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Medscape
Despite advances in cancer research, there remain
"surprising gaps" in the fundamental understanding of ovarian cancer,
according to a report published online by the National Academies of Sciences, Engineering, and Medicine.
One of the key findings of the report is that ovarian cancer should not be categorized as a single disease; rather, it should be considered a constellation of different cancers that involve the ovary.
There are several distinct subtypes with different origins, risk factors, genetic mutations, biologic behaviors, and prognoses.
Recent evidence suggests many ovarian cancers arise outside the ovary, such as in the fallopian tubes, and eventually metastasize to the ovary, according to the report. The cancers can also arise from cells that are not considered intrinsic to the ovary.
"We are tying to understand the root causes of ovarian cancer — why some women get it and why some don't, and why some women live for decades and others don't," said Beth Karlan, MD, director of the women's cancer program at Cedars-Sinai Medical Center in Los Angeles, who is a member of the Committee on the State of the Science of Ovarian Cancer Research, which is responsible for the report.
The committee was created by the Institute of Medicine, with support from the Centers for Disease Control and Prevention.
"We now have technologies that we can embrace to help us understand the root causes from a molecular level and immunologic level," Dr Karlan said during a press briefing held to highlight key findings of the report. We also need to understand individual behavior, in terms of exercise and diet, so that we can determine where we go from here, she noted.
"We are hoping to harness this knowledge in terms of early detection, risk assessment, prevention, and treatment. It was this type of expertise and interest that brought this committee together," she explained.
One of the Deadliest Cancers
Although ovarian cancer is relatively uncommon, it is one of the deadliest cancers. Each year, more than 21,000 women are diagnosed with ovarian cancer in the United States, and more than 14,000 women die from the disease.
Late diagnosis is a major concern, said Jerome F. Strauss III, MD, executive vice president for medical affairs and dean of the Virginia Commonwealth University School of Medicine in Richmond, who is chair of the committee.
"The diagnosis is often made when the disease is disseminated, and about 60% of women who are diagnosed with ovarian cancer are diagnosed at advanced stages," said Dr Strauss, who chaired the panel at the press briefing. "It is associated with a 5-year survival of less than a 30%."
Committee Findings
The committee looked at the continuum of care, from prevention and early detection, through diagnosis, treatment, and the management of recurrent disease, to survivorship issues, Dr Odunsi reported.
"As we went through the continuum, we realized that we should be prioritizing the study of high-grade serous carcinoma," he said. "That is another key point of this report."
This does not mean that other subtypes should be excluded from research, but the focus needs to be on high-grade serous carcinoma, he said.
There are gaps in research about the biology of ovarian cancers, in terms of novel therapies, and in early detection, Dr Odunsi reiterated.
"We still do not have a very robust early-detection strategy," he emphasized.
Another gap identified by the committee is access to care. "Even if we apply the standard of care," he explained, "there are significant proportions of the patient population who not going to be getting that care."
Known barriers to access to care are linked to certain parameters, such as socioeconomic demographics, nonwhite race, advanced age at diagnosis, and treatment-limiting comorbidities.
The two most significant predictors of whether a woman with ovarian cancer will receive the appropriate standard of care, and therefore have a better health outcome, are being treated by a gynecologic oncologist and being treated in a high-volume hospital or cancer center.
Access to this care, however, can be a challenge for many. "We need to identify barriers to both treatment and diagnosis," he said.
Concepts and Recommendations
The committee identified four overarching concepts and came up with 10 recommendations to take the report forward, Dr Strauss explained.
The recommendations are meant to be "intertwined and so need to be considered simultaneously, not sequentially." The sequence should not be considered an indication of importance or an order of implementation.
Overarching Concepts and Recommendations of the Committee
One of the key findings of the report is that ovarian cancer should not be categorized as a single disease; rather, it should be considered a constellation of different cancers that involve the ovary.
There are several distinct subtypes with different origins, risk factors, genetic mutations, biologic behaviors, and prognoses.
Recent evidence suggests many ovarian cancers arise outside the ovary, such as in the fallopian tubes, and eventually metastasize to the ovary, according to the report. The cancers can also arise from cells that are not considered intrinsic to the ovary.
"We are tying to understand the root causes of ovarian cancer — why some women get it and why some don't, and why some women live for decades and others don't," said Beth Karlan, MD, director of the women's cancer program at Cedars-Sinai Medical Center in Los Angeles, who is a member of the Committee on the State of the Science of Ovarian Cancer Research, which is responsible for the report.
The committee was created by the Institute of Medicine, with support from the Centers for Disease Control and Prevention.
"We now have technologies that we can embrace to help us understand the root causes from a molecular level and immunologic level," Dr Karlan said during a press briefing held to highlight key findings of the report. We also need to understand individual behavior, in terms of exercise and diet, so that we can determine where we go from here, she noted.
"We are hoping to harness this knowledge in terms of early detection, risk assessment, prevention, and treatment. It was this type of expertise and interest that brought this committee together," she explained.
One of the Deadliest Cancers
Although ovarian cancer is relatively uncommon, it is one of the deadliest cancers. Each year, more than 21,000 women are diagnosed with ovarian cancer in the United States, and more than 14,000 women die from the disease.
Late diagnosis is a major concern, said Jerome F. Strauss III, MD, executive vice president for medical affairs and dean of the Virginia Commonwealth University School of Medicine in Richmond, who is chair of the committee.
"The diagnosis is often made when the disease is disseminated, and about 60% of women who are diagnosed with ovarian cancer are diagnosed at advanced stages," said Dr Strauss, who chaired the panel at the press briefing. "It is associated with a 5-year survival of less than a 30%."
Committee Findings
The report is perhaps the most comprehensive document that has tackled the question of "where do we go from here" in ovarian cancer research,"One of the most important findings is that ovarian cancer it is not a single disease," Dr Odunsi told Medscape Medical News. "There are subtypes of ovarian cancers, and the most problematic is high-grade serous carcinoma, which affects about 60% to 70% of patients and is associated with very high mortality."
said Adekunle Odunsi, MD, PhD, deputy director and chair of the Department of Gynecologic Oncology at the Roswell Park Cancer Institute in Buffalo, New York, who is a member of the committee.
The committee looked at the continuum of care, from prevention and early detection, through diagnosis, treatment, and the management of recurrent disease, to survivorship issues, Dr Odunsi reported.
"As we went through the continuum, we realized that we should be prioritizing the study of high-grade serous carcinoma," he said. "That is another key point of this report."
This does not mean that other subtypes should be excluded from research, but the focus needs to be on high-grade serous carcinoma, he said.
There are gaps in research about the biology of ovarian cancers, in terms of novel therapies, and in early detection, Dr Odunsi reiterated.
"We still do not have a very robust early-detection strategy," he emphasized.
Another gap identified by the committee is access to care. "Even if we apply the standard of care," he explained, "there are significant proportions of the patient population who not going to be getting that care."
Known barriers to access to care are linked to certain parameters, such as socioeconomic demographics, nonwhite race, advanced age at diagnosis, and treatment-limiting comorbidities.
The two most significant predictors of whether a woman with ovarian cancer will receive the appropriate standard of care, and therefore have a better health outcome, are being treated by a gynecologic oncologist and being treated in a high-volume hospital or cancer center.
Access to this care, however, can be a challenge for many. "We need to identify barriers to both treatment and diagnosis," he said.
Concepts and Recommendations
The committee identified four overarching concepts and came up with 10 recommendations to take the report forward, Dr Strauss explained.
The recommendations are meant to be "intertwined and so need to be considered simultaneously, not sequentially." The sequence should not be considered an indication of importance or an order of implementation.
Overarching Concepts and Recommendations of the Committee
| Overarching concepts | |
| The study of high-grade serous carcinoma needs to be given priority because it is the most common and lethal subtype | |
| More subtype-specific research is needed to further define differences among the various subtypes | |
| Collaborative research, which includes the pooling and sharing of data and biospecimen resources, is essential because ovarian cancers are relatively rare and heterogeneous | |
| The dissemination of new information and the implementation of evidence-based interventions and practices are the final steps in the knowledge translation process | |
| Recommendations for researchers and funding organizations | |
| Design and prioritize preclinical, clinical, and population-based research agendas that take into account the different ovarian cancer subtypes | |
| Identify and evaluate the underlying mechanisms of both new and established risk factors for ovarian cancers in order to develop and validate a dynamic risk-assessment tool that accounts for the various subtypes of ovarian cancer | |
| Focus on the development and assessment of early-detection strategies that extend beyond current imaging modalities and biomarkers and that reflect the pathobiology of each ovarian cancer subtype | |
| Study the supportive-care needs of patients with ovarian cancer throughout the disease trajectory | |
| Recommendations for pathology organizations, professional oncology groups, and ovarian cancer researchers | |
| Reach consensus on diagnostic criteria, nomenclature, and classification schemes that reflect the morphologic and molecular heterogeneity of ovarian cancers, and promote the universal adoption of a standardized taxonomy | |
| Recommendations for clinicians and researchers | |
| Develop and implement innovative strategies to increase genetic counseling and testing and cascade testing for known germline genetic predispositions in appropriate populations | |
| Focus on quantifying the risk–benefit balance of nonsurgical and surgical prevention strategies for specific subtypes and at-risk populations | |
| Investigate methods to ensure the consistent implementation of current standards of care (e.g., access to specialist care, surgical management, chemotherapy regimen and route of administration, and universal germline genetic testing for newly diagnosed women) that are linked to quality metrics | |
| Focus on improving current treatment strategies | |
| Recommendations for researchers | |
| Develop more effective pharmacologic and nonpharmacologic therapies and combinations of therapies that take into account the unique biology and clinical course of ovarian cancer | |
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