Chemo Ovarian Cancer

[music playing]>> lori casey: just ahead on this edition of being well,oncologist dr. phillip dy will be here to talk about ovarian cancer. this type of canceraccounts for about 3% of cancers among women, but it causes more deaths than any other cancerof the female reproductive system. dr. dy will share a lot of information about preventionand treatment. stay tuned, being well starts right now.[music playing] >> female speaker 1:production of being well is made possible in part by sarah bush lincoln health systems;supporting healthy lifestyles, eating a heart-healthy diet, staying active, managing stress, andregular check-ups are ways of reducing your

health risk. proper health is important toall at sarah bush lincoln health system; information available at sarahbush.org. alpha-care specializingin adult care services that range from those recovering from recent hospitalizations tosomeone attempting to remain independent while coping with a disability, chronic illness,or age related infirmity. alpha-care, compassionate, professional home care. additional fundingby jazzercise of charleston. >> lori casey:thanks for joining us for being well today. i'm so please that dr. phillip dy is herefrom cancer care specialist of central illinois. >> dr. phillip dy:thank you very much for having me. >> lori casey:thanks for coming up; you're down in effingham,

correct?>> dr. phillip dy: yes.>> lori casey: how long have you been down there?>> dr. phillip dy: almost 17 years.>> lori casey: okay, well when we talk to you about topics,you had said, i'd really like to talk about ovarian cancer. why was that an importanttopic? >> dr. phillip dy:the reason why this is important for me and a lot of cancer specialists, is because there'snot a lot of emphasis on cancer of the ovary. we talk about breast cancer very often, lungcancer, prostate cancer, but not ovarian cancer.

and it's the most-- it's the leading causeof gynecological cancer deaths in the country. and we wanted-- i wanted women to know moreabout what it can present with. >> lori casey:okay, so not-- if i understand this right, it's not a lot of women get it but those whodo tend to die from it, is that true? >> dr. phillip dy:unfortunately, yes. >> lori casey:okay, so are rates of it going up in the u.s.? >> dr. phillip dy:it hasn't really changed in the last 10 years; it's almost the same. the-- it's more of we'retrying to diagnosis it earlier. but the rates have been the same in the last 10 years.>> lori casey:

okay.>> dr. phillip dy: but there's not a lot of knowledge about it,though. i mean, and we want this to be more open to the public and more research is beingdone right now. and so we hope that we can improve the outcome even better in the future.>> lori casey: okay. so, what-- who's most at risk in termsof maybe age and then ethnicity and lifestyle? >> dr. phillip dy:the caucasians are and the white race is more prone to develop ovarian cancer compared toblacks, hispanics, and other ethnicities. and we're not so sure why but it's mostlythe white population. and age, of course, is a big risk factor here. the most commonage diagnosis is the median age is 63.

>> lori casey:okay. >> dr. phillip dy:and most commonly, this is a cancer seen in age 70 and above. and so, you seldom hearabout people developing ovarian cancer who are younger than 50, unless you have a geneticdisposition to the cancer. >> lori casey:okay, so what kinds of risk factors can lead to ovarian cancer? or do they not know?>> dr. phillip dy: oh, there are; there are.>> lori casey: it's something to do with the hormones. so,studies have shown that the women who became pregnant the earliest, at the youngest agelike less than 25, and having multiple pregnancies

especially at the younger age, actually protectsyou against ovarian cancer. >> dr. phillip dy:and women, who have never been pregnant or become pregnant at an older age, are at ahigher risk. and it is also funny; studies have shown that women who take oral contraceptivesfor a long time have a 50% lesser chance of developing cancer of the ovaries.>> lori casey: okay, so what is the connection with havingchildren, lots of them, early versus one later in life? what's the connection between thatand the cancer? >> dr. phillip dy:what happens is if a woman becomes pregnant earlier in life and they have several pregnancies,the menstrual cycle is stopped. and so the

hormonal influences are not going on becauseduring that time of pregnancy, there's no hormones.>> lori casey: sure.>> dr. phillip dy: okay, so we feel that there's hormone influencesimilar to breast cancer that occurs in ovarian cancer as well.>> lori casey: which would explain why if you took birthcontrol for a long time, it kind of has the same effect as being pregnant, but reallynot. >> dr. phillip dy:exactly. >> lori casey:so, what are some of the early symptoms that

