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Cancer Program
report
Focus on Ovarian Cancer
Introduction
from the Chairman
Magee-Womens Hospital of UPMC continues its commitment to provide
comprehensive cancer care for its patients through a multidisciplinary approach.
State-of-the-art services provide the highest level in prevention, diagnosis,
and treatment. The physician and associated health care team work with the
patients and their families to develop personalized treatment plans to
customize care.
Physician specialists include breast and gynecologic oncologists, urologists,
gastroenterologists, surgical and medical oncologists, radiation oncologists,
behavioral health professionals, plastic and reconstructive surgeons, pathologists,
geneticists, radiologists, palliative care specialists, and melanoma specialists.
Other health care professionals include nursing services, pharmacists, dietitians,
social workers, sonographers, and technologists specializing in women’s cancers.
Support groups, varied educational activities, a patient resource room,
and Internet access to the Magee website are available. Magee, Magee-Womens
Research Institute, and the University of Pittsburgh Cancer Institute, an NCIdesignated Comprehensive Cancer Center, offer the most current therapies
and clinical trials. The Magee-Womens High Risk Breast Cancer and Ovarian
Cancer Programs provide women with a thorough assessment of their individual
risks, along with risk-reduction and surveillance strategies. A multidisciplinary
team consisting of medical staff and allied health professionals meets weekly for
a breast cancer conference and a separate gynecologic oncology Tumor Board
Conference to discuss patient evaluations, both for prospective and continuing
care, and plans for future care of selected patients with malignancies.
The Cancer Committee provides leadership and guidance to the cancer
program, ensuring that the highest quality of health care continues to be
provided for its patients. It also monitors and coordinates all cancer-related
activities. The committee meets bimonthly and consists of representatives from
each department involved in cancer management and care. The 2008-2009
Cancer Program Report describes the accomplishments and commitment to
excellence that the cancer program maintains at Magee.
This year, we decided to focus our annual report on ovarian cancer
and highlight key program accomplishments supporting ovarian
cancer patients.
Paniti Sukumvanich, MD
Chairman, Cancer Committee
Program INNOVATIONS
Novel Chemotherapy
Treatment to Improve
Patient Outcomes –
Hyperthermic Intraperitoneal Chemotherapy
(HIPEC)
Magee Womens Cancer
Program remains at the
forefront of patient care
and state-of-the-art
technology and treatment.
Through its commitment
to clinical innovations
and quality initiatives,
Magee’s cancer program
continues to expand its
capabilities in diagnosing
and treating cancer, as
well as managing
patient survival.
Gynecologic oncologists are combining
surgical intervention with concentrated
chemotherapy and hyperthermia to
improve prognosis for patients with
metastatic ovarian tumors. Unlike
conventional chemotherapy, which
when administered orally or intravenously, becomes diluted in the blood
stream, hyperthermic intraperitoneal
chemotherapy (HIPEC) bathes the
affected cancerous region with a high
concentration of heated chemotherapy,
with minimal to no exposure to the
rest of the body. The synergistic effect
of cytoreductive surgery, chemotherapy,
and hyperthermia offers an attractive
treatment alternative for the ideal patient.
After surgery to remove as much of
the tumor as possible, the abdomen is
closed off. Inflow and outflow tubes are
placed through the abdominal walls
and heated chemotherapy drugs are
circulated through the abdominal
cavity for 90 to 120 minutes. The lining
of the abdominal cavity acts as a barrier
to drug absorption into the blood stream,
so that higher concentrations of drugs
can be delivered directly to the tumor
site safely. Recirculating the fluid
through the abdominal cavity and
manually moving the patient during
the procedure assures even distribution
of the drug and heat throughout the
cavity. At the end of the procedure,
the drug is flushed out to avoid
further absorption.
Studies have shown that women
with recurrent ovarian carcinoma who
undergo HIPEC treatment tolerate
this procedure well with acceptable
morbidity. The largest series to date has
suggested that the time to progression
after HIPEC is 10 months, with
an overall survival in this group of
31 months.
A Case Study: Intraperitoneal
Chemotherapy
Patient profile: A 45-year-old female
presented to her primary care provider
with complaints of fullness in her
abdomen, loss of appetite, and abdominal
and pelvic pressure. During a physical
examination, a potential abdominal
mass was identified. CT imaging of
the abdomen and pelvis confirmed a
6 cm mass on the left ovary and a
small amount of fluid in the abdomen
and pelvis.
The patient’s primary care provider
referred her to the Magee-Womens
Gynecologic Oncology Program of
UPMC Cancer Centers for a possible
surgical intervention. After being seen
and evaluated by a gynecologic oncologist, she was scheduled for further
testing, including preoperative
colonoscopy, chest x-ray, and serum
tumor markers, to determine the
best options for treatment. Testing
revealed that the CA-125 was elevated
to 257 U/ml and the CEA, CA 19-9
were normal.
After further review of her case, the
patient’s gynecologic oncologist determined that the patient was a good
candidate for surgery. During the
procedure, part of her colon that was
in the pelvis was removed, along with
her uterus, ovaries, fallopian tubes,
and the pelvic mass. Her omentum,
which was noted to be infiltrated with
metastatic ovarian cancer, was removed,
along with enlarged pelvic and paraaortic lymph nodes. The patient’s
large bowel was reconnected, and
the surgeon placed an intraperitoneal
PORT-A-CATH®.
