Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, we’re here with Dr. Monica Prasad-Hayes, who is an associate professor of OB-GYN and a GYN oncologist, and the director of the GYN oncology fellowship at Mount Sinai. She is a friend of mine and a wonderful human. Monica, so happy you’re here. Thanks for coming.
Dr. Hayes: Thanks for inviting me.
Dr. Fox: Awesome, and it’s nice that I get to actually see you face to face. This is not over zoom. This is real two humans looking at each other.
Dr. Hayes: Unusual in these times.
Dr. Fox: So thanks for coming. I really wanted to talk about ovary cancer, in general. And obviously you’re the first person I thought of because this is something you treat, you work with every day, and you’re someone I know very well. So I think that’s great. And just so our listeners understand, like, who are you? You know, where are you from? How’d you get into this line of work? You know, what’s your story?
Dr. Hayes: So, I’m from upstate New York. I am the child of immigrants from India. And my father came here for his Ph.D. in physics and brought my mom, and we grew up in various places, but most recently really settled in upstate New York. So I consider myself from upstate New York. I did most of my schooling there and then came to New York for residency at Cornell, and also did undergrad at Cornell upstate, and then did my fellowship here at Mount Sinai, and did some research at Sloan Kettering along the way for a few years, and really stayed on faculty after fellowship at Mount Sinai.
Dr. Fox: How’d you get interested in OB-GYN in the first place?
Dr. Hayes: I love the idea of taking care of women. That was very important for me. And then I needed to also integrate my love for surgery. And so, the combination of the two naturally brought me to OB-GYN. And then within OB-GYN, really brought me to gynecologic oncology.
Dr. Fox: Our listeners, GYN oncology is one of the sub-specialties of OB-GYN. So you finish your training, and then you go on to take care of women with gynecologic cancers. But it is a very surgical-heavy field. I mean, you’re doing a lot of operating because a lot of these are treated with surgery,
Dr. Hayes: Right.
Dr. Fox: So in our field in OB-GYN, a lot of the people who finish and wanna do really advanced surgical training, this is one of the fields they would choose. Did you have any hesitation about going into a field that was, you know, with cancer and potentially, you know, bad outcomes and, you know, very sick people? Was that something that you found to be uplifting or was that a little bit daunting, you know, when you were starting the training?
Dr. Hayes: I think you have to…It’s kind of a calling. I think it is you know if that’s where you feel most comfortable. And I have to say, full disclosure, my father was a radiation physicist. So he worked in the department of radiation oncology, so I was exposed to cancer all my life…
Dr. Fox: And radiation, probably.
Dr. Hayes: And radiation. So that was not new. However, I feel most comfortable when I am with sick patients. And I really enjoy taking care of women who are sick and making them better.
Dr. Fox: It’s such an intense relationship. I mean, I just know from my training, when we were on the GYN oncology service, it’s obviously some of the women come in and they’re very sick, and they get better, and it’s amazing. And some of the women you’re helping them through illness where they’re not gonna get better, but it’s very intense. This is sort of almost on a parallel like what we do in obstetrics. These are, like, life-changing events. We’re talking about birth, about babies, about families. And you’re, you know, talking about either end of life or in the middle of life with potentially a diagnosis that just rocks people’s world, potentially find out you have cancer, and to come in and to be able to not only be proficient at what you do and excellent at what you do but also to navigate that just whole change that they’re going through in their mentality over life, it must be just really amazing in a certain sense.
Dr. Hayes: It’s a really amazing field. I have no regrets. Death is a part of life. And we learn how to make people better and cure them potentially. But we also learn and help people get through steps of dying, and how to go through living with a terminal illness and living well through that. And when are the times when we fight it and when are the times when we say, “This is no longer working, and maybe we should learn to live and think about not treating anymore?”
Dr. Fox: Right. And because cancer, like you were saying, there’s really three ways it goes. Either you have it and you basically get cured or almost cured. The other end of the spectrum is you have something that’s either from the outset incurable or becomes incurable. And then there’s in the middle where you have cancer but, you know, you’re moving along, and sort of, you know, you have up days, and down days, and setbacks, and victories, and all these things, but that can go on for 1, 2, 10, 20, 50 years based on the diagnosis, but they still have the diagnosis, and they’re still going through it during that time period. And, you know, I imagine there’s probably some times where you know which way it’s gonna go, but frequently when they come, you don’t know how it’s gonna end up.
Dr. Hayes: Right. Yeah. And so you have to give everyone the best chance that they can. And everyone is an individual. And I think that that’s really important. And especially in today’s medicine, there are so many different options with the same diagnosis. And as we’re speaking about ovarian cancer, there’s so many different options. And you really have to look at the individual. And it is the perfect disease to talk about living with a disease that can be terminal, it can be cured, and can be, like, a chronic illness for people.