women should be aware of or are there none?>> dr. phillip dy: you're very right about that, there's reallyno early symptoms for most patients. however, there's a few who are lucky that you can catchit. most of the symptoms from ovarian cancer are mainly due to gastrointestinal or urinarysymptoms, not gynecological. so, a lot of women ignore them. so, for patients who havecancer of the ovaries, most of the time the symptoms will be bloating, abdominal pain,pelvic pain, urinary frequency, or a feeling that every time you eat, you always get fullso fast, that's quite common. and a lot of times, we ignore it because we always thinkits reflux. and so we tell women that they have to be attentive to these things, especiallyif it's new and if it's frequent. and a lot

of people ask me how frequent; if it occursmore than 12 times in a month, these symptoms, they need to bring this to their doctor'sattention and they should not really stop until they get a satisfactory evaluation.>> lori casey: so, why is it-- are they-- do you get moreof those symptoms in the abdominal area and have to deal with more of your stomach orfeel like you may have stomach issues? >> dr. phillip dy:the reason for that is because most of the time when ovarian cancer spreads, unfortunately,it goes to the bowel, it causes fluid build up, and so you're full. and that's the reasonwhy-- so that's why when patients have these symptoms, 70% of the time, it's already advanced.>> lori casey:

so, it's kind of like a-- sort of like pancreaticcancer, you don't know you have it until it's too late. so, really, you know, we've got,you know, pap smears and mammograms to detect breast cancer and things like that, is therereally any early detection method? >> dr. phillip dy:not in ovarian cancer and that's part of the reason why most majority of patients are diagnosedat advanced age. for the average population, the recommendation is not to do any screeningbecause it's not been shown to help. in fact, there was a large trial a few years ago, it'scalled the plco trial, prostate lung colorectal ovarian cancer trial, that did the screeningtest, compared patients who were screened for ovarian cancer with cancer marker, ca125and trans-vaginal ultrasound versus no screening.

guess what happened? no difference in outcomefor cure, no difference in outcome for diagnosing them early and several women who were screenedwere subjected to unnecessary surgery. so, now a days we don't do screening unless there'sa strong family history of ovarian cancer or they have the genetic mutation for brca1or 2. or something called lynch syndrome, wherein they're at high-risk for ovarian cancer,then we do the screening for them. >> lori casey:so, you brought up brca1, that's the breast cancer gene, if you have that are your chancesof getting ovarian cancer increased, too? >> dr. phillip dy:significantly. >> dr. phillip dy:so, let me expand on that if i may.

>> lori casey:sure. >> dr. phillip dy:so, there are two kinds of brca mutation gene and the brca1 was the first one in chromosome17. and if somebody's a carrier for brca1, your odds of developing cancer of the breastis as high as 90% lifetime. and as for developing cancer of the ovary, it's about 35-50% lifetime.and if you are a brca2 mutation carrier, which is not as strong, then the odds of developingovarian cancer is about 15-20% lifetime. so, you can see the risk. now, the ordinary population,normal population, their risk of developing ovarian cancer lifetime is only 1.4%.>> lori casey: versus 50% for brca1. so, you can imagineit's high.

>> lori casey:so, i understand from my reading on the disease that if someone is diagnosed with it, justlike lung cancer, it's staged. can you kind of explain the stages and how you might goabout treating within the different stages? >> dr. phillip dy:yes, with staging, which would go along with a treatment, later on we will discuss aboutsurgery; almost always the staging is after surgery. so, for stage one the outcome's goodand of course, stage four is the worst. for stage one, it means that the cancer is limitedto inside the ovaries. and that's very important because when it's outside the surface of theovary, it's really not stage one, okay? and in stage one, there's one a, b, and c. forstage one a, which is the earliest stage,

the outcome for cure is more than 94%.>> lori casey: i mean, but we rarely see stage one; it'sonly 15% of all patients. stage two means it's gone out of the ovary and sometimes outsidekind of in the pelvis area. >> dr. phillip dy:the cure rate drops to about 70-80%. stage three means there's lymph node involvementor it's gone up above the pelvis more to the abdomen. and in these patients, the cure rateout of a five-year disease ratio for survival drops down already to about 40-50%. stagefour means, it's a lot more advance meaning some of them will present with massive fluidin the lungs, involvement of the liver, involvement of the spleen and five-year ovary survivalis no more than 15-20%.

