WOMEN'S HEALTH
OVARIAN CANCER: It Is a Time for Hope
Lynn Parker, MD
I
was honored when I was asked to write
a few words about the progress that has
been made in the prevention, diagnosis
and treatment of ovarian cancer. Despite
the scarcity of funds directed to research
in gynecologic cancers, much has been ac-
complished.
Rapid expansion of the field of genetics
has identified patients who have hereditary risk of gynecologic can-
cer. Mutations in BRCA 1 or 2 (human genes that produce tumor
suppressor proteins) are the most common and are associated with
hereditary risk of fallopian tube, ovarian and peritoneal cancers.
Patients with BRCA 1 mutations have a 40 percent risk of ovarian
cancer, whereas patients with BRCA 2 mutations have a 25 percent
risk of ovarian cancer. Patients with a strong family history of co-
lon, uterine, ovarian and renal cancers may have Lynch syndrome,
which is also associated with risk of ovarian cancer. RAD51C, RAD
51D, BRIP 1, CHEK1, BARD1 and other mutations have also been
associated with hereditary risk of ovarian cancer. One thing we as
physicians can do to decrease the incidence of gynecologic cancer
is take a good family history. If we can identify patients who are
at risk and refer them for genetic counseling and testing, we can
then quantify their risk based on testing results. Patients at genetic
risk can then be counseled about options to decrease their risk of
fallopian tube and ovarian cancer such as use of oral contraceptives
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and prophylactic surgery. All patients with ovarian cancer should
be offered genetic testing. In a disturbing study by Childers, et al
only 13.1 percent of all patients with ovarian cancer were advised
to undergo genetic testing and only 10 percent underwent testing.
[1] It is so important that primary care providers are also aware
of the importance of genetic testing and identifying risk, because
typically as a gynecologic oncologist we do not see these patients
until they have been diagnosed with cancer.
Another major advance has been the expansion of knowledge in
the pathogenesis of ovarian cancer. When prophylactic surgery was
being done for hereditary risk, serous tubal intraepithelial cancers
and incidental invasive cancers were found in the fallopian tube.
Serous tubal intraepithelial cancers and the cancer in the ovary
had identical p53 mutations [2]. For these reasons, it is believed
that serous cancers which are the majority of “ovarian cancers,”
actually arise from the fallopian tube. This is important because it
finally gives us a target to prevent these cancers. We can decrease
the risk of ovarian cancer by 85 percent by performing risk-reducing
salpingo-oophorectomy for those with hereditary risk, but recom-
mendations have been made to consider salpingectomies for tubal
sterilization as well as salpingectomies at the time of hysterectomy
in the hope of preventing ovarian cancer. Powell, et al. looked at
adoption of this process in the Kaiser Permanente Health system
with an increase of salpingectomies as an interval tubal procedure
from one percent in 2011 to 78 percent in 2016 [3]. My hope is