Can You Help Prevent Ovarian Cancer?

[MUSIC PLAYING] Welcome, everyone. I'm Dr. John Whyte. I'm the Chief Medical Officer at WebMD. And you're watching Cancer in Context. When we talk about cancer, we often don't talk about ovarian cancer. Yet, someone is diagnosed every 40 minutes. And within 5 years, most people diagnosed have died.

Yet, where are we in terms of screening, treatment, and what about prevention? Is there a way to prevent ovarian cancer? My guests today say there may be. Joining me is Dr. Rebecca Stone. She is director of GYN Oncology at Johns Hopkins. And Dr. Kara Long Roche. She is associate professor at Sloan Kettering. Doctors, thanks for joining me.

Thank you so much for having us.

Of course.

Well, let's start off with describing to our audience what are we talking about when we say ovarian cancer.

Well, ovarian cancer is actually many different diseases that are lumped under the heading ovarian cancer. The most common type of ovarian cancer, which accounts for about 75%, is called high-grade serous carcinoma.

And the most important things about high-grade serous carcinoma is that there are no symptoms of this disease when it is in its early forms, and there is absolutely no available screening or early detection test. And so, most patients come in when the disease is already widely metastatic and spread throughout the abdomen. And at that point, treatment is very difficult and often unsuccessful.

And Dr. Stone, what about people that are saying, "Oh, hey, can't you get a blood test to detect this?" We're not quite there yet, are we?

Yeah, unfortunately, that's right. You know, we've had a blood test that many people may have heard of called CA 125, but it's not a specific or sensitive marker for ovarian cancer. It's more a marker of inflammation in general, and it hasn't been shown to detect ovarian cancer in a sensitive enough way. For instance, it may be negative in a large number of patients who have ovarian cancer.

And so, it's just not reliable. And the reason that that is because ovarian cancer, really, at the end of the day, the vast majority of cases actually don't come from the ovary. We think they more likely come from the fallopian tube, and that has really proved to be a challenge when you think about screening.

Because we don't have any imaging that can even image the fallopian tube. And when cancer spreads from the fallopian tube, it more exfoliates in the abdomen, like dandruff, so to speak, instead of being in the bloodstream early on. And so we just haven't been able to detect it using traditional modalities of cancer detection.

And we all talked a while back about ovarian cancer and how it's so important to discuss the fallopian tube. And most people aren't familiar with it. I know, Dr. Stone, you have a picture of it in your background, if you want to come to that. And we don't want to do an anatomy lesson. But maybe help women and others understand why, Dr. Long Roche, is the fallopian tube so important when we talk about ovarian cancer.

Well, about 20 years ago, someone really started looking in the fallopian tubes of patients who are undergoing preventative surgery for various high-risk situations. And what they found is in the little fingerlike ends of the fallopian tube, that sit right near the ovary and are exposed to the surfaces in the pelvis, they found little tiny precancers, which we now call stic lesions or serous tubal intraepithelial carcinomas.

And 20 years of science amassed, and we now see that those stic lesions are really the source of the subsequent metastatic high-grade serous carcinoma. And it actually was a huge light bulb moment because we understood, finally, why screening wasn't working.

These cells were just kind of shedding off of the end of the fallopian tube, and people were having metastatic disease before there was anything to feel and, certainly, before any marker showed up in the bloodstream or any visible abnormality showed up on imaging.

So Dr. Stone, what is this prevention strategy, and who is it for?

Now that we have this understanding that many cases of ovarian cancer-- and we're talking about the case, the most common type of ovarian cancer, high-grade serous cancer, the most lethal type, the type that is really hard to cure, this type of cancer-- instead of mostly coming from the ovary, actually mostly comes from the end.

And that's what that picture is showing, the fimbriated end of the fallopian tube. And once women are finished with childbearing, then they have the opportunity to have the fallopian tube removed because it really doesn't have any form or function after childbearing is complete in the post-reproductive years of a woman.

And so you can have the fallopian tube removed without any real known health repercussions. And by removing the fallopian tube, that can substantially reduce someone's lifetime risk of developing the most common and deadly type of ovarian cancer.

So Dr. Long Roche, who should consider this? Is this for every woman? Is it only for women that have a history of ovarian cancer? What's your guidance to listeners?

It's a great question. So we do think about patients as two general categories; patients who have some identifiable high-risk situation, like a genetic mutation. And in those patients, the guidelines are very clear that tube and ovary removal will help to prevent or reduce the risk of developing ovarian cancer.

And in those patients, we are studying whether removal of the fallopian tube might be an acceptable replacement for removal of the tube and ovary because it doesn't cause menopause to just remove the fallopian tubes. In patients who are average risk, who don't have a genetic mutation or strong family history, we're looking for opportunities to safely remove the tubes.

We're not advocating for patients to call their doctors and ask for surgery. However, in a patient who might want permanent birth control or a patient who's already undergoing a hysterectomy, or maybe even a patient who's undergoing another type of abdominal operation, the fallopian tubes could be safely removed in these various circumstances. So we're really looking for those situations where we can add prevention without any added risk.