>> lori casey:does this cancer, you kind of talked about it a little bit earlier, does it have kindof a, i don't know, a pattern in which it spreads? does it typically go here and thenhere and here? or does it go anywhere? >> dr. phillip dy:yes, that's a very good question. unlike cancer of the uterus, cancer of the ovary is morepredictable. ovarian cancer typically spreads from the ovary itself, fallopian tube, uterus,and then the pelvis and then the abdomen before going to the chest. so, most patients evenwho have stage four generally don't have any involvement of the lungs. now, on the otherhand, uterine cancer it can spread anywhere so quickly because it decimates mainly bybloodstream. so, now, before i forget, it's

very important for the public to know thatthe grade of the cancer, meaning how it looks under a microscope, it's a very, very important.and so for the staging and when the cancer is grade one, it means it's mature looking,it looks like normal cells and the outcome is good. that's why for stage one a and b,generally we don't-- stage one a and b with grade one, meaning good grade, we don't givechemotherapy after surgery. but if it's aggressive looking, meaning grade three, they reallylooking very immature cells; they can behave like stage two and they all get chemotherapy.>> lori casey: so, staging and grading are two differentthings, just so we're-- so you're actually looking at two different things.>> dr. phillip dy:

that leads to my next question. how do-- what'syour treatment plan? how do you go about-- i know it has to depend, obviously, on stageand grading but what's the typical course? >> dr. phillip dy:yes. so for, once again, surgery is the first thing. so, it's very important that when aperson is diagnosed with a pelvic mass and you think it's ovarian cancer, you need tosee the right surgeon. and these surgeons are called gynecological oncologists.>> lori casey: okay, studies have shown that these specialists,these are gynecologists who are trained in ovarian cancer surgery. if they are the onesdoing the surgery, the outcome for survival-ship is significantly improved. there's a big difference.and the reason for that is because a surgery

for ovarian cancer is very difficult; it'snot easy. >> lori casey:okay, what makes it difficult? >> dr. phillip dy:generally when they do surgery, it's for diagnosis, staging and to also give the patient the bestchance of cure. when you do surgery for ovarian cancer, when you go in there, you need toremove all cancer that you can see. and typically it starts with removing the uterus, removingboth ovaries; you have to remove both, okay? unless it's very early stage one, but almostalways you still try to remove both because it can effect the other side later on. andtypically you would also remove lymph nodes automatically. plus an area called omentum,which is the fatty tissue that surrounds the

bowels. and you remove that as well and alot of times you have to also remove the bowels or bladder that's affected by the cancer.and also, they also, a lot of times, do biopsies of the diaphragm, which is the muscles separatingthe lung and below the lung. and if you're not an experienced gynecologist, you cannotdo all those things. >> lori casey:there's a lot in there. >> dr. phillip dy:it's very difficult. and nowadays, in what we should talk about later on, we do a lotof chemotherapy directly into the abdominal cavity now. and most of the time, the gynecologistwill put a port or catheter in the cavity during surgery. and we then start chemotherapyafter recovery.

>> dr. phillip dy:so, going back to treatment, with stage one, if it's stage one and slow growing, and it'snot aggressive, no chemotherapy until surgery. but if it's stage one but aggressive, chemotherapyfor about three to six cycles, which is every three weeks. stage two to stage four, everybodygets chemotherapy after surgery. and the term that we use for surgery it's called optimalcyto-reduction meaning the surgeon has to remove everything that he can see and bringdown the size of the cancer to less than one centimeter. so, studies have shown that ifit's left above one centimeter, if you leave the cancer behind above one centimeter, thecure rate or of survival significantly drops. >> lori casey:so, it's pretty aggressive if any is left.

>> dr. phillip dy:exactly and that's why you need an experienced surgeon.>> lori casey: yes, and the studies have shown that for stagethree and stage four, if you are able to do this best surgery, you can give chemotherapydirectly into the abdominal cavity along with iv chemotherapy and it can improve survival-shipalmost significantly by several, several months, that's why.>> lori casey: do you ever do radiation? or is that not atypical-- >> dr. phillip dy:radiation therapy? almost never. >> lori casey:okay, not for that type of cancer.

