Study: Cryoablation puts a chill on ovarian cancer tumors February 29, 2012Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, Uncategorized, uterine cancer, vaginal cancer.
Tags: cryoablation, femal reproductive system, late stage, ovarian cancer, treatment, tumors
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Study: Cryoablation puts a chill on ovarian cancer tumors
Cryoablation has been shown to be an effective form of treatment for ovarian cancer, and this “freeze and destroy” technique could offer an alternative to surgery or chemotherapy for patients whose disease is in the late stages and oligometastatic, according to research published in the Journal of Vascular and Interventional Radiology and presented at the 2012 International Symposium on Endovascular Therapy in Miami in January.
Hyun Bang, MD, of the department of radiology at Wayne State University School of Medicine in Detroit, and colleagues performed a study of 21 ovarian cancer patients who underwent ultrasound-guided, percutaneous cryoablation in order to assess complications, recurrences and overall survival. Forty-eight tumors on the soft tissue, liver and lungs were treated during the seven-year study period.
Results showed that the median survival was 56.9 months, though the authors noted an average period of 37.8 months occurred between the diagnosis of metastatic disease to the cryoablation procedure. For comparison, most women whose tumors aren’t successfully removed surgically—approximately 60 percent of cases—survive seven months to 30 months.
Bang and colleagues also calculated that cryoablation delivers results at a lower cost than alternative treatments. Medical costs in the study registered an average of $26,806 per life year saved compared with the current standard of care costing approximately $100,000 per life year saved.
“[Multisite cryoablation] of metastatic epithelial ovarian cancer is a well-tolerated treatment alternative, especially for patients with anesthesia risks, painful lesions or those seeking local control during chemotherapy,” concluded the authors. “Preliminary calculations of high patient survival and cost-effectiveness suggest that cryoablation could effectively and economically augment the palliative care of metastatic disease.”
Because cryoablation is performed using an extremely cold needle inserted into the skin, it causes less pain and offers a faster recovery than surgery, according to the authors.
The research team has published two papers detailing the findings as they relate to kidney and lung cancers, with a third recently submitted on colon cancer. Bang recognized the long-term effectiveness and financial benefits of the treatment in a statement, saying that with enough evidence and proven data, “eventually, people will start listening.”
Ovarian cancer is diagnosed in 22,000 women each year and is the most damaging cancer to the female reproductive system, according to the National Institutes of Health.
Tags: CA-125, chemotherapy, endometrial cancer, HIPEC, HITEC, malignant tumors malignant tissue, ovarian cancer, remission, surgery, treatment
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Targeted treatment for ovarian cancer to be studied at University Hospitals
Tuesday, February 28, 2012
CLEVELAND, Ohio — Physicians at University Hospitals Case Medical Center are developing four clinical trials to test a therapy that has been around for several decades, but which only recently has been used to treat ovarian, endometrial (uterine) and select other gynecologic cancers.
The studies, which physicians hope to begin this spring, have been designed for a very specific patient population — no more than a couple dozen women with ovarian or endometrial cancer will be enrolled in each one. The trials will help researchers compare and learn relatively quickly how to use heated intraperitoneal chemotherapy, or HIPEC, as effectively as possible, said Dr. Robert DeBernardo, a gynecologic oncologist at UH and assistant professor at Case Western Reserve University School of Medicine.
The procedure, administered in the operating room right after surgery to remove malignant tumors or tissue, flows a hyperthermic — or heated — sterilized chemotherapy solution through catheters directly into a patient’s abdominal cavity. The heat makes cancer cells “leak” so chemotherapy can enter the cells more effectively.
The effect of chemotherapy delivered directly to the abdomen is more potent than intravenous delivery, which takes longer to reach the intended area. And because the targeted delivery of HIPEC minimizes the rest of the body’s exposure to the treatment, it helps reduce some side effects, such as hair loss.
“Giving chemotherapy in the [operating room] is complicated, but it’s not something that can’t be done,” DeBernardo said. “We need to really show: Is this a beneficial therapy?”
Not only will the studies shed light on how well HIPEC controls when and where the cancer recurs, but they will also focus closely on side effects, costs and the length of hospital stays.
Here are the Phase 1 trials:
• A study involving the use of heated chemotherapy for ovarian cancer that has spread to the chest. What the surgical team has dubbed HITEC (the “T” coming from the word intrathoracic) is performed after minimally invasive lung surgery. “To my knowledge, no one has treated ovarian cancer [that has spread to] the chest like this,” DeBernardo said.
• A study for advanced ovarian-cancer patients whose cancer is in remission following surgery and chemotherapy. The patients will undergo HIPEC to prevent recurrence.
• A study for patients whose cancer recurs; HIPEC will be performed following surgery.
