Full Transcript Introduction and Guest Welcome 0:00 Welcome to The Coalition. 0:02 This is a talk show dedicated to discussing health, wellness, and inspiration. 0:07 I'm your host, Dr. 0:08 Shani Belgrave. 0:12 Hello, everyone. 0:14 Welcome to The Coalition. 0:16 I'm your host, Dr. 0:17 Shani Belgrave. 0:18 I am a bariatric and minimally invasive surgeon in Atlanta, Georgia. 0:22 You can get connected with me at www.drshanibelgrave.com. 0:28 I am elated to welcome back to the show today, Dr. 0:31 Michelle Glasgow. 0:33 Dr. 0:34 Michelle Glasgow is a renowned gynecologic oncologist who joins the show to share her expertise on ovarian cancer right on time for ovarian cancer awareness month. 0:47 Dr. 0:47 Michelle Glasgow, welcome back to the coalition. 0:51 Thank you so much, Dr. 0:52 Bella Grave. 0:53 I'm so excited to be here to speak with you yet again, third time this time. 0:57 Yes, the third time's a charm. 1:00 And of course, shout out to Brown University. 1:02 I've had the privilege of knowing Dr. 1:03 Michelle Glasgow. 1:05 We both did our undergraduate and medical studies at Brown University. 1:09 So we are experiencing another full circle moment from Providence to Atlanta. 1:14 So Dr. 1:15 Glasgow, can you please get us started by telling us about the magnitude of the problem? 1:21 How common and how significant is ovarian cancer? 1:25 So ovarian cancer is one of the most common gynecologic malignancies in the US. 1:32 I would say about 22,000 women are diagnosed every year. 1:35 And it is known to be a very lethal gynecologic cancer in that Perhaps about 14,000 women may die each year. 1:46 I always counsel women when they're first diagnosed, however, that this is a treatable cancer and that we are seeing improved survival because there have 1:57 been a lot of advances in treatment over the last few years. 2:02 Okay. 2:03 And so what are the signs and symptoms of ovarian cancer? 2:08 So first I'll just say, and I can talk about this a little bit more as we discuss further, is that there are several different types of ovarian cancers. 2:19 Not all ovarian cancers are the same. 2:23 One type differs from another type according to the cells that the pathologist sees under the microscope. 2:30 The most common type of ovarian cancer falls under the category of the epithelial type of ovarian cancer, and that cancer arises from the cells which are 2:41 on the surface of the ovary. 2:43 And then the other types, which are a little bit less common, fall under the category of germ cell tumors, which tend to be seen in younger women and then
Ovarian Cancer Overview and Symptoms 2:53 sex cord stromal tumors. 2:54 which can be seen in women, I'll say across ages. 2:57 But when most people hear ovarian cancer, they think of the epithelial type of ovarian cancer, typically the high-grade serous type, 3:05 which is the most common. 3:07 In terms of the symptoms of ovarian cancer, and I'll speak more to the epithelial type of ovarian cancer, the symptoms are very easy to confuse with other symptoms, 3:18 which you may find with other benign conditions. 3:22 So for instance, some women may experience bloating, constipation. 3:27 They may experience changes in weight. 3:31 They may feel that it's harder to close their pants or to pull their pants up. 3:36 They may experience some pain or discomfort or some urinary frequency. 3:42 And unfortunately for many women, because these symptoms can be confused with other conditions that are not cancerous, They may undergo evaluation with 3:53 many other physicians prior to seeing a GY oncologist, prior to undergoing imaging that shows a mass on their ovary. 4:05 So then how is it diagnosed? 4:09 So that's a really important question. 4:13 Ovarian cancer, I will say, has a bad reputation. 4:18 And again, I'm going to refer right now more to the more common epithelial type of ovarian cancer. 4:24 It has a bad reputation because when it is found in many cases, it's found at stage three or stage four. 4:33 The staging refers to where the cancer has spread to. 4:38 So a stage one ovarian cancer is a cancer that's just limited to the ovary. 4:43 Stage two is when it is extending outside the ovary and the pelvis, and then generally stage three involves spread to lymph nodes or the upper abdomen, 4:54 and stage four is more distant disease. 4:57 Partially because it can take a longer time to diagnose, most women are found to have stage three or stage four disease at diagnosis. 5:07 What that means is they may have a mass on their ovary, but then they may also have smaller tumors in their upper abdomen. 5:15 There is a finding called carcinomatosis, which is often seen with ovarian cancer. 