Ovarian Cancers Evolving Paradigms in Research and Care (2016) / Chapter Skim
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In particular, the failure to improve ovarian cancer morbidity and mortality during the past several decades is likely due to several factors, including • A lack of research focusing on specific disease subtypes; • An incomplete understanding of genetic and nongenetic risk factors; • An inability to develop and validate effective screening and early detection tools; • Inconsistency in the delivery of the standard of care; • Limited precision medicine approaches tailored to the disease sub types and tumor characteristics; and • Limited attention paid to research on survivorship issues, including supportive care with long-term management of active disease. The symptoms of ovarian cancers can be nonspecific, so they are often not seen as indicating a serious illness by women or their health care providers until the symptoms worsen, at which point the cancer is often 1
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Overall, little attention has been paid to managing the acute and long-term physical and psychosocial effects of ovarian cancer diagnosis and treatment or understanding when to transition to appropriate end-of-life care. This report gives a broad overview of the state of the science in ovarian cancer research, highlights major knowledge gaps, and provides recommendations to help reduce the incidence of and morbidity and mortality from ovarian cancers by focusing on promising research themes that could advance risk prediction, prevention, early detection, comprehensive care (e.g., treatment and supportive care)
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Rather, it refers to a constellation of distinct types of cancer involving the ovary. Ovarian cancers with epithelial differentiation (carcinomas)
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4 Continuum of Research to Advance Ovarian Cancer Prevention and Care Biology Innovative Research Designs Intervention Development Previvorship Survivorship Long-Term Survivorship Secondary Prevention & Diagnosis & Prevention & Early Treatment Monitoring for Detection Recurrence Management of Recurrent End-of-Life Care Disease Methods to Reduce Practice Related Disparities Supportive Care Research & Practice FIGURE S-2 Framework for research in ovarian cancer. NOTE: Colored figures represent phases of the ovarian cancer care continuum where research can be focused.
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. Ovarian carcinomas account for more than 85 percent of ovarian cancers, and more than 70 percent of ovarian carcinomas are high-grade serous carcinomas (HGSCs)
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; black arrows indicate fallopian tube epithelium (FTE)
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However, clinicians and researchers tend to combine them in many types of research. In spite of recent advances, the incomplete understanding of the basic biology of each subtype, including origin and pathogenesis, is an impediment to advances in prevention, screening and early detection, diagnosis, treatment, and supportive care.
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Tumor classification, nomenclature, and grading systems have changed over time as new insights have emerged, and evidence suggests that there is substantial variability in current surgical and pathological practices for the reporting of ovarian cancers. The implementation of a single, uniformly implemented nomenclature and classification scheme (with standardized diagnostic criteria)
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Multiple groups recommend that all women diagnosed with an invasive ovarian cancer receive genetic testing and counseling, for a variety of reasons, including to determine the appropriate therapies, to assess other health risks, and to estimate the risk for family members. Genetic counseling and testing are also recommended for the first-degree relatives of women with a hereditary cancer syndrome or germline mutation (i.e., cascade testing)
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While several nongenetic factors are associated with either an increased or a decreased risk for developing ovarian cancer, the patterns of association are inconsistent, and the strongest factors to date are those associated with the less common and less lethal subtypes. RECOMMENDATION 4: Researchers and funding organizations should identify and evaluate the underlying mechanisms of both new and established risk factors for ovarian cancers in order to develop and validate a dynamic risk assessment tool accounting for the vari ous ovarian cancer subtypes.
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Research on the impact of earlier detection on quality of life will also be important. Diagnosis and Treatment Compared to the situation over the past few decades, newly diagnosed ovarian cancers are now being more accurately and consistently staged, and a wider variety of treatment options exist.
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RECOMMENDATION 7: To reduce disparities in health care delivery and outcomes, clinicians and researchers should investigate methods to ensure the consistent implementation of current standards of care (e.g., access to specialist care, surgical management, chemotherapy regimen and route of administration, and universal germline genetic testing for newly diagnosed women) that are linked to quality metrics.
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Recurrent ovarian cancers have traditionally been categorized as platinum sensitive if recurrence is diagnosed more than 6 months from prior therapy or platinum resistant if recurrence is diagnosed less than 6 months from prior therapy, but this classification does not reflect the mechanisms of recurrent disease. Several assays have been developed (or are in development)
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The 2010 IOM report A National Cancer Clinical Trials System for the 21st Century outlined principles to improve the clinical trials system in general, including • Improve collaboration among stakeholders, including the use of consortia; • Define an effective mechanism for combining products in clinical trials; • Develop and evaluate novel trial designs; • Increase the accrual volume, diversity, and speed of clinical trials; and • Educate patients about the availability, payment coverage, and value of clinical trials. These principles are particularly relevant for ovarian cancer research, given the relative rarity of the disease combined with the diversity of subtypes.
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All of these approaches have merit because their effectiveness may vary within and among subtypes. Supportive Care Along the Survivorship Trajectory Most research on ovarian cancers focuses on the treatment of the disease rather than on how to improve the management of the acute and long-term physical and psychosocial effects of diagnosis and treatment across the trajectory of survivorship.
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Finally, as many women with ovarian cancer continue active treatment until the end of their lives, researchers need to help better define when disease-focused treatments are unlikely to be effective and the focus needs to shift to end-of-life care. A majority of women with ovarian cancer require long-term active disease management, necessitating more effective approaches for supportive care and self-management.
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A number of factors influence the movement of science into regular and effective use, including the complexity of health care systems, the capacity of practitioners and providers to absorb new knowledge, and the diversity of stakeholders. While the knowledge base on ovarian cancers has advanced, not all stakeholder groups are receiving important messages.
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A focus on distinct areas of research within and across the continuum of ovarian cancer care will help improve the lives of all women at risk for or diagnosed with an ovarian cancer.
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