• A study for patients who undergo chemotherapy prior to surgery and HIPEC during the surgery.
Ovarian cancer is especially challenging to treat, as it is often not detected until it has spread. The cancer antigen 125 blood test, which can detect elevated levels of CA-125 — a trait often found in women with ovarian cancer — is not recommended as a screening test in women with an average risk of the disease because elevated levels can signal many other conditions.
Over the past two decades, treatments have evolved and improved, says DeBernardo.
Not only has it become easier to perform aggressive tissue-removing surgery (the primary way to diagnose ovarian cancer), but surgeons have become more specialized in cancer-tissue removal. Women also are able to better tolerate treatment.
“The thing about women with ovarian cancer [is,] we don’t cure very many people with ovarian cancer,” DeBernardo said. “We can control it, we can keep it at bay. But it almost always comes back. That’s where HIPEC comes in. It may improve things.”
The Cleveland Clinic began treating abdominal cancers — appendix, colorectal, gastric, ovarian and peritoneal mesolthelioma (a cancer of the lining of the abdominal cavity) with HIPEC in 2010. UH followed suit last summer, with DeBernardo working with other surgical oncologists and general surgeons to launch the program at UH Seidman Cancer Center.
Buoyed by the results of a national study that appeared in 2006 in the New England Journal of Medicine that showed a higher rate of survival for women with ovarian cancer who were treated with HIPEC versus intravenous chemotherapy, hospitals began to explore the HIPEC option.
“The unfortunate fact is, even though it’s good science, there is still only a minority of women getting offered that treatment,” DeBernardo said. The reasons are varied, and include that not all women have ready access to a hospital with a gynecologic on-
cologist or other skilled staff who are able to integrate HIPEC as part of treatment.
Last August, led by DeBernardo, UH launched a dedicated HIPEC program for gynecological cancers. The surgical team performed its first HIPEC treatment in August 2011. Since then, there have been more than two dozen cases.
Jan Belleville of Hubbard was DeBernardo’s first HIPEC patient.
Other than feeling something — not pain, but something — in her lower abdomen in the summer of 2006, Belleville had no reason to think it was ovarian cancer.
“I had had fibroids and thought that was all it was,” said Belleville, 68. But it wasn’t.
Belleville was diagnosed with Stage 4 ovarian cancer, which by then had spread through her abdominal cavity to her liver. Her first surgery included radiation therapy. Chemotherapy followed.
After being in remission for a year, Belleville’s cancer returned to her liver. She had another operation, followed by more chemotherapy and radiation. The cancer went into remission for six months, then came back. After more chemotherapy, remission again for three months. But the cancer came back again. This time it had spread to her lungs.
After treating Belleville with different types of chemotherapy that proved ineffective, DeBernardo and his colleague, Dr. Jason Robke, decided to do something else.
Last summer, they approached her about having HIPEC/HITEC surgery. She would be their first case.
“I never have doubted that I was being guided in the right direction,” Belleville said.
In late July, she had the first of two HIPEC/HITEC operations, on the left side of her chest. Four weeks later, surgeons operated on the right side. Those surgeries — which were each roughly three hours long, including about 90 minutes for administering the chemotherapy — were the seventh and eighth since she was first diagnosed.
The surgeries stabilized Belleville’s levels of CA-125, the protein in the blood that is found in ovarian cancer cells at a much higher level than in normal cells.
Shortness of breath and lack of energy earlier this month prompted more tests; X-rays detected spots on her lungs, evidence that the cancer had returned there.
Despite the news, Belleville and her husband went ahead with a planned vacation to Florida. Last week, she started intravenous chemotherapy.
“I think it bought me a really nice Thanksgiving, a beautiful holiday over Christmas,” an upbeat Belleville said about the six-month remission that followed her HIPEC/HITEC procedure. “I don’t consider this [recurrence] a setback.”
Key discovery in the treatment of ovarian cancer February 26, 2012Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, Uncategorized, uterine cancer, vaginal cancer.
Tags: carcinogenesis, discovery, OGFr, opioidgrowth factor receptor, ovarian cancer, peptide-receptor, treatment
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Key discovery in the treatment of ovarian cancer
There is a great achievement in the study of ovarian cancer. Researchers have identified a peptide-receptor system, which will help in the understanding the progression and treatment of human ovarian cancer that affects a large population of women worldwide.
For this, researcher conducted this study on immunocompromised mice. They transplanted molecularly engineered humanovarian cancer cells to have a lower expression of opioidgrowth factor receptor (OGFr). They found that ovarian tumours grew rapidly.
These findings were made by the researchers at The Pennsylvania State University College of Medicine, Hershey, Pennsylvania. Their study brings a fresh insight into the pathogenesis and therapy of a lethal cancer that is the fifth most important cause of cancer-related deaths among women in the USA for over 75 years.