5:21 That refers to the spread of multiple small tumors in the upper abdomen. 5:26 You can have small tumors on the surfaces of the bowel, the intestine, the liver, the spleen, and then with more advanced stages you can have involvement 5:36 of fluid with cancer cells around the lung or in the lung itself. 5:43 So then most times when it's found how is it picked up then on a CT scan? 5:49 Yes, yes. 5:51 I will say that up to perhaps 15 to 20 percent of cases of ovarian cancer can be found at stage one. 6:00 They're not always found at stage three or four but In the majority of cases, they can be found. 6:07 And the reason for that again is because it can take a while for patients to actually undergo evaluation. 6:14 Sometimes they'll have symptoms that they don't seek out evaluation for because they think it's normal. 6:23 So some women think, especially as they get older, it's normal to have some more constipation or to gain some weight. 6:32 And women sometimes ignore those symptoms when they may be actual symptoms of ovarian cancer. 6:38 Or they may see other providers prior to seeing a gynecologist or a GYN oncologist who will order other types of tests, but not a CT scan. 6:48 So then what are the risk factors and kind of when is it most commonly found and what age group of women? 6:58 So it generally is found more in women who are considered perimenopausal or premenopausal women. 7:05 So I would say women above the age of 50 more, but unfortunately we are seeing more and more cases which are diagnosed in women who are younger. 7:16 in their 30s, 40s, even 20s in some cases. 7:20 I will say for the other types of ovarian cancer, the germ cell tumors especially, that's another type of ovarian cancer, 7:30 which typically is diagnosed in younger women.
Diagnosis, Staging, and Disease Spread 7:32 When they say younger, maybe like 18, 19 years old, they're early 20s. 7:39 And one thing I didn't add before is unfortunately, there is no good screening test for ovarian cancer. 7:46 So there isn't a test like a mammogram or colonoscopy, which you can undergo to find the cancer or find this condition in a precancerous phase before it develops. 7:57 So it's generally found when women are symptomatic or have some symptom and then undergo imaging, which shows a mass on their ovary. 8:05 Or in the cases of women with stage three or more advanced disease, where they'll find the mass on the ovary and other masses on the abdomen and pelvis. 8:15 So is there a difference in prognosis? 8:17 Because you mentioned that the epithelial type is more common, and then that was more prevalent in older women, but that there's a difference, 8:26 the germ cell, that is more common in younger women. 8:30 Is there a difference in the prognosis between those two types? 8:33 Yeah, that's a very good question. 8:37 I will say that for, I'll speak for the germ cell tumors first. 8:42 For most, for I'd say all ovarian cancers really, surgery at some point is central to the treatment. 8:50 And for germ cell tumors, fertility sparing surgery can be performed safely. 8:57 And I just mentioned that because a lot of the women with germ cell tumors are younger women. 9:03 in their teens or early 20s who haven't had children. 9:07 And they can often undergo surgery to remove the affected ovary, potentially lymph nodes as well. 9:15 And in some cases, they do need chemotherapy as well. 9:20 And they can still go on to have children in the future. 9:24 So I just want to emphasize that because I think it's very important. 9:27 For germ cell tumors, they can be cured of their disease and where they can go on to live years and decades into their adulthood. 9:38 For the other types of ovarian cancers, so the epithelial type as well as the sex cord stromal type, Surgery, again, is a mainstay of the treatment. 9:50 In terms of the prognosis, it really depends on their stage of diagnosis, whether it's a stage one or stage three. 9:59 as well as the cell type. 10:01 So it's a bit of a complicated answer in terms of the prognosis, but I will, I always tell patients who are newly diagnosed, 10:09 especially with the more common like epithelial high-grade serous type, that it is a treatable cancer, but it really does become a chronic disease because 10:20 for instance, for a patient with a stage 3C high-grade serous ovarian cancer, for instance, where a patient presents with an ovarian mass plus a lot of ascites, 10:30 which refers to a lot of fluid in the abdomen and pelvis, which just shouldn't be there, it's because of the cancer, plus small tumors on the bowel, 10:40 even the liver. 10:42 Those patients, they generally would be treated with a combination of chemotherapy and surgery. 