How common is complete clearance?

Surgical and blood-based minimal residual disease in patients with ovarian cancer after frontline therapy: Clinical outcomes and translational opportunities

https://tinyurl.com/4698cc7c

In the treatment of ovarian cancer, the most important determinant of survival is the effectiveness of the initial surgical procedure. The aim is complete clearance and for about 80% of women no residual cancer can be detected either by CT scan or plasma CA 125 levels. Despite this only about 20% of women will have been cured suggesting that residual cancer is present despite evidence to the contrary.

This study shows the true rate of minimal residual disease (MRD), by measuring circulating tumour DNA (CT DNA), and by repeat “second look” laparoscopy after completion of surgery and chemo.

Findings from the study showed that of 95 patients thought to have had a complete clearance at initial surgery almost half had MRD with abnormal CT DNA or second look laparoscopy. These women had worse survival and earlier recurrent disease. The authors suggest that searching for occult MRD should be part of standard treatment to enable correct management.

Nausea and Vomiting, when and why

Time-Trend Analysis and Risk Factors for Niraparib-Induced Nausea and Vomiting in Ovarian Cancer: A Prospective Study

https://tinyurl.com/6wauzndb

Niraparib (zejula) is one of two PARP inhibitor drugs approved by the TGA in Australia for maintenance therapy of ovarian cancer. A common side effect affecting up to 60% of patients is nausea and vomiting. Occasionally this may be so severe as to be life-threatening.

This prospective survey looked at the treatment course for 53 patients who underwent maintenance therapy with niraparib. 31 had treatment induced nausea and vomiting, for 3 of them this was severe with weight loss, dehydration, and malnutrition.

The adverse effect was greatest 8 hours after taking the oral medication, which is when the plasma concentration is greatest. The severity of the reaction decreased over time with less severe reactions being reported after 8 weeks. This may be due to dose manipulation which is common.

The authors note that nausea and vomiting are often causes for patients to cease treatment. Monitoring this side effect and correct timing for anti-emetic treatment with dose modification may avoid discontinuation.

Delay not always harmful

Earlier is not always better: Optimal time to initiate adjuvant chemotherapy after surgery for ovarian cancer

https://tinyurl.com/4y2kpmrr

Standard treatment of ovarian cancer includes chemo after surgery, either with or without neoadjuvant chemo beforehand. There has always been an imperative to begin chemo as soon as possible, hoping to reduce the risk of recurrence.

For some women with ovarian cancer, it is not possible to start chemo early. Either because of debility infection or circumstance. This study looks at outcomes for women who start chemo late and compares them to other women whose chemo is not delayed.

The retrospective study looked at the outcomes of 1700 women who had surgery for ovarian cancer at 5 German Hospitals during the period 2020-2021. They were divided into 3 groups; those who had chemo early (less than 3 weeks post-surgery), intermediate (3-5 weeks post-surgery), and late (greater than 5 weeks). The outcomes measured were progress free survival (PFS),
and overall survival (OS).

Results from this study showed both early and late groups had worse OS than those women who started their chemo in the intermediate time frame of 3-5 weeks post-surgery. Previous studies have shown more post-op complications for the early group and women who start chemo late often have more complex disease. Of interest is that PFS was similar for all 3 groups. The authors suggest that women whose chemo is delayed can be reassured that the delay will not cause immediate harm.

Limited understanding

Shared decision making for ovarian cancer survivors with different levels of health literacy: a qualitative interview study on knowledge and comprehension

https://tinyurl.com/n8ubvxhz

Management of ovarian cancer is best when the patient and the carer can share decision making. For this to occur both parties need to be fully informed and able to understand the process.

This shared decision making involves choice of therapy and detection of recurrence. A small retrospective study shows that many women have a limited understanding of medical terms and jargon, making decisions difficult.

A group of 17 women with ovarian cancer were asked about their understanding of the care they had received. They also answered a questionnaire aiming to determine their basic medical knowledge and confidence about sharing decisions.

Results from the study showed limited understanding about the course of their illness with false confidence in physical examination as a means of detecting recurrence. In general, there is a low level of medical literacy which makes shared decisions difficult.

Cataract and Ovarian Cancer

Ovarian Cancer and the Risk of Cataract Episodes: A Nationwide Cohort Study 

https://tinyurl.com/449xa994

Both cataracts and ovarian cancer are found in the elderly. It has been known that cataracts may develop in patients with cancer who have therapy, most often due to radiation but also as a side-effect of chemo.

One of the important causes of cataract is high oxidative stress, which is an imbalance of free oxygen and antioxidants. This is also linked to many cancers including ovarian cancer.A retrospective survey looks at the incidence of cataract in patients with ovarian cancer compared to the general population.

Using data from the Taiwan National Health Insurance database, 5000 women with ovarian cancer were matched with 20,000 women who were cancer free. About 10% of the cancer group had cataract, of whom less than half required surgery. Comparison with the control group showed a slight increase in cataract diagnosis of about 7%, for those women with cancer.

This study is limited by the small ethnic variation with most of the women being Han Taiwanese. However, the authors suggest that routine eye examination should be part of standard care for women with ovarian cancer.

Improvement, slow but real

Demographic trends in mortality due to ovarian cancer in the United States, 1999-2020

https://tinyurl.com/2py9489j

Progress in care for patients with ovarian cancer can be slow. It often seems that a cure is impossible and that there has been no improvement in the outcomes for women who face this great challenge.

However, it is important to recognise that change is occurring and that survival has significantly increased over recent times. This survey looks at mortality due to ovarian cancer and the trend of improvement in the US over the current century.

Using data from the CDC epidemiological database the decrease in deaths from ovarian cancer is shown with a reduction from the initial rate of 14.6/100,000 in 1999 to 10.2/100,000 in 2020. This dramatic change no doubt reflects better care and earlier detection of disease.

Sadly, the data also shows that this improvement is not universal. Somewhat surprisingly the death rate is highest in non-Hispanic white women at 13.5/100,000, whereas Asian women deaths from ovarian cancer declined to 7.5/100,000 over this time interval.

This disparity may be due to differences in BRCA mutation and age. Overall, it is encouraging to note the changing prognosis for ovarian cancer.

Ovarian cancer during pregnancy

Epithelial ovarian cancer and borderline tumours during pregnancy: a report from the International Network on Cancer, Infertility, and Pregnancy

https://tinyurl.com/4fbdzz6w

Any cancer found during pregnancy causes great concern, with possible damage to the foetus and mother being the main worry, although change in the progression of disease due to altered immunology also is a factor.

Fortunately, ovarian cancer is not common during pregnancy. This article looks at the available information with respect to maternal and foetal outcomes. 

About 1% of all pregnancies have an incidental finding of an adnexal mass. This is more often found now that ultrasound examination is part of the normal standard of care. There is a very low incidence of these masses being found to be malignant (0.2 -3/100,000). Of the malignant masses, three quarters are due to borderline tumours and one quarter invasive ovarian cancer usually epithelial.

Using the INCIP database 129 women were identified as having ovarian cancer discovered prior to childbirth. About half had invasive cancer the others, borderline tumours. 64% of these women had standard care with resection and chemo, the others had treatment deferred.

Birth weights of infants whose mother had received chemo were significantly reduced. Women who had standard treatment for ovarian cancer had better survival. Most cancers were early-stage, overall survival of 80% at 5 years was good. The numbers of cases are small but support active treatment of ovarian cancer during pregnancy.