The May 10 issue of JAMA had a very interesting article titled “Evolving approaches in research and care for ovarian cancers”. This was a report from the National Academy of Sciences, Engineering and Medicine. It was congressionally mandated and sponsored by the CDC. (Our tax dollars fund this.) Approximately 22,280 women are diagnosed with ovarian cancer in the United States each year, 60% are classified as advanced stage and the overall 5-year survival for these women is 28%.The report emphasizes the fact that most ovarian cancers do not arise in the ovary itself. Instead, the most common and aggressive form of ovarian cancer is now thought to arise in the distal end (the portion furthest from the uterus) of the fallopian tube. There are also multiple forms of ovarian cancer. The most aggressive is high grade serous carcinoma called HGSC. There are other forms of ovarian cancer termed endometrioid, clear-cell and low-grade serous cancers and they probably arise from different sites and cells of origin, including ovarian cysts and endometriosis.
Until recently the clinicians and researchers have combined these various subtypes of ovarian cancers into one disease and the committee emphasizes that they should not. They also reported that to date screenings with the blood test CA 125 and transvaginal ultrasound have not been able to reliably detect ovarian cancer at an early stage. They cite the largest and most recent screening trial from the United Kingdom which involved 202,638 women. The researchers in that study used an algorithm to assess increases in CA 125 levels which then served as a trigger for performing transvaginal ultrasound. As a result, there were a few less unnecessary operations for in doubly screened woman compared to women who had ultrasound alone and the disease was found at a somewhat earlier stage. There was a 15% relative reduction in mortality in the group that had the combined screening and an 11% in the group that had ultrasound only, but this was not considered a significant difference. They calculated that approximately 640 women would need to be screened annually for nearly 14 years to prevent one death from ovarian cancer. Based on this result, the committee did not recommend that this type of screening be done routinely here in the US.
They did suggest that researchers try to find other strategies and look for other specific biomarkers and ways to determine not only whether a cancer has developed but also to delineate its type. (As if we didn’t know this… most every medical report and recommendation will end with a “more research is needed”!) They also suggested new approaches to protect high-risk women from ovarian cancer. For example, when hysterectomy is done, the removal of the tubes rather than the ovaries may help prevent future ovarian cancer. Clearly current therapy, especially for late stage cancer is not sufficient. In the future immunologic and molecularly driven approaches specific to the different ovarian cancer subtypes may lead to better results, longer lifespans and perhaps even cures.