Ovarian Cancer


– Welcome to today’s web
chat about ovarian cancer. Thank you for joining us. My name is Ed Bottomley with the Michigan Medicine
Department of Communication. Our goal today is to
provide helpful information about ovarian cancer, and we’ll introduce our
panelists in a moment. But first, just a few housekeeping items. You can submit questions
at any time, even now, for our panelists to answer during the Q and A
portion of today’s chat. Questions can also be submitted
by commenting on this video, but please note that
your name or profile name will be visible to others
participating, if you do so. If you prefer a more anonymous option, you can send a private
message to us via Facebook, or you can email us at
[email protected] And that email address
is also on the screen. If you can’t stay for the whole chat, or want to share the
recording with a friend, a video of the chat in its
entirety will be available on our Facebook page
later today and posted to the Michigan Medicine YouTube
channel soon after that. So, I’d like to introduce
you to our panelists, Dr. Rebecca Liu and Dr. Shitanshu Uppal. If you guys could just
give me a few seconds on your expertise in this field. Dr. Uppal. – So, I’m one of the gyn oncologists. I’m an associate professor
at the University of Michigan and I’m also a co-director for Michigan Oncology Quality Consortium, which is one of the collaborative quality improvement
efforts by the university to improve the quality of
care for ovarian cancer. So, I’m also associated
with the medical school. We also run the fellowship in training the new generation of gyn oncologists. – Fantastic. Thank you. Dr. Liu. – I’m also a gyn oncologist
at the University of Michigan. I’ve been at the University
of Michigan since 1999. I practice both at University
of Michigan and St. Joseph Mercy Hospital and do
research in ovarian cancer. I also work on the Michigan
Oncology Quality Consortium with Dr. Uppal. We try to involve all of the
gyn oncologists in the state to improve the quality of care
for ovarian cancer patients, so I hope that you will
participate with us. – Thank you. Well, I’m excited to have both
of you with us here today. Let’s go straight into the questions. Reminding you can ask any questions on the Facebook feed
itself via direct message, or also via the email address,
which is on the screen. So, our first question, a
straightforward one here: What is ovarian cancer? Perhaps it isn’t a straightforward one. What is ovarian cancer? – (laughs) I don’t think it’s
really that straightforward. (everyone laughs) There are many types of ovarian cancer. There’s sort of a continuum. Some ovarian cancers are diagnosed in very young women in their teens, 20s, and some are diagnosed in
women who are postmenopausal. When we think about ovarian cancer, I think most people think about
epithelial ovarian cancer, diagnosed in women around
the age of 60 to 65. And it’s also known as the silent killer, which is a good opportunity to talk about symptoms of ovarian cancer. Most people call it the silent killer because the symptoms of
ovarian cancer are very vague. People may have kind of
bloating, indigestion, pelvic pressure, maybe some
sort of urinary problems, which everybody has had
those at one time or another. The key with ovarian cancer is
that these symptoms persist. And I like to think about this sort of how the people in the airline
industry have a checklist when they go through their flights, and if anybody thinks
that something is off, they stop and check it. So, I think that people should really do this for themselves. You know your own body. If you think something is off, and whatever doctor you see
says there’s nothing wrong, but you still feel like something is off, check it out. Go to your gynecologist. – Thank you for that. Dr. Uppal, anything to add? – No, I think Dr. Liu has covered this. But, I think one thing I
would like to add though is that as time goes by, we are recognizing that ovarian cancer, even though as a term refers
to one thing, as we know it, but when you dissect it out, it has so many different entities to it. And then, that also
impacts on the survival, where some cancers behave
much more aggressively, whereas the others do not. And then, there is
another component of it, where now we are recognizing
that there is a large portion, about one in five of
ovarian cancer patients, have a genetic component. So again, there are different
reasons why women get it and, even though it comes under the umbrella of the word ovarian cancer, these are multiple types of
diseases which we lump together, but more often than not, epithelial ovarian cancer is the one which we know as most often
the most aggressive cancer. – Thank you for that. So, the second question we had, I feel like we’ve answered it a bit. What are the symptoms or signs? Do you have anything to add to that beyond what Dr. Liu said? – Yeah no, I think the
main issue here is that, there have been studies
done on this, actually, where we’ve looked at symptoms, most notably by Dr.
