Treatment of Ovarian and Endometrial Cancers

Dennis Kuo, M.D.

(presented at the 2004 CAMS Annual Scientific Meeting)

             Epithelial ovarian cancer is the sixth leading malignancy among women in the United States.  It is however ranked fifth in annual mortality, as almost half of the patients with ovarian cancer will eventually succumb to the disease.  Epithelial ovarian cancer has such a high mortality rate because 70% of these patients are diagnosed in advanced stages (stage III and IV).  While patients with stage I ovarian cancer have a 5-year survival of 90%, patients with stage III or above have a 5-year survival of 35% or less.

             The risk factors include age, the theoretical concept of incessant ovulation, genetic predisposition, dietary or environmental factor.  The treatment for advance stage ovarian cancer is a radical surgical debulking procedure.  This would include hysterectomy, bilateral salpingo-oophorectomy, omentectomy, possible bowel resection, possible splenectomy, possible diaphragmatic stripping, possible pancreatectomy, and any other necessary procedure to yield a minimal residual disease of 1cm or less.  Studies have clearly indicated that optimal cytoreductive surgery followed by systemic chemotherapy would yield the best long-term survival.

             Currently Paclitaxel and Carboplatinum are the standard adjuvant therapy for patients after cytoreductive surgery.  It is a one-day infusion in the outpatient chemotherapy suite, which spells convenience for the patients.  While second-look laparotomy has not shown clear benefit in all the patients, prolonged maintenance therapy has shown promising value in prolonged patients’ long-term survival.

             Further research is focused on targeted therapy, gene therapy, or immunotherapy.  More efforts are required in order to improve on the overall survival and disease free interval for these patients.  Other than novel treatment, the emphasis should be on the development of screening techniques to detect disease in the early stage.

             Endometrial cancer is the most common gynecologic malignancy in the United States.  There are approximately 39,000 cases and 6300 deaths per year.  Unlike ovarian cancer, majority of the patients (over 80 %) are diagnosed in the early stage (I and II).  The risk factors included patients with hypertension, diabetes, obesity, nulliparity, and tamoxifen usage.  Majority of the patients affected with the disease is postmenopausal.

             The most common symptoms are postmenopausal bleeding or irregular menstruation.  It is important to remember that Pap smear is not a screening test for endometrial cancer, even though some of them may have an abnormal Pap smear.  While endometrioid carcinoma is the most common type of endometrial cancer, there are other types such as clear cell carcinoma, serous carcinoma that are more aggressive and are not associated with the risk factors mentioned above.

             The standard treatment for endometrial cancer is a hysterectomy, bilateral salpingo-oophorectomy, and a staging procedure.  Depending on the potential risk factors noted on the final pathology report, radiation therapy may be offered.  Minimal invasive surgery to perform the hysterectomy and staging procedure has become more prevalent.  In the hands of  a competent surgeon, laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and a staging procedure can be done with similar outcome as an open case.  Randomized study is currently being done to evaluate such hypothesis.  Chemotherapy to treat advanced or recurrent endometrial cancer is palliative at best.  The role of prophylactic chemotherapy in treating early staged disease with poor prognostic indicators is still unknown.

 Dr. Kuo is Assistant Professor of Obstetrics & Gynecology, Weill Medical College of Cornell University.