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The Mary How Trust Screening programme

Screening programmes are a recognised addition towards "being responsible for your own health". Questions regarding health/lifestyle and family history will be asked. A nurse will carry out the tests listed below. An ultrasound scan on the day of your screening appointment may be undertaken or a subsequent appointment made.

What is involved in the screening programme?

We do not carry out mammograms or cervical smears these should all be arranged by your GP under the NHS national screening programmes.

All results will be forwarded to your GP only, and treated in the strictest confidence. Results will not be given over the telephone.

Each individual screening costs the Trust approximately £70 and donations are invited to help cover this expenditure.

The Mary How Trust for Cancer Prevention
3 Church Street, Storrington, West Sussex RH20 4LA
Telephone: 01903 744899 Fax: 01903 746499
e-mail: mhtscreen@aol.com
JUST TELEPHONE/FAX/E-MAIL FOR AN APPOINTMENT

 

New trial in early recurrence

Chemotherapy for ovarian cancer can be effective, but some patients relapse quickly because their cancer did not respond to the drugs used. It has long been a goal of cancer specialists to tailor therapy to individual patients, but this has proved difficult. Now a new test looks promising and is being tried in patients with ovarian cancer who relapse during or within six months of their initial course of chemotherapy.

The trial involves taking cancer cells and culturing them for a short time with up to 12 different anti-cancer drugs to find which kill the cells most effectively. In some patients, the cells are obtained from ascites (fluid in the abdomen), while in others a biopsy is needed, obtained by keyhole surgery (laparoscopy) or during surgery for other reasons.

Due to the constraints of funding for chemotherapy within the NHS, only some centres are able to take part in the study, including Preston and Guildford. The study also includes other centres in Germany. Dr Ian Cree at the Institute of Ophthalmology is doing the laboratory tests. Interested oncologists are welcome to contact either doctor, but patients can get advice most easily from their oncologist .

Further information on the study is available on the Lancet web-site, http://www.thelancet.com/newlancet/sub/author/menu_NOD7.html

Dr IA Cree
Clinical Senior Lecturer, Department of Pathology, Institute of Ophthalmology, University College London, Bath Street, London EC1V 9EL
Tel: 0171-608 6808/6938
Fax 0171-608 6862

Alan Lamont and Ian Cree
London

 

Ovarian Cancer – An Overview

This piece sets out the different types of ovarian cancer, their characteristics and treatment differences where they exist. It is meant as a resource for readers who remain confused about this complicated issue. However, confining it to two pages means that there may be oversimplification in places.

Ovarian cancer is classified into different types on the basis of its histological appearance – that is, how it looks to the pathologist through the microscope. The majority of ovarian cancers fall within the category of epithelial ovarian cancer. The remaining 10% consist of rare types.

Epithelial ovarian cancer

The greatest clinical challenge among gynaecological cancers. Approximately 6400 new cases are diagnosed annually and this figure is rising. In the UK the overall five-year survival is around 28%. Optimists like me hope this figure is also rising. Three-quarters present with advanced disease, which has spread outside the pelvis.

Within epithelial ovarian cancer (OvCa) there are six subtypes (% frequency in brackets). Each is derived from a different type of tissue in the lower genital tract (also known as the Mullerian tract). However, within invasive cancers there is not a great deal of difference in prognosis for the first three and the distinction is mainly a pathological one.

Serious
This form accounts for around 70% of cases and is therefore the most common type.

Mucinous
This accounts for a further 10%. These tumours have a slightly worse prognosis than serous tumours.

Endometrioid
These tumours (5%) are more likely to be associated with disease in the uterus (womb) and sometimes an ovary is found to be affected when a woman is diagnosed with endometrial cancer.

Clear cell
These tumours (around 3-4%) have a poorer prognosis and tend to behave more aggressively. Pathologists do not usually grade these tumours since, whether they are Grade I, II or III, this tendency exists and grade is not helpful in predicting prognosis.

Borderline tumours
10-15% of ovarian cancers are borderline tumours, also known as tumours of low malignant potential. They tend to remain confined to the ovary for long periods and usually occur in premenopausal women. Implants outside the ovary can arise but there is currently no evidence that the course of this disease is altered by chemotherapy. However, some novel treatments such as matrix metalloproteinase inhibitors may well have a role: the difficulty is establishing a trial in a group of patients with an uncommon disease, as even somebody specialising in the treatment of ovarian cancer will only see a handful of such patients a year. An invasive group has been described and this type may behave more aggressively and ultimately lead to death; the disease course tends to be long over many years.

Treatment of the different types of epithelial cancers is essentially the same. In those fit to receive it the current gold standard is Taxol and a platinum analogue (cisplatin or carboplatin). This is based on the results of two randomised trials conducted in North America and Europe.

Germ cell tumours

Germ cell tumours of the ovary make up 3% of malignant ovarian tumours, so they are rare, just one-tenth as common as germ cell tumours of the testis. Hence advances in treatment have largely developed through treatment of the testicular tumours which are of the same origin – from the germ cells of the ovary – in other words the cells that ultimately become eggs.

