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What Are Essential Genetic Tests for Metastatic Breast Cancer Patients?

What Are Essential Genetic Tests for Metastatic Breast Cancer Patients? from Patient Empowerment Network on Vimeo

Genetic tests can help guide metastatic breast cancer care. Dr. Julie Gralow discusses essential genetic tests for metastatic breast cancer, and how results impact treatment decisions.

Dr. Julie Gralow is the Jill Bennett Endowed Professor of Breast Medical Oncology at the University of Washington, Fred Hutchinson Cancer Research Center, and the Seattle Cancer Care Alliance. More about this expert here.

See More From INSIST! Metastatic Breast Cancer

Related Resources:

 

How Genetic Mutations Affect Metastatic Breast Cancer Disease Progression and Prognosis

Metastatic Breast Cancer: Debunking Common Misconceptions

What Could Metastatic Breast Cancer Genetic Testing Advances Mean for You?

 


Transcript:

Katherine:                  

For a patient to get diagnosed, what are the essential tests?

Dr. Gralow:                

So, we’re talking about metastatic breast cancer here, and in the U.S., maybe up to 10% or slightly less of breast cancer is technically Stage 4 or metastatic at diagnosis. That means at the time we first found it in the breast, it had already spread beyond. So, an important thing that we’ll do with a newly diagnosed breast cancer is especially if there are a lot of lymph nodes are involved or the patient has symptoms that might say there’s something in the bone, liver, or lung is staging.

So, we’ll use scans – maybe a CAT scan, bone scan, or PET scan – and we will look at whether the disease has gone beyond the breast and the lymph nodes, and if so, where. So, maybe 8-10% of breast cancer diagnosed in the U.S. already has some evidence that it has spread beyond the breast, but the most common way that metastatic breast cancer happens is that a patient was diagnosed possibly years and years ago, treated in the early-stage setting, and now it comes back, and that is the most common presentation for metastatic breast cancer, and sometimes that can be due to symptoms.

As I said, if it comes back in the bone, maybe that’s bone pain. If it’s in the lung, it’s a cough. There are symptoms. Sometimes, it’s because we’ve done a blood test or something and we find some changes there.

And so, when a breast cancer has recurred, it’s really important to document that it’s really breast cancer coming back, first of all, and so, if we can, we generally want a biopsy, and we want to stick a needle in it if it’s safe to do, and look and verify that it looks like breast cancer, and also, it’s really important that we repeat all those receptors that we talked about from the beginning because it can change.

So, a cancer up front 10 years ago could have been positive for estrogen receptor, but the only cells that survived – mutated, changed – were estrogen receptor negative, so what comes back could be different. So, it’s really critical to get that biopsy, repeat the estrogen/progesterone receptor and HER2, and also, in an ideal world, now that it’s 2020 and we’re moving more toward genomics, to do a full genomic profile and look for other changes and mutations that could drive our therapeutic options.

So, staging, knowing where the cancer is, getting a good baseline by understanding where it is and how big it is so that we can follow it and hopefully see that it’s responding to treatment, and then, repeating all of the biology components so that we know what the best options are for treatment are really critical.

Katherine:                  

Right. How can patients advocate for a precise breast cancer diagnosis, and why is that important?

Dr. Gralow:                

Well, all those things I just mentioned are key. Knowing exactly where it is so that we can monitor it – for example, if the cancer has come back in the bones, we would add what we call a bone modifying agent, a drug like zoledronic acid or denosumab – Zometa or Xgeva – which can suppress bone destruction from the cancer, but if it’s not in the bone, we wouldn’t add that.                                   

And, we want to have a good look everywhere so that we can see if it’s responding because sometimes, the tumor can respond differently in one area than another. Also, I think it’s really important to know what your treatment options are by doing that biopsy, getting a full panel, and looking at potentially hundreds of genes that could be mutated, deleted, or amplified so that we know what our treatment options are.

And, we’re not going to use all the treatment options up front, so it’s helpful for knowing that if this treatment doesn’t work or is too toxic, what are the second-line or third-line options? So, we make sure that there’s what we call good staging up front so we know where the cancer is, and then we make sure that we’ve looked at it as best we can in 2020 with all the genomics.

 That would give us the best chance of being tailored – individualized – to the tumor. Sometimes, if we can’t biopsy it, like with a needle that would go into a liver spot, then increasingly, we’re looking at what we call liquid biopsies, and that can be drawing the blood and seeing if we can find parts of the tumor, whether it be the DNA or the RNA that’s floating around in the blood, and sometimes we can get that information out of the blood as well.