1
PROGRAM INNOVATIONS continued
The patient was in the hospital for six
days and was discharged without any
significant postoperative complications.
The chemotherapy plan included a
combination of intravenous (IV)
chemotherapy and intraperitoneal (IP)
chemotherapy. The schedule included
IV paclitaxel on day one, IP cisplatin
on day two, and then IP paclitaxel on
day eight. This schedule was repeated
six times through completion of therapy.
Prior to the start of the first course of
chemotherapy, the patient’s CA-125
levels dropped to 115 U/ml. The patient
continued to have her CA-125 monitored before the start of each cycle of
chemotherapy. Her CA-125 rapidly
declined to eight by the third cycle of
therapy. The patient’s fourth cycle of
chemotherapy was delayed due to the
development of nausea, fatigue, and a
low white blood cell count, requiring
the addition of IV fluids and medications to keep her white blood cell count
high enough for chemotherapy.
Although the patient felt slightly
fatigued and had mild numbness and
tingling in her hands and feet, at the
completion of IV and IP chemotherapy
treatment, she had no significant
complications. The patient’s IP port
was removed in the operating room
approximately four weeks after completion of chemotherapy.
Concerned about recurrence of her
ovarian cancer, the patient discussed
additional therapeutic options with her
gynecologic oncologist, including additional chemotherapy with monthly
treatments of paclitaxel; enrollment in
a clinical trial evaluating 12 months of
paclitaxel compared to 12 months of
paclitaxel poliglumex to no further
therapy; or observation.
After considering her options, the
patient chose to be enrolled on Gynecologic Oncology Group protocol 212
where she received 12 additional treatments of paclitaxel. During therapy she
received all treatment on schedule, but
had worsening of the numbness and
tingling in her hands and feet. As part
of the clinical trial, the patient had CT
scans every three months and monthly
CA-125 values drawn. Her CA-125
values returned to normal with a
highest reported value of 15.
The patient was then followed by the
Magee-Womens Gynecologic Oncology Program and her surgeon every
three months for the first 24-months,
and was seen yearly by her primary care
provider. At the 24-month visit, the
patient had a slight elevation of her
CA-125 to 37. As follow-up, a repeat
CA-125 analysis and a CT scan were
performed a month later. The CA-125
was 52, and her CT scan showed a 4
cm left pelvic mass.
The patient underwent a second surgery
for removal of the pelvic mass, and
during surgery was treated with hyperthermic chemotherapy using cisplatin.
Postoperatively she was hospitalized
for 11 days. After discharge she was
2
treated with a combination of
chemotherapy of carboplatin and
gemcitabine for six treatments. At
the end of treatment, her CA-125
was 12, and her CT scan showed no
evidence of cancer. The patient is now
in her second remission four months
after completion of her second course
of chemotherapy.
RoboticTechnology
Enhances a Suite of
Surgical Procedures
The Division of Gynecologic Oncology
at Magee-Womens Hospital of UPMC,
a leader in the use of minimally invasive
surgery to manage gynecologic cancers,
is using robotic technology to enhance
the surgical treatment of endometrial
carcinoma, isolated pelvic masses, and
cervical carcinoma. Robotic surgical
technology offers enhanced visualization
and dexterity that conventional minimally
invasive surgery (MIS), performed
using two-dimensional, long-shafted
instruments, does not provide. Studies
have shown that robotic surgery outcomes are consistent with standard
MIS. With recovery times reduced,
patients with malignant cancer can start
follow-up chemotherapy or radiation
therapy almost immediately, giving the
drugs a chance to work before the
tumor potentially returns.
Patient and Family-Centered Care Initiatives
Patient Navigator Program
In January 2008, as a result of the
Oncology Patient and Family-Centered
Care Initiative, an Oncology Patient
Navigator Program was initiated with
one year of funding thanks to support
from the Susan G. Komen for the
Cure®, Pittsburgh. Subsequently
the program has grown with additional
funding from the Magee Volunteer
Service Board.
Through the program, patient
navigators are available to provide
individualized assistance to patients,
family, and caregivers throughout their
health care experience. Their mission
is to help guide the patient through
their cancer diagnosis and treatment,
answering questions and providing
information about available resources
to ensure a comfortable experience
for the patient. Since its inception,
the patient navigators have interacted
with over 1,500 patients.
“LiveWell”
Survivorship Program
Patient advisors, as part of the Patient
and Family-Centered Care Initiative,
have assisted the Magee-Womens
Cancer Program in developing the
“LiveWell” Cancer Survivorship
Program in 2009 along with a multidisciplinary team of physicians, nurses,
social workers, navigators, and educators. Set to be fully implemented in
2010, the program has been introduced
to cancer survivors at Magee through a
few key programs:
Cancer Survivorship Workshop
Held in September 2009, nearly 300
cancer survivors and family attended
the workshop, which focused on issues
relevant to survivorship, including
genetics, nutrition, surveillance, recurrence, research, and a panel of breast
and gynecologic cancer survivors
telling their stories of survival. In
addition, survivors completed a
program assessment, which is being
used to develop the full survivorship
program for 2010.