Barbara Goff from Seattle, where they looked at the symptom inventory on how many times the
women have the symptoms and they came up with the
answer that more than 12 times if you have abdominal, pelvic
pain, sensation of bloating. If you eat, and you feel
like you’re full already and these symptoms are happening more than 12 times in a month, this is suspicious for ovarian cancer. Now, if somebody has had a history for a very long time for these symptoms, they might have another issue. But if you find these symptoms,
just like Rebecca said, even if your primary care doctor
or the person you’re seeing thinks that no further
evaluation needs to be done, but you know your body and
you think that this needs to be escalated and further
testing needs to be done, I think seeking another opinion
is the right thing to do. – Thank you. The next question that we have up: If I have symptoms, do
I go to my gynecologist? – Yes. So, we’re subspecialists and the gynecologists are
accessible to everybody. Gynecologists are accustomed
to doing pelvic exams. Unfortunately, we don’t
have a good screening test for ovarian cancer yet. There is no pap smear that
diagnoses ovarian cancer, there is no mammogram that we have, so the best thing that we have is a physical exam with your
gynecologist, a pelvic exam. Now, many women think that
after they’ve finished having children they don’t need to go
to the gynecologist anymore, but please go every
month, I mean, every year. Nobody wants to go every month (laughs). Every year. – [Ed] Thank you. – Yeah, I think in the communities, if the gynecologist is not available, the primary care doctors
do take on this role and do a wonderful job. They’re trained to look
for these diseases, so I think the short answer is yes. – Okay, thank you. Now, you touched on screening options. Could we talk about
that a little bit more? What options are there, if the screening options are limited? – So, I think for screening, before I go into the
details of the screening, I think you have to look at why do we screen for cancers? And what is the good and
the bad of the screening? And I think that’s the fundamental reason why we don’t have a good
screening test for ovarian cancer. But we are trying to
screen for any cancer. What we want is a test which is accurate, meaning it’s picking up the
people, those who have cancer, and at the same time, we want a test which is
not picking up people who do not have the cancer, but the test is labeling them that maybe you have ovarian cancer. The unfortunate reality
for ovarian cancer is that all the things that we’ve tried in terms of screening pick up a whole lot of women and label them as potentially
having ovarian cancer. And then we start on investigating, and sometimes doing
surgeries on these women, and eventually end up
hurting more than helping and finding the ovarian cancer in the specific cohort of women, which have been labeled as
possible ovarian cancer. So that’s where the problem lies in. So, we’ve have multiple attempts, most notably the test which
women might have heard about, is the CA 125. Now, we use this test in
treatment all the time, but as a screening, this test
has not been very helpful. You will end up, about one in 100 women
will have an elevated CA 125 during the time of their menses, or they have an infection, or any other reason the
test could be elevated, and now you’re labeling them, oh, you may have ovarian cancer and they might end up getting surgery, as I mentioned, that
that could be a problem. There have been other things, which are primarily
another test called HE4. One other big thing is
the pelvic ultrasound, which has been looked at for screening. And multiple trials, most noticeable one, which was done in the United
States, called the PLCO trial, was one of those trials where
they looked at the CA 125 and ultrasound to screen
for cancers and, again, the result was the same where
more women underwent surgery, but it didn’t help in
terms of the screening. So, it’s a long answer in saying no, we don’t have a good screening
test at this point of time. The Society of Gyn Oncologists, The American College of
Obstetrics and Gynecologists does not recommend screening
in women who are low-risk. Now, there’s a whole other category of women who are high-risk, and we can talk about that later, where screening is indicated, but I think if you have no family history and no genetic predisposition
of developing ovarian cancer, screening at this point of
time is not recommended. – Thank you for that. Anything to add, Dr. Liu? – Well, I think that,
you touched upon this, if someone has high
risk for ovarian cancer, then we need to be more vigilant about looking for ovarian
cancer in these patients. And those would be patients with a strong family
history of ovarian cancer. Basically, all patients
with ovarian cancer should have genetic testing. Genetic testing means, not only checking their blood
for a germline mutation, that means you’re born with this mutation and it makes you more
susceptible to breast cancer, usually breast and ovarian cancer, but now we know that we can test the tumor
also for these mutations. And if you have a mutation in a tumor, it gives you a whole nother
avenue of treatment options, so it’s very important that all of our patients get genetic testing. So, those are the patients. Family members of these
patients should be treated in the separate category
than the general population. – Thank you for that. The next question we have coming up: Are there different
stages of ovarian cancer? – Yes. All cancers have stages
one, two, three, four. Usually stage one means that the cancer is limited
to the primary organ, so ovarian cancer is
limited to the ovaries. Stage two means it’s spread to the pelvis. Stage three means it’s
spread into the abdomen. And stage four means
it’s gone to the liver, or even the lungs, or further. Unfortunately, many times we
see patients who come to us with stage three or four disease already because the symptoms are so vague and we don’t have a screening. I would say that when we find patients with a stage one cancer, it’s typically in those families
with the family history. Maybe they’re having a
prophylactic surgery, and then we found it by mistake. It’s not very often that we
find early stage ovarian cancer. – Anything to add, Dr. Uppal? – No, I think most of the cancers have the
similar structure of staging; starting in the organ
to going other places. And as Rebecca mentioned
that the unfortunate reality in ovarian cancer is most,
like about 75% of the patients, are stage three or above. And that’s something which is
directly related to the fact that we don’t a screening test. – Okay. Thank you for that answer. Next question we have up,
with regards to diagnosis: If I do have an elevated CA 125 level, does it always mean you
have ovarian cancer? What else could it be? – Yeah, I’ll mention a
few possibilities of that. Number one is that why
was the CA 125 test done? Was it done in hopes of
screening for ovarian cancer, or was it done for another reason? So, that would be important. But then if it’s elevated, it has to be put in the
context of family history, which would put you into a higher risk, but, otherwise, there are
a host of different reasons why CA 125 could be elevated. Anything which will
irritate the inside lining of your abdomen will elevate the CA 125, whether it’s an infection,
endometriosis, patients, even some of them who have
fibroids which are growing, could elevate CA 125. So, it’s a very non-specific test. It just tells you there is something going on in the abdomen. That something could be anything, not specifically ovarian cancer. – I really want to reiterate that. It’s very important
that people don’t think that CA 125 is the magic test because pregnancy can
elevate your CA 125– – Liver disease.
