Questioning Ovarian Cancer: Why Such A High Fatality Rate?

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Photo Credit: Wikimedia Commons
Photo Credit: Wikimedia Commons

There is tragic news coming from the entertainment world today.  Pierce Brosnan announced that his daughter, Charlotte, age 41, died of ovarian cancer three days ago.  This is the same illness that took her mother’s life in 1991 when she, like her daughter, was in her early 40s.

Angelina Jolie – who underwent a preventative double mastectomy earlier this year --  lost her mother to ovarian cancer in 2007.

According to the CDC, ovarian cancer is the second most common gynecological cancer, after uterine cancer, and it's the cause of more deaths than any other gynecological cancer.

The numbers look like this: ovarian cancer kills 15,000 women and approximately 22,000 new cases are diagnosed annually in the US.  Approximately 90% of cases occur in women over 40 and the majority of diagnoses are given to women aged 60 years or older.   According the the American Cancer society, the survival rate for patients who live for five years after they are diagnosed with ovarian cancer is 44%.

Unlike breast or cervical cancer, there is no reliable screening measure for ovarian cancer.  Once it is detected, the first line treatment option is surgery.

Earlier this year, The New York Times reported on a study that suggested the high fatality rate amongst ovarian cancer patients is attributable to widespread deficiencies in the typical treatment most women receive. The article reports that only a third of women with ovarian cancer receive "best practice" treatment, which the study says, is a complicated and intensive operation performed by a highly specialized surgeon.

Here is an excerpt from the article:

Cancer specialists around the country say the main reason for the poor care is that most women are treated by doctors and hospitals that see few cases of the disease and lack expertise in the complex surgery and chemotherapy that can prolong life.

If we could just make sure that women get to the people who are trained to take care of them, the impact would be much greater than that of any new chemotherapy drug or biological agent,”

said Dr. Robert E. Bristow, the director of gynecologic oncology at the University of California, Irvine, and lead author of the new study presented on Monday at a meeting of the Society of Gynecologic Oncology in Los Angeles.

Dr. Barbara A. Goff, a professor of gynecologic oncology at the University of Washington, in Seattle, who was not part of [the] study, said the problem with ovarian cancer care was clear: “We’re not making the most use of things that we know work well.”

What works best is meticulous, extensive surgery and aggressive chemotherapy. Ovarian cancer spreads inside the abdomen, and studies have shown that survival improves if women have surgery called debulking, to remove all visible traces of the disease. Taking out as much cancer as possible gives the drugs a better chance of killing whatever is left. The surgery may involve removing the spleen, parts of the intestine, stomach and other organs, as well as the reproductive system.

The operations should be done by gynecologic oncologists, said Dr. Deborah Armstrong of Johns Hopkins University, who is not a surgeon. But many women, she said, are operated on by general surgeons and gynecologists.

Last month, Slate published a piece written by Dr. David Chun, a medical oncologist at UCLA, who didn't quite agree with the gist of the Times article.  In his piece, Chan wrote that ovarian cancer’s low survival rate is attributable to the lack of effective screening for early detection.

Chan raised several points:

1. Ovarian cancer has a high fatality rate because there is at this time no good screening test. Fortunately, only about 1 percent of women get ovarian cancer. But unlike breast cancer, which can often be detected early with mammograms, ovarian cancer patients are often very advanced at diagnosis. That more than anything else accounts for the lower survival. Stage 1 patients have a cure rate that can exceed 80-85 percent. But the most common stage is 3 because of inadequate screening, and the cure rate is around 20 percent. These are cure rates, not survival rates which are higher. So early diagnosis would make a huge difference and scientists are working hard to find a good screening test.

2.Because most ovarian cancer patients are diagnosed late, surgery is often done urgently because of bowel obstruction, pain, or large amounts of fluid that accumulates in the abdomen.

3. America is big. Really big. Not everyone can go to Johns Hopkins, MD Anderson, Massachusetts General, Mayo Clinic, UCLA, Stanford, or an equivalent facility for care. It could take weeks to get an appointment. The patients are often unstable and can't wait. There are distance issues as well. Often patients are too ill to travel.

So if you look at SEER data, patients operated on by gyn-oncologists do a little better. A little better, not a lot better. Because the main problem is late diagnosis and to a much lesser extent inadequate surgery.

This program aired on July 2, 2013. The audio for this program is not available.