November 17, 2018

Ashkenazi women and ovarian cancer

Dr. Beth Y. Karlan is the director of the Cedars-Sinai Women’s Cancer Research Institute at the Samuel Oschin Comprehensive Cancer Institute. Her specialty is ovarian cancer, the deadliest of gynecologic cancers and one that is diagnosed in more than 22,000 women annually. As newly appointed editor-in-chief of Gynecologic Oncology, the medical journal of the Society for Gynecologic Oncology, Karlan will be in a unique position to help shape the direction of this field.
The Jewish Journal spoke with Karlan about the nature of ovarian cancer and its particular implications for Ashkenazi Jewish women.

Jewish Journal: What is most important to know about ovarian cancer?
Dr. Beth Y. Karlan: First, it isn’t rare. Ovarian cancer affects one in 60 women in the U.S.
Second, it doesn’t have to be deadly. When it is diagnosed early, the five-year survival rate for ovarian cancer is over 90 percent. We can even preserve fertility for many of these women. The problem is that there aren’t effective means of early detection in asymptomatic women. Thus, most women are diagnosed with late-stage disease.
Third, we need to debunk the myth that ovarian cancer is a ‘silent disease.’ Women and even some doctors still believe that there are no symptoms, but that’s wrong. In over 95 percent of cases, there are vague, nonspecific symptoms, which are overlooked by both women and their doctors.

JJ: What are these symptoms?
BK: They include abdominal bloating, pelvic and/or low back pain, early satiety or a feeling that you are getting full too quickly, and a change in the frequency or urgency of urination. Now these are very common complaints, and most often are due to many other causes. But when they occur together, are persistent and progress, day after day, then it’s time to call your doctor. Ovarian cancer isn’t silent. It whispers, and we need to learn to listen.

JJ: What should you do if you are experiencing these symptoms?
BK: If they persist, you should talk with your doctor and ask about having a transvaginal ultrasound and a CA 125 blood test. These are not screening tests for asymptomatic women, but are helpful diagnostic tests in the face of symptoms.

JJ: What puts a woman at high risk of developing ovarian cancer?
BK: The most common risk is age. The median age of diagnosis in the U.S. is 59. But the most significant risk factor is a family history of cancer. If you have a close relative with breast and/or ovarian cancer, you may be at a high risk of the disease.
Although ovarian cancer is a ‘female cancer,’ a woman is just as likely to inherit a risk of it from her father as she is from her mother. So it’s important to know about cancers in your paternal lineage as well as on your mother’s side. Another risk factor may be a personal history of cancer. If a woman has a previous history of breast cancer, she is also at higher risk of ovarian cancer. Lightning can strike twice.

JJ: Can you speak to the special concerns of Ashkenazi women?
BK: As we understand genetics and family history, we know that mutations of the BRCA1 and BRCA2 genes are associated with ovarian cancer — although these cases make up only 10 percent of all ovarian cancers. The frequency for carrying these mutated genes in the general population is one in 800. The frequency in the Ashkenazi population is around one in 40. That means 2.5 percent of the Jewish population carries this mutation.
For carriers, the chance of being diagnosed with cancer by age 70 approaches 85 percent for breast cancer, and is 40 percent to 60 percent for ovarian cancer. So for women with a family history, it’s appropriate to discuss testing with a genetic counselor and/or your physician.

JJ: What if you are found to have one of these genetic mutations?
BK: Knowing that you have the gene empowers you with knowledge so as not to be victimized — there are courses of action you can take. You can be more vigilant with screening. Or you can reduce your risk surgically. In terms of screening, at this time, I recommend transvaginal ultrasound and a CA 125 test, as well as a rectal-vaginal pelvic exam, to be performed at least annually.
You can also participate in studies, like the ones we are doing at The Gilda Radner Hereditary Detection Program at Cedars. And you may want to discuss this with family members, as they may also be at increased risk.

JJ: How is ovarian cancer treated?
BK: Treatment involves surgery and post-operative chemotherapy. Surgery is the cornerstone of treatment and should be performed by a specialist, a gynecologic oncologist. Chemotherapy has evolved over the last decade, and shows improvements in survival and quality of life, even with advanced-stage disease. The median survival time is more than five years, and I’m optimistic that it will be longer in the near future. Interestingly, women with a BRCA mutation who get ovarian cancer are more responsive to treatment and have even better survival rates. There are clinical trials of targeted therapies, and women can discuss eligibility and the pros and cons of participating in these trials with their doctors.

JJ: What are the promising directions in research?
BK: Better screening and more targeted treatments. Researchers are working on blood tests, which can identify tumor markers and indicate early-stage ovarian cancer. And when we find it early, we can cure it. Also, there are molecularly targeted therapies that are showing a lot of promise. These new molecules specifically target the tumor cells and are less toxic and have fewer side effects.