c, Ling Chen c, J. Phillip Miller c, Phillip Y. Roland d, David G. Mutch b, William A. Cliby e a Division of Gynecologic Oncology, Department of Obstetrics and Gynecology University of California, Irvine School of Medicine b Division of Gynecologic Oncology, Department of Obstetrics and Gynecology c Department of Biostatistics Washington University in St. Louis School of Medicine d Gynecologic Oncology, Department of Gynecology and Obstetrics Saint Francis Francis Hospital and Medical Center e Division of Gynecologic Surgery, Department of Obstetrics and Gynecology Mayo Clinic Discover Teach Heal

36 Adherence to NCCN Guidelines Race 35.6% 43.9% 51.3% 61.5% 56.4% 65.6% *p< ** * Discover Teach Heal

37 Adherence to NCCN Guidelines Payer * *p< ** Discover Teach Heal

38 5-year Overall Survival Adherent White41.4% Non-adherent White37.8% Adherent African-American33.3% Non-adherent African-American22.5% p< N=47,160 Adherent/Non-Adherent Care by Race Discover Teach Heal

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

40 Thank you!


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