Most times it’s not cancer

Ovarian cancer risk among older patients with stable adnexal masses

https://tinyurl.com/5fytnf57

Benign ovarian masses are common. About 30% of women with a normal menstrual cycle will develop an ovarian mass. For women with irregular menstruation this figure increases to 50%.

It is important to recognise this and avoid invasive surgery. This study looks at older women of over 50 years in age and demonstrates that, for stable tumours smaller than 10 cm in size, there is a low likelihood of cancer.

Almost 5000 women in this age group, presented to one community health organisation with ovarian masses, during the period 2016-2020. Of whom, more than 4000 had a stable appearance at repeat ultrasound examination 6 weeks later. Those women, with stable appearances, did not have surgery. 

During the almost 4 years of follow up, the incidence of ovarian cancer was very low, with only 11 cancers being detected (0.27%). The authors suggest that, with a stable appearance at the 6 weeks ultrasound, older women with a small ovarian mass do not need active follow up.

An impossible dream?

Reducing ovarian cancer mortality through screening: an impossible dream?

https://tinyurl.com/4524jh8f

The history of screening tests for ovarian cancer is not good. Two huge trials; the UKCTOCS with more than 200,000 recruits over 20 years and the PLCO trial with more than 3 million pathology samples showed no benefit in terms of survival from ovarian cancer.

This article addresses the stages of ovarian cancer using an alternative approach called the clinical continuum, which divides cancer into 3 phases, no disease, pre-clinical (detectable disease), and clinical (overt cancer).

Obviously for a screening test to be effective, cancer needs to be detected before the clinical phase. However, ovarian cancer is unlike other cancer in that the precursor occurs in the fallopian tube and there is an argument to say that, by the time ovarian cancer has occurred, it is always advanced and metastatic. This time interval between initial and advanced disease has been called, “the sojourn”. A short sojourn implies that screening tests are unlikely to be helpful.

Any ovarian screening test would have to demonstrate cost-effectiveness. Because of the short sojourn, screening would need to be at less than yearly intervals. Also, the authors note the continual decline in the incidence of ovarian cancer, over the last 100 years. These factors make the allocation of scarce resources to ovarian cancer screening unlikely.

Why Old?

The Gut Microbiome in Ageing and Ovarian Cancer

https://tinyurl.com/yk8nt6w6

Ovarian cancer is mostly a disease of the seventh decade. The reasons for this are unclear. One suggestion is that changes in the Gut bacterial flora or microbiome may be associated.

This review looks at which bacteria become more common with age and which decrease. Using data from previously published material, it is clear that bacteria which increase inflammatory change become more common, and that bacteria which assist oestrogen metabolism decrease.

The overall complexity of the microbiome changes with age, with some loss of diversity. However, no correlation of ovarian risk to bacterial diversity has been shown.

Most women with ovarian cancer receive antibiotic therapy during chemo, this has been shown in mice to change the microbiome and decrease survival from ovarian cancer.

No definite association between ovarian cancer and the aged microbiome is known but the inflammatory changes and altered oestrogen metabolism may prove to be important factors in the late presentation.

Prevention better than cure

FIGO position statement on opportunistic salpingectomy as an ovarian cancer prevention strategy

https://tinyurl.com/4db8sj3y

The importance of pre-cancerous change in the fallopian tubes as a precursor to ovarian cancer has led to suggest that removal of the fallopian tubes at the time of other abdominal surgery is a significant protective measure.

Now FIGO, (The International Federation of Obstetrics and Gynaecology) have issued a position statement saying they firmly support this.

Evidence for this position is linked to pilot studies in Canada which showed significant reduction in subsequent ovarian cancer rates when the tubes were removed at the time of hysterectomy, (this is not usual practice). 

In addition, an Austrian study showed good acceptance of additional surgery. When women facing gallbladder removal were offered tube resection, 60% accepted. The average increase in operating time was 13 minutes and there was no extra post-operative complication.

One less cause to worry

The impact of inter-cycle treatment delays on overall survival in patients with advanced-stage ovarian cancer

https://tinyurl.com/mrxpksk9

Many patients with ovarian cancer have interruption of their chemo. This may occur because of adverse side effects of treatment, or external factors such as other priorities and logistic issues.

This interruption may cause anxiety which can be expressed as concern that the chemo is less effective.

This retrospective study looked at more than 1500 women with advanced ovarian cancer first diagnosed during the period 2015-2019. The two-year survival for women who had an uninterrupted chemo course was compared to those whose chemo was unavoidably disrupted. Disruption is common with 37% having breaks of at least 7 days. No difference in survival was seen in the two groups.

Knowledge that chemo is just as effective despite interruption means that factors which affect the patient's quality of life can be addressed without fear of harm.

The real financial cost

Study Finds Nearly $70 Billion in Socioeconomic Losses Across 11 Countries Attributable to Ovarian Cancer

https://tinyurl.com/4spw37yz

Ovarian cancer is extremely costly to the individual, the state and the family of each patient. This study uses a true cost of illness approach to assess the annual economic burden of each case of ovarian cancer in high-, middle-, and low-income countries.

Factors included in this determination include cost of treatment, the opportunity cost of loss of productivity for the individual and the carers and the often-forgotten cost of unpaid carer time.

The sums are mind-boggling with an estimate of almost $70 Billion total annual expenditure and individual costs of up to 120 times the usual health expenditure per capita for low-income countries.

Obviously, there is concern about whether this is sustainable and shows the urgent need to reduce the incidence of ovarian cancer.

Alternative therapy ineffectual

Impact of metformin, statins, and beta blockers on survival in patients with primary ovarian cancer: combined analysis of four prospective trials of AGO-OVAR and ENGOT/GCIG collaborators

https://tinyurl.com/597m54hb

Anecdotal experience has previously suggested that off-label use of some commonplace drugs may improve survival for patients with ovarian cancer. This meta-analysis of 4 prospective randomised trials looks at the effect of some of these.

Data was obtained from the trials which recorded use of the additional drug treatment. The prime purpose of the trials having been assessment of efficacy of the enzyme inhibitor, Pazopanib. From the data, patients could be subdivided into two groups; those who had received additional drug therapy and those who had not.

Finding from the results show that use of off-label drugs was associated with greater co-morbidity. Neither metformin or statin therapy had any effect on survival. Use of betablockers had a negative effect, those patients had worse survival outcomes.