Cancer Survivors Day
Planned by a multidisciplinary committee, this program has become a tradition at Magee. The celebration of
survivorship includes an uplifting program with a welcome from one of the
oncology physicians, along with music
and food. More than 250 survivors
and their families, physicians, and
other care providers from Magee
attend each year.
3
Advocacy, Community Outreach, and Education
Part of the mission of Magee-Womens
Hospital of UPMC is to raise awareness
and offer support to cancer patients,
their families, and friends through
advocacy, education, and community
events. The 2008 ovarian cancer-focused
highlights include:
Community Education
Advocacy and Awareness
• Research Updates
Throughout the year, health care
professionals have participated in
numerous professional presentations
and community events both locally
and nationally.
• Cancer Risk Assessment
Walk to Break the Silence on
Ovarian Cancer
Magee was the presenting sponsor of
the National Ovarian Cancer Coalition-Pittsburgh Division’s annual Walk
to Break the Silence on Ovarian Cancer,
which takes place in September/October
each year. Many of Magee’s employees
and patients participated in this event.
Support Programs
Oncology social workers provide
counseling and support to patients
and their families, and facilitate group
support meetings and peer support
programs focused on ovarian cancer
patients.
• Ovarian Cancer Volunteer Program
• Picking Up the Pieces: a peer
support program sponsored by the
National Ovarian Cancer Coalition
(NOCC) in collaboration with Magee.
Ovarian Cancer Patient Care Fund
Through a generous donation from the
National Ovarian Cancer Coalition, an
ovarian cancer patient care fund was
established in 2008 to provide financial
assistance to ovarian cancer patients.
The fund is administered by the
Oncology Patient Navigators.
4
Magee experts presented a variety of
community programs throughout
2008-2009. Program topics included:
• Living with Cancer
• Clinical Innovations
Ovarian Cancer Education Series
The Ovarian Cancer Education Series
was initiated in 2006 in partnership
with the National Ovarian Cancer
Coalition (NOCC) and consists of
monthly lectures designed for all individuals seeking up-to-date information
about ovarian cancer: cancer survivors,
women recently diagnosed with the
illness, or women and their family
members concerned about the disease.
Continuing Medical
Education
Magee specialists presented at a
variety of professional education venues
regionally, nationally, and internationally
in 2008. Our experts continue to publish research, clinical care and outcome
articles, and abstracts in national and
international peer reviewed journals.
Tumor Board Conference
The Division of Gynecologic Oncology
sponsors a weekly multidisciplinary
Tumor Board Conference which
focuses on patient management issues
and current trends in gynecologic
oncology. It is attended by individuals
within the subspecialties of gynecologic
oncology, medical oncology, radiation
oncology, radiology, pathology, patient
care services, and social work. Clinical
dilemmas or controversial and unusual
patient cases are selected by the attending staff, presented by the senior resident, and discussed by the participants.
Radiographic and pathologic findings
are correlated with the clinical findings.
Rationale for an approach to the clinical
problem is discussed by the attendees.
At the end of each presentation, senior
residents, in conjunction with the
attending gynecologist, are asked to
formulate and explain their management
strategies to the group. This conference
allows discussion of different approaches
to the problems encountered in oncology. The meeting also provides the
opportunity for possible recruitment
of patients within research protocols.
The goal of the program
is to provide information
to women and their
loved ones to help
understand their illness.
Research
Magee physicians and researchers remain
on the cutting edge of discovering new
treatments with promising outlooks for
patients. Magee-Womens Research
Institute (MWRI) works in collaboration
with the University of Pittsburgh
Cancer Institute (UPCI) to investigate
cancers that affect primarily women,
including breast, ovarian, uterine, and
cervical cancers. Magee and UPCI have
a joint program in care and research
relevant to breast cancer, and Magee
and MWRI have formed the Jennie K.
Scaife Ovarian Cancer Center of
Excellence. Basic and clinical studies in
progress include clinical investigation,
mechanistic studies, and assessment of
the psychosocial and behavioral impact
of these diseases.
ClinicalTrials for Patients
with Hereditary Breast and
Ovarian Cancers
UPCI will be the primary site for
a clinical trial of ABT-888, a drug
previously proven in combination
treatments to improve chemotherapy’s
effectiveness by lowering cancer cells’
resistance to treatment. This trial will,
for the first time, examine ABT-888 as
a single agent for patients with cancers
related to BRCA 1 or 2 genetic mutations, which predispose patients to
breast and ovarian cancers.
cells in patients with BRCA mutations
are particularly reliant on the mechanism of DNA repair that is inhibited
by PARP.
In previous trials in which ABT-888
was used as a combination treatment,
it appeared to inhibit PARP, making
cancer cells more sensitive to
chemotherapy. The hope with this
trial is that patients with BRCA
mutations or certain other breast
or ovarian cancers may respond to
ABT-888 as a single agent.
This drug also is intriguing because
breast cancer patients with BRCA
mutations, who have exhausted all
other therapeutic options, may have
an additional treatment option. Other
trials also have suggested that ABT-888
also may have fewer side effects than
many other therapies.
The study is part of a National Cancer
Institute (NCI)-funded initiative to
develop new therapies to treat cancer
more effectively. The program at
UPCI is one of 15 in the country.