– Liver disease. Basically any kind of itis (laughs). Any kind of infection in the belly will make your CA 125 go up. I know a lot of people put a
lot of stock on that number, but it’s not black and white,
it’s kind of a gray issue. – Thank you for reiterating that. Thank you. Next question we have up. Now, you’ve touched on genetic
issues a few answers ago. This question is: If there is a family
history of ovarian cancer, should I have genetic testing done? – The first person to get
tested should be the person who had the ovarian cancer. If that person is negative,
then all the relatives, it’s less likely that the daughters and the sisters would have that mutation. So, that’s the most important thing. If we’re unable to test
that patient, then we can do a family pedigree, and basically take a very
detailed family history and then determine, by
the results of that, if that person should have
blood testing or whatever. – Yeah, I think one of the
other things I want to add to this question about genetic testing is that over a period of time,
our understanding is that one in five epithelial ovarian cancer, which is the most aggressive cancer, one in five of those patients when you screen them will
have a genetic component. So then we start drilling
down into their family members and we’ll find a lot of patients
who have the same mutation, specifically BRCA1 or 2,
then we have an option, or now they can undergo surgery, so you either remove the breasts
or remove tubes and ovaries when they’re done with childbearing, when they decide with their
provider the time is right, we can prevent a lot of
cancers from happening. The other thing I want to
add here is the question about genetic testing is
we’re in interesting times because the FDA just approved some of the kits from California where you can do BRCA1 and 2 genes yourself. There’s a lot of discussion
happening the community as to what does it all mean, but our stand is the
same that if you think there’s a family history, there’s a strong family
history of ovarian cancer, talk to your doctor,
talk to your provider. And as Rebecca mentioned, going into and drilling down into the details of the
family history and talking to a genetic counselor to
figure out what test are right because BRCA1 and 2 are
just the tip of the iceberg. There are other genetic
tests which are available, which predispose you to these cancers. So, I think those are available to you because they
are approved in the FDA and you can do those testings, but if those are negative and you have a family
history of ovarian cancer, that doesn’t take you off the hook. But it could be other things
you need to be looked at, and I think discussion with your doctor is important for that. – I think it’s really important for people to see a genetic counselor because if you have a test result, somebody needs to explain
it to you (laughs). It’s really unhelpful
if you have a yes or no. You don’t know how to interpret it, so it’s very important to
speak to a genetic counselor. – And I feel like this next question kind of flows perfectly on from that. If I have BRCA1 or 2 genes, should I get a hysterectomy if not diagnosed with ovarian cancer? – I think if you have a BRCA1 or 2 gene, you should be hooked in the system, talking to an expert who takes care of patients who have BRCA1 and 2 genes. These discussions are often very nuanced. I mean, the risk of cancer
is not a static thing. As you age, your risk goes up, and the risk is different
for BRCA1 and BRCA2. And having a discussion with
a team which has the expertise in dealing with these issues will, not only help you make this decision, but can also help you fulfill some, if you’re at an age where
you’re hoping to have children, then you can work with this team and see what is the best
time where you can reduce your risk of having cancer, but
also fulfill your fertility. Having a risk-reduction mastectomy
is an option, but, again, having a discussion with
this team is super important. The answer to your question, should I be getting a hysterectomy? That’s a question we
don’t have the answer yet. That’s a much more detailed question. Even when we do propose surgeries in patients with BRCA1 and 2, we usually remove tubes and
ovaries and leave the uterus; however, there is some new research which shows that they
have an increased risk of endometrial or uterine cancer, but we don’t have any society
recommendations on this. This question is actively
being debated right now in our society to come
up with the question whether hysterectomy is worth it or not. – I would just add that
our teams taking care of patients with BRCA1 and 2 mutations, or even other mutations that predispose you to ovarian cancer, are multidisciplinary teams, so there are surgeons, and
there are medical oncologists, and radiation oncologists,
and there’s a whole team. Plastic surgeons. It’s not just one person you’ll see. You will need to see a whole team and get all of your options so they can make a good decision. – Yeah, and then the last
point I would like to make with BRCA1 and 2 is breast and ovarian are the most common cancers, but that also predisposes, BRCA, predisposes you to other cancers as well. So, we have a focus in ovarian cancer, so we always think about ovarian cancer and we are here to discuss ovarian cancer, but we should not forget that
these mutations predispose you to gastrointestinal cancers, for example, pancreatic cancers. So, that just highlights the
importance of having a team which is used to taking
care of these patients. – Thank you, thank you for that. The final diagnosis question, or the last one that we have up right now. Life expectancy. How long would I have to
live after being diagnosed? – That is a– (everyone laughs) – I’ll give that to you. – Let me circle back to the
statement we made earlier. Ovarian cancer is not a one disease. So, I think if you have a cancer
which is not as aggressive and was diagnosed at an early stage, whether it was picked up
because you were going to your doctor and they
felt a mass during the exam, or you were having an
ultrasound for something else, or it was caught at a later stage, but still not an aggressive cancer, or you underwent the right treatments, the life expectancy could differ a lot. Rebecca could tell you, she’s been practicing a lot longer than I, but I have inherited some patients from a few of my partners. They have had ovarian cancers and they’re alive at 10 years, 15 years. So it’s not, even though
the numbers on the websites and everything will give you a summary that the statistics is five years survival of ovarian cancer is 40%. That can be very misleading
and, frankly, disheartening because this number
includes a lot of women who are diagnosed later in
the age when they are older and they’re not able to, they have other comorbidities, they have heart disease. If somebody is in their 80s and 90s, their risk is different than somebody who is diagnosed in their 30s and 40s. So, it’s difficult to
put all this together. The number 40% to 45% in five years is a very
oversimplification of the facts. So, I don’t have a good
answer to that question, but I think it varies. – You know, I think that is a good answer. And I don’t feel like you
should always be on the hook for bespoke answers to some of these very, very specific questions, but I really appreciate these answers. – I also would reiterate that you’ll see all these statistics
and numbers on websites, but it’s not one size fits all. There’s kind of a continuum, and we’re always
discovering new treatments. For example, now,
immunotherapy is very hot. We didn’t have that five or 10 years ago. And I think we’re starting
to treat ovarian cancer more like high blood pressure. It’s a chronic disease;