The opioid growth factor (OGF)(also-termed [Met5]-enkephalin)-OGFr axis plays a vital role in cancer as it is related to development, and cellular renewal by regulating cell proliferation. This study has also answered the requirement of this peptide-receptor system for the development of carcinogenesis.
The study has also found that Human ovarian cancer call lines that were genetically engineered to underexpress OGFr developed far more faster in tissue culture than control (empty vector/wildtype) cell lines.
Moreover, adding OGF to cultures of these genetically engineered cells did not respond to the inhibitory peptide and change cell number that showed the loss of OGFr interfered with the function of the OGF-OGFr axis with respect to controlling cell proliferation.
Immunocompromised mice in which ovarian cancer cells were transplanted that showed a reduction in OGFr exhibited tumours much earlier than controls, and these tumours developed more rapidly than controls.
With this knowledge that the pathway for OGF-OGFr regulation of cell proliferation in ovarian cancer is by way of escalating the cyclin-dependent inhibitory kinase proteins p16 and p21, it can be said that reducing the quantity of OGFr results in a rise in the number of cells entering the G1/S phase of the cell cycle.
This process has influence on increasing the progression of tumorigenic events.
These results reflects on the critical nature of OGFr in human ovarian cancer, and that the receptor along with its ligand, OGF, is necessary for deciding the course of these neoplasias.
Dr. Ian S. Zagon and Dr. Patricia J. McLaughlin found that endogenous opioids acts as growth factors, and have been pioneers in translating their findings from the bench to the bedside.
“Ovarian cancers frequently have a methylation of p16 that is associated with an increased progression of ovarian cancer and a loss of OGFr in ovarian tumors,” Dr. Renee N. Donahue a researcher in the Department of Neural and Behavioral Sciences said.
“The diminished expression of OGFr and its repercussions on tumorigenesis, only adds to the concern about the need for information concerning genetic and epigenetic changes that may impact the course of disease and its treatment.
“Our findings also hold potentially ominous overtones for those individuals taking naltrexone for addictive disorders. The dosage used for treatment of addiction blocks opioid receptors continually. The present findings that diminishing the OGF-OGFr axis by depleting the receptor exacerbates tumorigenesis, could place these patients using naltrexone at risk for accelerating disease processes that involve cell proliferation,” Dr. Donahue has been quoted as saying.
Dr. Steven R. Goodman, Editor-in-Chief of ExperimentalBiology and Medicine, opined that this forceful evidence confirmed the absolute requirement for OGFr (and OGF) as a tonically active inhibitory regulatory mechanism in ovarian cancer.
“As a corollary, amplifying the OGF-OGFr pathway is a novel and highly effective biotherapeutic strategy to suppress the progression of these deadly cancers,” Dr Goodman stated.
Experimental Biology and Medicine has published this study.
With inputs from ANI
Treatment of recurrent epithelial ovarian cancer. September 17, 2009Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, uterine cancer, vaginal cancer.
Tags: complete remission rate, mortality rate, ovarian cancer, platinum-based chemotherapy, recurrent epithelial ovarian cancer, treatment
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Treatment of recurrent epithelial ovarian cancer.
Ther Clin Risk Manag. 2009 Aug
Pisano C, Bruni GS, Facchini G, Marchetti C, Pignata S.
Oncologia Medica, Dipartimento Uro-Ginecologico, Istituto Nazionale Tumori, Napoli, Italy.
Epidemiologic analysis reveals that the mortality rate from ovarian cancer is continuously decreasing due to the improvement of surgery and chemotherapy. However, the prognosis of ovarian cancer patients is still unsatisfactory overall considering that only 30% of patients are alive after five years. In fact, although surgery and first-line systemic chemotherapy induces complete and partial response in up to 80% of patients with about a 25% pathological complete remission rate, recurrences occur in the majority of patients. The role of surgery in recurrent disease has been recently studied and many patients can receive an optimal secondary cytoreduction. Most of the recurrent patients are subject to a number of treatment regimens that, although palliative in nature, are also able to prolong survival. Important results have been obtained in particular in platinum-sensitive recurrent disease where a platinum-based chemotherapy is able to prolong progression-free survival and overall survival. Overall, our armamentarium for the treatment of progressive or recurrent ovarian cancer is significantly richer than in the past, and in many patients it is possible to achieve our goal of controlling the chronic behavior of the disease.
Straight talk about ovarian cancer November 16, 2008Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, uterine cancer, vaginal cancer.