Germ cell tumours themselves are divided according to their main cell type; they range from embryonal carcinoma at the most undifferentiated end of the spectrum (in other words very immature cells) via immature teratoma through to mature teratoma. The most common type is a dysgerminoma, accounting for 30-40%. A detailed discussion is not realistic within this space but if you have a germ cell tumour of the ovary then you should be managed within a specialist unit with particular experience. They tend to occur in young women (the majority between 10 and 30 years) and adolescents and if managed correctly usually have a good prognosis

The rare forms include:

Staging

The stage describes the spread of the cancer at the time of diagnosis and this should be established at the initial operation. Such an operation – carried out by a gynaecological oncologist in an ideal world – is known as a staging laparotomy.

The details of staging, which is complex, may be confusing. The table above outlines the basic stages; within each stage patients are divided into A to C, the latter being the highest risk. In Stage I, A denotes confined to the ovary and C that disease has spread outside the ovary or the capsule has ruptured. In Stage III this relates to the amount of disease left at the end of the operation, C being the greatest.

Grade

This is divided into three categories – I (low), II (intermediate) and III (high) – and is a prognostic factor. In other words, patients with low-grade tumours have a better outlook (and some may coexist with their disease for many years) than those with high grade tumour of the same stage. However, this is only one of a number of prognostic factors and cannot be taken in isolation. For example, a grade III Stage IA tumour will usually have a better outlook than a Stage IIIC grade I tumour.

Treatment

Cytoreductive surgery and chemotherapy are the mainstays of treatment but the median survival of around two years has hardly changed in decades. The latest Gynecologic Oncology Group study in the USA, involving Taxol in combination with cisplatin, has shown a wholesale change in survival, with a median to date of 37 months and represents an encouraging leap forward in this disease. This has been confirmed by the Intergroup study which first reported in May 97 with a disease-free survival advantage of 4.5 months, followed last May by an unexpected overall survival advantage of 10 months. Now there are several active agents in the treatment of cancer of the ovary and their use in the initial management of the disease will be clarified in the next 5-10 years.

Surgery

Gynaecological oncology has only become established as a subspecialty of obstetrics and gynaecology within the UK in the past decade or so. In that time the surgical management of ovarian cancer has become refined. Within clinical and particularly medical oncology (as the treatment is very largely confined to chemotherapy) only a small number of consultants declare a special interest.

Known as debulking, surgery aims to reduce the volume of disease as far as possible and should include bilateral salpingo-oophorectomy and total abdominal hysterectomy, omentectomy and, where possible, lymph node biopsy.

Chemotherapy

Current ‘ gold’ standard

Relapse therapy
Depends on treatment-free interval. Might include:

Developments in treatment

Hilary Thomas
Professor of Oncology, Royal Surrey County Hospital and University of Surrey

STAGING
Stage I Confined to ovary: A = within, B = bilateral, C = outside 
Stage II Confined to pelvis: A = within, B = bilateral, C = outside
Stage III Within abdomen: A, B and C refer to volume of disease
Stage IV Outside the abdomen, within either liver or lungs. A = lungs biopsy positive; B = liver


Comments

on Dr Osborne’s Article on “The Latest in intraperitoneal hyperthermia” in Autumn 1998 issue

I hope your readers will find it helpful if I take up the issue of intraperitoneal chemotherapy in conjunction with hyperthermia, as some of them may have been confused by Dr Osborne’s article, which appears to be arguing both for and against this treatment.

It is well proven that tumour cells are more susceptible to destructive measures when heated (hyperthermia), especially in combination with chemo- or radiotherapy. This is well documented in peer-reviewed scientific literature, as is the use of intraperitoneal chemotherapy without hyperthermia. The latter does not seek to replace systemic (intravenous) chemotherapy but has been used and tested, where systemic chemotherapy has either failed or been too toxic.

It is arguable whether drugs such as Carboplatin can be considered as “simple and well tolerated”. All chemotherapy agents are highly toxic in systemically used therapeutic doses. By contrast, intraperitoneal chemotherapy has the great advantage of delivering much smaller amounts of chemotherapy directly to the affected abdominal surfaces, with consequently much diminished whole body toxicity. Even if combined with hyperthermia, this procedure can be quite simple and need be neither “aggressive” nor “cumbersome”, although it has been so in some clinical trials, as in the one mentioned by Dr Osborne, which I take to be a recent study on the intraperitoneal use of Taxol under hyperthermic conditions presented at an ASCO meeting in 1998 by a Mr Orlando et al – but not in Orlando, as reported in his article.

Finally, I would like to comment on the statement that “many oncologists feel that the best treatment for their patients is to offer them access to these [i.e. antibody targeted] trials”. It is arguable whether access to a trial constitutes the best “treatment”, as in a double-blind randomised trial the chances of being in the positive (treatment rather than placebo) arm is 1 in 2-3. I am told that one such UK-based trial requests an exploratory laparotomy before treatment, a very significant trauma for anyone then not receiving any treatment. Also, the trials published so far using monoclonal antibody treatments have not shown any significant advantages and bone marrow suppression from the radio-isotope tagged antibodies has been a dose-limited factor in some. This points to significant radiation-related damage with potentially long-term side-effects.
However, monoclonal antibody treatments in general are potentially very important research and development areas and must be encouraged and pursued, because the future of oncology must grow beyond the rather untargeted and toxic chemotherapy prevailing today.
Dr F Schellander
Liongate Clinic, Kent

Editor's Note: We shall be offering Dr Osborne a chance for a final comment on this topic in our next issue. After that the topic will be closed until more evidence is available. It is clear that opinions, even among experts, are widely different.

 


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