Metastatic Breast Cancer Staging: What Patients Should Know

Metastatic Breast Cancer Staging: What Patients Should Know from Patient Empowerment Network on Vimeo.

Breast cancer expert Dr. Julie Gralow discusses metastatic breast cancer staging, including prognostic staging, breast cancer subtypes, and the meaning of metastasis.

Dr. Julie Gralow is the Jill Bennett Endowed Professor of Breast Medical Oncology at the University of Washington, Fred Hutchinson Cancer Research Center, and the Seattle Cancer Care Alliance. More about this expert here.

See More From INSIST! Metastatic Breast Cancer

Related Resources:

 

What Are Essential Genetic Tests for Metastatic Breast Cancer Patients?

Metastatic Breast Cancer: Debunking Common Misconceptions

What Could Metastatic Breast Cancer Genetic Testing Advances Mean for You?

 


Transcript:

Dr. Gralow:                

The staging of breast cancer has traditionally been by something we call anatomic staging, which has the tumor size, the number of local lymph nodes involved, and whether it has metastasized beyond the lymph nodes. So, that’s TNM – tumor, nodes, metastases. And so, that’s the classic staging, and based on combinations of those things, you can be a Stage 0 through Stage 4. Stage 0 is reserved for ductal carcinoma in situ, which is a noninvasive breast cancer that can’t generally spread beyond the breast, so that’s Stage 0, and then we go up for invasive cancer.

Interestingly, just a couple years ago, the big group that oversees the staging of cancers decided that in breast cancer, that TNM – the size, the lymph nodes, and the location beyond the lymph nodes – is not good enough anymore, so they came up with a proposal for what we call a clinical prognostic stage, which is a companion to the traditional TNM staging.

What they were getting at here was it’s not just how big your cancer is, how many lymph nodes, or whatever, it’s also at the biology of your cancer. So, this new clinical prognostic stage takes into account the estrogen and progesterone receptor of your cancer, the HER2 receptor at the grade, which is a degree of aggressiveness, and then, if your tumor qualifies, one of the newer genomic testing profiles that we use in earlier-stage breast cancer, such as the Oncotype DX 21-gene recurrence score or the MammaPrint 70-gene assay.

So, all of that goes into account now, and the whole point here is that the estrogen receptor, the HER2, the grade, and some of these genomics may actually make more difference than how many lymph nodes you have, where the cancer is, and how big it is, so it’s not just the size, but also the biology of the cancer that we’re trying to include in the new staging systems.

Katherine:                  

In this program, Dr. Gralow, we’re focusing on metastatic breast cancer. Would you explain when breast cancer is considered to have metastasized?

Dr. Gralow:                

That’s a great question because technically, if the lymph nodes in the armpit – the axillary area – are involved, that does represent spread beyond the breast, but if it stays in the local lymph node areas, it’s not technically called a metastatic or Stage 4 breast cancer. So, metastatic breast cancer would have traveled beyond the breast and those local lymph nodes, and some common sites would be to the bone, to the lungs, to the liver, less commonly – at least, up front – to the brain, and it could also travel to other lymph node groups beyond those just in the armpit and the local chest wall area as well.

Katherine:                  

What about subtypes? How are they determined?

Dr. Gralow:                

The main way that we subtype breast cancer right now is based on the expression of estrogen and progesterone receptor, the two hormone receptors, and the HER2 receptor, the human epidermal growth factor receptor. So, to date, those are the most important features when we subtype, and so, a tumor can either express estrogen and progesterone receptor or not, and it can overexpress or amplify HER2 or not, and if you think that through, you can come up with four different major subtypes, in a way, based on estrogen receptor positive or negative and HER2 positive or negative.

When all three of those are negative, we call that triple negative breast cancer, and that’s about 18-20% of all breast cancers as diagnosed in the U.S. And then, when all three are positive, we sometimes call it triple positive, and the reason that we subtype is because we know that those different subsets act differently and that we have different drugs to treat them with, and we’ve got great drugs in the categories of hormone receptor positive and HER2 positive, and increasingly, some recently hope in a new drug approval or two in triple negative breast cancer as well.

When Is a Full Mastectomy Appropriate for Metastatic Breast Cancer Patients?

When Is a Full Mastectomy Appropriate for Metastatic Breast Cancer Patients? from Patient Empowerment Network on Vimeo

Dr. Stephanie Valente discusses mastectomy for metastatic breast cancer patients, including common misconceptions around breast cancer surgery.

Dr. Stephanie Valente is the Director of the Breast Surgery Fellowship Program at Cleveland Clinic. More about this expert here.