Dr. Fox: Right. Shifting into ovary cancer, why is it such important cancer to talk about for women? Is it because it’s very common or is there something unique about it? You know, what would you say makes ovary cancer either very interesting or very specific?
Dr. Hayes: Well, I think right now, the amazing thing about ovarian cancer is that we still don’t have great early detection for ovarian cancer. And so, it is a disease for women that is common. It’s not the most common, but it is very common in women. And we don’t have early detection methods at this point in time. And so because of that, most of our patients with ovary cancer do present with advanced-stage disease.
Dr. Fox: Right.
Dr. Hayes: And that’s why it’s so important to get the message out about what are some of the symptoms of ovarian cancer in terms of trying to detect it earlier because we do have very good results for people that are detected with early cancer.
Dr. Fox: Right. Because as you were saying, you know, the main gynecologic cancers, in terms of how often they occur, right, cervical cancer is more common, endometrial cancer, cancer of the uterus is more common, but if someone has one of those diagnoses, they’re much less likely to suffer or die from it because it’s usually picked up at an early stage, meaning the cancer is either very small and localized to the uterus or the cancer itself is just slightly what they call, like, atypical, sort of just slightly cancerous, as opposed to like very unusual, whereas with ovary, that’s not the case. It’s less common. But if you’re diagnosed frequently, it’s already spread. And why is that? Like, just so our listeners understand, is it an anatomic reason? Is it a biological reason? Like, why would ovary cancer always present or usually present later as opposed to earlier?
Dr. Hayes: Well, the issue with the ovary, it is the deadliest cancer because the cysts are not palpable by patients. So, if you have a breast mass, typically by the time it becomes cancer, a lot of women will have imaging. It’ll be detected early, or sometimes they’ll palpate a mass. You can’t palpate your ovaries and you don’t often feel anything until the ovarian cyst is quite large. And during that time, what’s happening is that the cells can slough off of the surface of the ovary and then they seed into the abdomen. And so that’s how we get the spreading of the disease outside of the ovary onto surfaces in the abdomen and the pelvis.
Dr. Fox: Right. It’s just the way I always thought about it is the cervix is on the outside, you can see it, you can touch it, you can test it, so we do the Pap smear. Great. The inside part, the endometrium, it’s a little more internal in the body, but typically, anything that’s gonna sort of be off, she’s gonna bleed, it’s gonna come out the surface.
Dr. Hayes: They have early bleeding.
Dr. Fox: But in the ovary, they’re sort of deep down inside the belly. And they’re little. The ovaries are the size of grapes, walnuts…
Dr. Hayes: Walnuts. Yeah.
Dr. Fox: I mean, you know, they’re small. And so if they get a little bit bigger, no one’s gonna notice. You’re not gonna gain weight from it. You’re not gonna feel it. It’s not gonna hurt. There’s not gonna be symptoms. By the time you have symptoms from it, right, they have to be very big or there has to be fluid in your belly, or gaining weight, or this. And so, it’s challenging in that sense., And there is no Pap smear we can do on an ovary. Unfortunately, there isn’t a mammogram we can do for an ovary. Like, in the breast that could happen too, but again, the breast, it’s not as deep and you can do things like mammogram, but you can’t really do that for ovary and it’s a problem. And so what I’ve read is about 1 in 80 women, give or take, a little more than 1%…
Dr. Hayes: One in 70.
Dr. Fox: Yeah. So okay, I’m close. Not bad for an obstetrician. Between 1%, 1.5% of women have it in their lifetime. So, again, most women won’t have it. But those that do, it’s a much worse diagnosis in that sense because it presents later. And is this something that everyone’s at risk for equally or are there people may be at a higher risk for having ovary cancer compared to somebody else?
Dr. Hayes: So that’s a great question. So really what a lot of research is being done on is the genetics of cancer, and particularly the genetics of ovarian cancer. And so we know that at least 10%, with the current research evidence that we have, at least 10% is genetically inherited. And so, probably it’s closer to 20%…
Dr. Nathan: You just haven’t discovered the genes yet.
Dr. Hayes: We just haven’t discovered all of the genes, those are constantly being discovered currently. And now we have these, like, multi-gene cancer panels that we use. And so there is a genetic hereditary link. And oftentimes, it does go with breast cancer. And so we know that there are certain families and certain ethnicities that have increased risk. In particular, one of the most common that we know with ovarian cancer is the Ashkenazi Jewish population, where the risk is 1 in 40, rather than 1 in 70. And so we know that they have an increased risk of hereditary breast and ovarian cancer syndrome.
