1. OVARIAN CANCER: Recognition & initial management / where are we now Mr. Panos Sarhanis MD FRCOG Gynaecology Cancer Lead NWLH London

2. Aims & objectives  Present new disease data  Focus on new developments in recognition & initial management  Present local data  Highlight patient centered care P SARHANIS LONDON UK

3. 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.

4. Tumour biology – current targets  Targeted therapies Small molecules vs biologics Anti-angiogenic PARP Inhibitors P SARHANIS LONDON UK

5. 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. P SARHANIS LONDON UK

6. Background – ovarian cancer statistics UK 2006 (Cancer Res. UK 2009) ENGLANDWALESSCOT.NIUK CASES55283805001886596 Per 100000 21.42518.921.221.4 Age standardi sed 17.118.61419.116.9 / 100000 P SARHANIS LONDON UK

7. In the USA  Ovarian cancer is the leading cause of deaths form Gyn. Malignancies  5 th 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) P SARHANIS LONDON UK

8. 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. P SARHANIS LONDON UK

9. 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. P SARHANIS LONDON UK

10. STAGE: 5 Year Survival STAGE 1STAGE 2STAGE 3STAGE 4 90%70%23%N/A P SARHANIS LONDON UK

11. 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) P SARHANIS LONDON UK

12. Protective factors  Early parity, breastfeeding  Hysterectomy  Tubal ligation  COCP These factors can reduce the incidence by 30-60%! P SARHANIS LONDON UK

13. 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 P SARHANIS LONDON UK

14. 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. P SARHANIS LONDON UK

15. Communication  Good communication between healthcare professionals and 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. P SARHANIS LONDON UK

16. 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. P SARHANIS LONDON UK

17. 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. P SARHANIS LONDON UK

18. 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. P SARHANIS LONDON UK

19. 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 re- assessment if her symptoms persist P SARHANIS LONDON UK

20. 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. P SARHANIS LONDON UK

21. RMI  RMI I combines three pre-surgical features: 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). P SARHANIS LONDON UK

22. RMI  RMI = U x M x CA125 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 P SARHANIS LONDON UK

23. RMI & referrals  refer all women with an RMI I score of 200 or greater to a specialist multidisciplinary team P SARHANIS LONDON UK

24. P Sarhanis Gynaecology Workload & outcomes  2 WW referrals  Confirmed cancers 09- 10 NPH/CMHNPH/CMH April 08 to Mar 09 April 09 to Mar 10 14531730 endometrial45 28 2ww, 17 non 2ww Ovarian36 15 2ww, 21 non 2ww Cervical14 6 2ww, 8 non 2ww Unknown6 6 non 2ww Peritoneal3 2 2ww, 1 non 2ww Vulva5 2 2ww, 3 non 2ww total109

25. P Sarhanis Gynaecology 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.

26. Surgery  Optimal surgical staging constitutes: midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo- oophorectomy 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] P SARHANIS LONDON UK

27. P Sarhanis Gynaecology LOS- Towards Enhanced recovery

28. 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. P SARHANIS LONDON UK

29. P Sarhanis Gynaecology Patients expect  To be respected and kept informed  A comprehensive explanation through their journey

30. 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 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. P SARHANIS LONDON UK

31. P Sarhanis Gynaecology Patient satisfaction (09-10)  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 treatment.

32. P Sarhanis Gynaecology When you had surgery, did you feel that you were given enough information about the following? yesno 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%)

33. P Sarhanis Gynaecology GPs expect  Timely & comprehensive communication

34. P Sarhanis Gynaecology 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

35. P Sarhanis Gynaecology Research- largest recruitment in Network! Trial NameHospitalAccrual Apr 09 to 31 Mar 10 NSECGNP10 UKFOCSSNP39

36. THANK YOU! P SARHANIS LONDON UK