Diablo Valley Oncology & Hematology

Ovarian cancer represents about 25% of all female genital tract malignancies. However, there are more deaths from ovarian cancer each year in the United States than from endometrial cancer and cervical cancer combined. The lifetime risk of developing spontaneous ovarian cancer is about 1.7%. Epithelial ovarian cancer was expected cause 15,520 deaths in 2008. Mean age at diagnosis is 60. There has been a significant improvement in the five year survival rate for patients with ovarian cancer. This is likely a combination of better tumor debulking surgeries and better chemotherapeutic options.

Most patients with epithelial ovarian cancer do not have signs or symptoms until disease spreads to the upper abdomen. 70% of patients present with advanced disease. Symptoms for early stage ovarian cancer can include nonspecific pelvic discomfort, urinary frequency and constipation which are caused by an enlarging pelvic mass. With advanced disease, patients experience abdominal pain, bloating, anorexia, nausea and constipation.

The best tumor marker for ovarian cancer is CA 125. Minor elevations in CA 125 can also be seen in endometriosis, benign tumors, fibroids and in pregnant and postpartum women. In addition, moderate elevation of CA 125 can be seen in other adnocarcinoma such as breast and endometrial cancer. The sensitivity of CA 125 is 70% to 80% and the specificity is 98.6% to 99.4%. However, in the average risk population with low prevalence of ovarian cancer, the false positive can be unacceptably high.

The National Cancer Institute recommends screening for ovarian cancer in women with known genetic syndromes associated with this disease and for women with strong family history. Routine screening of women without family history of ovarian cancer is not recommended. The known genetic syndromes include hereditary breast and ovarian cancer syndrome associated with BRCA 1, BRCA 2 and Hereditary Nonpolyposis Colorectal Cancer Syndrome (HNPCC). The absolute risk of ovarian cancer in the presence of either BRCA 1 or BRCA 2 mutation ranges from 16% to 60%. For patients with HNPCC syndrome, the lifetime risk of ovarian cancer is 9% to 12%.

Epithelial ovarian cancer accounts for about 90% of ovarian cancers. Common histologies include serous, mucinous, endometroid, transitiona and clear cell types. Germ cell tumors include dysgerminoma, endodermal sinus tumor, malignant teratoma embryonal carcinoma or primary choriocarcinoma. Stromal tumors include granulose tumor or Sertoli-Leydig tumor.

Upon initial presentation, surgery is used for confirmation and staging of ovarian cancer. Stage I disease is confined to one or both ovaries. Stage II involves one or both ovaries with extension to the pelvic viscera. Stage III is associated with implants on the abdominopelvic wall or the serosal surface of the liver or involves small bowel or omentum. Stage IV disease involves distant metastasis. The 5 year survival for stage IA disease and grade 1 or 2 histology is greater than 90%. For high risk stage I disease and stage II disease, 5 year survival is 80%. For patients with stage III disease after optimal debulking, 5 year survival is 20% to 30%. This reduces to be less than 10% for stage III patients with suboptimal debulking and stage IV disease.

Stage I ovarian cancer with favorable prognostic features can be treated with surgery alone. For women with high risk, early stage cancer (Stage I grade 3 or stage II disease), adjuvant chemotherapy with platinum based agents show an 11% improvement in progression free survival and 8% improvement in overall survival. For stage III and IV disease, the current standard of care include maximal attempt at surgical cytoreduction followed by chemotherapy with platinum based agents.

Optimal debulking is an important part in the treatment of ovarian cancer. Retrospective data have shown that survival is better for women who receive chemotherapy in the presence of low volume disease. In the setting where optimal surgical cytoreduction cannot be achieved, an alternative approach is for the patient to receive chemotherapy up front. For patients who have a partial response to neoadjuvant chemotherapy, it may be appropriate to attempt surgical removal of macroscopic disease at that time.

As for the standard of care in chemotherapy for advanced ovarian cancer, studies have shown that paclitaxel/cisplatin combination is superior to cyclophosphamide/cisplatin combination. Later studies showed that carboplatin/paclitaxel is at least as effective as cisplatin/paclitaxel.

Intraperitoneal chemotherapy is an appealing approach for treating a disease that is largely confined in the peritoneal space. GOG 172 which was a phase III clinical trials demonstrated that this regional approach resulted in superior progression free survival and overall survival when compared with the intravenous approach alone. The disadvantage of this approach includes local toxicity, and requirement for intraperitoneal catheter placement.

Because of the high recurrence rate in patients with advanced ovarian cancer, the issue of whether consolidation chemotherapy may improve time to progression and overall survival was examined in a phase III trial comparing 3 and 12 cycles of taxol. Progression free survival favored the 12 cycle arm. However, overall survival was not different between the two arms. Therefore, the oncologist needs to discuss with the patient and allow them to decide whether the improved progression free survival justifies toxicities including peripheral neuropathy and alopecia.

For many patients with advanced ovarian cancer who have an initial treatment response, disease relapses at a later time. The treatment of patients with recurrent disease or resistant disease needs to be individualized. For people with long treatment free interval, similar drugs many be reused. There are also a number of single agent drugs with activity in ovarian cancer. These include altretamine, bevacizumab, docetaxel, etoposide, gemcitabine, liposomal doxorubicin, paclitaxel, tamoxifen, topotecan and vinorelbine.

Radiation can also play a role in the palliation of some patients with recurrent ovarian cancer. Symptoms such as pain from growing pelvic mass or bone metastasis can be palliated. Very rarely cerebral metastasis can develop which can also be treated with radiation.

The best treatment of ovarian cancer needs a team approach between the primary care physician, gynecological oncology surgeon, medical oncologists and radiation oncologists. As more chemotherapeutic agents become available and as we further understand the biology of epithelial ovarian cancer, we hope to further improve the overall survival and quality of life of our patients.