Dr. Fox: Right. I mean, when you see things that cluster in families or in ethnicities, there’s a lot of reasons that can happen, but one of them is genetic. There could be similar environmental exposures or similar diets, but one of the possibilities is genetic. And so, what you’re talking about is that a lot of families we’ll see in the family history a mix of ovarian cancer, breast cancer. These tend to go together. So if someone has either a personal history of breast cancer or they have a strong family history of breast cancer, they sort of assume they’re at risk for breast cancer, but they’re also at risk for ovary cancer. And then in addition to family history that goes into genetics, obviously, it is more common as you get older. It’s typically diagnosed in the 60s, I think. Is that like sort of the average?
Dr. Hayes: Yeah, average age is 60. Some of the other cancers that we know of now that may go with the genetic risk for prostate cancer, melanoma, pancreatic cancer, and there’s a lot of research being done right now on pancreatic cancer in BRCA positive patients, which is one of the genes that is involved with hereditary breast and ovarian cancer.
Dr. Fox: I mean, that’s the most famous one. It’s, you know, BRCA for BReast CAncer.
Dr. Hayes: Right.
Dr. Fox: But that gene got named for that but it’s…
Dr. Hayes: Two genes.
Dr. Fox: Yeah, 1 and 2, but those are the ones that, sort of, also increase the risk of ovary cancer. And how do women…? You know, you said they should look for the signs or feel for the signs. For women who present with signs and symptoms…I mean, they come to your office, they go to their gynecologist, they go to their regular doctor, and it ultimately ends up that they have ovary cancer, what are the symptoms that they would have?
Dr. Hayes: So they’re very common symptoms that all of us experience every day, but what you need to look for are frequency of these symptoms. So, some of the symptoms that people will come in and they experience more frequently with the diagnosis of ovarian cancer are feeling full early, so they feel like they have a meal, and they’re just feeling very full early on. So early satiety. It’s called bloating. So they feel very bloated, their abdomen…They may not be wearing the same clothes or they may not fit into their pants. They think that they’re gaining weight. And this is very common. A lot of women who are postmenopausal, which is the highest age frequency that develops ovary cancer, they may think that they’re just gaining weight. And so they don’t seek out a physician. But actually, they’re not really gaining weight, but the fluid starts to descend the abdomen. And so that is one of the signs.
People that have very frequent constipation. It’s not their normal constipation, they’re having many more episodes within a, you know, three, four-week period. People that have urinary frequency with a pelvic pressure of a mass in the pelvis can have to go to the bathroom more frequently and may have to get up in the middle of the night more frequently, and all these signs. And so, each individual symptom in and of itself is not something that you would think of out of the ordinary, but if you have a frequency of these within a short period of time that you didn’t experience two or three months ago and/or a combination of these symptoms, then it’s been found that this can be a sign for detecting ovarian cancer earlier than we would normally.
Dr. Fox: Right. I mean, it’s hard because a lot of these symptoms, as you said, are common in women without cancer, obviously. And so the thought is that these are signs of something getting bigger in your belly. So the ovaries themselves are getting larger, or what happens frequently in ovary cancer and other cancers is they, sort of, either secrete fluid themselves or your body secretes fluid, and so you sort of get, like, someone poured, like, a liter of water in your belly, and it’s sort of…so you’re, you know, two pounds heavier and you feel a little bit bigger.
And so let’s say someone is having those symptoms, right, or some of them and they’re not really sure, and so now they’re terrified, right, that they may have cancer, what should they do? Like, where should they go? Do they go to urgent care? Do they go to a gynecologist? Do they go right to a cancer specialist? A, where should they go? And B, what kind of tests would even be run to determine if it’s something that’s just right regular old-fashioned constipation versus something that’s, you know, cancer?
Dr. Hayes: So I would say a majority of our referrals come from three places. A lot of gastroenterologists will see patients because they’re referred by their primary care physician thinking that they have these gastric symptoms, and they’ll see the gastroenterologist who will get a scan, and then they’ll find that there’s an ovarian mass or ascites and consistent…
Dr. Fox: Ascites is the fluid in the belly. Right.
Dr. Heyes: Yes.
Dr. Fox: That’s okay.
Dr. Hayes: And then the second group, and I think the majority of cases, is from the gynecologist. And so I would recommend for patients that are worried about, those women that are worried, that they do seek out their gynecologists because the gynecologist is always thinking when they do an exam, is this ovary enlarged? Is this something that I need to triage, to get a scan on, a sonogram, and do I need to consult with a gynecologic oncologist?
Dr. Fox: Right. Right. So, basically, you see your doctor if you go to an internist and they’re not sure what’s going on.
Dr. Hayes: Right. That’s the third group.