Tags: arthralgia, ascites, chemotherapy, constipation, deep vein thrombosis, diagnostic tests, diarrhea, DVT, early signs, Epithelial cancers, Germ cell cancers, incessant-ovulation theory, inflammation theory, mucositis, myalgia, neuropathy, ovarian cancer, pituitary/gonadotropin hypothesis, prevention, radiation therapy, remission, screening, Stromal cell cancers, surgery, treatment, tumor markers
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Straight talk about ovarian cancer
VIRGINIA R. MARTIN RN, AOCN, MSN
Nursing2005 April 2005 Volume 35 Number 4 Pages 36 – 41
Learn how to help patients recognize and defeat this insidious malignancy.
Learn how to help patients recognize and defeat this insidious malignancy.
ACCORDING TO AMERICAN Cancer Society (ACS) estimates for 2005, 22,220 women will develop ovarian cancer and 16,210 will die of it. The leading cause of death from gynecologic cancer in the United States, ovarian cancer has historically had a poor prognosis, largely because over 70% of women affected have advanced disease at diagnosis.
But medical science is gaining ground. Thanks to improved diagnosis, staging, and treatments, 5-year survival improved from 37% in the 1970s to 53% in 1998. Let’s review how this insidious disease progresses, how you can help someone who has it, and what you need to know about promising screening methods that could lead to earlier detection and treatment.
Deep, changing organs
The ovaries are solid, slightly nodular, almond-shaped organs lying deep in the pelvis. Their hidden location, plus the fact that their size, shape, position, and histology change over a woman’s lifetime, help explain why ovarian cancer isn’t readily detected in the early stages. According to the National Comprehensive Cancer Network (NCCN), the median age at diagnosis is 63. This malignancy is rare in women under age 30.
Three major theories about the causes of ovarian cancer prevail:
* The incessant-ovulation theory zeroes in on how the monthly ovulatory cycle affects the ovaries. This theory holds that the epithelium may be more apt to mutate with each ovulation, so failure to break the cycle, as with pregnancy, increases the chance of mutation.
* The pituitary/gonadotropin hypothesis implicates elevated gonadotropin levels. Normally, the ovarian epithelium invaginates and forms inclusion cysts and clefts, but overstimulation by gonadotropins might trigger proliferation with subsequent malignant transformation.
* The inflammation theory considers monthly ovulation a possible cause of chronic inflammation and mutation in the epithelial cells that lead to ovarian cancer.
The causes of ovarian cancer are unclear, but genetic and endocrine factors raise the risk. (See How the problem starts .) The most significant link is a positive family history, which is present in 10% of women with the disease. Three hereditary syndromes in which ovarian cancer occurs more commonly affect certain families with a history of early breast and ovarian malignancies and hereditary nonpolyposis colorectal cancer.
Other factors associated with ovarian cancer include nulliparity, giving birth for the first time when over age 35, exposure to talc or asbestos, endometriosis, pelvic inflammatory disease, and living in a western industrialized country. On the bright side, researchers have identified seemingly protective factors, including a history of oral contraceptive use, giving birth before age 25, tubal ligation, breast-feeding, and hysterectomy.
Most commonly, ovarian cancer spreads via the peritoneal fluid that continuously circulates through the abdomen. Other routes for metastases are through the lymphatic fluid or by direct tumor extension. Bloodborne metastasis is rare, and this cancer rarely spreads beyond the abdomen, even when advanced.
Retrospective studies indicate that over 70% of women with ovarian cancer have symptoms for 3 months or longer before diagnosis. But the early signs and symptoms can be nonspecific, including increased abdominal size, bloating, early satiety, abdominal pain, indigestion, vaginal bleeding, and changes in bowel and bladder habits. Because these symptoms can be vague, a woman may not pay much attention to them.
Teach your female patients to always investigate any of these symptoms if they occur.
When a woman does seek treatment and an ovarian mass is discovered, the clinical approach depends on clinical findings. If she’s premenopausal, the health care practitioner will probably monitor her for a few ovulatory cycles and investigate further if the mass doesn’t disappear. In a postmenopausal woman, any ovarian mass must immediately be investigated for cancer.
Diagnostic imaging and tumor markers
Diagnostic tests to detect ovarian cancer include the following:
* transvaginal and abdominal ultrasound. A transvaginal approach provides better visualization of the ovaries than the transabdominal method, but the location of the ovaries varies in each woman, so a combination of both approaches is recommended.
* computed tomography (CT) scan of the abdomen and pelvis
* a blood test for the tumor marker cancer antigen 125 (CA-125), which can be elevated in ovarian cancer. Although an ovarian mass can cause an elevated CA-125 level, so can endometriosis, pregnancy, liver disease, or fibroids, so the marker isn’t specific.
Additionally, a woman can have ovarian cancer and a normal CA-125 level; only 50% of women with stage I disease have an elevated level. For this reason, the CA-125 isn’t recommended as a screening tool for healthy women, but it can be useful in women with diagnosed ovarian cancer.
