|
Sample
Case continued
Return
to case history
CASE/
DIAGNOSIS:43-year
old female with recently diagnosed stage IIIB endometrioid adenocarcinoma
of the right ovary
MDExpert
- Assessment and Recommendations
Disclaimer:
This opinion is based solely on my review of those medical records
provided to MDExpert by the treating physician. I have not examined
the patient nor is it my present intent to do so in the future.
Those opinions to be rendered herein are intended for advisory
purposes only. It is within the sole discretion of the treating
physician to determine the course, scope, and extent of treatment.
It is expressly agreed and understood that my review of those
records provided and the rendering of any opinion based upon my
review of those records provided do not create a physician/patient
relationship.
MDEXPERT
TREATMENT RECOMMENDATION AND RATIONALE
This
young woman with stage IIIB ovarian cancer has attained a clinically
defined complete response following standard platinum/paclitaxel
based chemotherapy. While this is gratifying, it is by no means
uncommon in the subgroup of patients with minimal disease following
completion of initial surgery. Her chance of future recurrence
is not small, and probably exceeds 70%. Unfortunately, at the
present time, additional therapy for patients in remission has
not been proven to substantially influence survival. The proposed
clinical trial of 3 vs. 12 months of Taxol is an ongoing GOG/SWOG
study and has been accruing patients since November 1999. No
survival data is available for the over 200 patients who have
been enrolled to date. I believe the rationale behind this study
is sound, and would strongly encourage the patient to participate
in this study.
ADDITIONAL
INFORMATION OR TESTING THAT WILL FACILITATE OR IMPROVE TREATMENT
DECISION-MAKING:
Does
the patient have any significant neuropathy? Taxol, in the doses
used in the study being contemplated, could exacerbate preexisting
neuropathy. If the patient has neuropathy greater than grade
1, I would defer further Taxol.
TREATMENT
ALTERNATIVES AND THE ADVANTAGES OR DISADVANTAGES OF EACH:
The
patient could consider a second look laparotomy, with further
treatment being based on the status of disease noted at surgery.
While this remains a popular option with some gynecologic oncologists,
second look surgeries have yet to be shown to influence survival.
The potential benefit of a second look is that if minimal or microscopic
disease is found further therapy can be given with the knowledge
that cancer is indeed still present. Based upon my experience,
in patients with Stage IIIB tumors who have undergone optimal
cytoreductive surgery, and who have rapid normalization of CA-125
following institution of chemotherapy, the likelihood of detecting
residual disease at second look is probably only about 25%. I
believe a small proportion of these patients can be cured
by additional chemotherapy. Intraperitoneal based treatment as
well as high dose chemotherapy with stem cell support are reasonable
options to explore in this subgroup. Nevertheless, I do not believe
that second look surgery is standard of care anymore, and the
efficacy of high dose chemotherapy or intraperitoneal chemotherapy
in patients with a positive second look have not been proven
to influence cure rates.
Aside
from GOG study 178, I am unaware of any other clinical trials
for patients felt to be in remission following initial chemotherapy
for epithelial ovarian cancer. In the absence of an NIH approved
clinical trial, I would not favor further cytotoxic chemotherapy
in this patient (unless a second look surgery documents the persistence
of disease).
Finally,
this patient should be aware that PET scanning has been touted
as being a more sensitive test that CT scan as a means of detecting
residual ovarian cancer. This opinion is not universally endorsed,
and both false positive and false negative results have been reported.
For this reason, if she should contemplate having a PET scan,
I would favor confirming a positive result surgically, which can
often be done laparoscopically.
ARE
THERE ANY CLINICAL TRIALS THAT YOU ARE AWARE OF, AND WOULD SPECIFICALLY
RECOMMEND FOR THIS PATIENT:
Other
than GOG 178, no.
ADDITIONAL
SPECIFIC QUESTIONS FROM THE PATIENT/PATIENT’S FAMILY:
Please
assess the value for this patient in participating in a study
of maintenance Taxol after having completed 6 cycles of carboplatin-taxol.
This
is a very reasonable study. While toxicity will not be minimal,
I would expect most patients should be able to tolerate Taxol,
in the doses prescribed, with manageable side effects. Quality
of life is important, and it should be emphasized to the patient
that, if she begins maintenance Taxol, she can withdraw from the
study at any point if she feels the risks outweigh the benefits.
SHOULD
THE PATIENT’S SIBLINGS OR CHILDREN BE CONCERNED ABOUT GENETIC
RISK FACTORS:
I
do not believe so. First, the patient has no children. Even
though the patient was diagnosed at an age younger than most women
with ovarian cancer, the family history presented does not suggest
to me that the likelihood of her carrying a BRCA1 or 2 mutation
is much greater than 10%. Accordingly, the risk that her brother
would carry a BRCA mutation would probably be less than 5%, and
his children (if any) would have a similarly small risk.
PROGNOSIS:
Guarded,
but cure is clearly possible in this case. If the disease recurs,
chance of cure diminishes drastically. Odds favor her being alive
5 years from now, though many patients with stage IIIB ovarian
cancer alive at 5 years will unfortunately have or develop recurrent
disease.
By:
Steven Waggoner, M.D.
University
of Chicago Cancer Research Center
Return
to case history
Return
to top of page
See
another case study
|
