12/7/2020

Treatment Options

Season 1, Ep. 2

Welcome to the Ovarian Cancer Education Podcast, a podcast centered around a cancer diagnosis and what that means, a podcast created to help physicians and patients learn from each other, connect, and share stories and knowledge. Today’s episode will focus on treatment options for ovarian cancer.

Vanessa:
Welcome to the Ovarian Cancer Education Podcast, a podcast centered around a cancer diagnosis and what that means, a podcast created to help physicians and patients learn from each other, connect, and share stories and knowledge. Today’s episode will focus on treatment options for ovarian cancer. I’m Vanessa, and I’m joined today by my guest moderator, Rachel.

Rachel:
Thanks, Vanessa. Hi there. I’m Rachel.

Vanessa:
We’re going to talk to ovarian cancer survivors, Emma and Bev. They shared some of their journeys with us in the first episode of this podcast, which focused on new diagnosis. Dr. Radhika Gogoi from the Karmanos Cancer Center in Detroit, and Dr. Shitanshu Uppal from Michigan Medicine in Ann Arbor, will be joining us again. They are gynecologic oncologists, which are doctors who specialize in cancers located in female reproductive organs. They’ll help us understand a bit more about ovarian cancer, and Rachel and I will help fill in the gaps.

Vanessa:
If you’re listening to this podcast, there’s a good chance that you or a loved one have been diagnosed with ovarian cancer, which can be a scary and uncertain time. This podcast will help provide information and insight, but there are a wealth of other resources out there for you. And we’ve included some of those resources in the show notes for this episode. We’ve also helped develop a patient navigation line with the state of Michigan to help patients find gynecologic oncologists. The phone number for that line is 1-844-446-8727.

Rachel:
So we’re talking about treatment options today.

Vanessa:
Yes, let’s set the stage for that first though. There are many treatment options for cancer that we aren’t covering as a part of this episode. And there are treatments and drugs that Emma and Bev reference as a part of their experiences that aren’t appropriate for all patients. Clinical trials are what physicians and care teams use to test new treatments and techniques to try to improve cancer care. Those trials happen every day, all over the world. To participate in one, patients must meet qualifications related to the specific treatment or technique. Every year, those trials are reviewed. Based on successful trials, updates are made to the regulations that are considered standards of care for the medical community. We’re hoping to cover some of those basic standards of care and to help patients and loved ones understand the language of cancer treatment better.

Vanessa:
Let’s let Dr. Gogoi start us off. She’ll begin by explaining next steps for a patient with ascites, which is a fluid buildup in the abdomen, carcinamotosis, which means that there is disease visible on scans, and an elevated CA-125, that’s a blood test. Those are all tests that would make a patient’s doctor think that someone might have cancer.

Dr. Gogoi:
So a healthy patient with ascites, carcinamotosis, and an elevated CA 125 should seek the opinion of a GYN oncologist. Data suggests that patients have better outcomes when they’re cared specifically by a physician that specializes in GYN cancers. Depending on a number of factors, including the patient’s medical condition, amount and location of the disease, the physician will decide whether surgery first or chemotherapy first is a better option. Ultimately, the goal of surgery is to remove all disease, and this may be better achieved if chemotherapy is given first, shrinking the tumors and then surgery, or surgery first followed by chemotherapy. The doctor may also recommend additional testing, including a colonoscopy or a biopsy of the mass or ascites to get a diagnosis of the cancer.

Rachel:
So basically the treatment options are surgery and chemotherapy, but the order of what happens first changes based on the patient?

Vanessa:
You got it. Sometimes it isn’t even a definite that they’re going in for cancer at all. Emma had an oophorectomy, which is a surgery to remove one or both ovaries, and they were pretty sure she didn’t have cancer. She’ll tell you about what happened.

Emma:
So I had an oophorectomy to remove just the ovary that my mass was on. And before I went into surgery, my surgeon thought that there were very, very, very low odds that I might have cancer. It was part of the conversation and it was, I wouldn’t say an afterthought, but it was definitely, it kind of felt at the time, and this is me sitting in that chair as someone that assumed it wasn’t going to be cancer too. It kind of felt like she was saying, Oh, I need to mention that it’s a possibility, but for most people your age that are present with this type of imaging, that it’s not cancer. I don’t know if she used the term 99% of the time, but that was definitely kind of how it came across to my mom and I, so we were feeling really good about it like, okay, we’ll go through the surgery and I’ll go home and that’ll be it.