Surgery: First and foremost
Surgery is the mainstay of treatment for ovarian cancer, and a gynecologic oncologist has the most training to perform the exploratory laparotomy. The goals of surgery are to determine a definitive diagnosis, to stage the disease if cancer is present, and to remove as much of the tumor as possible. (See Staging ovarian cancer .) The procedure includes a total abdominal hysterectomy, bilateral salpingo-oophorectomy, scraping the abdominal surface of the diaphragm, peritoneal cytology, omentectomy, pelvic and para-aortic lymph node sampling, and peritoneal and random biopsies.
Although disease stage is the key prognostic factor for ovarian cancer, other factors influence outcome. They include the volume of cancerous tissue remaining after surgery, histologic type and grade, the woman’s age, and her overall condition or performance status. (See Rating performance .) A woman whose performance status is 0 to 2 is more likely to respond to chemotherapy, experience less toxicity, and have better outcomes. Findings associated with a poorer prognosis include a clear cell, mucinous, or poorly differentiated (unclear cell type) tumor, and diagnosis after age 69.
Is additional treatment warranted?
If your patient has well-differentiated stage IA or IB ovarian cancer that’s been surgically removed, she’s considered low risk and needs no further treatment. The oncologist will determine a follow-up plan.
Stage IA or IB ovarian cancer with a poorly differentiated tumor and stages IC, II, III, and IV disease are classified as high risk, and the patient requires chemotherapy. Scientists are still seeking the optimal regimen, but early clinical trials have shown that combination therapy with a platinum compound such as cisplatin or carboplatin is superior to using a single agent. The NCCN states that paclitaxel/carboplatin is the preferred regimen. (See Exploring chemotherapy options for other choices.)
A complete remission from cancer means all signs and symptoms disappear; remission after initial therapy that lasts 5 years may be considered a cure. Although 75% to 80% of women with ovarian cancer achieve a complete remission after initial therapy, 80% of them have a recurrence. Unfortunately, recurrent disease isn’t curable, so researchers are exploring strategies to prevent or delay recurrence, such as improved induction and maintenance regimens and the use of intraperitoneal chemotherapy.
Currently, intraperitoneal therapy is recommended only in the context of a clinical trial, but researchers have been studying it closely because ovarian cancer tends to stay in the abdomen. Study results show higher rates of progression-free survival and overall survival, but the challenges of administering therapy and managing toxicity are formidable.
Remission and monitoring
A typical woman with complete remission from ovarian cancer undergoes regular CA-125 monitoring and periodic abdominopelvic CT scans to check for recurrence. In most cases of recurrent disease, the CA-125 level rises above normal before the woman develops symptoms. Even when the CA-125 level is elevated, most oncologists don’t start chemotherapy unless a pelvic examination or abdominopelvic CT scan indicates disease recurrence; treating measurable disease lets the practitioner identify a response.
If a woman’s cancer recurs, her response to initial chemotherapy and the length of time until recurrence help determine subsequent therapy. If she achieved complete remission and didn’t have a recurrence for more than 6 months after completing initial therapy, her disease is considered drug sensitive and she’ll probably receive the same regimen.
Ovarian cancer that recurs less than 6 months after a woman achieves a complete remission is considered drug resistant . If the cancer doesn’t respond to initial therapy at all, it’s labeled drug refractory . Drug-resistant or drug-refractory disease is typically treated with a different agent, or the woman may be offered the option of participating in a clinical trial. If curing ovarian cancer isn’t possible, the patient may receive salvage therapy , which is chemotherapy to help manage symptoms and possibly prolong survival.
When recommending a treatment approach for recurrent disease, the oncologist considers the woman’s prior responses, quality of life, toxicity profile, current symptoms, disease volume, the ability of her gastrointestinal system to absorb drugs, her age, other illnesses, and social issues.
Radiation therapy may be included in the palliative treatment plan and may help if the patient has uncontrolled vaginal bleeding or pain. Radiation to the entire abdomen isn’t often considered because it’s toxic. For recurrent disease in a specific area, a radiation oncologist should outline a treatment plan. The goal of all palliative treatment is to balance the toxicities with quality of life.
Providing education and support
Research indicates that the more a patient feels threatened or harmed by cancer, the more education and support she needs. With ovarian cancer, her psychosocial and physical challenges might include advanced disease at diagnosis, repeated cycles of aggressive treatment, little respite from therapy, and a poor chance of survival. Your challenges are to address her psychosocial needs while preparing her for treatment and helping her manage adverse reactions to treatment and advanced disease.
Preoperatively, educate your patient and her family about the surgical procedure for ovarian cancer and what to expect afterward. Explain that after surgery, you’ll monitor her for infection, circulatory complications, fluid and electrolyte imbalances, and pain, and that you’ll work with the surgeon to manage any problems.
