Ovarian Cancer: Symptoms, Diagnosis and Treatment

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Hi, everyone. I'm your host, Dr. Erica Newlin. Welcome to Ob/Gyn Time. During this season we are focusing on topics related to gynecologic oncology, meaning cancers of the female reproductive organs. On this episode, I'd like to welcome Dr. Robert DeBernardo and Dr. Michelle Kuznicki who will be talking to us about ovarian cancer. Dr. DeBernardo, Dr. Kuznicki, thanks so much for joining me on the podcast.

Robert DeBernardo, MD:

Well, thanks for having us.

Michelle Kuznicki, MD:

Thanks for having us.

Erica Newlin, MD:

Yeah. Can you tell us about your role in The Cleveland Clinic and a little about your background?

Erica Newlin, MD:

Why don't you start, Michelle?

Michelle Kuznicki, MD:

Sure, yeah. So I'm Michelle Kuznicki as you said. I'm a gyn oncologist at Cleveland Clinic here. I see gynecologic cancer patients at Fairview Hospital, in Sandusky and also at Main Campus.

Robert DeBernardo, MD:

I'm Rob DeBernardo. I run the section so technically I'm Michelle's boss to make sure she sees patients with (laughing) gynecologic cancer. I do the same thing actually. It's kind of a, it's a lot of fun.

Erica Newlin, MD:

Well, let's start by clarifying anatomy. Where are the ovaries and what purpose do they serve?

Michelle Kuznicki, MD:

Sure. The ovaries so they're part of the female reproductive track. They sit up higher next to the uterus. Their two main functions are to produce eggs for reproductive purposes and to produce the sex hormones.

Erica Newlin, MD:

And we often talk about ovarian cancer as one entity, but are there a different types of ovarian cancer?

Robert DeBernardo, MD:

There are and I think when we talk about ovary cancer, I think a lot of times people think of the kind of the one that we all fear, which is something called epithelial ovarian cancer, or very simply kind of cancer of the skin of the ovary, while there are multiple other types because the ovary is a very dynamic organ. That can have multiple different cancers. That's the one I think most people think about when we say ovary cancer. And in that category there's a number of sub-classifications, none of which I think probably for this discussion are really important.

Erica Newlin, MD:

Sure. Are the different cancers treated differently?

Robert DeBernardo, MD:

Epithelial ovarian cancer in general is treated the same but some of our other ovary cancers like granulosis cell cancer of the ovary or a borderline tumor of the ovary, these are treated very differently.

Erica Newlin, MD:

And are there certain people more at risk for ovarian cancer?

Michelle Kuznicki, MD:

Certainly patients who have a strong family history of different cancers including ovarian cancer, breast cancer, colon cancer, these are patients that we would potentially recommend genetic screening to see if they would be predisposed to ovarian cancer but family history is the biggest thing we think of when we think of risk factors.

Erica Newlin, MD:

And a lot of my patients ask about screening like regular ultrasounds, regular lab work, is there any screening that can be done?

Robert DeBernardo, MD:

Can I take that one?

Erica Newlin, MD:

Sure.

Robert DeBernardo, MD:

There is absolutely no such thing as a screening test for ovary cancer. This is one of the areas that I really... I don't I don't know what the expression is (laughing) but I get really upset about it. We've studied this very in depth and there is no way unfortunately to pick up this cancer at an early stage with screening. So we don't recommend it. So if, as Michelle was saying if somebody has a very strong family history, they should see either one of us or someone like yourself to have a conversation and genetic evaluation. And risk reduction surgery where we remove the ovaries and tubes before they have a chance to become cancer is the absolute best way to mitigate that risk. Screening, all we're going to do is find an advanced cancer and so it just gives people false hope.

Erica Newlin, MD:

For sure. And what symptoms would raise suspicion for ovarian cancer?