Early-phase clinical trials are the first
step for all new therapeutics, and they
are designed to evaluate the safety and
dosing of novel therapies that have
shown promise in earlier animal and
preclinical studies.
According to the study’s principal
investigator, Shannon Puhalla, MD,
assistant professor at the University of
Pittsburgh School of Medicine and
breast oncologist at Magee-Womens
Cancer Program of UPMC Cancer
Centers, ABT-888 targets the polymerase (PARP) family of enzymes
responsible for a wide variety of cellular
processes in cancer cells. Cancer cells
have been shown to have increased
levels of PARP, which is believed to
cause resistance to chemotherapies
and other cancer treatments. Tumor
5
RESEARCH continued
Ovarian Cancer ClinicalTrials
Principal
Investigator
Sponsor
Protocol Title
Ovarian Epithelial Cancer
Phase I
Kristin Zorn, MD
Sanofi-AventisOX-06-009
Phase I dose-escalation parallel study of intravenous docetaxel/intraperitoneal oxaliplatin and intraperitoneal docetaxel/intravenous oxaliplatin in platinum-sensitive and
platinum-resistant recurrent ovarian, primary peritoneal, and fallopian tube cancer
Phase II
Thomas
Krivak, MD
Genentech07-081
A Phase II, multicenter, randomized, blinded, placebo-controlled trial of carboplatin
and gemcitabine plus bevacizumab in patients with platinum-sensitive recurrent
ovary, primary peritoneal, or fallopian tube carcinoma
Robert P.
Edwards, MD
GOG 170N
A Phase II evaluation of a urokinase-derived peptide (A6) (IND# 64,298) in the
treatment of persistent or recurrent epithelial ovarian, fallopian tube, or primary
peritoneal carcinoma (170 series)
Kristin Zorn, MD
Novartis/
GenentechRAD-BEV
Phase II study of RAD001 and bevacizumab in recurrent ovarian, peritoneal,
and fallopian tube cancer. An investigator-initiated, single-institution trial at
Magee-Womens Hospital of UPMC
Phase III
Joseph P.
Kelley III, MD
GOG 212
A randomized, Phase III trial of maintenance chemotherapy comparing 12 monthly
cycles of single agent paclitaxel or XYOTAXTM (CT-2103) (IND 70177) vs. no
treatment until documented relapse in women with advanced ovarian or primary
peritoneal cancer who achieved a complete clinical response to primary
platinum/taxane chemotherapy (NCI Version 01 27 05) (GOC 05-004)
Robert P.
Edwards, MD
GOG 252
A Phase III clinical trial of bevacizumab with IV versus IP chemotherapy in ovarian,
fallopian tube, and primary peritoneal carcinoma NCI-supplied agent(s):
bevacizumab (NSC#704865, IND #7921) NCI Version 6/12/09
Robert P.
Edwards, MD
MorphoteckMORab003-003
A randomized, double-blind, placebo-controlled, Phase III study to assess the
efficacy and safety of weekly farletuzumab (MORAb-003) in combination with
carboplatin and taxane in subjects with platinum-sensitive ovarian cancer in first relapse
Robert P.
Edwards, MD
MorphoteckMORab003-004
A randomized, double-blind, placebo-controlled, Phase III study to assess the efficacy and safety of weekly farletuzumab (MORAb-003) in combination with carboplatin and taxane in subjects with platinum-sensitive ovarian cancer in first relapse
Prospective/Retrospective Study
Francesmary
Modugno, PhD
6
Novel risk factors and potential early detection markers for ovarian cancer HOPE
(Hormones and Ovarian Cancer Prediction)
RESEARCH continued
Principal
Investigator
Sponsor
Protocol Title
Ovarian Low Malignant Potential Tumor
Phase II
Robert P.
Edwards, MD
GOC 06-03
A single-arm open label, Phase II study to assess the safety and efficacy of the trifunctional
antibody catumaxomab (anti-EpCAM x anti-CD3) administered intraperitoneally in
ovarian cancer patients with recurrent symptomatic malignant ascities
Non-Treatment (Specimen/High Risk)
Robert P.
Edwards, MD
GOG 136
Acquisition of human gynecologic specimens to be used in studying the causes,
diagnosis, prevention, and treatment of cancer
Thomas
Krivak, MD
DOD-GynOnc# 04-124
Tissue and data acquisition activity for the study of gynecologic disease as part of the
gynecologic disease program
Robert P.
Edwards, MD
Precision
Therap.-PT- 301
A non-Interventional prospective study of the accuracy of the Precision
Therapeutics, Inc. Chemoresponse Assay in patients with recurrent epithelial
ovarian, peritoneal, or fallopian tube cancer
Robert P.
Edwards, MD
Scaife Foundation-Gyn-Onc
22-096
Prognostic marker: acquisition of blood samples and tissue for research purposes
Gyn-Onc#
23-071
Magee-Womens Hospital of UPMC Women's Cancer and Cancer-Like
Disorders Registry
7
2008 Site Specific Analysis
Ovarian Cancer
FIGURE 1: 2008 GYN PRIMARY SITE DISTRIBUTION
Ovarian cancer accounts for approximately 3% of all cancers
in women. It ranks second in the nation among gynecologic
cancers, following cancer of the uterine corpus. An estimated
21,650 new cases are expected in the U.S. in 2008. During
1987-2004, ovarian cancer incidence declined at a rate of 0.9%
per year. A woman’s lifetime risk of developing invasive
ovarian cancer is one in 71.