Dr. Fox: Right, or your gastroenterologist, they’ll hopefully send you for some further testing, whether it’s an ultrasound or a CAT scan, and you can pick up masses on the ovary with an MRI, a CAT scan, an ultrasound. Either one of those three may not be the only or the best one, but it’ll see something unusual in the ovary, even if it doesn’t know exactly what it is, something will get picked up. So really any sort of imaging, other than maybe an X-ray will sort of [crosstalk 00:16:24]…?
Dr. Hayes: Typically, sonogram is the first step.
Dr. Fox: Yeah, that’s what we would do is an ultrasound. There’s no radiation. It’s easier to do. You can do it in-office. It’s fast. And then, you know, if the ovaries look normal and there’s nothing going on, there’s no fluid in the belly, women can be, you know, almost entirely reassured that it’s not anything related to the ovaries in that sense.
Dr. Hayes: Almost, I mean, there are rare cases.
Dr. Fox: Almost entirely, obviously. Never entirely, but basically the concern as far as those symptoms is let’s make sure you don’t have these big ovaries or fluid in your belly. There must be women who get diagnosed with ovary cancer, who don’t present with these symptoms. I mean, either it’s just picked up incidentally on having their appendix taken out and someone saw a mass on the ovary or they were having a CAT scan because they had something else and this is found. Is that something you see commonly, rarely where you get…? Again, I’m sure you get referrals for potential problems with women who actually have ovary cancer. How often do they just, sort of, get picked up by happenstance?
Dr. Hayes: So I think that’s the rare situation. And that’s when we can actually find it early because we don’t have adequate screening tests currently. The majority of those cases where it’s seen intraoperatively at the time of surgery for something else, there’s a cyst on the ovary, the majority of those are benign cases. The majority of the time where they see a cyst incidentally on a scan, that’s typically these benign cases and people don’t need to worry about every cyst that’s found on a CAT scan or an MRI. However, there are cases where we will incidentally find those. And the nice thing about that is that it’s typically an early cancer because they are completely asymptomatic.
Dr. Fox: Right. And again, just to get back to the principle, if the prognosis for someone who has ovary cancer, and again, these are all averages, right, you can have an early-stage and do very, very poorly, and you can have a late-stage and survive forever. I mean, these are just, you know, percentages. But on average, the earlier the stage, the survival rates are markedly different.
Dr. Hayes: Correct.
Dr. Nathan: Right. If someone comes in and they have the earliest stage, stage one ovary cancer, you know, they’re unlucky, but they’re lucky enough that they got it caught early and you remove the ovary and you treat them, what would you tell them is the likelihood they’re gonna basically be fine if it’s stage one truly?
Dr. Hayes: For stage one, truly, like early-stage and they didn’t need chemotherapy confined inside the ovary, you say, “Your survival is really over 90%. And so we’re gonna watch you closely over the next 5 to 10 years, but really, you should go on and live your life normally.”
Dr. Fox: Right. And what about, how would you contrast that to the latest stage, which would be stage four? As someone who gets diagnosed with that stage, what would be…? The same outcome that’s good, what percentage of women would have that? If it’s not 90%, what would it be?
Dr. Hayes: The majority of patients actually present with stage three, I’d say, and those, it’s somewhere in between, you know, if you look at like American Cancer Society, they’ll say, like 5-year survival around 20% to 30%. What we really typically see is probably around 40% to 50%. Stage four, probably less. And you’re looking at more like 20% in those patients. But we treat those patients all very aggressively. And there are those percentages of patients who are going to beat it. That’s really where we go for a cure.
Dr. Fox: Right. I mean, again, these are just percentages, but it just sort of gives the picture of how different it is and why the idea of trying to develop a screen is so critical because, again, you have two women, they both get ovary cancer, but one shows up to her doctor at stage one and one shows up at stage four, the chance that the first woman’s gonna survive is three or four or five times as high as the other woman, just because, again, they’re both unlucky, but she was lucky enough to be found early. And how ultimately is ovary cancer diagnosed? Is that diagnosed by an ultrasound or a CAT scan? You have to actually operate on someone to make the diagnosis, right?
Dr. Hayes: To be certain, you have to have a tissue diagnosis. So it either has to be surgically, which is the majority of the cases, or you get a needle biopsy. For patients that maybe can’t undergo a surgery or it’s deemed on imaging that it’s too extensive to actually get what we call an optimal surgery or optimal debulking surgery then we will typically get a tissue diagnosis with radiology, get a core biopsy, and then have the pathologist look at the slides to make the diagnosis.
