28.04.2014

Ovarian cancer treatment based on stage

Patient assessment is needed prior to initiation of chemotherapy and the patient's medical record must be reviewed (as with any chemotherapy regimen). Prior to administering IP chemotherapy, the nurse verifies that the order is correct by identifying the “five rights”: right patient, agent, dose, route, and frequency.
Nurses need to educate patients and families about the importance of connecting the tubing to the correct site. FIGURE 1 Intraperitoneal (IP, left) and intravenous (IV, right) ports for delivery of chemotherapy.
The following three studies are based on our experience at Memorial Sloan-Kettering Cancer Center using a fenestrated IP catheter. These studies show that catheter-related complications have decreased over time, and suggest a learning curve regarding placement technique, administration, and management of IP chemotherapy from 1991 to the present. Two controversial procedural points regarding administration of IP chemotherapy are flushing of an IP port and warming of the IP fluid.
Nurses play an essential role in caring for women with ovarian cancer who are receiving IP chemotherapy. Patients should be educated about what to expect with the IP route of chemotherapy, including possible side effects and complications. Epithelial ovarian cancer is the leading cause of death from gynecologic malignancy in the United States, with approximately 15,000 deaths per year.
The approach to treatment for newly diagnosed ovarian, fallopian tube, and primary peritoneal cancers has typically been the same. Other studies have sought to improve the outcomes observed with IV carboplatin and paclitaxel by adding additional drugs to a platinum-doublet backbone. The role of biologic therapies in the first-line treatment of newly diagnosed ovarian cancer is under active exploration.
The role and dosing of IP chemotherapy in newly diagnosed optimally debulked ovarian cancer remains an area of discussion. Despite the above findings, adoption of IP chemotherapy as the standard of care for optimally cytoreduced stage III disease has been controversial. A. Atypical Hyperplasia = abnormal tissue growth 1) simple hyperplasia without atypia = a proliferation of cel s, but the basic structure of the endometrium is relatively unchanged 2) complex hyperplasia without atypia = individual cel s may be enlarged, but the internal makeup of the cel s is considered to be normal.
Additional potential contributors: ? Family history – possible genetic link ? Hereditary nonpolyposis colorectal cancer (HNPCC). F. Symptoms of endometrial cancer ? Abnormal uterine bleeding ? Heavy bleeding during or between periods, and bleeding after menopause. Prevalence & Incidence ? An estimated 20,180 women wil be diagnosed with ovarian cancer in the US in 2006. A. Risk Factors 1) Continuous egg production (never pregnant, never used birth control, or first birth after age 30) 2) Early menstruation (periods starting before age 12) or late menopause (after age 52) 3) Obesity 4) Diet – saturated fat increases risk, high fiber lowers risk 5) Fertility drugs – studies indicate prolonged use clomiphene citrate, especial y without achieving pregnancy, may increase the risk for developing LMP tumors. Science, Technology and Medicine open access publisher.Publish, read and share novel research.
Demographic and Clinical Characteristics of Mucinous Epithelial Ovarian Cancer, and Survival Following a Mucinous Epithelial Ovarian Cancer DiagnosisSherri L. Table 3, Figure 1 and Figure 2 show the demographic and clinical characteristics significantly associated with mEOCs compared to other epithelial ovarian cancers, after adjusting for other factors. Bone cancer is one of the most difficult types of cancer to diagnose, one of the most painful types you can have, and one that has a mixed response to treatment efforts. Bone cancer in many ways can be broken down into two types based on its origin, neither of which changes its prognosis considerably. If bone cancer originated in the bone, it is usually discovered because of a bone fracture, or some unrelated condition involving a bone.
Many times an unrelated injury may be x-rayed, and a careful radiologist notices a ?spot? on the x-ray that requires further evaluation. As bad as this is, it is secondary to when the cancer originated elsewhere and has spread to the bones as part of an ongoing metastasis.