Corpus Uteri - 328
Ovary - 153
Cervix Uteri - 84
Vulva - 80
Fallopian Tube - 21
In 2008, ovarian cancer was the second most common gynecologic cancer site diagnosed and treated at Magee-Womens
Hospital of UPMC, with a total of 153 cases. Total analytic
(cases first course diagnosed and or treated at this facility)
ovarian cancer cases were 134 and total nonanalytic (cases first
course diagnosed and treated at an outside facility) were 19.
[Table 1] [Figure 1]
TABLE 1
Primary
Site
Total
Percent
Class of Case
Analytical
Non
Analytical
Corpus
Uteri
328
46.9%
313
15
Ovary
153
21.9%
134
19
Cervix
Uteri
84
12.0%
76
8
Vulva
80
11.4%
74
6
Fallopian
Tube
21
3.0%
18
3
Peritoneal
20
2.9%
18
2
Vagina
14
2.0%
12
2
700
100.0%
645
55
Data Source: Magee-Womens Hospital Cancer Registry
8
Peritoneal - 20
Vagina -14
Data Source: Magee - Womens Hospital Cancer Registry
2008 Geographic Distribution by
County and State
As a large referral center, Magee provides services to many
western Pennsylvania counties [Table 2] and surrounding
states [Table 3]. In 2008, the total gynecologic cancer patient
population in Allegheny County equaled 41.7% and the
ovarian cancer patient population equaled 38.6%.
The out-of-county patient population was 51.7% for
GYN cases in Westmoreland County, Fayette County,
Butler County, and Washington County having the largest
number of referring patients. Out-of-state patient population
was 6.6%. The out-of-county patient population was 51.6%
for ovarian cases with Westmoreland County, Washington
County, Fayette County, and Beaver County having the
largest number of referring patients. The out-of-state
patient population was 9.8%.
2008 SITE SPECIFIC continued
TABLE 2: 2008 SUMMARY BY STATE AND COUNTY — PENNSYLVANIA
GYN
Cases
Total #
GYN
Cases
Total %
Ovary
Cases
Total #
Ovary
Cases
Total %
GYN
Cases
Total #
GYN
Cases
Total %
Ovary
Cases
Total #
Ovary
Cases
Total %
Allegheny
292
41.7%
59
38.6%
Jefferson
8
1.1%
2
1.3%
Westmoreland
75
10.7%
13
8.5%
Somerset
6
0.9%
1
0.7%
Fayette
39
5.6%
7
4.6%
Greene
5
0.7%
0
0.0%
Butler
30
4.3%
5
3.3%
Indiana
5
0.7%
0
0.0%
Washington
29
4.1%
12
7.8%
McKean
5
0.7%
3
2.0%
Erie
25
3.6%
6
3.9%
Venango
4
0.6%
1
0.7%
Beaver
23
3.3%
7
4.6%
Bedford
3
0.4%
0
0.0%
Mercer
23
3.3%
6
3.9%
Cameron
3
0.4%
0
0.0%
Cambria
18
2.6%
4
2.6%
Warren
3
0.4%
0
0.0%
Lawrence
12
1.7%
1
0.7%
Centre
2
0.3%
1
0.7%
Blair
12
1.7%
6
3.9%
Clarion
2
0.3%
0
0.0%
Armstrong
9
1.3%
1
0.7%
Elk
2
0.3%
0
0.0%
Clearfield
9
1.3%
1
0.7%
Huntington
1
0.1%
1
0.7%
Crawford
8
1.1%
1
0.7%
Lycoming
1
0.1%
0
0.0%
654
93.4%
138
90.2%
County
Total cases PA counties gyn cases
Total cases PA counties ovarian cases
County
9
2008 SITE SPECIFIC continued
TABLE 3: OUT OF STATE
2005 Incidence Comparison
United States-Pennsylvania-Allegheny
County-Magee-Womens Hospital
GYN
Cases
Total #
GYN
Cases
Total %
Ovary
Cases
Total #
Ovary
Cases
Total %
Florida
2
0.3%
1
0.7%
Indiana
1
0.1%
1
0.7%
Primary Peritoneal Cancers
Missouri
1
0.1%
0
0.0%
2006 Primary Peritoneal Cancer (Female)
Magee-Womens Hospital – United States – Pennsylvania
New York
5
0.7%
2
1.3%
Ohio
13
1.9%
4
2.6%
Tennessee
1
0.1%
1
0.7%
Texas
1
0.1%
1
0.7%
West Virginia
22
3.1%
5
3.3%
Total
46
6.6%
15
9.8%
Total PA
counties and
out of state
700
100.0%
153
100.0%
State
In 2005, there were 19,842 cases of ovarian cancer in the
US, 1,134 cases of in PA, 130 cases in Allegheny County,
and 131 cases at Magee. [Figure 2]
In 2006, there were 705 cases of primary peritoneal cancer
or extra-ovarian cancer in the United States, 46 cases in
Pennsylvania, and 18 cases at Magee. In primary peritoneal
cancer, only the surface of the ovary is involved with the
majority of the tumor in the peritoneal cavity. The clinical
presentation, surgery, treatment, and prognosis are
the same as those of ovarian cancer. [Table 4]
FIGURE 2: 2007 GEOGRAPHIC BREAKDOWN OUTSIDE STATES
Data Sources: Magee-Women’s Hospital Cancer Registry [Table 3].