Dr. Fox: Right. So it has to be looked at under a microscope by pathologists to say, number one, it’s cancer. Number two, it came from the ovary. Number three, what is, sort of, like the grade of how bad of a cancer it is? The stage is not typically a pathologist, that’s typically clinically like how far in the body it’s spread. So the grade is, sort of, how bad the cancer looks under a microscope. And the stage is how far in your body has it spread? And each of those is, the higher the grade, the worse it is. And the higher the stage, the worse it is, but they’re sort of…they’re not independent of each other, but they’re different ways to look at prognosis. And then ultimately, just in broad strokes, how do you treat ovary cancer, like, what goes into treatments for ovary cancer? It’s different for everybody, but sort of conceptually, what are you doing?
Dr. Hayes: So the mainstay is surgery. Really, you need to take out the cancer, and then it’s a combination of surgery and chemotherapy. And that timing really depends on the individual and what we see at the time of diagnosis, whether to do surgery upfront, what we call primary surgery, and that’s the majority of cases that we treat in this country, as opposed to doing what we call neoadjuvant chemotherapy for very advanced stages where we will give a few cycles of chemotherapy first and then do an interval surgery to remove the cancer followed by more chemotherapy. But the two mainstays of treatment are really surgery and chemotherapy.
Dr. Fox: So someone is diagnosed and they undergo surgery, and it’s successful in the sense that you took out as much tumor as you could see, and you give them the chemotherapy. And then the chemotherapy is for three months, six months, how long is it typically being given?
Dr. Hayes: So it really depends on the stage. But the typical course is about four-and-a-half months. And then we talk about things called maintenance therapies and that can go on for a few years after the cessation of the chemotherapy.
Dr. Fox: And that means, sort of, like, they come back and every X amount of months or years they get some chemotherapy in that sense?
Dr. Hayes: Depends on what type of maintenance therapy but one of the therapies are targeted therapy. So we do once every three weeks, we make an intravenous infusion a 30-minute infusion of a targeted therapy. Bevacizumab is one of those examples.
Dr. Fox: When you say targeted, you mean towards their specific type of ovary cancer or…?
Dr. Hayes: It’s actually targeted to ovary cancer in general. Bevacizumab is a medication that’s a VEGF inhibitor and so it targets the VEGF receptor on the cancer cells. Then the biggest discovery actually in recent years has been the effectiveness of PARP inhibitors, which is actually an oral pill, which is really nice for patients so that they don’t have to actually come in to get an infusion, they can actually just take a pill after chemotherapy. Actually, this was recently FDA approved in the last year-and-a-half for BRCA-positive patients because it’s very, very effective in patients who have a genetic predisposition for ovary cancer and was also recently FDA approved for non-BRCA patients and has been shown to be effective in them as well. And so we’re really excited about the PARP inhibitors as maintenance therapy.
Dr. Fox: And then when you’re following these women, I guess that you’re just making sure that they don’t have a recurrence of tumors in their body. Is that sort of, like, that’s how you would sort of decide, oh, it isn’t working? And then is it possible that they would come back and get surgery again? Like, are there people that get multiple operations potentially?
Dr. Hayes: There are. It’s a little controversial, and we have, you know, historically done secondary cider reduction. And there is a group of patients who are perfect candidates for secondary cider reduction who’ve had long intervals of being in remission and are very sensitive to chemotherapy. And so this is something that’s been hotly debated, especially in the last year, and heavily researched. There are two randomized trials that have recently been reported on in the United States. Interestingly, recently reported in “The New England Journal” that secondary cider reduction was not effective. And then in Europe, they just reported that it was effective in patients who are platinum sensitive who have a long interval. So the jury is still out on whether…
Dr. Fox: Still debating.
Dr. Hayes: …secondary cider reduction is effective or not. But I will tell you anecdotally that, you know, we do think that there is a role for secondary cider reduction in our patient population.
Dr. Fox: And I would assume a lot of women also, it’s just there’s something even psychological about it, like, you know, I had a tumor, it got removed, right, tumors, they got removed, I was on chemo, I’m doing well for five, six, seven, eight, nine years, you know, I feel great. And then suddenly, I have a tumor again, almost to say like, “Well, now it’s not…” “No, are you crazy? Take it out.” And it’s almost, like, these things are obviously complex, but you can just sort of see why a patient would be like, “I don’t care what they say, like, I want this out of me. And let’s do it again.” And so…
Dr. Hayes: It’s a tough question.
Dr. Fox: …there’s some science behind it, but it’s not certain what the right thing to do…
Dr. Hayes: Well, so the data, you know, in “The New England Journal” article showed that if you give them chemotherapy, as opposed to surgery…
Dr. Fox: They do just as well.
Dr. Hayes: …they do just as well and actually they may have a higher survival. So it’s a little bit difficult to tease that out. But the desktop trial, which is the European trial, actually showed a very different outcome.