>> dr. phillip dy:not for this type of cancer because it's more, it's more widespread when it occurs so wedon't generally do it. >> lori casey:so, let's talk, i know you brought some new-- there's always new research, thankfully, andnew treatments available. what's-- what are some of the new trials out there?>> dr. phillip dy: well, the-- let me just give you a flavorhere. >> dr. phillip dy:just in the last one-year, a few new drugs were approved, okay? one is the anti-angiogenesisdrug called avastin or bevacizumab, which has been approved for different cancers inthe past like lung cancer, colon cancer. what

this drug does is that it destroys the abilityof cancer cells to create new blood vessels. so, when you do that there's no nourishment,the cancer cells die, okay? so, this drug, which is approved recently, to be given alongwith chemotherapy, and it was compared to chemotherapy alone for reoccurring ovariancancer. and it was shown to improve the overall outcome. now, we're not there yet where it'sbeen shown to improve overall survival but it's been shown to improve the time whereinthe patient can be cancer free. so, that's one advantage. the other one is a drug calledolaparib. olaparib, these are pills, these are what we call parp inhibitors.>> lori casey: okay, parp inhibitors-- parp is somethingto do with a dna system wherein cancer cells

rely on this parp to do dna repair so thatthey can recover when they're being killed. so, we now have pills that can inhibit theability or stop the ability of cancer cells to repair themselves. and it's been approvedjust a few weeks ago. >> lori casey:okay, whoa. >> dr. phillip dy:i know. and it's been show-- it's showing a lot of promise. however, right now, theparp inhibitors, these pills are only approved if you are tested positive for the brca mutation.>> lori casey: so, as an oncologist, do you recommend womenget the brca test? >> dr. phillip dy:always, always.

>> dr. phillip dy:so, the-- the recommendation in the year 2014-2015 is that anybody who's been diagnosed withcancer of the ovary, because cancer of the ovary is not very common, 22,000 diagnosesin a year accounting for 40,000 deaths a year. since it's not that common, a lot of patientswith ovarian cancer could be due to genetics, okay? when i say a lot, we talk about 5-10%but that's still a lot compared to other cancers. >> dr. phillip dy:so, it's currently recommended that all patients with ovarian cancer, no matter how old theyare, okay? no matter how old they are, should be tested for the brca gene now. they shouldbe. >> dr. phillip dy:okay, and because it can really make a very

big difference now.>> lori casey: is that something that you find some of yourpatients, then, are not-- are they wanting to do that? it's a scary thing, what are youfinding? are women-- >> dr. phillip dy:not in the last five years. before that, a lot of women were worried about insurance,however since there was a federal law that came out several years ago before presidentclinton was finishing office, there's a federal law that nobody can be discriminated uponthe results of this genetic testing. >> dr. phillip dy:so, i emphasize that every time and probably in a month, i order brca testing maybe inabout at least 5 patients minimum. and they

know that this could be life saving for themand for their families, so it's really amazing. >> lori casey:so, is there a typical age at which a lot of your patients are getting the test?>> dr. phillip dy: testing? yes, the recommendation is this,if a family member has been tested positive for brca1 or 2 gene, the next of kin, okay,would be either siblings or daughters or even sons, for-- particularly for ovarian cancerthough, you want to screen them starting at age 30.>> lori casey: okay, so young.>> dr. phillip dy: yes, 30. if they're positive for it and then,for them, if they were tested positive though,

the only way you can really cure them, toprevent it from ever developing is by doing prophylactic or preventative removal of theovaries and fallopian tube. but if you're too young, it's so hard to recommend it becauseyou want to have kids. but the recommendation is that you should do it no later than age40. >> dr. phillip dy:because the typical age for developing cancer for brca1 or 2 gene mutation is earlier than63, it's 50. so you want to do it at least 10 years before that. on the other hand, ifyou're already finished with family and you're brca positive, i've got patients wherein theydo it before they turn 30. they already have their ovaries removed and that generally,almost always, it's not 100% guarantee, but