10:50 In terms of the order, the goal of surgery when there's obvious spread of the cancer is to get out all the visible disease. 10:58 So when a patient is seen by a G1 oncologist, they will undergo imaging, which will usually either include a CT of the chest, 11:06 abdomen, and pelvis or a PET scan, and then they'll make an assessment If the patient can undergo what we call or we refer to as optimal cytoreductive surgery, 11:17 which means they undergo surgery and there's no visible cancer left, they also make the assessment of whether the patient is well enough to undergo such 11:27 an extensive surgery. 11:28 And if it's felt that those patients can undergo such a surgery, they'll generally undergo surgery first and then receive six chemotherapy treatments thereafter, 11:39 and then go on a pill to prevent the cancer from returning. 11:45 But for patients who it's deemed that surgery is not the best option for them first, they'll then receive what we call neoadjuvant chemotherapy,
Risk Factors and Protective Factors 11:54 which refers to receiving three cycles, generally sometimes four, of chemotherapy first, and then they undergo repeat imaging. 12:02 And once we see that they're having an adequate response, then they undergo surgery. 12:07 And then they usually receive three cycles of chemotherapy after that. 12:12 I will say that for both groups of patients, whether they undergo surgery first and then chemotherapy or chemotherapy, surgery, 12:21 and then more chemotherapy, the chances of entering a remission, and I always describe to patients having a clear scan, are very high. 12:32 About 80%, but about at least 60% of those patients will develop recurrence, usually within two to three years. 12:44 There's a small percentage of patients. 12:48 less than 25% who will recur within six months of completing chemotherapy. 12:55 And those patients do have a poor prognosis. 12:58 Those patients are what we describe as platinum resistant or platinum refractory if the cancer were to grow while they were receiving chemotherapy. 13:08 But for those patients who develop a recurrence two to three years after or even some women may develop a recurrence five years after completion of treatment. 13:18 We often treat with chemotherapy again. 13:21 And some patients can be on, it can be a bit of a roller coaster, but where they're on and off treatment for years. 13:31 So I really describe the treatment and the prognosis for those patients with a high, especially a high grade serosilverin cancer when they recur as truly 13:43 chronic because it is a cancer that they can live with, but live with on and off treatment. 13:49 And I also mentioned to patients when I meet with them, especially when they recur, I just emphasize the importance of quality of life because I think 13:59 that's really important to consider on these treatments, especially chemotherapy, that they can live with the cancer on and off treatment with a decent 14:09 quality of life. 14:10 As the side effects can be tolerable for most, but the chemotherapy does have side effects and I always counsel patients on what those side effects may be. 14:20 Each chemotherapy is different. 14:21 Each chemotherapy has different side effects, and some patients are able to tolerate treatments better than others. 14:28 And it's always an important discussion to have. 14:32 Well, thank you so much, Dr. 14:34 Glasgow, for being so thorough. 14:35 I wanted to go back a little bit, especially since this is not a cancer that can be screened for, for us to talk about risk factors. 14:44 Yeah. 14:46 So one of the strongest risk factors is a genetic mutation. 14:53 So the genetic mutations which are known the best to the public are the BRCA mutations. 15:00 So BRCA1, BRCA1, BRCA2, they can increase the risk of ovarian cancer up to 40% and they are associated with breast cancer. 15:14 For the epithelial type of ovarian cancers, I just want to mention, I'm sorry I did not mention this earlier, is that there's ovarian cancer, 15:23 but then there's also fallopian tube cancer. 15:27 And you can develop a cancer in the fallopian tube and essentially it presents the same way as ovarian cancer. 15:32 It's treated the same way as ovarian cancer. 15:34 And then there's also another cancer called primary peritoneal cancer, which is a cancer of the peritoneum, which is the lining of the abdomen and the pelvis. 15:44 And again, it presents and is treated the same way. 15:49 But going back to risk factors, I just thought about that. 15:53 Going back to risk factors, I always tell new patients who told me that they've undergone genetic testing and they were told they don't have a BRCA mutation. 