Robert DeBernardo, MD:

I usually tell them anything that I would have after I eat a really good meal, so nausea, bloating, you know, diarrhea, constipation. Maybe some discomfort. People, if they notice their abdomen getting bigger and bigger, their clothes not fitting, those are kind of the symptoms that most people would experience. They're very non-specific and we all get them. So it's really kind of hard to know. But if those symptoms are going on for several weeks it's definitely worth a conversation.

Michelle Kuznicki, MD:

Yeah. I would also add gird or reflux, that's new and is refractory to any superficial intervention. That should definitely be looked into further.

Erica Newlin, MD:

And to that point as you mentioned, they're very non-specific symptoms and a lot of my patients who are asking about screening are asking about symptoms, so these can be very difficult to pick up on. So patients who have strong family histories as you mentioned definitely worthwhile to-

Robert DeBernardo, MD:

Right. And any concern. I mean, this is why these podcasts are so important like nobody is really thinking about ovary cancer. In fact it's a very uncommon cancer but it needs to be on the radar. And if people are experiencing these type of symptoms, it could be one of a whole bunch of things. Your gallbladder, you could have a hernia. You can have some diverticulitis. All those things are super common, but if ovary cancer needs to be on the list of things that we consider, because it's relatively easy to diagnose. And with good treatment, it's actually a very treatable disease.

Erica Newlin, MD:

Mm-hmm. How is ovarian cancer diagnosed?

Michelle Kuznicki, MD:

I think it depends on how the patient is presenting and what the situation is. So potentially in an early stage ovarian cancer, that might require surgical removal of the ovary in order to get a diagnosis. Sometimes if there is fluid in the abdomen or other areas that might be biopsy, they could have a non-surgical biopsy for diagnosis.

Robert DeBernardo, MD:

But many times we're making this diagnosis in the operating room because people will come in with a constellation of symptoms like we talked about, imaging that shows fluid and tumor. And with certain blood work, we can say, "Yeah, this looks like ovary cancer."

Erica Newlin, MD:

Mm-hmm.

Robert DeBernardo, MD:

So sometimes we actually make the diagnosis in the operating room at the time of their surgery.

Erica Newlin, MD:

Sure. And if someone has received a diagnosis of ovarian cancer and is preparing for their visit with a GYN oncologist, what kind of things can they expect for next steps in their workout? You mentioned surgery as diagnosis.

Robert DeBernardo, MD:

So first thing, I would say is if you're coming to see a GYN oncologist because you're told you have ovarian cancer, I would take that with a bit of a grain of salt.

Erica Newlin, MD:

Mm-hmm.

Robert DeBernardo, MD:

The vast majority of people that Michelle and I see don't have ovary cancer. They might have a suspicious mass. They might have something on their ovary. So the first thing I would say is not to panic but get into to see one of us. It's very easy to go right to the worst place. We all do. It's very natural. And so I think I take a deep breath and say, "Okay. I'm going to go a specialist and they'll tell me what's going on. Do you want to handle the rest of that question?

Michelle Kuznicki, MD:

Yeah, I completely agree with that. I think a lot of people are told based on the best information that the provider has that they're seeing that they are worried that they have ovarian cancer they have ovarian cancer based on imaging findings that are not, quote-unquote, "diagnostic" like we were saying before of how do we get a diagnosis? So I think not to panic and just to try to get to one of us and get the accurate information.

Once we make a diagnosis of ovarian cancer, I think the important things to consider is that there is treatment and to get in with ideally a GYN oncologist who takes care of these patients specifically because we have the best depth and breadth to take care of what we need to take care of.

Erica Newlin, MD:

And then what does cancer staging mean and how is ovarian cancer staged?

Michelle Kuznicki, MD:

Staging of a cancer for any cancer typically means how far has it spread from where it started. So for an ovarian cancer, if the cancer started in the ovary or the fallopian tube how far away from those organs has these cancer cells spread? Stage one is typically confined to the ovary. Stage two would be spread to the other ovary. Stage three is typically spread outside of the pelvis and then stage four is spread to other organs such as the lung or the liver.