Gigi Q. Chen, MD, received her medical oncology and hematology training at University of California at Davis. She now practices at Diablo Valley Oncology and Hematology at the California Cancer Research and Treatment Center at Pleasant Hill, California. Her facility specializes in comprehensive, cutting-edge treatment of all forms of cancer through clinical trials, chemotherapy, biological treatments, diagnostic imaging, and radiation. She is on the medical staff of John Muir Medical Center in both Walnut Creek and Concord and the San Ramon Regional Medical Center.

Diablo Valley Oncology and Hematology Medical Group's breast cancer specialist, Tiffany Svahn, M.D. was given the honor of accepting a Proclamation declaring October Breast Cancer Awareness Month and October 16th National Mammography Day in the City of Orinda. Dr. Svahn received this recognition because of her dedication, hard work, leadership and perseverance in the fight against breast cancer.

Seeing approximately 800 breast cancer patients a year, Dr. Svahn's approach involves treating the whole person, not just their disease. "I find it important to address not only my patient's medical needs, but their emotional and psychological ones as well. In addition to focusing on treatment of the disease, I urge my patients to lead a healthy life style with exercise and good nutrition and I help them learn about the different aspects of wellness," says Dr. Svahn.

As a recognized leader and expert in her field, Dr. Svahn was recently asked to organize and lead a national event for East Bay breast cancer survivors. Held in major metropolitan areas across the country, the event is called "the Many Faces of Breast Cancer". Dr. Svahn and Diablo Valley Oncology and Hematology Medical Group partnered with the American Cancer Society, the Wellness Community, and AstraZeneca to bring this program to the community. It was held at the Lesher Center for the Arts in Walnut Creek on Saturday October 24th with a full house of breast cancer survivors!

Dr. Svahn has been in private practice since 2006 at Diablo Valley Oncology/Hematology Medical Group located at the California Cancer and Research Institute in Pleasant Hill. She is board certified in Internal Medicine and Medical Oncology and has full privileges at John Muir Medical Center's Walnut Creek and Concord Campuses and San Ramon Regional Medical Center. Her group's facility is the largest freestanding community focused cancer center in central Contra Costa County and provides comprehensive cancer and blood disorder care all at one convenient location. There are six medical oncologists and one radiation oncologist in the group and they each focus on one or more specific tumor types and blood disorders. This specialization gives patients an extra level of comfort and confidence knowing they are being cared for by the very best, most knowledgeable practitioners in the field.

The California Cancer and Research Institute is a three story building located in a peaceful, park-like setting at 400 Taylor Blvd in Pleasant Hill. The facility opened in 2008 and is a contemporary and serene space where patients come for medical oncology & hematology appointments, radiation, chemotherapy and biological treatments, diagnostic imaging, clinical trials and supportive services. The comment physicians hear most from their patients is, "You've made this so much easier for me. I can see all my doctors and get state-of-the-art treatment all in one location plus I know you are talking to each other about my medical care and condition. It's like coming to a mini-Stanford or UCSF." That is the benefit of a community setting facility - patients don't have to travel far to receive academic level medicine with cutting-edge services where they can navigate through the system faster and easier.

Pleasant Hill, CA - Diablo Valley Oncology & Hematology Medical Group celebrates first year anniversary of the opening of the California Cancer and Research Institute in Pleasant Hill. It is the largest nonhospital, freestanding community based cancer treatment facility in Contra Costa County and provides what every cancer patient wants and deserves%u2026the very best in leading-edge cancer treatment with services all in one convenient location.

"We made it our priority to establish the first and finest comprehensive cancer center in the East Bay," says Dr. Matthew Sirott, President and CEO of Diablo Valley Oncology/Hematology Medical Group. There are six medical oncologists and one radiation oncologist in the group and they each focus on one or more specific tumor types and blood disorders. This specialization gives patients an extra level of comfort and confidence knowing they are being cared for by the very best, most knowledgeable practitioners in the field.

California Cancer and Research Institute is a three story building located in a peaceful, park-like setting at 400 Taylor Blvd in Pleasant Hill. The facility opened in 2008 and is a contemporary and serene space where patients come for medical oncology appointments, radiation, chemotherapy treatments, diagnostic imaging, clinical trials and supportive services.

Gathering state-of-the-art equipment, electronic medical records, and multiple specialties under one roof provides for better coordination of patient care. "It allows an ease and convenience for patients that couldn't be done before," Dr. Sirott says. "If I see a patient, order a PET-CT, and decide this person needs to see a radiation oncologist, they can do so on the very same day. The radiation oncologist can evaluate the patient and if necessary, he can treat the patient that day. Because we have these services and physicians working together at the same location, communication and coordination of patient treatment is more efficient and much better. Even the academic centers, which do have all of these pieces, are harder to utilize. That's the benefit of a community setting - you don't have to travel far to receive academic level medicine with cutting-edge services where you can navigate through the system faster and easier."

"Many patients today get radiation therapy and chemotherapy at the same time, so it's great for them to come to our center for both services and not have to do so much running around," says Dr. Kamath. "The thing I hear often from patients is, 'You've made this so much easier for me. I can see all my doctors and get my treatment in one location, and I know you are talking to each other about my medical care. It's like coming to a mini medical center.'"

"When someone is first told that they have cancer, they are shocked, they're scared, and of course they want to get the best treatment they possibly can," says Dr. Kamath. "I think this facility is very unique in that we don't just treat cancer, we treat people with cancer. We use the most advanced, proven technologies to deliver the same level of care as a Stanford or a UCSF, and we do it in a very personalized way," he adds. "We take care of each of our patients as if they were a close family member; they become part of our DVO family."