it will definitely improve their odds of developingcancer of the ovary. >> lori casey:so, it sounds like as far as preventative things, is there really a lot that we cando with diet and exercise? i mean there are genetic things, like what you've just said,but for the rest of the population that might not have that genetic connection, is thereanything that we can do preventative wise? >> dr. phillip dy:there is nothing definite yet, at this point. but of course, if you have a strong familyhistory, some of my patients have gone to the point of doing preventative hysterectomy,with removal of both ovaries. and in some of them it's justified, especially if you'vegot two or more family members with cancer

of the ovary. now, exercise and diet has notbeen shown yet to improve the prevention; however, we are currently doing a trial thatwe're conducting with the gynecological oncology group, which is the largest pure gynecologicalcancer group in the country. wherein we're trying to see where diet and exercise canimprove outcome in regards to preventing cancer from coming back in patients who are survivorsfor ovarian cancer. and so, we're hoping that to make a difference here.>> lori casey: that's what i was going to ask, if you arefortunate enough to survive this, are your chances of maybe getting cancer of the cervixor the ovary or of the uterus increased? >> dr. phillip dy:in general, not.

>> dr. phillip dy:but unless you have the genetic mutation. so, if you're brca1 and 2 positive, your riskof breast cancer is super high and patients who are brca1 and 2 positive are also proneto other cancers like bladder cancer, prostate, pancreas, as well. now, the other geneticmutation is the lynch syndrome. >> dr. phillip dy:lynch syndrome is an old term now for what we call an hnpcc syndrome, which hereditarynon-polyposis colon syndrome. >> lori casey:that's quite a mouth full. >> dr. phillip dy:yes, it is actually the most common genetic mutation for disposing any of us to coloncancer.

>> dr. phillip dy:number one, it's the most common, okay? i have more than 30 families i'm following rightnow. so, this syndrome the main cancer in the syndrome is colon cancer; colon cancer--and you'll see several family members who have it. the number two cancer in this familyis cancer of the uterus. >> dr. phillip dy:breast cancer is also increased; but cancer of the ovary is also increased and a lot ofspecialists forget that. so, these are the two syndromes, the brca1 and this lynch syndromeare the two genetic, genetic mutation type of scenarios that people should be aware of.so, women all over should be aware of their family background and insist on doing genetictesting, it saves lives.

>> lori casey:so, you had-- i wanted to wrap up here, you had said, you know, that the symptoms arekind of, you know-- >> dr. phillip dy:vague? >> lori casey:vague. what advice would you give to a woman out there who might think she has this andpursue that to get some kind of answer because sometimes it's hard for us to, you know, ifthe doctor says no, it's nothing, how do you pursue that?>> dr. phillip dy: very good question, lori. it's a-- once again,they have to be very attentive to what their body's telling them.>> lori casey:

they should not allow anybody, even a healthcareprofessional, to say, oh that's just in your mind, you're just paranoid, you should notdo that because these symptoms that are very vague, the bloating and all these things,could be a lifesaver for you if you bring it to the attention of a doctor and do sometests for it. okay? so, i always encourage patients who have the brca gene in their family,that any family member who have these symptoms, who, for example, they refuse to do the testing,they should bring it to us and almost always, they should demand, if they're not gettingthe right answer and you feel that there's something wrong, because it is not-- thisis something new for you, you should demand a trans-vaginal ultrasound and you shoulddemand a cancer number, ca125. even though

it's not really good for screening, but ifyou have those symptoms, you should demand those tests to be done. and later on, maybe,a cat scan. >> lori casey:okay. well dr. dy, thank you so much for coming by the show. this has been very informativeand i know our viewers out there appreciate the information.>> dr. phillip dy: appreciate that, lori. thanks for having me.>> female speaker 1: production of being well is made possiblein part by sarah bush lincoln health systems; supporting healthy lifestyles, eating a heart-healthydiet, staying active, managing stress, and regular check-ups are ways of reducing yourhealth risk. proper health is important to

all at sarah bush lincoln health system; informationavailable at sarahbush.org. alpha-care specializing in adult care services that range from thoserecovering from recent hospitalizations to someone attempting to remain independent whilecoping with a disability, chronic illness, or age related infirmity; alpha-care, compassionate,professional home care. additional funding by jazzercise of charleston.[music playing]