Erica Newlin, MD:

And would that decision often be made during surgery or through imaging?

Michelle Kuznicki, MD:

We make a lot of these diagnosis through imaging, but sometimes especially in the early stage, we will make those based on surgical pathology.

Erica Newlin, MD:

And can you discuss when surgical treatment of ovarian cancer would be the recommended treatment?

Robert DeBernardo, MD:

So most people with ovary cancer are going to have surgery. You know that both chemotherapy and surgery play critical roles in this. So just broadly speaking almost everybody with an ovary cancer will have both chemo and surgery. It's a bit of a complicated rubric. Like Michelle was saying if we have an early stage disease, surgery is going to play a very important role in diagnosing and staging it how far has it gone and that's then going to dictate treatment from there.

Since most of our patients are going to come in with more widely metastatic disease, we'll make a determination in the office based on their health and the distribution of the disease whether we start with surgery and then follow up with chemo, or we start with chemo and then go to surgery. So complicated rubric.

Erica Newlin, MD:

Sure. This is likely a complicated question as well but what kind of surgeries might someone expect?

Robert DeBernardo, MD:

For early stage disease we do a lot of minimally invasive surgery and so that's certainly feasible. But given the fact that this cancer in the advanced stages is going to involve not just the ovary deep in the pelvis but could be something up by the spleen and the and up by the lungs. We're generally doing these surgeries through big open incisions.

Erica Newlin, MD:

And then sometimes we might use the term debulking. Can you describe what we mean by that and how that pertains to ovarian cancer?

Michelle Kuznicki, MD:

Sure. So that word really comes into play for those bigger surgeries like Dr. DeBernardo was talking about. So when we have imaging findings that suggests that this is a more advanced ovarian cancer that has spread outside of the ovary, at that point the goal of surgery is to get all of the visible cancer out so that's the term when we use the term debulking, that's really what that means.

We know that the patients who do the best after surgery are the ones where we're able to get all of the visible tumor out. So that typically will involve removal of the ovaries, a hysterectomy if the patient still has the uterus and then essentially removing any other area of disease including potential bowel resections, stripping of the peritoneum which is the lining of the abdomen, addressing anything around the spleen. So we sometimes have to do many different procedures during that debulking surgery in order to get all of the cancer out.

Erica Newlin, MD:

And then we've talked mainly about epithelial ovarian cancer which is often found in our postmenopausal population, or women who are older. But in ovarian cancer overall are there any options for patients who want to retain their childbearing option?

Robert DeBernardo, MD:

So most women like you said are going to be menopausal or even if they're in their 40s generally have completed their childbearing. So fertility is generally not something that we have to deal with although we can. I mean, the day and age that we are now and we are seeing younger patients with ovary cancer. Fertility is always something that we consider. So epithelial ovarian cancer, again pretty uncommon but we can still be conservative. We have the technology to salvage ovary and freeze that, harvest eggs so that people can still potentially have their own biologic children. But for an advanced ovarian cancer really getting all that disease out is important.

Fortunately, for younger women that have an ovary cancer, it typically won't be this epithelial ovary cancer. There are a lot of cancers of the ovary that just are very different and the majority of those, we can treat very conservatively so that even if a 25-year-old has a dysgerminoma for instance, we can just remove that ovary, do the staging if they need chemo. They still have another ovary in the uterus and they can go on and have as many children as they want typically.

Michelle Kuznicki, MD:

Yeah. It's worth in the case that person is diagnosed with an ovarian mass or a pelvic mass and they're concerned for ovarian cancer. It's just always important to advocate for yourself and ask about whether these options are there or not.

Robert DeBernardo, MD:

And that's critical because I think patients that we see, I mean, they're coming in convinced they have cancer and even when they do, that becomes the whole focus. But we need to think about things like fertility because many of our patients are going to live a long time.

