Dana-Farber Cancer Institute: Ask The Expert About Gynecologic Cancers

Dr. Matulonis, of the Medical Gynecologic Oncology Program answers questions about cervical and uterine cancer

Dana-Farber Cancer Institute: Ask The Expert About Gynecologic Cancers

Dr. Matulonis is the Medical Director and Program Leader of the Medical Gynecologic Oncology Program at Dana-Farber Cancer Institute and the Associate Professor of Medicine at Harvard Medical School. Dr. Matulonis serves on multiple committees focused on advancing the treatment of gynecologic malignancies and has received several awards for her dedication and excellence in her field. Click here for Dr. Matulonis’ bio.

Each year in the United States, more than 12,000 women will be diagnosed with invasive cervical cancer, more than 22,000 women will be diagnosed with ovarian cancer and more than 49,500 women will be diagnosed with uterine cancer. Understanding treatment options, the role of different doctors specializing in the treatment of gynecologic malignancies, and how and when to access new and innovative cancer treatment options available through clinical trials is essential in order to achieve the best outcome from cancer treatment.

Join us on CancerConnect to view the Q&A on uterine cancer, ovarian cancer, and cervical cancer. You can also view the Ask the Expert Q&A with Dr. Matulonis below.

Uterine Cancer

Question:I have a question about Stage IV uterine cancer followup protocol. I had surgery, radiation and chemo, completing treatment in August 2011. I’m currently NED. I recently had to change oncologists due to insurance issues. The new oncologist I was referred to is WAY less aggressive on follow-up visits and testing (preferring to wait until symptoms reappear) than the oncologists who treated me. I’m really uncomfortable about it and I plan to switch again to the University of KS oncology program. I’ve googled my fingers off trying to find a recommended protocol with no luck. Would you please describe the best practices for follow-up of stage IV uterine cancer for 5 years after the conclusion of treatment?

Answer:The Society of Gynecologic Oncology published follow-up guidelines in 2011 which can be accessed [here](. If you look at Table 2 in the linked recommendation, there are details for follow-up for uterine cancer based on low, intermediate or high risk for recurrence.

Question:I have Stage 3 uterine cancer. I was treated with 3 rounds of Brachytherapy in the vagina followed by 6 months of taxol and Carboplatin chemotherapy. I could not have full pelvic radiation because seven months prior I had finished chemotherapy to treat Waldenstroms Macroglobulinemia (WM) and therefore the bone marrow was not strong enough to withstand full pelvic radiation. My doctor is now recommending that I have the pelvic radiation. The radiologist is concerned because of my past history of ulcerative colitis, although it has not been active for many years. In your opinion do you think the treatment I did have is enough for my best chance of a non-reoccurrence or or do I have the pelvic radiation, for 15 days and risk the possibility of having major flare up of ulcerative colitis. I am very upset and would appreciate your opinion.

Answer:Sounds like you have two reasons why the pelvic radiation was put on hold: WM diagnosis and your history of uterine cancer. We don’t know the importance of radiation therapy for stage III uterine cancer but our radiation oncologists will usually recommend pelvic radiation in addition to chemotherapy. On the other hand, you have two reasons why the radiation wasn’t recommended; I would have a frank conversation with your radiation oncologist about the pros/cons of the radiation and definitely would seek a second opinion from a radiation oncologist who specializes in gynecologic cancers.

Ovarian Cancer

Question:What can we do to prevent ovarian cancer?

Answer:If someone is part of a high risk ovarian cancer family and they test positive for a BRCA-1 or -2 germline mutation, that woman can have her ovaries and fallopian tubes removed; doing that will definitely lower her risk.

Question:Is taking curcumin recommended for prevention of recurrent ovarian cancer? Is there anything you can recommend to help prevent recurrence?

Answer:Curcumin given to ovarian cancer cells growing in culture has been successful but unfortunately, one cannot ingest the amount of curcumin orally that could kill ovarian cancer cells. There are no medications thus far that have been shown to prevent recurrence but several are being tested including PARP inhibitors and ipilimumab which is an immunotherapy; these are all on clinical trials.

Question:If I have had ovarian cancer is there any genetic screening to determine if my two daughters (ages 42, 35) will have a hereditary cancer risk?