Dr. Fox: The Europeans, man. They always throw a wrench in the system, those Europeans. And one of the interesting things that I don’t think a lot of people know about GYN oncologists specifically is it’s one of the few fields where the surgeons, like you, might also be the one actually prescribing and administering the chemotherapy, right?
Dr. Hayes: Correct. I do a lot of chemo as well.
Dr. Fox: But in most fields, like if someone goes to…they have pancreatic cancer, there’s a surgeon who may or may not operate on their pancreas, but then they don’t see the surgeon again, they see a medical oncologist who, you know, says, “Okay, now you need this chemotherapy.” I know in some places for gynecologic cancers, it’s done that way, the surgeons operate, gynecologists do that. But for many…your training includes both. So when someone finishes…
Dr. Hayes: Everyone is trained to do both.
Dr. Fox: So and I think that’s…I want to talk about that for a second because I think people don’t realize that you’re the surgeon but you’re also…you’re actually the oncologist, you’re doing the cancer treatments for them, the chemotherapy. Are there other fields that even have that? Is that done in, like, brain cancer? Is that done in any fields? I can’t think of any really.
Dr. Hayes: Not any that I can think of. It’s one of the things that I love about gynecologic oncology, it is unusual.
Dr. Fox: Yeah. You’re a surgeon and you’re like an internist, you know, a specialist in cancer at the same time.
Dr. Hayes: You learn a lot about chemotherapy during fellowship that you just don’t get that training during residency.
Dr. Fox: But also just for the patient to have one person or one team of people who they’re the ones deciding which treatment you need, but they’re gonna do either one. So sometimes when you have different people, I do this, I do this right, the medical oncologist is like, “Oh, you have chemo, that’s what I do.” I’m not talking like from a financial perspective. They just believe this is what works and the surgeon’s like, “Do what I do.” And even if it’s not real, sometimes there’s a perspective of that potentially, but just like one-stop shop shopping so to speak.
Dr. Hayes: It’s nice because you can…from one perspective, I love it because you can see your patient for many, many years…
Dr. Fox: Right, continuity.
Dr. Hayes: …and really have that continuity. And I feel that the patients really build that trust in you. However, I will say in institutions where they do separate the two, the medical oncologist and the gynecologic oncologist work really well together. It really is more of a team approach rather than…
Dr. Fox: I’m not throwing Sloan under the bus.
Dr. Hayes: It’s very much a team approach. And there are some, you know, within our own group that also do the same. So it’s not just one institution versus another.
Dr. Fox: But it’s interesting, though, that certainly you’re all trained to do it. And I think that’s also good for access of care. That’s also good because in more remote areas, you know, you can see your one doctor, your GYN oncologist, and he or she will treat you and be the person treating you the whole time. You don’t have to go to different offices and maybe in different towns. It’s a really interesting thing.
So let’s go into screening for a second. So if someone’s like hearing this and like, “Oh my god, like, I don’t wanna get ovary cancer. If I get it, I want to have an early stage. Like, let’s do screening tests.” Why don’t we have good screening tests currently? You know, what is it about the screening test? I know there’s an option to do ultrasound, right? To do, like, a routine frequency ultrasound. And there’s also an option, there’s certain blood tests you could do called tumor markers where if you have cancer, they go up. You can have them for other reasons. So, why does that not seem to work in the general population?
Dr. Hayes: So they’ve done multiple studies, both here, in Europe, we’ve really tried to tease this out with the available markers, blood markers that we have and research on new markers as well as looking at transvaginal ultrasounds. And the large studies really have not shown that in the general population you actually have a good screening method with any of these modalities. Now, in a higher risk population, there have been studies that have shown that it is effective and that it should be used. But in the general population, you end up having many more what we call false positives. So people that may have ovary cancer that you end up taking to surgery that actually don’t have cancer. And so that risk is thought to be much higher than the risk that you should be taking, like the positive predictive value we call it, for the general population.
Dr. Fox: Right. It’s one of these things that sometimes it’s hard to grasp like, well, if it works for a higher risk group, why would it work for me? And I think it’s just, you know, conceptually, the basis of the problem is that these tests aren’t perfect, right? Meaning you can have cancer and these tests could be normal, and you can not have cancer and these tests can be abnormal. And so they have their percentages. And so if you have a group of women, let’s say you have 100 women, and 20 of them are gonna get ovary cancer, it’s a pretty high-risk population.
Dr. Hayes: Much higher than the general population.
