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Ovarian cancer care: What PCPs need to know

Stephanie V. Blank

Editor’s Note: This story has been updated on Sept. 12, 2018 to include updates since its publish date in 2017. 

In the United States, ovarian cancer, along with cancer of the fallopian tubes and primary peritoneum, are the fifth leading cause of mortality in women, according to the National Cancer Institute.

Detection of ovarian cancer is difficult because the ovaries are small and embedded deep within the abdominal cavity; therefore, it is particularly important for clinicians to be aware of symptoms, such as abnormal or any bleeding after menopause, nausea, unexplained weight loss or gain, fatigue, or a constant feeling of fullness, according to a press release issued by Mount Sinai.

“With the advent of PARP inhibitor approvals for maintenance therapy as well as immunotherapy, many women are on cancer treatments long term,” Stephanie V. Blank, MD, director of gynecologic oncology at the Mount Sinai Health System, told Healio Internal Medicine.

“When an oncologist or gynecologic oncologist is deciding whether to give a patient maintenance therapy, the most important factor is tolerance of the medication and side effects,” she added. “Patients may present to their PCPs with side effects of PARP inhibitors or immunologic agents believing these to be separate issues. PCPs should be aware of the side effect and stay in close communication with that patient’s oncologist.” 

With September designated as National Ovarian Cancer Awareness Month, Healio Internal Medicine spoke with Blank about the role of primary care physicians in the care and post-care of patients with ovarian cancer. – by Alaina Tedesco

Question: What are the risk factors associated with ovarian cancer that PCPs need to be aware of?

Answer: When thinking about risk factors and ovarian cancer, it is important to remember that most women who develop ovarian cancer will not have any of what we consider to be risk factors, so lack of risk factors should not be part of ruling out the diagnosis.

Family history of ovarian, breast or other cancers, as well as a known genetic mutation increasing the risk of certain cancers are risk factors. Never having children, obesity and possibly hormone replacement therapy may increase ovarian cancer risk.

Q: Who should PCPs encourage to get screened?

A: Screening for ovarian cancer — something like a pap test or a mammogram — does not yet exist, although that would be the very best way to fight this disease.

As to when a primary care doctor should consider ovarian cancer — a work up for vague abdominal or pelvic symptoms should include a transvaginal ultrasound and a CA-125 [test]. A woman can have ovarian cancer even without an obvious ovarian mass on a CT scan.

Q: Are there drug-drug interactions with medications for ovarian cancer treatment that clinicians need to monitor?

A: There are several drug-drug interactions of note (usually the person administering the chemotherapy is monitoring much of this too):

• Chemotherapy, in general, can compromise a woman’s immune system or make her anemic. Therefore, monitoring stress and advising the patient to maintain good hand hygiene and a healthy diet is important. PCPs should also make sure vaccinations are up to date including flu vaccine.
• Chemotherapy can be hard on the kidneys, so PCPs may need to work with the person administering chemotherapy to avoid other drugs hard on the kidneys.
• Bevacizumab can cause hypertension and PCPs will frequently be involved in managing this. Oftentimes, women who are already hypertensive need to add additional medications if on bevacizumab. Bevacizumab can also cause renal impairment and a PCP may be asked to help with this.
• Poly ADP ribose polymerase (PARP) inhibitors can cause thrombocytopenia, anemia and bumps in creatinine. Again, it will be important to minimize other medications that have these same side effects.

Q: What are the prospects for women if ovarian cancer is caught early?

A: If ovarian cancer is caught in the early stage — before it has spread — it is curable, with 92% of these patients living more than 5 years after diagnosis. Most of the time, however, ovarian cancer is not caught early. The signs and symptoms are nonspecific and can be explained by many other conditions (eg, upset stomach, weight gain due to getting older), so ovarian cancer is not necessarily the first thing or even one of the first things a patient or her doctor thinks is the cause. Additionally, by the time ovarian cancer causes symptoms, it has usually spread beyond the ovary.

Q: What is the clinical role of the PCP in post care?

A: A woman with ovarian cancer is likely to respond to her treatment, so her PCP should continue to be her PCP. Routine care does not fall by the wayside once a woman has ovarian cancer. She should still take her hypertension medications and keep her diabetes under control. She still should have her cholesterol tested and get her mammograms. Her flu shot is extremely important. Sometimes patients feel they are going to the doctor all of the time — and they are, it is just their gynecologic oncologist and not their PCP — and pay less attention to their other medical issues.

Q: Is there anything else clinicians should know about ovarian cancer that I have not mentioned?

A: Women with ovarian cancer will have better outcomes if cared for by a gynecologic oncologist. Being seen by a doctor specially trained in the management of women with gynecologic cancers impacts survival. If ovarian cancer is suspected in a patient, her PCP should get her to a gynecologic oncologist.

Disclosure: Blank reports no relevant financial disclosures.