we keep treating it, it comes back, we treat it again. We might have another treatment, we might have a clinical trail. And so, the treatment now is different than it was five years ago, even. – Thank you. And I think you
read my mind a little bit because we’re going to move
on to treatment options. What treatment options are available? – I can start with this. One of the things, which most of my research is in looking at whether women with ovarian cancer
get the right treatment when they get diagnosed. The unfortunate reality in
the United States is only about 60% to 70% of the women
get the right treatment. So, that’s something we can
make a lot of difference because if everybody got
the correct treatment, we would have a bigger chunk of women who would be cured from
the disease right upfront. And even when the cancer comes back, having had the right treatment before, pushes the recurrences farther, so puts you at a better track. In general for a cancer, which is a most common scenario we see is generally women in their 60s to 70s, they would have cancer usually
in the stage three disease. What they need at that time is a combination
chemotherapy and surgery. So, what we’ve found in our research is sometimes they get the chemo, but not the surgery,
sometimes the surgery is done, but not the combination chemotherapy, they only get one drug. Those are the things which
we can make a huge difference by giving the right treatment. But generally, it’s a combination
of treatment and surgery. The other thing I want to
emphasize in the treatment of ovarian cancer is who treats
your ovarian cancer matters. We, Rebecca and I and our partners here in gyn oncology are obstetrics
and gynecology trained, but specializing in only
treating cancers in women. So, we don’t do anything
else but treat these cancers. And there’s data to support that women who actually see a gyn oncologist during their treatment
have better survivals. So even if they are getting
treatment from closer to home, if there is not a gyn
oncologist available, the guidelines both from
The American Society of Clinical Oncology and The Society of Gynecologic Oncologists are that at some point, a consultation with the gyn oncologist
should have happened. And then, they could get chemotherapy closer to home with medical oncologists, but the surgery part, we are specially trained
to do these surgeries. Sometimes these surgeries
last for six to eight hours and how much effort is
made in these surgeries directly translates to the
survival in these patients. So, seeing a gyn oncologist
and also participating in a discussion with your doctor. Am I getting standard of care? And this line is relevant to any cancer. Am I getting the standard of care? Is something which people can do to improve their chances
in getting treatment. – I think we should highlight
that there are websites where people can check to see that they’re getting the
standard of care treatment through the National Cancer
Institute, through the NCCN. There’s a link for patients,
there’s a link for physicians, and there are hyperlinks, so it’ll take you to other websites. If I have this, I should
be getting A, B, C, D. – Great. And for those watching live, we’ll get those links and
post them up afterwards. – Yeah, and sometimes what
is listed on that document may not be the right thing for you, but putting it out in front of your doctor and having a discussion, why am I not getting this is helpful because then you get the satisfaction that okay, my physician has looked through everything and they’ve made a choice
of doing this because maybe my kidney is not doing
as well as other people, so that’s why they decided to do a different kind of chemotherapy. But I think, as patients, they should not shy away
from asking these questions and holding us to a higher standard. Are we doing the standard of care or not? – Great, thank you. Another treatment question here, with newer options, how do you treat ovarian
cancer as a chronic disease, as you mentioned? – Well, we have many treatment
options for chemotherapy. It’s not a black and white question. I guess I’m going to revert
back to our discussion about genetic testing
because that’s most relevant. Since 2007, the National
Cancer Institute has asked us to refer all patients
with ovarian cancer to a genetic counselor, but only about one in five women are referred
to a genetic counselor. We know that, but in the last year, some new treatments have opened up for patient with BRCA1 and 2 mutations, they’re called PARP inhibitors. And now that we have
different treatment options for patients with these genetic mutations, more patients are getting tested, okay. So, these treatments are open to
patients who have mutations, genetic germline mutations and also somatic
mutations in their tumors. So, you know what? If your tumor didn’t
get tested 10 years ago when you were diagnosed, we’re
going to test your tumor now because you might be
eligible to be treated with these new medications that
are oral chemotherapy agents. There are also immunotherapy
clinical trials that are open, and this is really, I think,
a new area of treatment for all cancer patients. Really retraining or reeducating your immune system to fight your cancer. It’s, I think, very exciting. And a lot of these are oral medications that people can take at home. Sometimes they’re taken in conjunction with regular chemotherapy. It’s very nuanced. There are many clinical trials open. Again, there’s another
website, clinicaltrials.gov, which we will post. But, it will list. You can search for your
cancer type, where you live, how far you’re willing to travel. And then, I guess we can mention different kinds of clinical trials. It’s kind of confusing for people. So, there’s phase one clinical trials, which means they’re testing
for side effects of a new drug. It might help you, we don’t know. Phase two trials means that there’s activity probably in your drug. We really want to make sure that it’s going to work in ovarian cancer. Phase three trials are the best because that means we have a new drug and it’s going up against
the gold standard. So, if anybody finds a phase three trial that they can get into, you need to try to get into that. – Yeah, I just want to clarify something about when we use the
word chronic disease. I don’t want people to think that ovarian cancer is
treated just like diabetes. It’s much more serious than that. – [Rebecca] It is, yes. – But, we often, in our conversations, will call it a chronic disease, which is, in some way, we are a
little optimistic about it. When you go and talk to
people maybe 20 years ago, when you mentioned the
word ovarian cancer, mortality was very, very high. Most women would not live
as long as they do now. Partly because, as Rebecca mentioned, we have multiple different
kinds of treatments, the drugs which have come up. So, they go on living longer. Now, the best thing is if
they didn’t have this cancer, but sometimes we get stuck with
the hand we are dealt with. But even in those circumstances, if they are taking the
drugs orally or once a week they’re coming and getting
the chemo and they go on and they can carry on for a
number of years and do things which are very important to
them in their personal life. It gets labeled as
something you live with. That’s what the definition
of a chronic disease is. But two and two are not
equal; we recognize that, but I think, still, we find this exciting that women with ovarian cancer can go on and live longer than what they did before. – I mean, I guess I should clarify, ’cause I’m the one who said
(Shitanshu laughs) to treat it like a chronic disease. I mean, the best case scenario is you treat somebody and they’re cured. – Yes.