Answer:Depends on your age and your family history. However, if your ovarian cancer is called a “high grade serous” this is the type of ovarian cancer that can be transmitted from generation to generation via high risk gene. In addition, you would be tested not your daughters since they don’t have ovarian cancer. I would consult a genetics counselor so a better approximation can be determined for your family risk.

Question:I had ovarian cancer, type 1B. Following total hysterectomy and chemotherapy, CA 125 has been less than 2, for 2 years, what are my chances of recurrence?

Answer:Congratulations! There is a still a chance of recurrence but it gets lower every year. Five years will be an important milestone too.

Question:Are any new treatments that look promising for low grade ovarian cancer that presented first as a borderline tumor and recurred as low grade?

Answer:Low grade serous cancers are much different than other ovarian cancers; I would suggest that you have your cancer “genotyped” which may be able to occur at your hospital center. In addition to drugs such as hormonal agents (aromatase inhibitors, tamoxifen) which can be active, clinical trials that test drugs called “MEK” inhibitors are showing real promise. There will be several studies that are focusing on different biologic agents such as MEK inhibitors in the near future. The websitelists all available studies.

Question:What is the most likely prognosis with undifferentiated cancer in one ovary?

Answer:If the stage is really stage I with a grade 3 cancer, you have an excellent chance of the cancer never returning, likely >75%. We don’t know how much chemotherapy impacts those statistics but chemotherapy is typically recommended.

Question:Any thoughts on the best clinical trial going for platinum resistant ovarian cancer?

Answer:LOTS going on…..I would peruse thewebsite to see what studies are close to your home.

Question: Are any hospitals working on a vaccine against ovarian cancer-in the NY area?

Answer:I believe Memorial Sloan Kettering has one available; U of Penn definitely does.

Question:I have stage III3c serous epithelial ovarian cancer. I enrolled in a clinical trial in which I received Taxol (IV), Carboplatin (IP) and Avastin (IV) that ended in March 2012. Now, I receive only Avastin (IV) for the remaining months. However, there is a possibility that my cancer has metastasized to my right iliac bone. I am awaiting the results of a bone biopsy and should know the results by the end of this month. If I have bone mets, what general treatment options would you recommend? Is there a clinical trial I could enroll in?

Answer:Bone metastases from a high grade serous ovarian cancer would be very unusual and I agree with your oncologist that a biopsy should be done. If you do have a recurrence that is documented on a biopsy, another clinical trial is an option, re-use of carboplatin, weekly taxol, doxil, etc. So there are many options for you.

Question:I had stage III ovarian cancer and finished treatment about 6 months ago. I am so scared about a recurrence– what should I be looking for, are their symptoms or just elevated CA?

Answer:Often the CA125 is able to pick up recurrence in the absence of symptoms. If symptoms do appear, they would include ones that you may have experienced at diagnosis and include abdominal bloating, shortness of breath, changes in bowel habits such as diarrhea and/or constipation, pelvic or abdominal pain.

Question:I have stage IV platinum resistant ovarian cancer and have had gemcitabine. I have lesions on liver and outside of colon, is there another treatment for me?

Answer:Absolutely; depends on when you last received carboplatin but re-use of that drug could be done, weekly taxol or taxotere, doxil as well as topotecan are all next options.

Question:How successful have PARP inhibitors been when used with patients with the BRCA-1 and BRCA-2 mutations? What is the future of PARP inhibitors for use in treating ovarian cancer?

Answer:PARP inhibitors have definitely shown activity in recurrent ovarian cancer, particularly in patients with a germline BRCA 1 or BRCA2 mutation as well as those who do not harbor a mutation but have a high grade serous histology.

Question:When will olaparib be available?

Answer:Olaparib and other PARP inhibitors are available on clinical studies (www.clinicaltrials.gov) . Several phase III studies that test olaparib plus other PARP inhibitors should be underway later this year; therefore, if these studies are positive and the FDA accepts the data, a PARP inhibitor could be on the market in the next 3 years.

Question:I have PPC/Ovarian cancer simultaneous primaries, Stage IIIC back in April 2010. After optimal debulking I have never had a remission, and have been on consecutive chemo/treatment for over 2 years. I am BRCA negative, and have also been in a dendritic immunotherapy trial (CVAC) for 2 months until I recurred. I am now on my 7th consecutive drug combination after having partial responses on all the others. I am clearly running out of options of what to do next, if my current regimen proves either ineffective or intolerable. What types of things can I do next to ensure I can continue to battle this disease?

