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Clinical Crossroads | Clinician's Corner

Management of Ovarian Cancer:  A 75-Year-Old Woman Who Has Completed Treatment

Panagiotis A. Konstantinopoulos, MD, PhD, Discussant; Christopher S. Awtrey, MD, Discussant
JAMA. 2012;307(13):1420-1429. doi:10.1001/jama.2012.269.
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Ovarian cancer includes primary tumors of epithelial, sex cord–stromal, or germ cell origin as well as metastatic tumors that frequently originate in the gastrointestinal tract. Approximately 90% of ovarian cancer is epithelial in origin and constitutes a major therapeutic challenge because of its advanced stage of presentation in most patients. Epithelial ovarian cancer is the most lethal gynecologic malignancy and the fifth most common cause of female cancer death in the United States, with approximately 1 in 70 women developing this disease in their lifetime. Several important advances in surgical and medical management of this disease have led to prolongation of survival and improvement of quality of life of patients with ovarian cancer. Using the case of Ms W, we discuss the signs, symptoms, risk factors, and prognostic factors of epithelial ovarian cancer; review the evidence for surgical and postoperative medical management; and present the current recommendations for screening and follow-up.

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Figure 1. Histology of Ms W's Biphasic Mixed Endometrioid/Clear Cell Adenocarcinoma
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A, Clear cell component with hyalinized papillae lined by nonstratified cuboidal epithelium (black arrowheads) with cytoplasmic clearing. B, Areas of endometrioid histology with a predominance of gland (yellow arrowheads) formation (hematoxylin-eosin, original magnification ×100).

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Figure 2. Typical Appearance of a Complex Ovarian Cyst on a Transvaginal Color Doppler Ultrasonogram
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Complex ovarian cyst with septations, solid components (blue arrowheads), and evidence of flow within a solid component (yellow arrowhead).

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Less is more in follow-up for cancer
Posted on March 27, 2012
Paul Cornes, BM BCH
Bristol Haematology & Oncology Centre, UK
Conflict of Interest: None Declared
After a complete response with FIGO stage IIIc Endometrioid/Clear- Cell ovarian adenocarcinoma Mrs W. can be reassured that the best follow up plan for her is now clear from randomized trials.
The aim of all treatment is to help patients live longer and live better. The composite measure of this is the QALY (quality adjusted life year). Medical technology can detect relapses months, or sometimes years, before symptoms recur. However there is no survival advantage to this.
Asymptomatic patients are made ill with treatment toxicity from second line chemotherapy when they could be well and enjoying life. The MRC-OVO5 trial randomized patients between a clinical follow up intervening only when symptoms arose against treatment directed by rising CA-125 tumor markers [1]. Survival was identical in each arm of the trial but the quality of life was worse in the arm followed by surveillance markers.
This seems initially surprising, as ovarian cancer, like breast cancer, although incurable in metastatic relapse, can respond again and again to chemotherapy. All we learned in medical school told us that cytotoxic chemotherapy worked best against minimal volumes of disease. This should favor early intervention against a lower bulk of disease. However MRC-OVO-5 only confirms the GIVIO study in breast cancer [2]. This randomized breast cancer patients in remission between clinical follow up based on history and examination or follow up with regular scans. As before, scans could detect asymptomatic relapses months or years early, but survival was unchanged and toxic treatment was given to patients when they could be well. They lost quality of life without living longer.
These trials now force oncologists to rethink a central tenet of our learning and have faith in the QALY as a trial endpoint. Far from intervening in low bulk asymptomatic relapsing cancer, we now find that response to second line chemotherapy seems proportionally greater the longer we wait as tumors regain their sensitivity to treatment. Oncologists now need to revise our textbooks and regain our faith in the skills of the clinic. We need to treat the patient and not the tests.
Listening, examining and directing tests to our clinical findings rather than the reverse adds quality to a survivor's life and saves the precious resources of patient time and hospital money. The astonishing cost of time associated with medical care for cancer patients is substantial and there is a clear QALY gain from dropping the scans and blood tests from her follow up plans [3].
In the follow up clinic, when I listen to her story, I hope to hear the successes of Mrs W's teaching sessions she has reinstated for this fall.
REFERENCES
[1] Rustin, et al. Early versus delayed treatment of relapsed ovarian cancer (MRC OVO5/EORTC 55955): a randomised trial. The Lancet. 2010. 376: (9747)1155-1163.
[2] Liberati A. The GIVIO trial on the impact of follow-up care on survival and quality of life in breast cancer patients Ann Oncol (1995) 6(suppl 2): S41-S46
[3] Yabroff KR, Davis WW, Lamont EB, Fahey A, Topor M, Brown ML, Warren JL. Patient time costs associated with cancer care. J Natl Cancer Inst 2007;99:14-23
Conflict of Interest: None declared
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