– You don’t see the cancer. The next best scenario
is you treat somebody and their disease is stable. It doesn’t change, but they
can still live their life and they have a good quality of life. They can do the things they want to do. – Absolutely. – If you’re treating somebody and their cancer is not
responding to the treatment, that’s when we need to change. – Thank you, thank you for that. One more treatment question, after treatment, what’s the likelihood of
ovarian cancer recurrence? – High. Very high, but, at the same time, people, when somebody gets the treatment, they’ve gotten the right treatment, and they’ve gotten the
standard of care treatment, what we see is that at five years, for somebody with the advanced cancer, somewhere from three to
four women would be alive and an even smaller fraction
would be completely cured. So, it is really important
to continue following up with your doctor so they
can keep an eye at it and make sure that if the
recurrence was discovered, that it’s discovered early enough so that the treatment can be started. But it does put you at a difficult place ’cause you’re living in the shadows of this disease where
you’re always thinking, is it going to come back? So, I tell my patients all the time that, from our perspective, when we are done with the treatment, we believe that everybody
is cured until they are not. Because, otherwise, it becomes
very difficult to carry on with your life thinking that
this is going to come back. – Thank you for that. – We do keep a really
close eye on patients. So, after they finish
their initial treatment, we’ll see them very
often, every three months, and then as time goes on, the risk of a recurrence drops off, so we will space out their appointments, and we try to celebrate a little bit when we reach different milestones. But we keep close contact
with our patients. – Thank you for that. We’re going to move on to some
more of our questions now. What kinds of support groups are there for people with ovarian cancer? – There are multiple support groups. I think I’ll mention MIOCA, (laughs) Michigan Ovarian Cancer Alliance. It was started by a patient
at the University of Michigan, who was a nurse, and her daughter, Pam Dahlmann, is also a nurse, and they started this
enormous network, I think, that includes, not just
University of Michigan patients, but patients from all over the state. They’ve had information courses for patients that are free
of charge, will have support. People will come and give
talks about treatment options, genetic counselors have given talks. We’ll have talks about alternative medicine
at these meetings. They meet monthly. I know there’s a Gilda’s Club meeting on the other side of town,
so there’s multiple groups, but I think it’s really
important for patients to feel like they’re part of a community and they’re not going
through this process alone because it’s very difficult
to go through alone, and they need the social support of people that are going through
it at the same time. Not only their family members and friends, but other patients. I think it’s very, very helpful for them. – Thank you for fielding this
broad range of questions. The next one that we have up, are there ways to prevent ovarian cancer? – I think one of the good
things about prevention is, obviously, we don’t have to deal with any of these disease-related issues. You can break this question down into two different categories. One is general lifestyle
things which you can do, which will reduce your
risk for all cancers. And then there are things you can do specifically in ovarian cancer. I can answer both of them. The lifestyle things,
which are, in general, keeping your weight in check because there was a report just
now recently that in women, overweight is becoming
the number one reason of developing more cancers,
even more so than smoking. So, that’s number one. Regular exercising, maybe vigorous exercising
for about 30 minutes. Something which makes you winded. You can’t have a conversation. That kind of exercise. But, after talking to your
doctor, if it’s safe to do so. Then, eating healthy. Going to some of the websites from the NIH and see what that entails. It’s a huge conversation in general. But all those healthy
lifestyle issues will reduce your risk of developing any cancer. But, ovarian cancer specifically, we know one intervention which is definitely helpful is
oral contraceptive pills. If you’re premenopausal and there are no contraindications to starting
oral contraceptive pills, then oral contraceptive pills can reduce your risk of ovarian cancer. The ovary forms a cyst when
it ovulates every month and the oral contraceptive
pills, by design, reduce that and have an ability to reduce, on a population level, the ovarian cancer. So that’s something specific. Do you want to add something other for ovarian cancer prevention? – Well, I would say people might say, what makes me at high-risk, what makes me at low-risk
for ovarian cancer? Basically, the less you
ovulate (laughs), the better, for ovarian cancer risk.
