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“Dr. Burnett called and told me it didn’t look good and he had made an appointment with the best oncologist in town.” Vanderbilt’s Howard Jones III, M.D., one of the best-known gynecologic oncologists in the country, performed

further tests and decided to operate. He discovered Foley had stage III ovarian cancer which required surgical removal of the ovaries followed by chemotherapy.

Since the 83-year-old Foley had been focused on the risk of heart disease, she didn’t realize her age also made her a prime candidate to develop cancer of the ovaries – two walnut-sized reproductive organs that sit on either side of the uterus in the lower abdomen. According to the National Cancer Institute, 50 percent of all women with ovarian cancer are over the age of 65, but younger women can also be affected.

It is post-menopausal women like Foley who are most likely to develop tumors in the epithelial cells covering the outside of the ovary. Nearly 90 percent of all ovarian cancers are epithelial cancers which can be notoriously difficult to treat in late stages.

Foley’s referral to Jones, director of the Division of Gynecologic Oncology, ensured she would receive a treatment regimen that gave her a fighting chance

of surviving the often-deadly disease because with ovarian cancer, more than many other forms of cancer, what you do first matters.

That first step usually entails surgery to identify and remove the tumors. Several recent studies indicate patient prognosis is improved when the initial surgery is performed by a specialist with expertise in cancer surgery. Intensive training enables these surgeons to remove more of the cancerous tumors which often spread beyond the ovary into the abdominal cavity.

“Whether it’s early disease or advanced disease several studies show patients have better survival with gynecologic oncologists,” Jones said. “We’re more aggressive and we give chemotherapy in a more integrated way because most of the time gynecologic oncologists give their own chemotherapy. It’s an integrated form of treatment from the start.”

At Vanderbilt that integrated treatment is provided by a team of specialists in several medical disciplines who meet every week to discuss and manage each patient’s case. Surgeons confer with pathologists, radiation oncologists and others to determine how best to treat each patient, some of whom have genetic precursors that make them vulnerable to ovarian cancer.

A very opportunistic disease
Even with the best initial treatment ovarian cancer remains one of the most deadly forms of malignancy. The National Cancer Institute estimates 22,430 new cases of ovarian cancer in the United States in 2007, with 15,280 deaths. While ovarian cancer is not the most common of the gynecologic cancers, it is the most common cause of death among women who develop cancer of the reproductive organs.

“If we catch ovarian cancer when it’s confined to the ovary at stage I we can cure about 90 percent of those women, but the problem is we don’t often catch it when it’s stage I,” said Marta Crispens, M.D., assistant professor of Obstetrics and Gynecology at VUMC.

Nearly 75 percent of the time ovarian cancer patients are diagnosed when the disease has already advanced to stage III or stage IV. The reason: ovarian cancer has few warning signs during early stages of the disease. Sometimes patients report no symptoms at all. Other times those symptoms can be as subtle and quiet as leaves rustling softly in the breeze…and as easily dismissed by women and their physicians. Pain or swelling in the abdomen, pain in the pelvis and gastrointestinal problems such as gas, bloating or constipation are signs of ovarian cancer, but they can also be symptomatic of other milder health care problems. Women who are aging may write off that lower abdominal “pooch” as one of the less desirable, but sometimes inevitable, side effects of menopause.

But ignorance in these cases isn’t bliss – it can be dangerous. Unlike breast cancer which has been the subject of a massive public education campaign urging women to check their breasts and get regular mammograms, most women don’t know what to look for, so ovarian cancer manages to sneak up quietly and deliver an unexpected blow.

Harriet Foley had blamed the slight pain in her abdomen on a tight undergarment.

“I wore a girdle and I thought the tender spot was where the girdle was too tight. I had that slight pain for at least a month before I went in for my routine physical.”

Time was not on her side. While her gynecologist quickly ordered additional tests when he discovered her painful response to the pelvic exam, all too often women and their physicians don’t investigate the cause of those symptoms early in the disease progression. That allows the cancer time to spread beyond the ovary, and ovarian cancer is a very opportunistic disease.

“Cancer of the ovary flakes off the surface of the organ,” said Jones. “It can go to the lymph nodes through the lymphatic channels. It can go to the lungs through the venous channels, but mostly what it does is flake off, and the cancer cells float around in the abdomen. The omentum, the fatty apron that hangs down from the stomach, sweeps up all of these cancer cells and they start growing. There’s good blood supply in the omentum, which makes it an ideal environment for tumor growth.”

Ovarian cancer also may metastasize to the liver or other organs within the abdominal cavity, so surgery to remove it may be extensive.

“If I’m able to get most of the tumor out then I can tell that woman she has a three out of four chance of achieving a remission which means seeing all of the clinical signs of cancer go away,” said Crispens. “Unfortunately, while we’re very good at achieving remission we’re not so good at keeping people there. What happens is that most women will eventually recur. The median time to recurrence is about two or three years and at that point a woman may be on chemotherapy the rest of her life.”

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Nearly 70 percent of the time ovarian cancer patients are diagnosed when the disease has already advanced to stage III or stage IV.
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