Erica Newlin, MD:

Mm-hmm.

Robert DeBernardo, MD:

And sexual function, there's lots of other things that often can get pushed to the side because I just want to live. So that's what we try hard to do for our patients.

Erica Newlin, MD:

And you mentioned a little bit in saying that most patients with ovarian cancer will get chemotherapy and surgery. But in people who were good candidates for surgical management of their ovarian cancer, how do you decide who needs that additional treatment?

Robert DeBernardo, MD:

So again for epithelial ovary cancer, typically when it's advanced, everybody is going to need chemo. There's some very select patients that you can avoid chemotherapy. That's going to depend on stage and histology. So the specific type.

Erica Newlin, MD:

Sure. And what does chemotherapy look like for ovarian cancer?

Robert DeBernardo, MD:

(laughing) That's a complicated question, so I'm going to answer it very simply. The backbone of our therapy are really two drugs. One is a platinum and the other is a taxane. They've been around forever and they're actually very well tolerated. We administer them typically through an IV although sometimes we can give them in the abdomen as well. I think most, everybody that I see is more afraid of the chemo than the surgery, but honest to God, recovering from surgery can often times be harder than dealing with chemotherapy side effects, at least for these drugs.

Erica Newlin, MD:

Sure, yeah.

Michelle Kuznicki, MD:

I have a lot of patients who ask me about this and they're very worried about chemotherapy, but chemotherapy is very different depending on the type of cancer you have and many of their friends or family who've had chemo often times have not had ovarian cancer. They've gotten other chemotherapies for breast cancer or colon cancer or something different. So our chemotherapy, it's generally pretty well tolerated. I mean, we typically are seeing patients a little bit on the older side. Even patients in their 80s or 90s are getting these chemotherapy regimens and we can dose it in a way that makes it quite tolerable.

The nausea is not too severe. The other side effects like fatigue or muscle aches are very manageable. And then we monitor any other side effect, you know, more specific side effects of the chemotherapy.

Robert DeBernardo, MD:

And the good news is as their cancer responds, they feel better and better. So honestly we see patients with these advanced ovary cancers and they're very close to death and super sick. And after a few cycles of chemo are like, "Oh my God, I feel so much better," despite the fact that maybe I lost my hair and I have some nausea for a couple of days.

Robert DeBernardo, MD:

I mean, it's overall a win.

Erica Newlin, MD:

Mm-hmm.

Robert DeBernardo, MD:

One of the nice things about seeing one of us is we not only do the surgery but we give the chemo as well. So we're kind of very familiar with the entire journey from the diagnosis until we're in remission.

Erica Newlin, MD:

Is that usually the case for GYN oncologists-

Erica Newlin, MD:

... doing the chemo and the surgery?

Robert DeBernardo, MD:

Not all. Here in Cleveland, yes and certainly at the clinic. But there are some programs around the country that medical oncology deals with the chemo and GYN oncology will do the surgery. So it varies on location and region.

Erica Newlin, MD:

Sure. And then what other additional treatments may be used for ovarian cancer?

Michelle Kuznicki, MD:

We can use a lot of different treatments in addition to chemotherapy. So we have some other targeted agents that we use in the front line. There's a medication called Avastin that we sometimes add to chemotherapy to help it work a little bit better. There's also a group of medications called PARP inhibitors that we've started using a lot more especially in the frontline treatment after patients get their first chemotherapy. Once that's over, some patients are candidate to get this PARP inhibitor pill as a maintenance treatment to help prevent regrowth of the cancer, which is very effective in some patients.

Most of the other treatment options and later lines for ovarian cancer are still some type of chemotherapy that is most effective... The immunotherapy drugs that we use for some other cancers they have been studied a lot in ovarian cancer, but currently they're not very effective by themselves. So there's a number of different clinical trials looking at these immunotherapy drugs with combinations of other drugs to get them to work better. And there are a number of clinical trials looking at different types of drugs to help those work better.