Emma:
And for as shocking as it was to hear that I needed surgery when just days before I thought that I might’ve just been gaining a little bit of weight, it was like, okay, good. At least this will be the end of the road. But, yeah. I had laparoscopic surgery too, and I am grateful for the fact that I have a very small incision that is now, I don’t know, at least for me being a young woman, I definitely still have a fair amount of vanity where I don’t want to have a crazy garish kind of scar on my abdomen. And I was, it wasn’t something that was like an active concern of mine before going into surgery and I don’t even think I was fully aware of the fact that I was having laparoscopic surgery, I just knew I was going to get surgery and it was like, okay, just get the thing out of me. Thank you. I don’t care how you do it.

Emma:
But in retrospect, I’m very grateful for that because my father being a colon cancer survivor has, and of course he had his surgery in the 90s, so that technology wasn’t available to him at the time. He’s got a very large scar on his abdomen. And of course, growing up, knowing that and seeing that scar on my dad from time to time, it was definitely a passing thought that it was like, Oh, no, I don’t want that though, please. So I’m so glad that that’s not the case for me. But yeah, everything, as far as I know, I think everything, at least as it was described to me and that I’ve read in paperwork, everything went really according to plan with the surgery up until the point where they did a couple of biopsies and that’s when the cancer came up in the middle of my surgery. And so then my surgery ended up taking a little bit longer because they had to go in and check and make sure that it wasn’t in any surrounding tissue.

Emma:
So at least I know, hearing from my parents that they went in thinking it was going to be a certain number of hours, and as those hours came and went, it was really scary for them that suddenly things were taking longer, but it was just the surgeon doing their due diligence to make sure that the cancer wasn’t in other places.

Rachel:
She talked about a laparoscopic surgery. Can you help me understand what that means exactly?

Vanessa:
Dr. Gogoi explains the different kinds of debulking surgeries really well. Debulking means pretty much what it sounds like. They’re trying to get rid of the bulk of something. In this case, that’s the cancer.

Dr. Gogoi:
Debulking surgery is any surgery with the goal of removing all visible cancer. To do this, the GYN oncologist will likely have to remove the uterus, the cervix, both fallopian tubes and the ovaries, as well as a portion of the omentum. The omentum is a fat pad that is in the upper abdomen and seems to be involved in collecting floating cancer cells. Lymph nodes, which are small packets of tissue that drain organs may also be removed. Occasionally, a portion of the bowel may also have to be removed.

Dr. Gogoi:
The difference between open cases and the laparoscopic cases is the approach. An open case involves an incision in the midline, generally up and down, from above the belly button to the pubic bone. Laparoscopic cases are done through smaller incisions, mostly described as Band-Aid size incisions. The end result of both of these surgeries or the goal of both of these surgeries is to remove all visible cancer.

Rachel:
Dr. Gogoi talked about some pretty intense stuff. It sounds like Emma had an easier surgery than some patients.

Vanessa:
No surgeries are easy, of course, but it’s true that most ovarian cancer patients have larger surgeries. Ovarian cancer is frequently diagnosed late because it’s difficult to diagnose. That means that the disease has often spread more than it had for Emma. Let’s let Bev tell us about her.

Bev:
So my surgery I was told was going to be a six or a seven hour surgery. They were going to, actually they did, they cut me open from top to bottom and did a full hysterectomy, scraped out any cancer that was in there. And they also removed my omentum. So actually, while they had me open, I did have, it was a unique process that they did and they literally heated up the chemo and sprayed it inside my cavity. Then when they actually glued my incision, I thought maybe I was going to have staples because I’ve talked to other women and they were stapled. And that really kind of scared me being stapled for some reason. I don’t know why, but when I woke up, I was in ICU a little longer than normal because of the chemo that was sprayed inside of me. They wanted to keep an eye on me and just make sure that I was going to react good to it.

Bev:
So yeah, when they were wanting me to get up and move, it’s almost instantly, they want you to move, but I was afraid that I was going to like, all these staples were going to come out if I moved. And when the team of doctors came in to look at it, they actually took the bandage off and was saying how good it looked and I really wanted to see it because I never had, this was actually the very first surgery I’ve ever had, and I’ve never had any type of staples or stitches or anything. So I wanted to see what it looked like. And I asked about the staples and they said, no, you weren’t stapled. You were glued. So that was pretty interesting.