If your patient will receive chemotherapy, teach her and her family about the major adverse reactions. Explain how to prepare and respond if she develops fatigue, nausea, vomiting, hair loss, diarrhea, constipation, mucositis, neuropathy, arthralgia and myalgia, or myelosuppression.
Problems such as depression and anxiety are common when a patient faces serious illness and possible death. She may need help coping with such issues as premature menopause; loss of fertility; altered body image, sexual function, and family relationships; impaired functional capacity; financial problems; and loss of spiritual well-being.
Assess her for mood changes, feelings of worthlessness, inability to concentrate, fatigue, insomnia, impaired functioning, agitation, restlessness, and apprehensiveness. Review her medical history, current medications and treatments, nutritional status, pain rating, elimination pattern, and sexual history for factors that may contribute to depression.
Listen to her concerns and refer her to support services, such as the local chapter of the ACS. Managing her symptoms, participating in a support group, meeting with a mental health professional, and taking antidepressant or antianxiety medication all can help resolve depression and anxiety.
Finally, if cure isn’t an option, you can give your patient and her family tremendous support when you help them cope with end-of-life decisions and involve the hospice team when the time is right.
Managing the effects of advancing disease
Complications of advancing ovarian cancer can pose significant nursing challenges. Here’s a review of assessment findings and management strategies for common problems.
Ascites , accumulation of fluid in the peritoneal cavity, occurs when channels that normally remove fluid are blocked or when cancer cells prevent absorption of peritoneal fluid. Symptoms include early satiety, dyspnea, increased abdominal girth, constipation, and pain.
Suspect ascites if your patient has a protuberant abdomen with bulging flanks, an everted umbilicus, diminished bowel sounds, shiny or taut abdominal skin, and dullness to percussion in dependent areas of the abdomen. (For details, see “Assessing for Ascites” in the February issue of Nursing2005 .) An abdominal ultrasound usually confirms the diagnosis.
The treatment for ascites is removing the fluid. The oncologist may perform paracentesis in the office or in the radiology department with ultrasound guidance.
Intestinal obstruction involving the small or large intestine may plague a patient with progressing ovarian cancer. Tumor growth in the abdomen or adhesions can cause a partial or complete obstruction that interferes with peristalsis. An obstruction can be acute or chronic. Signs and symptoms of acute obstruction include acute abdominal distension and pain and projectile vomiting. Symptoms of chronic obstruction include abdominal distension and discomfort, constipation, and nausea and vomiting.
Hyperactive bowel sounds may be the first sign of acute intestinal obstruction as the bowel tries to move digestive contents past the blockage. Teach your patient to recognize problems and to immediately contact her health care provider if they occur.
A patient who develops an acute intestinal obstruction may need hospitalization and insertion of a nasogastric tube to decompress her bowel. Because a woman with advanced cancer may already be debilitated, surgery is considered only if conservative interventions fail or she’s in acute distress.
Deep vein thrombosis (DVT) is a risk for all cancer patients because of prolonged immobility, tumors that decrease or obstruct blood flow, and hypercoagulability associated with cancer. Common signs and symptoms include unilateral leg edema or pain accompanied by tenderness, warmth, and erythema. The treatment for DVT includes anticoagulation therapy and possibly placement of a filter in the inferior vena cava.
Malnutrition is one of the greatest challenges for a woman with ovarian cancer. Treatments or advancing disease may take away her appetite, causing her to lose weight. This wasting syndrome is called cancer cachexia , an advanced state of protein-energy malnutrition. Besides weight loss, signs of cancer cachexia include decreased subcutaneous tissue, edema, abdominal distension, dry skin, and behavioral changes such as irritability. Cancer patients with weight loss generally have poor performance status, poor response to chemotherapy, poor median survival, and possibly a greater infection risk.
Measures to protect the patient from malnutrition include treating the underlying problem, delaying chemotherapy, getting a nutrition consult, and medications (such as corticosteroids, megestrol, hydrazine, dronabinol, nabilone, oxandrolone, growth hormones, and medroxyprogesterone). Advise her to eat frequent, small meals served at room temperature; eliminate disagreeable food odors; get help with food preparation; and use nutritional supplements.
Lymphedema , an accumulation of lymphatic fluid in the interstitial tissue, occurs when the tumor blocks the lymphatic system or when lymph nodes have been removed. Lymphedema associated with ovarian cancer affects the legs. The affected leg maintains full sensation, but with edema, range of motion decreases and the skin feels tight to the patient.
Your patient should be referred to a knowledgeable practitioner in lymphedema management. The severity and grade of lymphedema determine the interventions, which may include range-of-motion exercises, meticulous skin care to reduce the risk of skin breakdown, elevation, massage or physical therapy to manually aid drainage, compression bandaging, or sequential pump therapy.