General factors ? these include the patient’s age, general health, response to previous treatments, etc. When all types of bone cancers are considered in an aggregate, the survival rate is roughly 70 percent. The situation improves, however, if a bone cancer is discovered when it is localized in one area and has not spread into nearby lymph nodes. One-third of all bone cancers are diagnosed only after the cancer has spread to a lymph node or another symptom.
Sadly, when bone cancers are discovered that have spread from a distant region of the body, such as colon cancer which has metastasized to the bone, survival rate is only about 30 percent. Survival rates are defined as surviving five years after diagnosis, whether someone is in the middle of ongoing treatment or not. Some patients may have both an IV and an IP port; it is important to identify the ports correctly prior to accessing them.
The nurse also ensures that the appropriate supportive medications are ordered for safe administration. Use of laparoscopic surgery or different chemotherapy agents to treat this disease also may be factors in the decreased incidence of complications. It is important for us to understand the diagnosis, treatment plan, and potential side effects of treatment.
Research still is needed to determine the optimal regimen and scheduling, as well as the best way to administer IP chemotherapy and manage patients receiving it. National Cancer Institute clinical announcement on intraperitoneal cancer for ovarian cancer. Alberts DS, Liu PY, Hannigan EV, et al: Intraperitoneal cisplatin plus intravenous cyclophosphamide versus intravenous cisplatin plus intravenous cyclophosphamide for stage III ovarian cancer. Markman M: An update on the use of intraperitoneal chemotherapy in the management of ovarian cancer. Trimble EL, Thompson S, Christian MC, et al: Intraperitoneal chemotherapy for woman with epithelial ovarian cancer. Weisberger AS, Levine B, Storaasli JP: Use of nitrogen mustard in treatment of serous effusions of neoplastic origin. Dedrick RL, Myers CE, Bungay PM, et al: Pharmacokinetic rationale for peritoneal drug administration in the treatment of ovarian cancer. Howell SB, Pfeifle CL, Wung WE, et al: Intraperitoneal cisplatin with systemic thiosulfate protection.
Black D, Levine DE, Nicoll L, et al: Low risk of complications associated with the fenestrated peritoneal catheter used for intraperitoneal chemotherapy in ovarian cancer. Makhija S, Leitao M, Sabbatini P, et al: Complications associated with intraperitoneal chemotherapy catheters. In this article, we will review recent advances in our understanding of the pathogenesis and management of epithelial ovarian cancer. The standard IV regimen of platinum and paclitaxel was established in a study by McGuire et al.
Anti-angiogenic agents have demonstrated activity in the recurrent setting, and two trials are currently investigating whether the addition of bevacizumab to first-line treatment will improve clinical outcomes. Logistical concerns regarding IP chemotherapy, including the 24-hour administration schedule for day 1 paclitaxel as well as the regimen's toxicities, have prevented more widespread adoption of IP chemotherapy.[23] Additionally, some centers have modified the GOG 172 regimen to reduce toxicities and decrease technical difficulties. In addition, bevacizumab will be added to the chemotherapy regimen on cycle 2 of each arm, and all three arms will also entail a year of bevacizumab maintenance therapy.


If you interesting in "Uterine & Ovarian Cancer" powerpoint themes, you can download to use this powerpoint template for your own presentation template. It is sometimes cal ed uterine cancer.? Vast majority are adenocarcinomas – commonly detected during perimenopause ? but there are other cel s in the uterus that can become cancerous — such as muscle or myometrial cel s. However, the cel s have proliferated to the point where the normal structure of the endometrium is interfered with. The lighted tip of the instrument is inserted through the vagina and cervix into the uterine cavity. Adjusted relationship between age and risk of mucinous epithelial compared to serous epithelial ovarian cancer.
Adjusted relationship between age and risk of and mucinous epithelial ovarian cancer compared to other epithelial ovarian cancer.
Adjusted odds ratios and 95% confidence intervals for demographic and clinical characteristics of invasive epithelial ovarian cases by subtype, New York and Northern California. Six-year survival following an invasive epithelial ovarian cancer diagnosis by subtype, New York and Northern CaliforniaTable 4. Adjusted relationship between age and risk of death within six years following an epithelial ovarian cancer diagnosis. A total of 34 cases were excluded from the analysis on the basis of race or ethnicity data. Bone cancers can be tricky, and a person’s outcome may be tied to any of these factors, all of these factors, or even none of these factors. When the cancer has remained in one area, but has spread to the regional lymph nodes, the survival rate is just under 70 percent.
All material provided on this website is provided for informational or educational purposes only. Prior to accessing the IP port, the nurse verifies placement of the port by reviewing the postoperative notes or CT scan report. If an IP port is aspirated, there should be no blood return because the port sits in the peritoneal space. At MSKCC, prior to initiating IP chemotherapy, two nurses will trace the IP chemotherapy agent and tubing to the patient's IP port and connect the tubing in order to verify the correct route of administration. It has been suggested that use of peritoneal catheters with fenestrations and Dacron cuffs is associated with a greater incidence of bowel adhesions and erosion into the bowel.[2] IP ports do not have Dacron cuffs at this time. Other complications included catheter-related infections (three patients), inflow obstruction (five patients), and inability to access the port (one patient). Further research is warranted to identify the best device with which to administer IP chemotherapy.
As healthcare professionals, it is essential for us to look for opportunities to improve patients' outcomes and quality of life.
Intraperitoneal (IP) chemotherapy has been shown to yield superior progression-free survival (PFS) and overall survival (OS); however, logistical problems and toxicities have limited more widespread adoption. These results suggest that the fallopian tube should be considered as a possible field of origin for pelvic serous carcinomas, and investigation currently continues in this area. Optimal cytoreduction (defined as residual ?1 cm) was achieved in 48% of patients receiving primary debulking surgery and 83% of patients who received neoadjuvant chemotherapy.
Grade 3 or 4 anemia was more common in the dose-dense group, but other toxicities were similar between the two treatment arms. For viewing only, you can play with our flash based presentation viewer instead of downloading the ppt file. 3) Hyperplasia with atypia = precancerous, Approximately 25-30% of hyperplasia in this category wil progress to endometrial cancer. There the doctor can inspect any abnormal tissues and, using a tiny electrified loop, can even take samples for later lab analysis.
Multivariate proportional hazards results of invasive epithelial ovarian cancer cases, New York and Northern California. The relationship between age and epithelial subtype was nonlinear; ages 55 years and younger were more often associated with mEOC compared to both serous and other EOCs (Figures 1 and 2). To date there is no study regarding the type of implantable port to be used for IP chemotherapy.
Makhija et al.[15] analyzed the charts of 301 patients and identified 30 (10%) who had catheter-related complications. Markman and Walker[17] stated that fenestrated catheters seem to encourage fibrous sheath formation and bowel adhesions and are difficult to remove in the ambulatory setting. There are currently no evidence-based guidelines for solution temperature during IP administration. In the care of patients receiving IP chemotherapy for ovarian cancer, there are myriad critical points for nursing intervention that will affect the success of the procedure, the comfort of the patient, and the patient's sense of well being.
Recent studies have also suggested that a “dose-dense” schedule of paclitaxel in combination with carboplatin may result in improved outcomes, and the impact of biological therapies in the first-line setting is under active investigation.
These results have raised the question of whether a dose-dense schedule should be considered for patients receiving first-line IV chemotherapy and could represent a new option for the treatment of appropriate patients with advanced ovarian, peritoneal, or fallopian tube cancer.
The primary endpoint for this study was PFS, with a statistical plan to analyze each of the bevacizumab-containing arms individually against the control arm. The remaining 31 cases were excluded because race or ethnicity information was unspecified or missing. The nurse must be familiar with the regimen, specific agent(s) being administered, and clinical considerations for each agent. As with any other chemotherapy treatment modalities, staff should wear PPE (personal protective equipment) when administering chemotherapy. Others have recommended the use of a venous implantable port connected to a single lumen venous catheter (9.6 French). In our institution's ambulatory office setting, however, we remove the IP ports without complications or difficulty. Those who support warming the solution suggest there is an added therapeutic antitumor benefit and it prevents patients from feeling cold. The study, which was powered for non-inferiority, demonstrated no difference in median OS (29 vs 30 months) or PFS (11 months in both groups).
If both of the bevacizumab-containing arms demonstrated benefit compared to the control, the bevacizumab arms would be compared to one another. The cancer has spread from one (or both) ovaries to distant organs, such as the liver or lungs. Stage was defined using the International Federation of Gynecology and Obstetrics (FIGO) system, with categories I, II, III IV, or unknown. Additionally, targeted therapy remains an active area of investigation, with evidence of activity from agents such as PARP inhibitors, anti-angiogenics, and PI3 kinase inhibitors.
Based upon these results, the authors concluded that neoadjuvant chemotherapy should be considered, given the similar survival outcomes and the increased relative morbidity of primary debulking surgery. A total of 1,873 patients was accrued to this trial, with a median follow-up of 17.4 months.
MSKCC has developed administration guidelines for each agent to ensure a standard approach to preparation and administration of the agent. Here, we review recent advances in our understanding of ovarian cancer and its treatment in both the newly diagnosed and recurrent settings. All other hazard ratios in the model are calculated from the model including the interactions.


Laterality was collapsed into unilateral (single ovary involved at diagnosis: right, left, or unspecified), or bilateral (both ovaries involved at diagnosis) categories. Schymura5[1] Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA[2] Centers for Disease Control and Prevention, NPCR-Contractor, Atlanta, GA, USA[3] Public Health Institute, Sacramento, CA and University of California, Davis, USA[4] Amgen, Inc, South San Francisco, CA, USA[5] New York State Registry, Albany, NY, USA1. Comorbidity was defined using the Deyo-Charlson Comorbidity Index [22, 23], a commonly used measure of disease burden.
IntroductionOvarian cancer is the fifth leading cause of cancer death in the United States, and contributes significantly to the worldwide cancer burden [1].
It is recommended that the volume be greater than 1,500 mL, to result in abdominal distention. The lack of gynecologic-specific symptoms and effective early detection methods for ovarian cancer leads to a preponderance of late-stage diagnoses.
Any comorbidity present in the 12 months prior to or 4 months following an ovarian cancer diagnosis was included. Ovarian cancer is a surgically-staged and treated disease, and the application of appropriate, guidelines-based treatment is currently the only option to reduce ovarian cancer mortality [2]. Type of treatment was defined to distinguish patients who received various combinations of surgery and chemotherapy. The National Comprehensive Cancer Network (NCCN) [3] and the National Institutes of Health (NIH) [4] publish widely used treatment guidelines for ovarian cancer cases in the United States.
In descriptive analyses, chemotherapy was further categorized by receipt of specific agents. Both NCCN and NIH’s Physician Data Query (PDQ) incorporate tumor histology into treatment guidelines.
These categories consisted of surgery and platinum agent (cisplatin or carboplatin) receipt, surgery and platinum agent and paclitaxel receipt (standard treatment for EOC) [24], and surgery and any chemotherapy agent or combination of agents other than cisplatin, carboplatin, or paclitaxel.
While the NCCN publishes guidelines for the three main types of ovarian cancer, epithelial, sex cord-stromal, and germ cell tumors [5]; the PDQ offers guidelines only for the most common epithelial tumors.
While epithelial tumors account for about 90% of all ovarian neoplasms, they are not a homogenous group [5].
AnalysesStatistical testing was performed using the likelihood ratio chi-square test for discrete variables. The four main epithelial subtypes (serous, mucinous, clear cell, and endometrioid) can have very different clinical and pathologic patterns. Among epithelial ovarian cancer subtypes is mucinous epithelial ovarian cancer (mEOC), a relatively rare subtype accounting for approximately 14% of invasive ovarian cancer cases [6].
A generalized logits model was fit to determine the characteristics associated with epithelial subtype. Age was transformed in all models using restricted cubic spline functions to allow for nonlinearity [25]. Pathologic studies have determined that mutations in the K-ras oncogene are more common in mEOC compared to other subtypes [12], while mutations in the BRCA1 tumor suppressor gene are less common [13]. Due to the lack of availability of grade and stage information for some cases (31% for grade; 15% for stage), missing indicator variables were included for each variable in all models.
Despite their distinctive nature, mEOCs are included in overall epithelial ovarian cancer treatment guidelines, as standard care for all epithelial subtypes is defined in the same manner [3,4]. Because of potential issues with using missing indicator variables, separate models that imputed missing data were fit (data not shown) [26,27].
Because of the differences in risk factors and presentation, a few studies have examined differences in outcomes of mEOC compared to other epithelial subtypes. Many have found lower response rates to chemotherapy and inferior outcomes compared to other subtypes [14-16].
Based on these results, it has been suggested that mEOC be treated as a different entity and not grouped along with epithelial tumors in standard treatment and also in clinical trials for epithelial ovarian cancer [17]; however, these suggestions have yet to be widely adopted or implemented. Statistical testing for differences in unadjusted survival rates across epithelial subtypes was performed using the log-rank test.
While the existing evidence seems consistent, studies producing this evidence have contained small numbers and generally represent the experience of individual institutions. For adjusted survival, a time-dependent Cox model was used to determine the predictors of six-year survival.
ObjectivesThe objective of this chapter is to fully characterize mEOC using a population-based approach. Time-dependent covariates for surgery and chemotherapy were used to prevent an artificial inflation of the association between treatment and survival.
We add to the paucity of existing literature on mEOC with an analysis that utilizes ovarian cancer medical record data from two large populations in the United States, New York and Northern California.
Cases were considered as not receiving treatment until the date of the procedure; they were considered as having received treatment after the date of the procedure. We comprehensively examine demographics, pathologic characteristics, and the outcomes of treatment for mEOC. Interactions between epithelial subtype and treatment were included to determine if the effects of surgery and chemotherapy varied across subtypes. We compare these characteristics to other epithelial subtypes in order to determine whether clinical presentation or outcomes differ among epithelial subtypes.
The proportional hazards assumption was assessed using time-dependent covariates and the Schoenfeld residual correlation test. Finally, we discuss the results of this research in the context of published studies on mEOC. Stratified log[-log S(t)] plots were used to help determine time intervals within which the PH assumption held.
An interaction between laterality and time was included in the final model to satisfy the PH assumption. Setting and populationThe data presented and analyzed here are from the Ovarian Cancer Treatment Patterns and Outcomes (OCTPO) study, funded by the Centers for Disease Control and Prevention (CDC), and conducted by the New York State and the California Cancer Registries [18-20]. The New York State Cancer Registry (NYSCR) conducts surveillance on all 19 million New York state residents, and the two components of the California Cancer Registry (CCR) that were funded for this study serve the contiguous geographical area of Greater San Francisco-San Jose and Sacramento regions, providing surveillance for a population of 9 million residents in California. Both the NYSCR and the CCR conduct high quality, population-based cancer surveillance, and routinely review medical records to abstract demographics, tumor characteristics and treatment data as part of state-mandated cancer surveillance. Demographic and clinical characteristics of mucinous epithelial ovarian cancerThe characteristics of ovarian cancer cases in New York and Northern California are presented by epithelial subtype in Table 2. For this retrospective study, additional detailed patient, tumor, and treatment data were collected by these registries from multiple sources including hospital, outpatient facility and physician records. The study population included patients with invasive epithelial ovarian cancer diagnosed between 1998 and 2000. Only invasive cases of epithelial ovarian cancer were included; benign and low malignant potential tumors were excluded. Higher percentages of low grade tumors and unilateral ovarian involvement at diagnosis were also present with mEOCs compared to other EOC types. Data classification Histology was collected according to World Health Organization International Classification of Diseases for Oncology, third edition (ICD-O-3) morphology codes [21].
All epithelial histologies collected were collapsed into categories for analysis according to Table 1.



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