Chad A. Hamilton, MD, presents the case of a 49-year-old woman with BRCA wild-type ovarian cancer and offers his initial impressions.
Case: A 49-Year-Old Woman with BRCA-WT Ovarian Cancer
Chad A. Hamilton, MD: Good evening. My name is Chad Hamilton. I am a GYN oncologist with Ochsner Health in New Orleans, Louisiana. And this evening, we’re going to be discussing a case-based review of a 49-year-old woman with BRCA wild-type ovarian cancer. This is a case of a 49-year-old who presented to her primary care physician complaining of abdominal bloating and nausea. And this is actually a pretty common presentation. Often patients will have seen their primary care [physician] or maybe a gastroenterologist on a number of occasions, as the symptoms of ovarian cancer can often be very nonspecific. Her past medical history is only significant from mild hypertension. She has a family history; her mother died of breast cancer at age 59. And she had a cousin on her mother’s side who died of ovarian cancer at age 65. I pause when I see a family history like that. It’s just enough to raise my suspicion a little bit. Breast cancer, of course, is very common and many people will have family members with breast cancer, but a family member with ovarian cancer is a little unusual if that was truly what the diagnosis was.
We have some imaging on this patient. Her CT revealed small-volume ascites and bilateral 8-cm adnexal masses and a CA-125 of 285. Her CT scan is clearly abnormal, and this CA-125 certainly raises suspicion in this patient. Though at 49, premenopausal, postmenopausal, perimenopausal, CA-125 is not completely reliable when there are mild elevations. The bilaterality of her masses could be consistent with a [gastroenterological] process, so I might also consider getting a CEA [carcinoembryonic antigen test] in this patient or at least check her colon cancer screening history.
After all this, it looks like she proceeded to surgical intervention. She underwent an exploratory laparotomy followed by omentectomy, bilateral salpingo-oophorectomy, and resection of peritoneal modules. She had an optimal cytoreductive surgery with less than 1 cm residual disease after surgery, and her final stage was stage 3C high-grade serous cancer.
In my practice, this is someone I might actually consider doing a diagnostic laparoscopy to assess for resectability before committing her to a primary debulking surgery. Though her CT scan certainly [seemed to indicate] her disease was going to be resectable, the decision between primary debulking and a neoadjuvant approach to ovarian cancer and neoadjuvant chemotherapy approach is sort of a critical early decision we make on these patients, most commonly made on the basis of the patient’s performance status or, alternatively, their frailty and then the surgeon’s estimation of the resectability of the disease.
We move on to treatment. She was treated with IV [intravenous] carboplatin and paclitaxel with sort of a standard regimen for chemotherapy-induced nausea and vomiting prophylaxis. And of course, carboplatin and paclitaxel has been the standard of care since [the Gynecologic Oncology Group study] GOG-111, which was in 1996. So for nearly 3 decades, that’s been our standard of care. It’s exciting that recently we have some things to add to that first-line treatment where we’ve really been fairly stagnant for a number of years.
Her treatment-related adverse effects were persistent daily nausea and vomiting on day 1 after chemotherapy. This is a little bit unusual for patients to have significant nausea these days. Our antiemetics are pretty good at controlling nausea. And certainly, we don’t like our patients to have vomiting. She did have a persistent problem with that after chemotherapy. And then after chemotherapy, her CA-125 had normalized to 14 and she clinically had no evidence of disease, or NED, but she did report continuing daily nausea. Certainly, the normalization of her CA-125 is a good sign. And the faster that normalization during treatment, the better the prognosis. Other good prognostic factors are her age and baseline performance status. But ultimately, we know that despite achieving complete remission in 70% to 80% of our patients with advanced ovarian cancer, most of them, 80% to 85%, will recur at some point. Though the prognosis of this patient is relatively good relative to ovarian cancer, we know that she probably will recur, and in all likelihood, potentially succumb from her disease at some point.
Transcript is AI-generated and edited for clarity and readability.