There's a newer medication that is a type of chemotherapy but it's engineered in a way where it's very specific to the patient's cancer. So it's given through the IV. It actually skips most of the normal tissue and it's targeted specifically to the cancer cell so we're able to maximize the cancer killing effect while minimizing the side effects and the toxicity and that's a lot of where our newer drugs are moving a lot of the new clinical trial drugs that are coming through the pipeline are much more specific and targeted so hopefully we'll have a lot more options in the future.

Robert DeBernardo, MD:

In addition to that, we're moving into some very sophisticated immunotherapy. So instead of these drugs that you see advertised on TV that kind of upregulate the immune system to help identify we're looking at engineering people's immune cells, teach them about the cancer and give them back. We have a clinical trial that's ongoing with that which is extremely promising and hopeful.

In addition in certain circumstances another surgery can be helpful. Radiation in certain circumstances. So I think, you know, what I was taught if the cancer doesn't behave why should we? So we have lots of options and if somebody is listening to this podcast and they have a recurrent ovarian cancer, I think it pays to go out and see somebody like here at the clinic where we just see a ton of this cancer. The more and more recurrences we have, the more complicated it becomes and so to get more and more and better options I think seeing somebody that has a wealth of experience and dealing with this disease because people can live with years and years and years with this disease with multiple recurrences. But you don't want to just keep doing the same thing again and again like taxol and carbo forever and ever. There's all kinds of great options now.

Erica Newlin, MD:

Mm-hmm. For sure. And for people who have completed treatment for their ovarian cancer what should they expect surveillance to look like?

Robert DeBernardo, MD:

Well, I think it's a little different for everybody but I think most of us are going to see those patients back every three to four months for a certain period of time of year, two three and then sort of space things out from there. The surveillance visits are looking not just for cancer recurrence, but honestly there's a lot of survivorship stuff that goes on. I mean, people even when you're 75 years old, if you have a life-threatening cancer I mean it changes you.

And so we want people to get re-engaged with life, heal psychologically as well as physically. There are some longer term consequences of the chemo and the surgery which we also work with. So that ongoing follow up is I know a big part of what I like about taking care of these folks because it's not just surgery. And "Oh, your cancer is gone. I'll see you whenever." I mean, these are people that we get to know for years.

Erica Newlin, MD:

Mm-hmm. Great. And we'll have an episode later in the season specifically devoted to survivorship concerns.

Robert DeBernardo, MD:

Great.

Erica Newlin, MD:

What would you recommend or say to someone newly diagnosed with ovarian cancer?

Robert DeBernardo, MD:

The bottom line it's not a great disease to have, but there's treatment. We can get, I would say 95% of patients with an advanced ovary cancer, we can get into remission. So as much as it's a horrible thing to have to deal with, and it's not easy there's light at the end of the tunnel. So I think it's, you know, between surgery and chemo it's about four to five months. Then you get your life back and you get healthy, and you're in remission. And then you can go and live a full life. And most of our patients can.

Erica Newlin, MD:

Mm-hmm.

Robert DeBernardo, MD:

Even if their cancer recurs down the line, you know, maybe we have two three years of being cancer free, then we're dealing with it again.

Michelle Kuznicki, MD:

Yeah, I would add to that as Dr. DeBernardo said these are relationships that we have with our patients over years and years and it's really important that the patient feels comfortable with their oncologist and feels like, you know, they're really getting the best treatment and they're being told all of the options. So if something doesn't seem right, if they're not comfortable with that particular person, you know, we send people for second opinions all the time because it's really important that the patient feels like they're getting the best care and they're comfortable 'cause that's going to be your person for a while.

Erica Newlin, MD:

Well, thank you both so much. It was so great to talk to you.

Robert DeBernardo, MD:

Thank you for having us.

Michelle Kuznicki, MD:

Yeah, thanks. Thanks for having us.

Erica Newlin, MD:

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.