Commonwealth of Pennsylvania Department of Health. Bureau of Health
Statistics and Research, Harrisburg, PA: September 2009 [Figure 2].
100,000
U.S. Cancer Statistics Working Group. United States Cancer Statistics:
1999-2005 Incidence and Mortality Web-based Report. Atlanta (GA):
Department of Health and Human Services, Centers for Disease Control
and Prevention, and National Cancer Institute: 2009 [Figure 2].
10,000
1,000
100
10
1
Total Cases
10
United States
PA
Allegheny
County
Magee-Womens
Hospital
19,842
1,134
130
131
2008 SITE SPECIFIC continued
TABLE 4
FIGURE 3: 2006 HYSTOLOGY COMPARISON US PA MWH
100%
Primary Peritoneal Cancer 2006 Comparison
US vs. PA vs. MWH
90%
US
PA
MWH
705
46
18
80%
70%
Data Source: NCDB, Commission on Cancer, ACoS. Benchmark Reports, v9.0
60%
Histology
50%
2006 Histology Comparison – Ovarian Cancer
Magee-Womens Hospital – United States – Pennsylvania
40%
30%
Primary ovarian tumors can be divided into three groups based
on cell origin. Epithelial carcinomas are the most common
and account for approximately 90% of all ovarian cancers.
Sex-cord stromal tumors and germ cell tumors are relatively
uncommon. Metastatic, pseudoneoplastic, or uncertain
behavior, is a fourth group.
According to the American Joint Committee on Cancer
(AJCC), all epithelial ovarian tumors should be subdivided
as presented by the World Health Organization (WHO) as
follows: serous tumors, mucinous tumors, endometrioid
tumors, clear cell tumors, Brenner, undifferentiated tumors,
and unclassified tumors. Histologic evaluation is an important
prognostic factor in that all stages of borderline tumors have
a better prognosis. [Figure 3]
20%
10%
0%
US
PA
MWH
Papillary Serous
Cystadenocarcinoma
21.1%
15.8%
32.4%
Other Specified
Types
18.4%
17.2%
24.5%
Clear Cell Adenocarcinoma, NOS
5.4%
4.9%
10.8%
Endometrioid
Carcinoma
10.1%
11.4%
8.8%
Serous Surface Papillary Carcinoma
8.1%
11.2%
6.9%
Serous Cystadenocarcinoma, NOS
19.8%
21.8%
6.9%
Adenocarcinoma,
NOS
9.4%
8.2%
6.9%
Mucinous
Carcinoma
3.6%
4.4%
2.9%
Carcinoma,
NOS
4.2%
5.2%
0.0%
Data Source: NCDB, Commission on Cancer, ACoS. Benchmark Reports, v9.0
11
2008 SITE SPECIFIC continued
Age
Race
2006 Age Comparison – Ovarian Cancer
Magee-Womens Hospital – United States – Pennsylvania
2006 Race Comparison – Ovarian Cancer
Magee-Womens Hospital – United States – Pennsylvania
About 90% of women who get ovarian cancer are older
than 40 years of age, with the greatest number being 55 years
or older. In women over the age of 45, an ovarian mass has
approximately a 30–40% chance of being malignant. In
women less than 45 years of age, or premenopausal women,
an ovarian mass is more likely to be benign, with malignant
tumors making up less than 15%.
White women have the highest incidence rate for
ovarian cancer. [Figure 5]
Germ cell tumors occur more frequently in patients 20 years
of age or less. Epithelial ovarian tumors are more common
in women of reproductive age and in postmenopausal
women. Within these two groups, malignant epithelial ovarian
carcinomas tend to occur after the age of 60, whereas benign
and low malignant potential or borderline ovarian tumors tend
to occur in the 40–60 year age group. Sex-cord stromal tumors
are most common in women from
40 to 60 years of age. [Figure 4]
FIGURE 4: 2006 AGE COMPARISON US PA MWH
35%
30%
20%
15%
10%
5%
0%
Pedi- 16-29 30-39
atric
40-49 50-59
60-69 70-79
80-89
90+
US
0.8%
2.7%
4.3% 14.3% 25.7% 23.3% 17.8% 10.6% 0.6%
PA
0.3%
1.4%
3.5% 10.1% 23.4% 24.5% 21.5% 14.2% 1.1%
MWH
0.0%
6.9%
2.9%
5.9% 32.4% 17.7% 18.6% 15.7% 0.0%
Data Source: NCDB, Commission on Cancer, ACoS. Benchmark Reports, v9.0
12
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Black
Native
Hispanic American
Asian/
Pacific
Other/
Unknown
Race
White
US
78.6%
8.7%
5.1%
0.2%
3.3%
4.1%
PA
85.8%
10.6%
0.8%
0.0%
0.5%
2.2%
MWH
97.1%
2.9%
0.0%
0.0%
0.0%
0.0%
Data Source: NCDB, Commission on Cancer, ACoS. Benchmark Reports, v9.0
25%
Age
FIGURE 5: 2006 RACE COMPARISON US PA MWH
2008 SITE SPECIFIC continued
Staging
2006 Stage Comparison – Ovarian Cancer
Magee-Womens Hospital – United States – Pennsylvania
Stage is an important prognostic factor. Clinical evaluation,
operative findings, radiology, as well as histopathologic evaluation, are used to determine stage. Hysterectomy and resection
of the ovarian mass start the pathologic staging procedure.