Bev:
Some of the doctors had a concern about how red my incision was and my doctor told them, yes, it’s supposed to be that way because of the chemo that they sprayed in me. And that’s was one thing that they wanted to watch afterwards, was to see how it was reacting with my body, I guess. So actually the incision, it actually healed really well. I’m really happy with that.

Rachel:
I’ve been nervous about staples too, I think. I’ve never heard of that spraying process, but I’ve talked about before.

Vanessa:
That’s a topic we might cover in a future episode. Not all facilities have that available, and it’s definitely not something that all ovarian cancer patients need as a standard of care. Chemotherapy is more traditionally given before or after surgery. If the surgery happens first, it’s called adjuvant. If chemotherapy is done first to shrink the cancer before the surgery, it’s called neoadjuvant. Dr. Gogoi can tell us how that decision is made and we can talk later about how chemotherapy is usually administered.

Dr. Gogoi:
The decision really is made based on a number of factors, including the overall health of the patient and careful evaluation of the imaging, like a CAT scan or ultrasound to decide the likelihood of being able to get the cancer out completely.

Vanessa:
It’s difficult because as a patient, you’re thrown into this situation where suddenly surgeries and complicated treatment plans are a major part of your life. Bev struggled with that too.

Bev:
I always told my sister that if I ever got cancer, I’m never taking chemotherapy or radiation. But when you get to that situation, what options do you have really? So chemotherapy. I did do a lot of research on just plain diet plans, eating the right food, but I knew that I needed more than that. So chemotherapy is the treatment option that I had.

Rachel:
Bev just mentioned radiation therapy. We haven’t really talked about that yet.

Vanessa:
That’s true. Radiation therapy isn’t a primary treatment for ovarian cancer. It does sometimes play a role, but because of where ovarian cancer is located in the body, using radiation can be harmful in other ways. Chemotherapy works far better, so that and surgery are the main treatment options for ovarian cancer.

Rachel:
Okay. So can you tell me how chemotherapy actually works?

Vanessa:
Dr. Uppal does a great job at that.

Dr. Uppal:
So chemotherapy is in broad terms, administration of cytotoxic substances, which are basically chemicals which have been tested and tried and they kill rapidly dividing cells in human body. The rationale is that they kill the cancer cells more than they kill the normal human cells. And the normal human cells have the ability to regenerate whereas the cancer cells do not have that ability. And ultimately, there’s more damage to the cancer than the person receiving the chemotherapy.

Dr. Uppal:
There are certain areas in human body where cancer or non-cancer cells divide very rapidly, and we see that those are damaged by the chemotherapy sometimes temporarily and sometimes permanently. So if somebody is receiving chemotherapy and they lose hair, that’s because hair follicles have cells which are actively dividing. Giving them chemotherapy kills those cells, and then the hair drop-off. Similarly, we often see patients with chemotherapy saying that they are vulnerable to infections. And the reason for that is because the bone marrow from where all the blood lines are made, the red blood cells and the white blood cells and the platelets, from those, the white blood cells are the ones which fight infection.

Dr. Uppal:
So chemotherapy goes and kills the white blood cells, which are rapidly dividing and the counts fall, as a result, patients who are receiving chemotherapy are now vulnerable to infections. They may become anemic if their red blood cell count goes down and we have to give them transfusions. If their platelets fall down, they are at a risk of bleeding. In other words, these chemicals all have side effects, and some chemicals have different side effects than others. Some chemotherapies cause damage to the heart. Others can cause what we call as neuropathy, where the sensation in your fingers is changed after chemotherapy. And some of these side effects, as I said, can be permanent and lifelong.

Rachel:
Sounds scary and complicated.

Vanessa:
It’s not always an easy process, but chemotherapy has come a long way.

Rachel:
Is it only administered through an IV?

Vanessa:
Typically, yes. There are other methods, but that’s still the most common.

Dr. Uppal:
So for chemotherapy to be administered there are may different ways. Sometimes it’s given as pills, which is increasing nowadays. Many of the new chemotherapies are now given orally, but the traditional approach and still the most common approach is that they are given in the IV as an infusion. And for majority of the patients, these chemotherapies can cause a lot of reaction in their veins. And if it’s delivered through vein in their arm, over time what we find is that it becomes difficult to get intravenous access in these patients. So what we typically recommend is to get a port, which is a larger IV placed under the collarbone, mostly on the right side. And it facilitates the delivery of chemotherapy.

