Treatment Planning in Ovarian Cancer



Maurie Markman, MD: If I could turn to a second issue, it’s really the idea of the health care team that’s going to be involved in the care of a woman who’s diagnosed with ovarian cancer. Dr. Chura, who’s typically involved in the care of a patient with ovarian cancer?

Justin Chura, MD: The bias I have is that the care can be directed by a gynecologic oncologist, a specialist, that can take care of the disease from the operating room, to the chemotherapy infusions, to the survivorship afterward, to sort of provide a continuum of care for that patient. Gynecologic oncologists have spent several additional years studying and treating ovarian cancer, and that really becomes a core of our expertise. Having a gynecologic oncologist as part of the treatment team, from my perspective, is critical for patients to have comprehensive and longitudinal care, so that they’re not passed off from provider to provider along the way.

Maurie Markman, MD: Justin, a woman now has ovarian cancer, or is highly suspected of ovarian cancer, or might even have had that diagnosis of ovarian cancer. She comes in to see you for that first conversation, usually with her family. What do you talk about, at that point in time? It’s a new diagnosis of ovarian cancer.

Justin Chura, MD: We first talk about the apparent stage of the disease, whether that’s based upon CAT scan or prior biopsy findings. We acknowledge that it’s not a variable that we can change, but it is important in terms of the prognosis for the person in front of us. We then talk about what our treatment plan will be, and how we will sequence the treatments. The cornerstones, as you know, are surgery and chemotherapy. Sometimes, it will be surgery followed by chemotherapy. Sometimes, it can be chemotherapy with surgery in the middle, followed by additional chemotherapy. And then, we also look at the overall condition of a patient and discuss what we think can be tolerated by the body in terms of the stress of surgery, or the stress of treatment.

As a physician, there’s only a couple points of influence that I can really impact. I can’t impact whether a patient is going to have cancer that responds to chemotherapy or not. I can’t impact their stage when they walk through the door. But one of the biggest impacts I can have is with the surgical intervention. Can we achieve a complete resection of all of the cancer that’s there? That’s the one role where a gynecologic oncologist can play a big role in a patient’s overall prognosis. We know that patients who have complete resection of their disease tend to do better in terms of overall survival, compared to those who don’t.

Maurie Markman, MD: With all of the information that you’re attempting to deliver in a very difficult situation, are there a few key points that you hope to convey to that patient and her family or advisors, who are going to help remember all of that stuff later, at that point in time?

Justin Chura, MD: I think one is that despite being diagnosed with advanced stage cancer, people shouldn’t go home to prepare to die, as Anya did. For most women, we can achieve remission. With the combination of surgery and chemotherapy, we can get to a point where a patient will be in remission for a period of time. And then, as I explain to patients, there are several milestones that we walk past in terms of prognosis.

So, the first, we said, is stage. We can’t influence that. The second is the success of the surgery, in terms of removing the tumor that’s there. Can we resect every area of cancer? The next is, what is the response to chemotherapy? Is the patient platinum-sensitive? Do we achieve a remission? Then, in achieving that remission, what really will drive prognosis is how long that remission lasts, whether it’s 1 month, 1 year, or 3 years. That really changes how we then approach the patient, when there’s recurrence. Those are some of the key milestones that we have to walk down. And obviously, we don’t know, for the individual, until we start down that path. But despite advanced stage, despite what sounds like a horrible diagnosis, most women will have a response to treatment.

Maurie Markman, MD: You very clearly, very eloquently, described very important issues that need to be discussed with the patient and her family. You and I obviously have a lot of experience doing that. We do it often. We know what we want to say and how we want to say it. On the other hand, for the patient and her family, this is their first time. And for initial diagnosis, it’s only going to happen once. Patients and families come at different points in their lives, and they have different backgrounds, etc. How do you deal with the patient and the family? You know what you want to convey, but again, they’re at different points, different places in their lives, etc. How do you deal with that variability?

Justin Chura, MD: Part of that is assessing the patient’s understanding of her disease, as well as the family members who are present. A lot of people will have come in trying to have done some basic research to have a sense of what the treatments may be. And although there are a lot of resources, there are only a few reliable and credible ones that I would point patients towards. It’s assessing where the patient is in her understanding of what we can achieve. What is realistic, and what is not? And then, it’s about trying to really individualize the discussion and, eventually, the treatment plan, to meet the goals of treatment and goals of care for the patient.

Maurie Markman, MD: Anya, obviously you have a wonderful doctor, and you’ve been through this journey now for a number of years. How important is that health care team, the doctor and the individuals working with that team? How important was it, or is it, to you, and for other patients, in your opinion?

Anya Khomenko: The initial conversation, right after the diagnosis, is of prime importance. It’s up to the doctor to instill hope. My first doctor, who also happened to be a wonderful doctor, told me, “Statistics are only good for the research. Don’t look at the statistics.”

Maurie Markman, MD: You are not a statistic.

Anya Khomenko: “You’re not a statistic. Actually, you have a 50/50 chance.” He was right. Dr. Chura also says the same thing. He says, “If I could clone you, I could try different modalities and different drugs. But I can’t.” Every person responds differently physically, emotionally, and mentally. The main objective, aside from the treatment from the doctor, is to instill hope. It’s achievable. I know people who have survived this disease, and I know people who live long. We all should have this hope.

Transcript Edited for Clarity

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