– Yes. – So, birth control pills decreases your number of ovulations you have. Somebody, Andy Berchuck
at Duke, did a study. He counted number of lifetime ovulations, and if you had many more
lifetime ovulations, you were at a higher
risk for ovarian cancer. So, if you’ve had more
children, or if you breastfeed, that also decreases your
risk of ovarian cancer because it stops ovulation. For some reason, tubal ligation
also decreases your risk. We don’t really know why, but now we think that
ovarian cancer might start in the end of the
fallopian tubes, so removal of the fallopian tube has
something to do with it, even if the ovary is still there. And all the healthy
lifestyle choices you said, really reducing your weight is key. – Yeah, I think that Rebecca brings a really important point that women who, this is applicable to a
very specific population. If you’re done with childbearing, and you were having a C-section, and in the C-section you
were asked a question, do you want to have more children? And the answer is no. In the past, we would tie the tube, now we just take the entire tube out. I think that’s something which
we think will reduce the risk of ovarian cancer because
there is some new research, which is coming up, which is showing that a lot of these ovarian cancers
actually start in the tube. This is still an area
of active investigation. We don’t yet recommend that women, once they’re done childbearing, go and electively remove their tubes. This is still an area
of active investigation. There are no recommendations on that yet. But definitely in the
high-risk population, if you have a strong
family history, again, talking to the genetic counselor, you will definitely be
steered towards a direction where tubes and ovaries are removed once you’re done childbearing. I think these are all possible ways of reducing ovarian cancer. – So you both mentioned
weight as a prevention. Can it affect your recovery as well? – Recovery from treatment? Yes, I think that obesity is associated with so many different things
that affect your health; high blood pressure, your
risk of heart attack, all these other things. This all contributes to
how we can treat you. Our treatment is sort of limited by what you can tolerate
physically and emotionally, but physically also. Some of the drugs affect your heart, so if your heart is not in good condition, we can’t give you that chemotherapy. We have to consider all
the different parts of you, not just the cancer. We have to consider you as a whole. Even just recovery from
surgery is really improved if you have good physical
health going in to surgery. We know that if you are a
walker and you regularly walk, even just two weeks before surgery, you’re going to do better with surgery. So, being physically
active is always a plus. Reducing your weight. Some people ask, is sugar bad? Does cancer like sugar? Is it okay if I eat candy? I think that everything in
balance is a good rule of thumb. – I think the obesity is a
huge topic in the setting, but I think, overall, I would say we poorly understand the obesity. We don’t know why some people
gain more weight than others. That’s an area which is heavily
being investigated right now that how we can stop the
obesity crisis we have. But the short answer is yes, those who are already at a higher weight, every stage of the treatment it is slightly more difficult for us. That doesn’t stop us from
doing our best, but, overall, if you were to compare patients in terms of their surgical outcomes, patients who are overweight, there’s higher risk of
infection in the incisions, surgery in general is a
little bit more difficult, so that does affect their outcomes. Later on in the treatment
when we have chemotherapy, then it is really important that, some of the work done in the University of
Michigan by Dr. Griggs, who is one of the
medical oncologists here, showed that patients who
were higher weight got less chemotherapy because the protocols, which had a weight restriction or a limit, were not given the entire
amount of chemotherapy which was recommended for these patients. So, there are lots of nuances in this, but yes, that can negatively affect you. It should stay on people’s
radar in terms of prevention that by taking an active approach in their weight management, they can reduce risk of
lots of different diseases, not just ovarian cancer. – Thank you for that. The next question, do supplements or vitamins
help reduce the risk of getting or having a
recurrence of ovarian cancer? – Do you mind if I take this one (laughs)? – No, please. – Yeah, I say this
because this is a question which I’m very passionate
about this subject. And the reason for this
is that the evidence supporting this is close to zero. There are two aspects to this. Number one is I would recommend people who are really interested in knowing about this conversation is Frontline from PBS did a huge one-hour documentary on supplements in the United States. It’s not an FDA-regulated market. And specifically in that commentary, there were two issues they mentioned. Number one was, when
you’re taking supplements, there was an issue that, are you getting the supplement which they are claiming is in there? And the second thing was
the efficacy of the dosing, especially in vitamin D. Some of the brands which were selling it had wide ranges of it. The other issue is
we’ve not have any study which shows that by taking
these vitamins and minerals that people have reduced
the risk of cancer. As a matter of fact, study
after study which has come out has shown that these
interventions are not helpful. Now, if somebody is deficient in a vitamin because of a reason, because of the diet they
choose or maybe they have some GI malfunction and
their physician thinks that they should be
supplemented for that vitamin, I am not talking about that population. I’m talking about, in general, people who are able to
eat a healthy lifestyle. I think the last thing I would say is that if you have a cancer and if we presumed that your cells and your body
did really well with vitamins, so will the cancer cells. You’re feeding them, in
addition to yourself. So, no matter how I look at it, I personally cannot come to a conclusion that these things are helpful. There are no recommendations
from our societies that people should take
supplements to prevent or treat cancer with
minerals and vitamins. So, I am not in the favor of that, but I think this is a
question which will surface again and again and there’s an active– – I think it’s very confusing to people because when they get
diagnosed with cancer, all of their friends and family will say, oh I heard you should take
this, this, this, and this. And if you have an inflammatory state, you’re more likely to have cancer. And I do think that inflammation
is associated with cancer, but it’s important to recognize that we don’t have an FDA
for herbal supplements. Even if it says you’re getting curcumin, you don’t know what the
soil conditions were, what it’s contaminated with. It’s not regulated the way
other medications are regulated, so it’s always a better
idea to get these nutrients through your food than
by taking supplements. – Yeah, so I usually tell
my patients that if you want to do it and you think that
this is important to you, don’t spend a fortune on it, make sure you’re getting
it from the right source, and make sure that they’re
not making you sick. Anything, including other supplements, which Rebecca mentioned
in treatment of cancer. Sometimes we’ll get questions like, I’ve heard online that
this particular thing is really good for treating cancer. I don’t know. We don’t have a study to
support for or against. So, in that setting, if they’re taking it and they feel good, I just tell them that if you
start developing side effects which were not in line with the chemotherapy we are giving you, then, obviously, the next thing to blame would be the
possible supplements. – It’s also important that you tell your doctor what you’re taking. – Yes.
– Because some of the things, if you’re taking very high
doses of antioxidants, it may counteract the
effect of the chemotherapy. If you’re taking a lot
of garlic and fish oil, those are blood thinners, we need to know that you’re doing that before you go to surgery. So always bring your bag of pills (laughs) to the doctor’s office
so we can look at them. – Thank you, thank you for that. And next question we have up, can you get pregnant after
diagnosis and treatment? – Yes.
– Yes. – If, during the surgery, the uterus and both
ovaries were not removed. In younger patients, specifically within the
spectrum of ovarian cancer, they are much more likely to have cancers which are low-grade, not as aggressive. But, even high-grade, super
aggressive cancers can happen in women in childbearing age, and in those settings, sometimes it’s a shared decision-making on fertility preservation. One thing I would say is that if they are in this unfortunate scenario that they have ovarian cancer and they are about to
embark on a treatment, seeing a fertility expert
is really important. Now, if somebody has had the treatment, they’re free of disease, they
have a uterus and ovaries, even one, the next question then is, did the chemotherapy affect their ovaries in a negative way that
they are not functioning? Most of the treatments we
do in ovarian cancer are not as toxic to the ovaries, so generally they recover the function, and if they’re menstruating,
yes, they can have children. – Thank you for that. Next question we have up, can talc powder give me ovarian cancer? – Want to go for it? – There’s a lot of discussion about this. And I think we don’t know. We don’t really know. I think this conversation has been going on for many, many years. I don’t think anybody is
really doing rigorous research on this because how can
you do research on this? There’s no model. You can’t have a control group
and you can’t expose patients to talc on purpose because
we just don’t know. There’s not really great animal
models for ovarian cancer, other than chickens and, I mean, there’s not a good way to study that, so we don’t really know. – Thank you. – Best to avoid it, I guess, would be the answer at this point. – Next question we have up, are there environmental
causes for ovarian cancer? (Rebecca laughs) I guess that’s a tricky one too. – I think this is all
along the lines of talc. There’s no specifics about this. We can’t say that if
you live in this area, you’re in danger of having ovarian cancer. We cannot say, for
example, like lung cancer. If you smoke, you’re at
high-risk for lung cancer. We can’t really say that about
anything for ovarian cancer. We just don’t know. You maintain a healthy lifestyle, and you eat more fruits and
vegetables than processed food, that’s all we know. – Thank you. What is the difference
between ovarian cancer and an ovarian cyst? – I’ll go back to those
Venn diagram analogies, like where they say all dogs are animals, but not all animals are dogs. All ovarian cancers
can have cysts in them, but all cysts are not ovarian
cancer, if it makes sense. So, you can have cysts which
are not ovarian cancer. You can have normal cysts, you can have cysts which
are completely benign, they have no cancer in them. But, regardless of that, if you have small cysts on an ultrasound, which was done for whatever reason, women in their premenopausal
years will always have cysts. Then generally, the gynecologist
will repeat the scans, unless they’re very large cysts. In those setting, nevertheless, I think the short answer is that they should be investigated. If somebody has done an ultrasound and there are multiple cysts, it could be a polycystic ovarian disease. So, a cyst is basically saying that there’s a small enclosed area with a little bit of fluid inside of it. Now, whether it’s an indication that this cyst is an ovarian cancer
or not, sometimes it is. And when you serially follow these, you do an ultrasound and it’s growing, and that’s how some
patients get referred to us that they had cysts and they are growing, and they’ve done a CA 125 level in this patient and it’s elevated, all these things are pointing
that they might have cancer, we’ll typically go in and
remove these and figure out whether this is cancerous
cysts or benign cysts. More often than not they
are benign, which is good, but no cyst should be completely ignored. But, if it’s a discussion with the doctor, and they think that this is not a cyst you should be worried about, then let them take care of it. – And all women have cysts because you every time you ovulate, you make a cyst.
– A cyst. – So, it depends on the context. How old are you? Where are you in your menstrual cycle? How big is it? How long has it been there? So, it’s a conversation to
have with your gynecologist. And the gynecologist, if they need us, they will call us and say, could you please see this patient? Tell me what you think. And then we have a conversation about it. – We get much more alarmed
when the cysts are happening in somebody who is
postmenopausal just because, in that age group, the
ovarian cancer is more common. When you’re postmenopausal and you’re not making cysts regularly on the ovary, why should there be a cyst? So, we get a lot more
alarmed in that setting. – Thank you. We’re into the final 10 minutes here. It looks like we’ve got a
couple of questions left. This one is looking forward, where do you see the future of ovarian cancer diagnosis
and treatment going? – I think there is a lot of excitement about looking for screening tests. As we mentioned earlier, there’s no pap smear or
mammogram for ovarian cancer, but people are finding out that if you have a certain type
of bacteria in your system, you’re more likely to have colon cancer. I think we’re going to find
that with ovarian cancer. I think it’s not really the bacteria, but it’s your immune system. What does your immune system do with different types of
infection and how does your immune system get
rid of abnormal cells? So, I think that screening and treatment is all
going to come down to, how can we tune up your immune system? I think that’s a really
big area of research. – Yeah. I think if you break it down into like three different buckets. There’s a bucket of what Rebecca mentioned about this before you develop the cancer. The prevention strategies
and early detection. That’s like this one area, and I think that’s the area
we have to focus the most on because, for everything you do, you will prevent the cancers
and you don’t have to deal with the aftermath of what happens. The second bucket is, this is the part, where I
do the most of my research, is that once you’ve developed the cancer, making sure that everybody is
getting the right treatment. If you could imagine a world where 100% of women got the standard of
care when they got treated, they got genetic testing all the time, their family members who
tested positive got their tubes and ovaries removed at the right time after a discussion with their physician, now we’ve reduced the number of cancers. So, that’s where I focus. Rebecca has had a lab for
a long period of time. Dr. McLean, who is one of our partners, who is actively studying. Kathy Cho is another of
our Michigan Medicine ovarian cancer researchers. They are focusing on newer treatments that why some cancers stop
responding to chemotherapy. How can we reverse that
mechanism that they continue to be sensitive to chemotherapy? Or trying to develop newer drugs. In all three buckets, there’s a lot of activity
which is happening. And then the immunotherapy question. And I think there’s
lots of clinical trials which are coming in the pipeline. How they do in ovarian
cancer is to be determined, but we’re optimistic in this. – There was a statistic you gave earlier about the percentage of patients who aren’t getting the correct treatment. Could you give that to me one more time? – Yeah. In our research, we’ve looked at, from the National Cancer Database, that 60% to 70% of the patients are not getting standard of care treatment. When you look at it, especially, there’s a lot of
disparities in cancer care. There’s disparity of race,
there’s disparity of ethnicity. The biggest disparity in ovarian cancer we see is the geographical disparity. If you are from a rural area where there’s no access to a gyn oncologist
or, frankly, an oncologist, it is much more likely that you will not be getting a standard of care because it’s difficult to
travel 10, eight hours. We see this first-hand. A lot of our patients are
from the upper peninsula. We try to work with the
physicians over there, and they are amazing people out there. They refer patients to us and co-manage the patients with us. So, we see the challenges
and how difficult it is. In other states, I think similar
challenges are happening. And then, the last disparity
is the age disparity. When you’re older, sometimes standard of care
treatment is not given, people don’t do aggressive surgery. Now, I’m not advocating
aggressive surgery in people who are older and they have a high risk from having complications
during the surgery, but as populations are aging
and people are healthier, the chronologic number
should not mean anything. What we should take into account is how is their functional status. If somebody is 80 and
they’re driving their car, and they’re going shopping
themselves, they’re living alone, they’re doing everything, they should get treatment the same way as somebody in their 50s would. But, time and time again
we see, as you age, you don’t get the same treatments. That’s something we can do now, as opposed to hoping for
newer treatments to come and newer tests to show up. – Thank you. As we wrap up this live chat, let’s have one final question. If you could do a brief recap. Give me some more statistics
of ovarian cancer, when to see a doctor, prevention tips, anything else you’d like to share for our final five minutes (laughs). – I want people to remember
that you can cut your risk of ovarian cancer in half by
taking the birth control pill for at least five years, if you don’t have a
contraindication to that. That’s important to note. Don’t ignore the symptoms. Ovarian cancer is not
really a silent disease. Really pay attention to how
you’re feeling, see your doctor, see your gynecologist regularly. I don’t know. Do you have
more to add (laughs)? – No, I think these things
with the genetic testing we’ve talked about, these
are really important. I would urge people to be a participant, an active participant in their treatment for themselves or their loved ones, if they, unfortunately, have this disease, and figuring out from
some credible websites what should be done, and is it being done, and, if not, having a conversation with
the physician, why not? And as I mentioned before, there might be good reasons
why it’s not happening, but that knowledge is super helpful. In addition to all this, one other thing, since we are running out of time, I wanna mention is a lot of things we mentioned where the research
is necessary, for example, in the early testing
phase, or in the treatment, or making sure people are
getting the right treatment, these research endeavors need money. Money comes from some of the
National Institute of Health, NCI, National Cancer Institute grants. Our group has shown, and we presented this data in
The Society of Gyn Oncology, is there is a huge disparity
in funding in ovarian cancer. For how lethal this cancer is, we get a fraction of money
to study this cancer, as opposed to lung
cancer, or breast cancer, or prostate cancer. Now, whenever I talk about this, I get an argument that yeah, but those cancers are really common. But one thing people
forget is that the number of women we are losing with this cancer actually puts it really high on that list. And the number of life
years lost because a lot of women develop this
cancer in their 50s and 60s. If life expectancy in
the United States is 80, we’re losing 30 years of life. So, people should reach out to their elected members and say that there should
be some equitable form of distribution of NIH dollars
in studying these diseases. Otherwise, what’s going to happen is that we’ll have cures in other cancers, but not in this disease,
and that worries me. We’ll be left behind and, unfortunately, gynecologic cancers are being left behind. We found the same thing
in endometrial cancer, which is a uterus cancer,
and in cervix cancer. We need money to be able
to do this, and, frankly, what we are asking for is grants. These are scientifically
vetted grants, not donations. So, this is super important in this field. – It’s very important. We need to do these large clinical trials, national trials, not
just in one institution, trials that include patients
from all over the country because ovarian cancer is not common, so we need to be able to study
large groups of patients. – Yeah, we have no
shortage of brilliant minds and what they need is some money to help their research effort so we can move the needle on this cancer. – Well, thank you. I think that wraps up today’s chat. Thank you both for your
time and expertise, guiding us through all
these nuanced answers. I think this has been very, very valuable. I have a link that I can give everybody, and we’ll also post
onto our Facebook page. For more information on ovarian cancer, please visit rogelcancercenter.org/oci. That can be a useful link too. Dr. Uppal, Dr. Liu, thank
you so much for your time. – You’re welcome.
– Thank you for coming on to this Facebook Live, everybody who’s been here
and posted questions. Thanks again. – Thank you.
– [Rebecca] Thank you.

4 thoughts on “Ovarian Cancer

  • I have severe pain in my back and lower abdomen
    Nausea
    Loss of appetite
    I have thought I have kidney stones but they say it is nothing and I got cysts in my ovary 😭😭😭😭😭😭but hospital say I dont have anything if so why I have more pain in my abdomen and back pain in manner I have to visit emergency room 😭😭😭😭😭😭😭😭😭 it for 1 year help meeee wat to do

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