Laparotomy and staging biopsies should be performed of all
suspicious sites, such as the omentum, mesentery, liver,
diaphragm, and pelvic and para-aortic lymph nodes are
required for a complete staging procedure. Pelvic washings
are also required for staging.
A tumor limited to the ovaries is Stage I disease. A tumor
involving one or both ovaries with pelvic extension and/or
implants is Stage II. Stage III is tumor involving one or both
ovaries with microscopically confirmed peritoneal implants
outside the pelvis. Superficial liver metastasis and tumor
limited to the true pelvis but with histologically verified malignant extension to small bowel or omentum is also Stage III.
Stage IV ovarian cancer is a tumor involving one or both
ovaries with distant metastasis including pleural effusion and
positive cytologic test results existing or parenchymal liver
metastasis. Distant site spread is considered to be end stage
disease. Germ cell tumors are most likely to spread to distant
sites while sex-cord stromal tumors stay localized and take
many years to spread to distant sites. [Figure 6]
FIGURE 6: 2006 STAGE COMPARISON US PA MWH
50%
40%
30%
20%
10%
0%
Stage
I
II
US
19.4%
7.7%
IV
Unknown
42.2%
PA
20.7%
MWH
27.5%
III
18.5%
12.2%
7.9%
38.2%
19.4%
13.9%
3.9%
33.3%
20.6%
14.7%
Data Source: NCDB, Commission on Cancer, ACoS. Benchmark Reports, v9.0
13
2008 SITE SPECIFIC continued
FIGURE 7: 2006 1ST COURSE TX
COMPARISON US PA MWH
First Course ofTreatment
2006 First Course Treatment Comparison
Magee-Womens Hospital – United States – Pennsylvania
100%
90%
Treatment options are usually surgery, including total abdominal
hysterectomy, bilateral salpingo-oophorectomy, pelvic and
para-aortic lymph node dissection, and ovarian tumor cytoreduction debulking. This would be followed by a primary
chemotherapy that contains a platinum and a taxane based
compound. Factors affecting treatment choice depends on
the tumor type, stage, age, and co-morbidities of the patient.
Magee-Womens Hospital participates in multiple clinical
trials for ovarian cancer, including nationwide trials from
the Gynecologic Oncology Group (GOG). Magee is the only
parent GOG institution in southwestern Pennsylvania with
the ability to open any national trial being run by the GOG.
Magee is one of the first hospitals in southwestern Pennsylvania
to use intraperitoneal chemotherapy. This treatment involves
infusing cisplatin and paclitaxel directly into the abdomen and
has been shown to improve survival by more than 16 months
over traditional intravenous chemotherapy. This treatment
can only be used in patients with optimal resection of disease.
Magee is also the only hospital in southwestern Pennsylvania
to use a newer treatment called hyperthermic intraoperative
peritoneal chemotherapy (HIPEC) for ovarian cancer. The
chemotherapy is poured into the peritoneal cavity while the
patient is still in surgery at the time of debulking. A major
advantage of such treatment is that chemotherapy can reach
more places in the abdomen while the abdomen is open for
surgery. The chemotherapy is heated to a temperature higher
than the normal body temperature, and is thought to be more
effective in destroying cancer cells.
Intraperitoneal chemotherapy causes fewer side effects
than chemotherapy given intravenously, because of the high
concentrations of chemotherapy solution reaching the blood
stream through IV chemotherapy. [Figure 7]
14
80%
70%
60%
50%
40%
30%
20%
10%
0%
US
PA
MWH
Surg. & Chem
59.7%
60.9%
65.7%
Surg. Only
23.4%
24.6%
16.7%
No 1st Course Rx
5.7%
5.5%
3.9%
Chem. Only
5.7%
6.5%
8.8%
Other Specified
Therapy
5.5%
2.6%
4.9%
Data Source: NCDB, Commission on Cancer, ACoS. Benchmark Reports, v9.0
2008 SITE SPECIFIC continued
FIGURE 8: 2006 SURGICAL PROCEDURE
COMPARISON US PA MWH
Surgery
2006 Surgical Procedure Comparison – Ovarian Cancer
Magee-Womens Hospital – United States – Pennsylvania
100%
All primary ovarian cancers and borderline or low malignant
potential tumors require surgical staging to determine future
treatment. Patients with optimal debulking after surgery have a
better prognosis than those with suboptimal debulking. Optimal
debulking is considered less than one cm of residual tumor.
[Figure 8]
80%
60%
40%
20%
0%
US
PA
MWH
Debulking;
cytoreductive Surg.