Dr. Uppal:
Now, many of these chemotherapies have different schedules that depends on what type of cancer is being treated and what stage of the disease the patient is in. And if this is a new diagnosis or a recurrent malignancy, sometimes they are given every three weeks. Sometimes chemotherapies are given every week. So those schedules depend on the type of the cancer, stage of the cancer, and where the patient is in their disease process.

Vanessa:
Bev had her chemotherapy administered through an IV and she had an interesting experience in the infusion center.

Bev:
So my chemotherapy sessions, they were kind of interesting. The first one that I had, actually, I had two choices. I could either have a bed or a reclining chair. They gave me the bed. That was the first one and that was the first time actually that I ever had that one. And it was relaxing, but it was really nerve-wracking too, because knowing that you’re going to get chemotherapy injected into your body, I guess. They do make it really comfortable for you there though. I really didn’t have any issues with chemotherapy. My infusions, there was one time that I did, and I don’t know if it was because it was being infused too fast because it should be going in slowly. But what happened was it was just really quick. I’m sitting there talking to the nurse that was starting the infusion, and all of a sudden, I started going numb. My lower back was just instantly in pain and I thought I was going to pass out. My heart was just beating so fast.

Bev:
So I asked her what was going on and she, as soon as she seen that I was reacting, then she stopped the infusion instantly. And just as fast as she stopped the infusion, it started to dissipate. But at that same time, she had already called for help and there are six doctors there.

Vanessa:
So an important thing to realize with what happened at Bev is the communication is very important. Bev knew that something had changed. She knew something was wrong. And she said something immediately. A lot of patients are nervous or scared about speaking up, but the information is really important for the care team. The more information, the better.

Rachel:
I would imagine that the reactions patients have to chemotherapy depends a lot on their individual schedules.

Vanessa:
Yes. And learning about them can be very overwhelming.

Emma:
So I know that I got two cancer drugs, and I think it was Carboplatin and Taxol, Carbo/Taxol, whatever that combo was called on the internet. I remember at the time doing a little bit of light Googling and investigation and kind of backing out of that really quickly when I know at least for me personally, I have a history. When I was very young, I got a, well, not very young, but a teenager. When I was a teenager, I got a tetanus shot and they give you the little slip after you get the shot that’s kind of [inaudible 00:00:21:42], this is what tetanus is and facts about the vaccine and stuff. And I know something about reading that. I almost passed out reading it in the car and my mom was like, okay.

Emma:
So I just remember I had kind of a, I felt I was starting to have a similar reaction just reading about the drugs and what the drugs are and what they do. And of course, with Googling inevitably you kind of quickly stumbled upon long-term side effect type stuff. And that’s when I heard the words of my oncologist in my head to not Google things and his reminder that no one goes to the internet to write rave reviews about their experience certainly with chemo drugs, but really with anything. So after that, I really did a good job of staying away from it and just dealing with my reaction to the drugs and just like, especially when you, at least for me going through chemotherapy, it was easiest to take it day by day where it was like, okay, if I wake up feeling terrible, I just treat that as a sick day. Or it’s, okay, I was going to be in bed feeling crappy all day and trying to fight back the nausea.

Rachel:
I feel like nausea is the most common thing I hear people talking about when they go into chemotherapy.

Vanessa:
We’ll cover reactions and how to help treat them more in our chemotherapy specific episode. But yes, nausea is definitely common. Bev had nausea too.

Bev:
But after having chemo, the very next day, literally, after each chemo session, the very next day I felt invincible that I could do anything. And I did, you know what I mean? I cleaned house, did laundry, whatever I could do. But the second day wasn’t the best day. The second day was actually one of the worst days because I just felt drained, and maybe it was because I felt so energetic the first day. But my son told me that after chemo, I’m always confused and forgetful. And he was really correct about that. I was confused and forgetful.

Bev:
So with the chemo, they gave me, I always called it after chemo medication because it was medication to help me with the nausea. And I never got sick. The worst thing that happened was I think constipation actually, because with the chemo and then the after chemo medication, actually makes you constipated. And that was really tough because that was a lot of pain. And kind of after my surgery too, with the chemo, after the surgery, I really didn’t even want to take that medication because after being cut open and just still being sore and then having the chemo and knowing that it was going to make me constipated, I really didn’t even want to take it because in my opinion, the constipation was the worst part of chemo for me other than losing my hair, I guess. I used to have a lot of hair, but it does grow back.