Dr. Fox: Yeah. I feel like if you have a very high-risk group, you’re like, “All right, this is a really high-risk group,” you know, any blip in the test, right, or the blood test goes up, the ultrasound goes up, you know she’s at such a high risk to begin with, you’re gonna act on it as soon as you can, and there’s a better chance you’re gonna actually pick up an early cancer. But if, let’s say, only 1 or 0 of 100 women are going to have cancer, all those blips, you’re gonna take them to the operating room, and none of them are gonna have cancer. And so, yes, you may have “saved or improvedthe outcomes on one person,” but you’ve also had to operate on 50 people to do it.
Dr. Hayes: To get that one.
Dr. Fox: And maybe 1 of those 50 has a complication from surgery, or you remove ovaries and then she has complications from early menopause or whatever it might be.
Dr. Hayes: That’s exactly right.
Dr. Fox: And so it is hard. And also, the other thing that people debate is, well, how many surgeries is the right number to do to pick up one? Is it 10? Is it 50? Is it a million? And there’s no way to answer that because how would you…it’s almost an opinion for how many surgeries should you be doing on healthy women in order to pick up one early ovary cancer, nobody knows. So it’s tough.
Dr. Hayes: I think the answer really right now is that we need to do more research, we need funding for more research on detection of early ovarian cancer. And that really has not been a focus in, you know, our healthcare research for a long time.
Dr. Fox: If one were developed, if you could find a blood test or some form of imaging that can, you know, say with pretty good certainty, “Hey, this woman’s at much higher risk for ovary cancer than she was yesterday, then before she had this test,” and then you could say, okay, then you could catch them in stage one, you’re going to reduce the mortality from it significantly like we have with Pap smears. You know, when Pap smear was invented, in places where people do regular Pap smears, it’s very unusual to die from cancer of the cervix. It happens, but it’s very, very, very unusual, but only because they screen for it. In places where they don’t screen for cervical cancer, people die from cervical cancer all the time. Because it is a cancer, it’s dangerous. And so, yeah, but in high-risk women, so someone knows they have a gene or they have a family history, what is it that you do recommend in terms of their screening, you know, the ones that aren’t perfect but are better for this population?
Dr. Hayes: So in those patients, we have found that transvaginal ultrasounds and the blood marker, CA 125, has been helpful in kind of detecting who may be developing an early cancer. The problem with these is that they’ve actually never detected early cancers, they may show an abnormality and at that point, the patient may already have an advanced stage cancer. But if we do it at a frequent enough time point that we may start to detect this earlier. And so there was a study that was done in England that showed that…you know, they looked at yearly screening and did show that it was beneficial in that high-risk group, and now they’re trying to look at it in more frequent…
Dr. Fox: Like every six months or every four months.
Dr. Hayes: Every four months, exactly, is what they’re trying to look at. Here, for the high-risk groups, everybody does it a little bit differently. I do every six months screening, I think that’s pretty much standard of what most people are doing, every six months screening in the high-risk population.
Dr. Fox: And have you, in your own practice, seen from these strategies women who get picked up with stage one or stage two cancer, where you’re pretty confident if you weren’t doing this, they would have shown up a year later with stage three, or six months later?
Dr. Hayes: Well, you know, the studies haven’t really shown that. Even…
Dr. Fox: Just anecdotally.
Dr. Hayes: …high-risk population, it’s shown that like when they do…you know, for people that are getting risk-reducing surgery prophylactically, if they do have a cancer, it’s usually picked up in a more advanced stage. But our goal is to really pick it up early and we do start to see little blips in CA 125 or, you know, something a little unusual on the sonogram. And it may not be cancer at that point, but in those high-risk patients, that really prompts us to go and do the surgery.
Dr. Fox: Right. So I wanna talk about, finally, the things that women can do to lower their risk. So I wanna start first in the highest risk group because obviously the things they’re going to do are going to be more aggressive. And so someone who’s at a higher risk for ovary cancer, either because of a gene or because of a family history or for whatever reason, what are her options aside from screening? Like, what could she do to potentially actually lower her risk?
Dr. Hayes: So the most effective strategy for people who have a genetic risk is to do what’s called risk-reducing surgery. So that risk-reducing surgery for women with hereditary breast and ovarian cancer is removal the tubes and ovaries pre-menopausally, and the age depends on what type of gene mutation they may have. But typically, it’s when they’re done with childbearing around the ages between 35 to 4o for like BRCA1 patients, 40 to 50 for patients with a BRCA2 mutation, in addition to talking about things like mastectomy and other procedures. And it’s a hard decision to make because those women will go into a surgical menopause once they’ve done their surgery.
Dr. Fox: Meaning once you remove a woman’s ovaries, basically she’s going into menopause?
Dr. Hayes: She is in menopause.
Dr. Fox: And so that is the downside of doing it. And there’s some risk to the surgery, but as surgeries go, it’s not a very…
Dr. Hayes: It’s very straightforward.