Answer:I would suggest you have your cancer genetically tested for something called “somatic mutations” which may be done at your hospital. I would also have you consult with a hospital that has a Phase I clinical trial program since those are the types of clinical trials you are eligible for. A good website that describes all clinical trials being conducted isand you can search for studies.

Question:What is your opinion of the use of Metformin to treat ovarian cancer for patients who do NOT have diabetes?

Answer:Don’t recommend it off a clinical trial

Question:I have stage IV ovarian cancer, I had weekly taxol for 4 weeks with rising CA125, then gem/carbo which seemed to help but now one of the remaining tumors has grown, what kind of chemo could I have next?

Answer:There are a number of off-study drugs that are available such as doxil, topotecan, Avastin and I would also consider clinical trials.

Question:Is maintenance therapy recommended for stage 4 if the patient is NED after frontline treatment, and can 12 additional treatments of taxol (full dose spaced 21 days apart) cause cancer to be resistant to Chemo?

Answer:There is no FDA-recommended treatment after 6 cycles of carboplatin and taxol; I don’t offer women additional taxol after completing their initial carboplatin and taxol.

Question:I was diagnosed 5 years ago with stage 3 C ovarian cancer. I had the debulking surgery and six treatments of Carbo/Taxol. Four weeks after my last treatment my CA125 began a climb quickly. I’ve taken all the usual second line drugs. My tumor sites are not operable- spleen, liver, curvature of stomach. So my question is: What is the best suited trial for me? Or the next best drug out there?

Answer:I would suggest you have your cancer genetically tested for something called “somatic mutations”. I would also have you consult with a hospital that has a Phase I clinical trial program since those are the types of clinical trials you are eligible for. A good website that describes all clinical trials being conducted isand you can search for studies.

Question:My doctors are talking about HIPEC, can you tell me what that means exactly?

Answer:Heated intra-peritoneal chemotherapy; our center doesn’t use it and there have been no studies supporting its use in ovarian cancer.

Cervical Cancer

Question: Why for two years following treatment for cervical cancer would the doctors be watching the CA125 marker? I have just gotten a second opinion from a gynecological oncology Dr. that says the CA125 marker should never have been used for a guide since my external, internal radiation treatments and Chemo. there is no way to do biopsies due to fybroid tumors blocking my uteris and insurance will not cover a pet scan, unless cancer is detected (my understanding the detecting of cancer by a pet scan could also be just inflammation due to radiation scarring) So please explain how a patient is told they will be watch for 5 years fairly closely if there is not anyway to detect what is going on internally. Many of my symptoms that would fit return of cancer also fit side effects after cancer.

Answer: I agree with you that following cervical cancer after treatment is difficult and your doctors have to take into account your symptoms (are they changing or worsening which would be more suspicious for recurrent cancer), physical exam, scans (CT, PET etc) and then blood work. Many times, in the absence of a scan showing definitive recurrence, a biopsy has to be done to confirm a diagnosis of recurrence. The CA125 blood test is not specific for ovarian cancer and can become elevated with other gyn cancers, lung cancer, breast cancer, etc. So, I also sometimes follow it after someone has been treated, but it should never solely be used to detect or determine a recurrence of the cancer.

Question: I was diagnosed with cervical cancer in 2011, I had chemo, ext. radiation, and internal radiation. I have been cancer free for the last year and six months. My stage was 2b and I have fibroid tumors. I still have issues, and wonder if this is typical after all this time? Lower abdominal pain, bowel issues, some bleeding rectal and vaginal, fatigue, been through many test and pet and cat scans, angiogram, (sp) , I just can’t seem to get out of this state. I have let any and all my doctors know how I feel, but nothing is showing up. Any thoughts as to what direction I might take?

Answer: If all your tests don’t show cancer (which is great), then these symptoms are likely from the radiation.

**The Ask the Expert Guest Moderator is not intended to be a substitute for healthcare professional medical advice, diagnosis, or treatment. Speak to your healthcare provider about any questions you may have regarding your health.*

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