(Focus - India)
According to Globocan’s 2020 projections, by 2040, the number of women around the world diagnosed with ovarian cancer will rise almost 42%. It is often called the "silent killer" because symptoms may not present themselves until the disease has progressed to an advanced stage. This makes early detection and awareness essential in the fight against ovarian cancer. Who are at risk of ovarian cancer? How are ovarian cancer patients treated and managed?
To learn more about it, we had a short discussion with Dr. Hemangi Jignesh Kansaria, a renowned Obstetrician & Gynecologist from Seth GSMC and KEM Hospital, Mumbai, where she discussed the importance of cancer screening in women with BRCA1, BRCA2, lynch syndrome and family history of ovarian or breast cancer.
Dr. Hemangi Jignesh Kansaria is Obstetrician-Gynecologist and Associate Professor at King Edward (VII) Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India.
Patients with a family history of ovarian or breast cancer are more prone to ovarian cancer. Patients with BRCA1, BRCA2, and lynch syndrome also have a higher risk of developing ovarian cancers, so these patients need to be screened.
Doctor, the evidence says that only 20% of ovarian cancer cases are diagnosed at earlier stages [1]. What would be the reason for the late presentation of ovarian cancer?
Dr. Hemangi - The late presentation of ovarian cancer is because these patients are mostly asymptomatic, and there are no universal screening guidelines. According to ACOG and WHO, universal screening is not required, and these ovarian cancers are mostly asymptomatic. So, they usually present late in late.
What about the scenario in India, doctor?
Dr. Hemangi - In India also, patients mostly present late. Sometimes younger patients present with pain, and when we do sonography, we detect germ cell tumors, but for epithelial ovarian cancers, patients usually present late to us.
Doctor, we understand that the exact cause of ovarian cancer is still not known. According to you, who is at risk for developing ovarian cancer and needs mandatory screening?
Dr. Hemangi - Patients with a family history of ovarian or breast cancer are more prone to ovarian cancer. Patients with BRCA1, BRCA2, and lynch syndrome also have a higher risk of developing ovarian cancers, so these patients need to be screened. These patients after 35 years of their age require prophylactic salpingo-oophorectomy after finishing family. The patients who refuse the surgery can undergo these screenings.
We have PARP and VEGF inhibitors but there are not many novel therapies in the pipeline. CAR-T cell therapy is used for haematological cancers, but there are studies where these are also used for solid tumors.
Doctor, as mentioned ovarian cancer is often diagnosed at an advanced stage, but cancer comes back or recurs in more than 80% of women even after the treatment [2]. How are recurrent ovarian cancer patients treated and managed?
Dr. Hemangi - If recurrent ovarian cancer patients are sensitive to chemotherapy, platinum-based chemotherapy is given, which contains paclitaxel and carboplatin. And resistant patients can be treated with PARP inhibitors and VEGF inhibitors.
Are there any novel therapies in the pipeline?
Dr. Hemangi - We have PARP and VEGF inhibitors but there are not many novel therapies in the pipeline. CAR-T cell therapy is used for haematological cancers, but there are studies where these are also used for solid tumors. But they have not proved that it is safe to use, and more trials are required to confirm that it can be used.
Doctor, is there any other cell-based therapy alternative to CAR-T cell therapy that is being investigated for treating ovarian cancer patients?
Dr. Hemangi - Both the FIGO guidelines and British guidelines mention PARP inhibitors and immunotherapy. I have spoken to my colleagues from leading institute for cancer treatment in India about T-cell receptor therapy, and it is not being used in India right now and is still under trial.
Doctor, though surgery could remove most cancer tissues, some cancer lesions may be missed. However, last year, the FDA approved a new imaging drug Cytalux (pafolacianine), that helps identify ovarian cancer lesions during surgery [3]. What are your thoughts on this drug?
Dr. Hemangi - It detects cancer tissue, which the naked eye cannot see during surgery. So, it's very helpful if we use this dye half an hour before surgery to remove complete cancer tissue from the body. So, it's very helpful, but it is not used in Mumbai.
Is there any reason, doctor, for it is not being used?
Dr. Hemangi - It may be because it requires advanced techniques.
Some studies state that women who have used oral contraceptives are approximately half as likely to develop ovarian and endometrial cancer compared to women who have never used them [4],[5]. At the same time, we understand that these medications have other risks like cervical cancer, breast cancer, etc. Can you share some light on this based on your experience, doctor?
Dr. Hemangi - I have not come across such patients. The risk of these cancers is slightly higher when oral contraceptive pills are used, but it's not too much.
According to you, what factors need to be considered before taking birth control pills to balance both benefits and risks of birth control pills?
Dr. Hemangi - If it is for a shorter duration, it is okay. But if it is for a longer duration, patients should be evaluated to rule out these cancers.
Most women depend on their husbands and don't approach doctors early, maybe because of socio-economic status or transportation issues. So, they should go to the doctor immediately when they have some symptoms.
Doctor, are there any government programs to increase awareness of ovarian cancer screening in India?
Dr. Hemangi - I had a conversation regarding this with my colleagues, and we discovered that it's not cost-effective to do a universal screening. There is no need for universal screening for ovarian cancer. Of course, patients who are at high-risk need to undergo compulsory screening.
Are there any challenges with the treatment and management of ovarian cancer in India?
Dr. Hemangi - Most women depend on their husbands and don't approach doctors early, maybe because of socio-economic status or transportation issues. So, they should go to the doctor immediately when they have some symptoms.
To conclude our session, what would be your key takeaway message to ovarian cancer patients and their caregivers for effectively managing the disease?
Dr. Hemangi - Whenever a woman notices changes like a distinction of the abdomen, bloating, or loss of weight, they should immediately consult a doctor. If there is an ovarian tumor, they should take treatment as early as possible and follow whatever the oncologist says.
Thank you very much for your time, doctor!
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