Dr. Fox: It’s really more that they have to go into menopause from that age. So they’re sort of like, what age do I wanna pick for menopause to, sort of, reduce my risk? Now, does it eliminate the risk of getting ovary cancer? If someone takes out their ovaries and their tubes at age 35 and they don’t have cancer at the time they take it out, is there a 0% chance they’ll get ovary cancer or it’s just very, very low?
Dr. Hayes: So as you know, Natey [SP], we never say 0%.
Dr. Fox: Okay. Is it under 1%? Is it something like that? Or is it just…?
Dr. Hayes: We think it’s around 2%. So if you look at the studies, it’s basically you’re reducing your risk of ovary and fallopian tube…I should mention also that really, it’s fallopian tube cancer that we’re talking about. Most ovary cancers are actually thought to be fallopian tube cancer, and we’re reducing the risk by 80% to 95% just by removing the tubes and ovaries on both sides. However, there is something called primary peritoneal cancer, there’s about a 2% risk of…2% to 4% risk of primary peritoneal cancer. And the reason for that is that the lining of the abdomen is made up of the same cell type as the lining of the ovaries and the fallopian tubes. And that’s where the cancers arise from, the lining. And so we cannot get rid of that primary peritoneum because that’s just the lining of the whole abdomen and that really, it’s a very small risk, but it’s not 0%.
Dr. Fox: Right. But it takes them closer to what the general population risk is. If they went from, you know…
Dr. Hayes: Even less because now they don’t have their ovaries or tubes.
Dr. Fox: Right. And so that is one thing women can do is that operation. There’s also talk about just removing the tubes in certain women, like if they’re, you know, not having kids anymore and they were going to get…instead of their tubes tied, so to speak, removing the tubes entirely does lower the risk of…whether it’s worth doing.
Dr. Hayes: Well, you know, we don’t know yet. This is actually something that’s very actively being studied right now. We hope because that would be an amazing interval surgery for women to try to reduce their risk, women that we know have a genetic risk. Because most, you know, ovary cancers arise from the tubes, the thought is that maybe we could just remove the tubes and leave the ovaries for their hormonal function because the tubes have no hormone-producing function.
Dr. Fox: Right. They won’t become menopausal if you remove the tubes and leave the ovaries.
Dr. Hayes: Right. And so we’re hoping…we’re actually part of a large national organization that does clinical trials and we’re actually doing this trial right now. We’re really excited about this clinical trial because we hope that it’s a positive trial, meaning that there is a reduction in cancer in women that just get their tubes out. And then maybe we can remove the ovaries closer to like 50 when they would go through natural menopause.
Dr. Fox: Right. It seems like worthwhile to have two small operations and push off menopause 15 years, rather than have it at once. Yeah, I hope it works. That sounds great.
Dr. Hayes: I’m really hopeful too.
Dr. Fox: What about for women who really have no increased risk of ovary cancer, they just have baseline risk? I know there are some things that women may not realize actually do lower their lifetime risk of ovary cancer like taking a birth control pill at some point in their reproductive lives. It’s been shown that if, you know, women who’ve taken birth control pills, for, I think, just a year or two, they have a lower risk of ovary cancer in their lifetime. The thought process is I think that the ovary is not, like, turning over as much with eggs coming out. So there’s less, sort of, change in that lining. And so, that. Pregnancy lowers the risk. Nursing lowers the risk. All these things that reduce the risk or reduce the times a woman’s gonna ovulate.
Dr. Hayes: Later menarche, so women who start getting their periods later. And that’s all the theory…and then, you know, early menopause, the theory being that every time you ovulate an egg out of the ovary, you are rupturing the surface, and so that needs to repair. And so on a genetic level, you could have a higher risk of, you know, genetic alterations and mutations when you’re repairing that each month.
Dr. Fox: Right. Wow. So that’s something that all women can consider if they’re, you know, concerned or just they say, “Hey, I’ve been on a birth control pill, I’m happy to know my risk is lower.”
Dr. Hayes: Even women who have a genetic risk and women who don’t have a genetic risk, we know that they have a lower risk of ovary and endometrial cancer on the birth control pill.
Dr. Fox: Monica, this has been fantastic. I learned a ton. I had forgotten all of this essentially, and it’s great to have you here. It’s great to have you nearby in case we need you. And our patients need you and women need you. Thank you for what you do. It is really important work. As you said, it’s a calling. I totally agree. It’s hard, but it’s rewarding. And it’s not just rewarding for you, but obviously rewarding for all your patients. So thank you.
Dr. Hayes: Thank you. Thanks for having me. It’s been fun seeing you.
Dr. fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
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