29.1%
28.8%
47.1%
Unilateral or bilateral
omentectomy, partial
or total hysterectomy
28.5%
26.9%
16.7%
No surg. to the
primary site
18.0%
18.6%
11.8%
BSO W/
hysterectomy
15.2%
17.3%
14.7%
Unilateral SO; unk
if hysterectomy done
4.2%
3.6%
3.9%
Total removal of
tumor or single
ovary
1.6%
1.9%
2.9%
Surgery, NOS
1.2%
0.3%
1.0%
Pelvic exenteration
1.1%
0.8%
0.0%
Unk if surg.
performed
1.0%
1.9%
2.0%
S-O, NOS
0.1%
0.0%
0.0%
Data Source: NCDB, Commission on Cancer, ACoS. Benchmark Reports, v9.0
15
2008 SITE SPECIFIC continued
Survival
1998-2001 Observed Survival of Ovarian Cancer
Patients by AJCC Stage
Magee-Womens Hospital – United States – Pennsylvania
Ovarian cancer is the fifth most frequent cause of cancer death
in women after lung and bronchus, breast, colorectal, and
pancreatic cancers with an estimated 15,520 deaths in 2008.
Ovarian cancer causes more deaths of any other cancer of the
female reproductive system. Most patients with ovarian cancer
have widespread disease at presentation. As a result, yearly
mortality in ovarian cancer is approximately 65% of the
incidence rate. A woman’s lifetime risk of dying from invasive
ovariancancer is one in 95. [Figure 9]
References
American Cancer Society. Cancer Facts and Figures 2008.
Atlanta: American Cancer Society; 2008.
Commonwealth of Pennsylvania Department of Health.
Bureau of Health Statistics and Research, Harrisburg, PA:
September 2009.
FIGURE 9: 5-YR OBSERVED SURVIVAL 1998 - 2001
US AND NJ, NY, PA AND MWH
American Joint Committee on Cancer. Ovary. In: AJCC Staging
Manual. 6th edition.
100
New York: Springer; 2002: pg. 275-279.
90
U.S. Department of Health and Human Services; National
Institute of Health, National Cancer Institute, Ovarian Cancer,
Baltimore, MD: 2009.
70
PERCENT
http://www.cancer.gov/cancertopics/pdq/treatment/ovarianepithelial/healthprofessional/allpages
80
U.S. Cancer Statistics Working Group. United States Cancer
Statistics: 1999-2005 Incidence and Mortality Web-based
Report. Atlanta (GA): Department of Health and Human
Services, Centers for Disease Control and Prevention;
Washington, DC: National Cancer Institute; 2009.
60
50
40
30
20
10
0
0 Years
1 YEAR
2 YEARS
3 YEARS
US Stage I
100%
98%
95%
93%
4 YEARS
91%
5 YEARS
88%
NJ, NY, PA Stage I
100%
98%
95%
92%
90%
88%
MWH Stage I
100%
98%
95%
92%
92%
89%
US Stage II
100%
92%
86%
81%
75%
71%
NJ, NY, PA Stage II
100%
91%
83%
78%
71%
65%
MWH Stage II
100%
96%
93%
85%
81%
81%
US Stage III
100%
83%
67%
53%
42%
34%
NJ, NY, PA Stage III
100%
81%
64%
50%
41%
34%
MWH Stage III
100%
82%
64%
50%
41%
30%
US Stage IV
100%
63%
45%
32%
24%
19%
NJ, NY, PA Stage IV
100%
57%
40%
29%
21%
16%
MWH Stage IV
100%
68%
41%
20%
14%
12%
Data Source: NCDB, Commission on Cancer, ACoS. Benchmark Reports, v9.0
16
2008 CANCER Committee ROSTER
Paniti Sukumvanich, MD
Chairman
Beverly Gaetano
Medical Social Work
Shannon Puhalla, MD
Medical Oncology
Gretchen Ahrendt, MD
Department of Surgery
Priyanka Gopal
Nutrition Services
Denise Stahl, RN, MSN
Palliative Care Specialist
Anna Ardine-Jones
Nutritional Services
Judy Herstine
Administrator, Women’s
Cancer Services
Susan Stollings, PhD
Sr Clinician, Behavioral
Medicine & Oncology
Ronald Johnson, MD
Department of Surgery
Jules Sumkin, DO
Radiology
Deidre Cleary
Clinical Research Coordinator, Breast
Cancer Research
Joseph Kelley III, MD
Gynecologic Oncology
Winifred Teuteberg, MD
Palliative Care
Jeannine Konzier
Quality Management
Darcy Thull
Cancer Genetics
Karen Cooper, LCSW
Patient Navigation
Kim Marks
Clinical Registry Information Services
Tracy C. Nagy, RN, BSN, MSN
Women’s Cancer Center
Lindsay Corporon, Pharm D
Clinical Pharmacist
Betsy Martinelli
Senior Communications Manager
Sharon Winters
Registry Information Services
David Dabbs, MD
Pathology
Louise Mazur, RHIT, CTR
Tumor Registry
Robert Edward, MD
Gynecologic Oncology Research
Ketul Patel
Vice President, Operations
Mary Ann Aviles, RN
Patient Care Services
Sushil Beriwal, MD
Radiation Oncology
17
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