Rachel:
Oh, that’s true. You do hear a lot about constipation and hair loss too.

Vanessa:
Emma lost her hair too like Beth did.

Emma:
I think because like, again, I think it’s something that people kind of know happens. They just associate cancer with hair loss even if people don’t have a cancer that, even if people are taking chemo drugs that don’t cause hair loss. I think that’s almost like people are less aware of that to some extent at this point, like you can take chemo drugs and it won’t be evident looking at the persons that are taking chemo drugs because they might not lose their hair.

Vanessa:
She also found a good way to make the situation positive.

Emma:
There were definitely things that I did just to make myself more comfortable. For sure, I lost my hair going through chemo and I’d shaved my head before I started losing my hair. So there were certain like, I was definitely thinking about where I was like, I didn’t like the idea of brushing my hair and just massive clumps of my very long hair at the time falling out. So trying to imagine what that would be like, I was like, I’m going to go out and shave my head now instead. And actually I was able, I had just enough hair to donate all that, which was one nice thing. So it kind of felt like I avoided a little bit of emotional trauma and I helped someone else. So it felt like a win-win at the time.

Rachel:
Wow, that’s great.

Vanessa:
I know. It’s hard to find bright moments in journeys with cancer, but they do happen. Bev found some positivity in her journey too.

Bev:
Yeah. I do feel that I’ve gotten some positivity out of experiencing cancer. My emotions has been off the board, but it just brings you closer to yourself, I guess. It just makes your eyes more wide open with your surroundings, the people around you, and just having a lot of faith just seeing all the people that really care about you. A lot of people really come together and that’s pretty positive all in itself and you have to stay positive. And then actually, I think having the cancer does make you more positive on the outlook of life.

Rachel:
I like the concept of being closer to yourself. That’s really beautiful.

Vanessa:
Yeah. And the support of her loved ones who helped her. Chemotherapy is a very large topic and what we’ve covered here is just a small part of it. Our next episode, we’ll go into more depth, if it’s a subject you’re interested in. As a reminder, there is a patient navigation line you can call if you or someone needs help finding a gynecologic oncologist. That number is 1-844-446-8727. And don’t to check out the show notes in resources. Thank you again for joining us.

Vanessa:
The information contained herein, is information only. Users are solely responsible for all medical care and services delivered to their patients and all decisions related to such medical care and services. Neither MOQC nor the regions of the University of Michigan shall be responsible for any delivery of medical care or other services to any patient or any decisions, acts or omissions of persons in connection with the delivery of medical care or other services to any patient.

Michigan Dept. of Health and Human Services (MDHHS) Ovarian Cancer Patient Navigation Line:
1-844-446-8727
https://www.michigan.gov/mdhhs/

Society of Gynecologic Oncology: Ovarian Cancer
https://www.sgo.org/patient-resources/ovarian-cancer/

Foundation for Women’s Cancer: Ovarian Cancer
https://www.foundationforwomenscancer.org/gynecologic-cancers/cancer-types/ovarian/

NCCN Patient Guidelines: Epithelial Ovarian Cancer
https://www.nccn.org/patients/guidelines/content/PDF/ovarian-patient.pdf

American Cancer Society: Ovarian Cancer
https://www.cancer.org/cancer/ovarian-cancer.html

Center for Disease Control and Prevention: Ovarian Cancer
https://www.cdc.gov/cancer/ovarian/index.htm

Clinical Trials
https://clinicaltrials.gov/

Facing Our Risk of Cancer Empowered (FORCE)
https://www.facingourrisk.org/

Michigan Oncology Quality Consortium
https://moqc.org/

Michigan Ovarian Cancer Alliance (MIOCA)
https://www.mioca.org/

National Ovarian Cancer Coalition (NOCC)
http://ovarian.org/

DISCLAIMER
The information contained herein is information only.  Users are solely responsible for all medical care and services delivered to their patients and all decisions related to such medical care and services.  Neither MOQC or the Regents of the University of Michigan shall be responsible for any delivery of medical care or other services to any patient, or any decisions, acts or omissions of persons in connection with the delivery of medical care or other services to any patient. These materials were made possible by a generous grant from the Michigan Department of Health and Human Services.