Pleural effusion occurs when the rate of pleural fluid production exceeds its removal rate from the pleural space, such as when a tumor invades the thoracic duct, or when ascites fluid seeps through the diaphragm. Signs and symptoms may include dyspnea, decreased or absent breath sounds, decreased tactile fremitus, or dullness to percussion. An effusion is treated by draining the fluid via thoracentesis or insertion of a tunneled indwelling pleural catheter.
What about screening and prevention?
Current screening methods for ovarian cancer aren’t sensitive or specific enough for routine use. A woman with a positive family history, however, should have a formal risk assessment with an extensive family history, education, risk estimation and counseling, optional genetic testing, and specific screening and prevention strategies. Screening strategies often include a rectovaginal pelvic exam, a CA-125 blood test, and transvaginal ultrasound.
Scientists are exploring the natural history of ovarian cancer to develop cost-effective, sensitive screening strategies. Researchers studying cell proteins are developing a test that tracks trends in multiple tumor markers specific for ovarian cancer. The first published study reported 18 of 18 stage I cancers and 63 of 66 healthy controls accurately identified, yielding 100% sensitivity and 95% specificity. A yet-unpublished study accurately identified 22 of 22 cases of early stage I disease, 81 of 81 cases of stage II to stage IV disease, and 68 of 68 cases of benign disease. The test must be validated and standardized before being used as a screening tool.
Prevention strategies for ovarian cancer may include a prophylactic bilateral oophorectomy in high-risk women who’ve finished childbearing. Other prevention strategies being used in clinical trials include the use of oral contraceptives and other drugs such as acetaminophen and the synthetic retinoid, fenretinide.
Finally, you have many opportunities to improve the outlook for ovarian cancer. Educate your female patients about the signs and symptoms and emphasize the importance of reporting “insignificant” symptoms that could be early warning signs. Early detection and treatment offer the best chance for survival.
Education, support, and hands-on care
Patient outcomes for ovarian cancer are getting better as detection and treatment methods improve. When you give a woman the education, support, and hands-on care she needs to combat this malignancy, you bolster her ability to successfully fight back.
How the problem starts
Three major categories of ovarian cancer have been identified:
Epithelial cancers , arising from the cells lining or covering the ovaries, account for 90% of ovarian malignancies. Epithelial cancers are further classified as serous (most common), endometrioid, clear cell, mucinous, and poorly differentiated.
Germ cell cancers start in cells destined to become ova.
Stromal cell cancers start in the connective tissue cells that hold the ovaries together and produce female hormones.
Staging ovarian cancer
Stage I: Tumor limited to the ovaries
IA , limited to one ovary, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsule intact
IB , limited to both ovaries, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsules intact
IC * , limited to one or both ovaries, tumor on ovarian surface, capsule ruptured, ascites or peritoneal washings containing malignant cells
Stage II: Tumor involving one or both ovaries with pelvic extension
IIA , extension or metastasis to the uterus or tubes, no malignant cells in ascites or peritoneal washings
IIB , extension to other pelvic tissues, no malignant cells in ascites or peritoneal washings
IIC * , pelvic extension, ascites fluid or peritoneal washings containing malignant cells
Stage III: Tumor involving one or both ovaries, peritoneal implants outside the pelvis or regional lymph node metastasis
IIIA , gross tumor limited to the true pelvis, negative nodes, microscopic peritoneal metastasis beyond the pelvis
IIIB , macroscopic peritoneal metastasis 2 cm or less in greatest dimension beyond the pelvis
IIIC , abdominal implants greater than 2 cm in greatest dimension or positive regional nodes
Stage IV: Tumor involving one or both ovaries, metastasis greater than 2 cm in greatest dimension beyond the pelvis. If pleural effusion is present, cytologic test results must be positive. Parenchymal liver metastases equals stage IV.
The Eastern Cooperative Oncology Group established the following scale to rate the effects of cancer and its treatments on the patient.
0 Normal activity, asymptomatic
1 Symptomatic, fully ambulatory
2 Symptomatic, in bed less than 50% of the time
3 Symptomatic, in bed more than 50% of the time but not bedridden
4 100% bedridden
SELECTED WEB SITES
Women’s Cancer Network and CancerSource
Last accessed on March 3, 2005.
Virginia R. Martin is the clinical director of ambulatory care at Fox Chase Cancer Center in Philadelphia, Pa.
The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.
Exploring chemotherapy options
The current standard regimen for advanced ovarian cancer is paclitaxel (Taxol) and the platinum compound carboplatin. Alternatives are docetaxel (Taxotere) with carboplatin or paclitaxel with cisplatin, another platinum compound.