16:03 It's not just the BRCA mutation, which increases the risk of ovarian cancer. 16:08 There are other mutations. 16:10 And now when we perform genetic testing for ovarian cancer, usually patients will undergo a multi-gene panel. 16:18 because there are other mutations, for example, Paul B2, RAD51C, and D, Brip. 16:26 The mutations are associated with Lynch syndrome, which is also associated with endometrial cancer, can increase the risk of ovarian cancer. 16:36 So you can have genetic mutations, but then I also mentioned family history, because patients can have a strong family history of ovarian cancer, 16:45 but they may not have a genetic mutation. 16:48 and their family history cannot be ignored. 16:52 For those women who have a strong family history of ovarian cancer especially and have a negative genetic mutation or don't have a mutation, 17:00 I'll tell them that it's possible that they have a mutation but it just hasn't been identified yet according to the tests that we have available for genetic testing. 17:16 In terms of other risk factors, I think it's also important to comment on those factors which are protective. 17:25 But before that, I will say that endometriosis can increase the risk of ovarian cancer as well as using assisted reproductive technologies, 17:37 meaning using IVF to conceive. 17:40 Sometimes that can increase the risk. 17:42 of ovarian cancer. 17:43 But then there are protective factors. 17:45 So for instance, breastfeeding, pregnancy, these are protective factors. 17:53 And then also tubal ligation, but specifically removal of the fallopian tubes. 18:01 And the reason for that is that there has been some research which has shown that ovarian cancers actually start in the edge, 18:10 what we call the fimbria or the fingers of the fallopian tubes. 18:15 So in the past, for instance, when women expressed that they wanted to tie their tubes to prevent as a form of contraception and to prevent future pregnancy, 18:26 their tubes were actually tied. 18:30 or they were burned surgically. 18:32 But now for those women who are expressing they would like a tubal ligation, many gynecologists are actually removing the whole fallopian tube because 18:43 of the link with ovarian cancer. 18:46 The other risk factor or protective factor I'll mention which can reduce the risk of ovarian cancer is also the use of oral contraceptive or birth control pills. 18:57 I was just gonna add another risk factor, obesity. 19:01 Um, I will say that is a risk factor, but it's not as consistent as the others. 19:06 Yeah. 19:07 But, um, unfortunately I'm finding that obesity I think increases the risk for so many different cancers, but it is a risk factor too. 19:17 The thing that I wanted to touch on is when you talked about family history and that someone may have a strong family history of ovarian cancer, 19:27 but test negative on the panels, and that just means that it's maybe a mutation that hasn't been discovered yet. 19:34 How would you counsel those women? 19:36 Do you recommend prophylactic salpingectomy? 19:39 I mean, not salpingectomy, oophorectomy? 19:41 So that's a really good question. 19:44 Depending on their age and their family history, I would counsel them on that option. 19:51 For women who have a known mutation, there are guidelines, actually, according to which suggests that women should have, 20:00 for instance, a woman with a BRCA1 mutation. 20:03 It's suggested that she have her ovaries and fallopian tubes removed between the ages of 35 and 40, or when she has completed childbearing. 20:15 For a BRCA2 or a PALB2 mutation, that recommendation is for after the age of 40. You did mention salpingectomy. 20:27 So a salpingo-ufrectomy is removal of the ovaries and the fallopian tubes, and a salpingectomy is removal of just the fallopian tubes. 20:35 In answer to your question, for a patient who has negative testing but a strong family history, I would definitely discuss removal of the ovaries and the 20:44 fallopian tubes. 20:45 prophylactically, the question is always the timing, because a lot of these women who I'm seeing with either mutations or a family history tend to be premenopausal. 20:57 And with removal of these organs, they go into premature surgical menopause. 21:04 And then that's a discussion of how to handle the symptoms of menopause, and then whether to pursue hormone replacement therapy or not,
Prevention, Surgery, and Hormone Therapy 21:14 and then For those women who have a mutation, which would also increase their risk for breast cancer, then that is also a discussion with their breast 21:25 specialists and or medical oncologists on hormone replacement therapy. 21:29 There is quite a bit of research looking into the benefits of prophylactic salp injectomy. 21:36 So just removing the fallopian tubes to try to reduce the risk of these ovarian and fallopian tube cancers prior to removing the ovaries, 21:46 especially for those women who are younger and have completed childbearing, but they are not yet ready to remove their ovaries and then go into menopause. 21:57 But that's not yet standard of care. 22:00 But that is an area of research. 22:03 I'm so happy you brought up the hormone replacement, because that is a hot topic right now. 22:11 almost an explosion of perimenopause and menopause care. 22:14 Oh, yeah. 22:15 That is a hot topic. 22:17 It's a controversial topic. 22:19 Yes, yes, yes. 22:21 Because as I'm listening to different talks and seeing what's going on, I just want to see what your thoughts are on this. 22:30 What do you think? 22:31 Do you think that people that are using hormones topically, to control some of the symptoms that it might be an option in people who have had a cancer 22:45 risk as opposed to systemic hormones or is that still unclear? 22:52 So I will say that topical hormones do have a risk of systemic absorption. 23:03 I'll just say that that is something important to consider in terms of cancer risk. 23:12 But the other thing I'll mention is that I think a lot of topical hormones may fall under the realm of being compounded. 23:25 our society, when I say our society, like ACOG, the American College of Obstetricians and Gynecologists, as well as SGO, 23:34 the Society of Gynecologic Oncologists, they recommend when hormones are used that they be prescribed in sort of the FDA format or FDA approved forms. 23:49 I am Hesitant, I don't recommend compounded hormones just because I have seen where patients have received hormones that are compounded where the doses 24:02 are incorrect. 24:05 Or there's an issue with the absorption and then they develop a side effect related to that particular use of the hormones. 24:15 Often I will see patients who've developed abnormal bleeding in the setting of compounded hormone use. 24:24 So that is something that I just caution patients on in terms of the compound, the use of compounded hormones. 24:31 But I will say that for patients who have a gynecologic cancer, and this is just a general statement because it can get a little bit complicated, 24:46 but for women who have a gynecologic cancer that is not hormonally driven, and that's an earlier stage, hormone replacement therapy is safe. 24:59 And there's a lot of research to show that. 25:02 So for ovarian cancer, for my patients with ovarian cancer, I'll discuss, depending on the exact type of ovarian cancer, 25:10 I will discuss hormone replacement therapy with them for those women who are premenopausal. 25:17 at their diagnosis. 25:19 For those women who are post-menopausal and who've already been in menopause at their diagnosis, I generally don't just start hormone replacement therapy. 25:28 I think that the best time to start hormone replacement therapy is when you go into menopause. 25:33 But for my patients who have an earlier stage and don't have a hormone hormonally driven cancer or have a cancer that has positive hormone receptors, 25:45 I will talk to them about hormone replacement, depending on their symptoms. 25:51 Well, beautifully stated. 25:52 I just wanted to reiterate that while the show is educational in nature, that these are very complex topics. 26:00 And so people really would need to get a one-on-one consultation with their provider as they try to make decisions related to their health. 26:10 Thank you so much. 26:11 So Dr. 26:12 Michelle Glasgow, what would be your takeaway message for people to know about ovarian cancer? 26:20 So what I would say is to know your body. 26:26 Simply know your body and know when something is changing. 26:31 And if you're concerned that something is changing, don't forget about your gynecologist. 26:37 A lot of women, will go to their primary care doctor or another specialist and they never think about seeing their gynecologist. 26:48 Because unfortunately, a lot of women, especially after they finish having children, they don't go back to their gynecologist. 27:00 Or if they undergo like a hysterectomy removing their uterus and cervix, but don't have their ovaries removed, they also don't go back and they forget 27:11 about their gynecologist. 27:12 And I just say, just don't forget about your gynecologist, especially if you have any new symptoms and specifically the symptoms of like bloating, 27:27 constipation, new pelvic pressure, changes in how you urinate or how you have bowel movements.
Takeaways, CA-125, and Contact Information 27:35 Just remember, especially if you do have your ovaries still, or even if you have had your ovaries removed, you can still reach out to your gynecologist 27:46 because they may view you and order tests that your other specialists may not order. 27:55 Um, one test I just want to mention, which we haven't talked about those, the CA 125 level, um, because we've talked a bit about imaging, 28:04 but I just want to mention the CA 125 level is that is a test, which is a tumor marker, which is ordered sometimes when there's concern for ovarian cancer. 28:14 And I always like to tell patients that that is not a perfect test. 28:20 So it's very helpful to order when women have a mass, but unfortunately the only way to know if cancer is there, is present, 28:29 is by examining tissue that's removed surgically. 28:34 But for younger women who have a CA125 level drawn, it could be elevated because of cancer, but it can also be elevated if they're menstruating, 28:45 if they're having their periods. 28:48 or if they have a UTI or if they have like an appendicitis or diarrhea or something like that. 28:54 And then similarly, women can have up to 15 to 20% of women can have ovarian cancer and have a normal CA125. 29:04 So I always counsel women, sometimes women will go to their primary care doctors and request the CA125 level be drawn and they may not know about all the 29:17 things other conditions other than cancer that can cause it. 29:20 So just another reason to reach out to your gynecologist if you have any new symptoms or if you want to discuss the role of testing or screening. 29:31 Well, thanks so much. 29:32 I thought that takeaway was brilliant because when we first started the conversation and you mentioned the symptoms, it sounded a lot like irritable bowel 29:41 syndrome or, you know, something along those lines. 29:43 So I can see how someone may not even think that those symptoms would have anything at all to do with their ovaries. 29:50 So that's a great takeaway. 29:52 And I also love the fact that you pointed out the CA125 because it's so important in medicine to understand that if you check something and it doesn't 30:03 come back positive, it doesn't necessarily mean you do not have a certain condition. 30:08 So just to make sure that you're seeing someone who knows how to synthesize everything and put it together. 30:16 Dr. 30:16 Michelle Glasgow, you already know you have to come back again. 30:19 I'd love to. 30:22 I love talking with you and just talking about the conditions that I treat every day. 30:27 Absolutely, absolutely. 30:29 So Dr. 30:30 Michelle Glasgow, what is the best way for people to reach out to you? 30:34 I think the best way is to just to call our office. 30:38 I believe the number is 770-721-9400. 30:39 One of the things that we pride our my office prides ourselves on is you call us and someone picks up right away. 30:50 So you don't have to listen to the props. 30:54 So just call the raffles. 30:56 Wonderful. 30:57 Well, thank you so much, Dr. 30:59 Michelle Glasgow. 31:00 We will see you another time. 31:02 Thank you. 31:04 Well, everybody, thank you so much for tuning in to a very impactful episode of The Coalition. 31:10 I'm your host, Dr. 31:11 Shani Belgrade. 31:11 You can stay connected with me, www.DrShaniBelgrade.com. 31:16 Very special thank you to Dr. 31:19 Michelle Glasgow, renowned gynecologic oncologist at Northside Hospital Cherokee. 31:24 You can get connected with Dr. 31:25 Michelle Glasgow by giving her office a call. 31:27 You guys make sure that you share this episode with friends and family, your neighbors to raise awareness for ovarian cancer. 31:34 I'll see y'all next time.
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