Importantly, because the fallopian tube is a critical organ in reproduction-- it doesn't make any hormones, but it's important for reproduction, that probably the most important eligibility criteria is that a person be done with having children, so be in their post-reproductive phase of their life.

But are there myths about ovarian cancer that still persist? Do women say, "Well, they're already going to their OB/GYN. No one has mentioned this." But what can we do to fix this?

Absolutely. I mean, I think many women think that if they go to their OB/GYN once a year, and they have a Pap smear, that they're being checked-- and the reality is that while Pap smears are amazing and life-saving for cervical cancer, they don't check for ovarian cancer, and we don't have any test.

And so unfortunately, we're left with trying to find opportunities to reduce risk because there is, unfortunately, no way to find it early.

Because when they have signs and symptoms, it's going to be too late.

Correct.

And I think one of the other big activation barriers to this is that it's not just patients where we have a big knowledge gap. It's actually the medical community in general. This discovery of the fallopian tube origin of the most common and lethal type of ovarian cancer is not well known in the medical community.

And so one of Dr. Long Roche's missions together with me is to really achieve much better knowledge, education, mobilization around this discovery so that we can increase knowledge about and access to fallopian tube removal as a prevention strategy.

Tell us about this. Why did the two of you team up on this?

Well, Dr. Stone and I have been friends for a long time. We were co-workers for a short period of time at Hopkins, and we both spend hours and hours and hours of our weeks and our days taking care of patients and women with ovarian cancer.

And so we hate the disease. We hate what it does to our patients and their families. And we want nothing more than to spare the suffering that this disease causes. And both of us felt like it was our professional and personal mission to find a way to put ourselves out of a job in taking care of these patients.

But you've called it "intercepting" ovarian cancer. Is that right?

Yeah.

What do you mean by that, Dr. Stone, intercepting it?

So when we think about the earliest interventions that we could have, prevention is the most early, right? Prevents even precancer or cancer from developing. But there is also this newer intervention of interception, meaning that when a high-grade or high-risk type of precancer forms or maybe even the earliest, earliest form of cancer, and that spectrum may be very blurry, that we can do things to prevent the development of higher-stage, more aggressive, uncurable cancer.

And what the role of salpingectomy, or fallopian tube removal, is an interception in addition to prevention is not really clear at this point. And one of the biggest reasons for that is that we don't really understand the biology of the precancerous lesions that develop in the fallopian tube, what Dr. Long Roche was describing as these stics or serous tubal intraepithelial carcinoma.

We know that if that is found at the time somebody is having their fallopian tubes removed for prevention. That if a precancer is found, that they still have a high risk of later in their life, 10 years down the road, developing high-grade serous cancer of the peritoneum.

And so that means that there probably are some more dangerous types of precancers out there or we're unable to recognize this type of cancer in its very earliest form. And then the next problem is that even when we find it, what do we do about it?

And so that's when-- Karen and I, it's very important to us, that this project, if you want to call it that, this endeavor is not just a big public health campaign, but that actually the science moves and advances along with it.

OK. So Dr. Long Roche, what should patients say to their doctor? Should they ask-- how do the start that conversation with their OB/GYN?

I think that the first thing patients need to do is discuss their own risk with their doctor. So patients need to have an open conversation about whether they might be high-risk, because if they're high-risk, based on family history or genetic mutation, then there's a very specific pathway that they need to be counseled on and offered guideline-based prevention.

If a patient is average-risk, then I think the conversation is a little more nuanced, and patients really need to keep the conversation open, especially as it pertains to any planned abdominal surgeries.

So as women determine what the best contraception is to meet their needs, as they complete their families, as they undergo other procedures or GYN surgeries, this is a good thing to ask about. If we're going to be in the pelvis doing surgery, should we remove the fallopian tubes while we're there?

Dr. Stone, I want to follow up on Dr. Long Roche's comments about high risk. So clearly, we can look at family history by asking family members. But in terms of if there is genetic mutations, these inherited mutations that put you at higher risk, we don't routinely order genetic panels for most patients.

What about these over-the-counter tests? Does that help guide patients in understanding whether they have these inherited mutations that may put them at increased risk for ovarian cancer?

So there are some over-the-counter tests, but they don't do gene sequencing the way that medical-grade genetic testing does. And so even if somebody has a negative over-the-counter test, that can give them false reassurance that they're not at increased genetic risk.

And so particularly, for people who have a first- or second-degree relatives who have ovarian cancer, certainly people who have a strong family of breast cancer, especially early onset breast cancer, those patients really should talk to their doctor about having medical-grade genetic testing and meeting with a genetic counselor.

Where can people learn more about what you're both doing?

Yeah, the website is www.outsmartovariancancer.org. And so, we're putting together a online hub or website, if you may, where patients and providers, health professionals can go and access lots of education materials about reproductive anatomy and physiology, ovarian cancer, in general, and prevention.

Well, Dr. Stone, Dr. Long Roche, I want to thank you for taking the time today to help raise awareness of ovarian cancer and potential strategies to prevent it.