Recent clinical trials found no difference in survival between patients receiving carboplatin with either docetaxel or paclitaxel, but the docetaxel/carboplatin group had a greater incidence of myelosuppression. Those receiving paclitaxel/carboplatin had more neuropathy. Newer drugs being combined with carboplatin and paclitaxel are topotecan, liposomal doxorubicin, and gemcitabine.
The Gynecologic Oncology Group (GOG), a research group funded by the National Cancer Institute, is currently conducting a clinical trial for high-risk early-stage disease comparing three cycles of paclitaxel/carboplatin followed by surveillance versus paclitaxel alone weekly for 24 weeks. The GOG is also proposing a clinical trial on the use of carboplatin and paclitaxel combined with bevacizumab to treat advanced ovarian cancer.
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* Knowing whether rupture of the capsule was spontaneous or caused by the surgeon and whether peritoneal washings or ascites was the source of malignant cells helps the clinician decide whether a case should be categorized as stage IC or IIC. [Context Link]
Leg Swelling and Ovarian Cancer November 14, 2008Posted by patoconnor in cancer, gynecological cancer, ovarian cancer.
Tags: causes, chemotherapy, foot swelling, leg edema, leg lymphedema, leg swelling, lower limb lymphedema, lymph node removal, lymph system, node biopsy, ovarian cancer, radiation, risk factors, treatment
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Arm and Leg Swelling After Cancer
With the advent of better and more effective cancer treatments, the survival rate for all cancers has risen dramatically. With this progress, a new and often misunderstood and misdiagnosed complication has arisen.
Many cancer survivors , having overcome cancer, find themselves with sudden and often unexplained swelling, usually of the arms or of the legs.
This swelling occurs because of one of several factors.
First, the swelling begins after lymph nodes have been removed for cancer biopsies.
Second, the swelling may start as a result of radiation damage to either the lymph nodes and/or the lymph system.
Due to either the removal of lymph nodes or damage to the lymph system, your body is no longer able to rid itself of excess fluids. The fluids collect in the limbs effected and swelling beings.
This swelling is called lymphedema. The swelling that occurs is permanent, and while it is not curable it is treatable.
Permanent Leg Swelling
****In the situation of any permanent leg swelling whether the cause is known or unknown, the diagnoses of lymphedema must be considered****
There are several groups of people who experience leg swelling from known causes, but it doesn’t go away or unknown causes where the swelling can actually get worse as time goes by.
This group includes those who have had the injuries, infections, insect bites, trauma to the leg, surgeries or reaction to a medication. When this swelling does not go away, and becomes permanent it is called secondary lymphedema.
Another extremely large group that experiences permanent leg swelling are cancer patients, people who are morbidly obese, or those with the condition called lepedema. What causes the swelling to remain permanent is that the lymph system has been so damaged that it can no longer operate normally in removing the body’s waste fluid. In cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries. This is also referred to as secondary lymphedema.
Group three consists of people who have leg swelling from seemingly unknown reasons. There may be no injury, no cancer, no trauma, but for some reason the leg simply is swollen all the time.
The swelling may start at birth, it may begin at puberty, or may begin in the 3rd, 4th or even 5th decade of life or sometimes later. This type of leg swelling is called primary lymphedema. It can be caused by a genetic defect, malformation or damage to the lymph system while in the womb or at birth or be part of another birth condition that also effects the lymph system. This is an extremely serious medical condition that must be diagnosed early, and treated quickly so as to avoid painful, debilitating and even life threatening complications. Treatment should NOT include the use of diuretics.
What is Lymphedema?
Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system.
A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema.
What are the symptoms of Lymphedema?
If you are an at risk person for leg lymphedema there are early warning signs you should be aware of. If you experience any or several of these symptoms, you should immediately make your physician aware of them.
1.) Unexplained aching, hurting or pain in the leg.
2.) Experiencing “fleeting lymphedema.” This is where the limb may swell, even slightly, then return to normal. This may be a precursor to full blown leg lymphedema.
3.) Localized swelling of any area. Sometimes lymphedema may start as swelling in one area, for example the foot, or between the ankle and knee. This is an indication of early lymphatic malfunction.
4.) Any arm inflammation, redness or infection.
5.) You may experience a feeling of tightness, heaviness or weakness of the leg.
How is Lymphedema Treated?
The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MDT), there are variances, but most involve these two type of treatment. It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally. With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size.
What are some of the complications of lymphedema?
1. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immuno-deficient.
2. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.
3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.
4. Loss of Function due to the swelling and limb changes.
5. Depression – Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.
6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections.
7. Sepsis, Gangrene are possibilities as a result of the infections.
8. Possible amputation of the limb.
9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.
10. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections.
11. Chronic localized inflammations.
Can lymphedema be cured?
No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation.