by Richard Mansour, MD
While treatment of cancer has evolved over hundreds of years, the specialized practice of medical and clinical oncology was not widely implemented until the 1960s, due to the progression of chemotherapy treatments. During this time, surgeons, although highly skilled, were not trained in oncologic procedures nor did they have the extensive research, medical image advancement and specialized training like a modern day oncologic gynecologic surgeon has today. Ultrasound was a new but emerging skill for radiologists, CT scans were experimental, and there were no MRI or PET scans. The cancer antigen 125 (CA-125) blood test had not been approved for clinical use. The familial tendency to ovarian cancer due to the BRCA1 and BRCA2 mutations were yet to be discovered. Much of what we know and practice regarding ovarian cancer has totally changed over the past 50 years.
The importance of mutations in the BRCA1 gene was reported in 1994 and BRCA2 in 1995. Mutations in the BRCA genes gives a woman an increased lifetime risk of developing breast and ovarian cancers. Three cancer-related mutations in these genes are found in 1 in 50 Jewish people of eastern European heritage and are associated with very high lifetime risk for breast and ovarian cancer. Although BRCA mutations are most common in families who have Jewish ancestry, they also appear in Caucasian and African American women. We now know the incidence of ovarian cancer in BRCA mutation carriers is markedly reduced if an oophorectomy, the surgical removal of one or both ovaries, is performed at age 35 for BRCA1 and age 45 for BRCA2. Surgical standards have advanced in numerous ways. Multiple studies have reported improved outcomes when ovarian cancer surgery is performed by a gynecology oncology surgical specialist versus a general surgeon or a general gynecologist. These outcomes are due to the extensive training and experience of a gynecologic surgical oncologist. Chemotherapy has had major improvements over the past 40 years as well. Cisplatin, a chemotherapy drug, was applied to ovarian cancer in the 1980s, followed by the more tolerable Carboplatin in the 1990s. In the late 1990s, Paclitaxel was successfully added to Cisplatin and Carboplatin, achieving deeper and longer remission than ever
seen before in both advanced ovarian cancer and post-operative adjuvant therapy. A more recent advance was the finding that pre-operative chemotherapy with Paclitaxel and Carboplatin increased the surgical success in selected patients with a large intra-abdominal ovarian cancer burden. Large improvements in anti-nausea medications and drugs to reduce bone marrow suppression have improved tolerability of these treatments. Most cases of ovarian cancer are aggressive. Although patients live much longer now than years ago, this type of cancer usually returns and is challenging to control. Successful strategies to
keep patients in remission have been elusive in the past, but recently, a class
of medications that exploits DNA repair defects, such as BRCA mutations, has been found to sustain remission in a substantial percentage of patients. Medical oncology continues to advance. I have had the privilege of seeing advanced aggressive ovarian cancer survival after diagnosis increase from 3 to 6 months in the 1970s to 24–60 months in the current era. The quality of life has improved, and the toxicity of the therapy has been moderated. The fellows that we are training today may get to participate in the cure of this disease thanks to past and current clinical trials and research. www.lsuhs.edu/fwcc
Dr. Richard Mansour is
a Professor of Medicine
and Program Director of Hematology/Oncology Fellowship at LSU Health. September is National Ovarian Cancer Awareness Month.