See More From INSIST! Metastatic Breast Cancer


Transcript:

Dr. Valente:                

So, there are a lot of reasons that a woman undergoes a mastectomy. The first one is choice. So, anytime somebody is diagnosed with breast cancer, they actually have the choice of whether or not they want to remove their whole breast. So, even if their cancer is small, they do have the option of removing the whole breast. If the cancer is smaller, they might have the option to save the breast, which is called a lumpectomy.

Sometimes cancer is found, and it’s a little bit more advanced where saving the breast is not an option. So, the cancer is larger than a lumpectomy would allow. And sometimes that’s what’s called the extent of disease. So, the amount of breast tissue that’s involved requires a majority of the portion of the breast to be removed.

So, just because a woman has breast cancer that’s made its way out of the breast, into the lymph nodes, or beyond – so, metastatic cancer – doesn’t necessarily mean that she needs a mastectomy. So, just because you’ve got metastatic cancer doesn’t necessarily mean that the breast needs to be completely removed.

So, I think that one of the biggest misconceptions is that the more aggressive somebody is with their surgery, the better their chances with survival.

And again, taking a step back and saying you can choose a more aggressive surgery, but a more aggressive surgery doesn’t necessarily mean it gets you out of chemotherapy or it gets you out of radiation therapy. Those things are recommended, independent of a woman’s choice for the type of surgery that she may or may not pick.

Metastatic Breast Cancer: Accessing the Best Treatment For YOU

Metastatic Breast Cancer: Accessing the Best Treatment For YOU from Patient Empowerment Network on Vimeo.

How could genetic testing results impact your metastatic breast cancer treatment options? In this INSIST! Breast Cancer webinar, Dr. Julie Gralow discusses essential testing, the latest targeted therapies and emerging breast cancer research.

Dr. Julie Gralow is the Jill Bennett Endowed Professor of Breast Medical Oncology at the University of Washington, Fred Hutchinson Cancer Research Center, and the Seattle Cancer Care Alliance.

Download Program Resource Guide


Transcript:

Katherine:

Welcome to Insist Breast Cancer, a program focused on empowering patients to take an active role and insist on better care. Today, we’ll discuss the latest advances in metastatic breast cancer, including the role of genetic testing and how this may affect treatment options. I’m Katherine Banwell, your host for today’s program, and joining me is Dr. Julie Gralow. Welcome, Dr. Gralow. Would you introduce yourself?

Dr. Gralow:   

Hi, thanks, Katherine. I’m Dr. Julie Gralow. I’m the Jill Bennett Endowed Professor of Breast Medical Oncology at the University of Washington, Fred Hutchinson Cancer Research Center, and the Seattle Cancer Care Alliance.

Katherine:    

Excellent, thank you. Before we begin the discussion, a reminder that this program is not a substitute for seeking medical advice. Please refer to your own healthcare team. Well, Dr. Gralow, let’s start by helping people understand how breast cancer is staged. Could we go through those stages?

Dr. Gralow:     

The staging of breast cancer has traditionally been by something we call anatomic staging, which has the tumor size, the number of local lymph nodes involved, and whether it has metastasized beyond the lymph nodes. So, that’s TNM – tumor, nodes, metastases. And so, that’s the classic staging, and based on combinations of those things, you can be a Stage 0 through Stage 4. Stage 0 is reserved for ductal carcinoma in situ, which is a noninvasive breast cancer that can’t generally spread beyond the breast, so that’s Stage 0, and then we go up for invasive cancer.

Interestingly, just a couple years ago, the big group that oversees the staging of cancers decided that in breast cancer, that TNM – the size, the lymph nodes, and the location beyond the lymph nodes – is not good enough anymore, so they came up with a proposal for what we call a clinical prognostic stage, which is a companion to the traditional TNM staging.

What they were getting at here was it’s not just how big your cancer is, how many lymph nodes, or whatever, it’s also at the biology of your cancer. So, this new clinical prognostic stage takes into account the estrogen and progesterone receptor of your cancer, the HER2 receptor at the grade, which is a degree of aggressiveness, and then, if your tumor qualifies, one of the newer genomic testing profiles that we use in earlier-stage breast cancer, such as the Oncotype DX 21-gene recurrence score or the MammaPrint 70-gene assay.

So, all of that goes into account now, and the whole point here is that the estrogen receptor, the HER2, the grade, and some of these genomics may actually make more difference than how many lymph nodes you have, where the cancer is, and how big it is, so it’s not just the size, but also the biology of the cancer that we’re trying to include in the new staging systems.

Katherine:    

In this program, Dr. Gralow, we ’re focusing on metastatic breast cancer. Would you explain when breast cancer is considered to have metastasized?

Dr. Gralow:  

That’s a great question because technically, if the lymph nodes in the armpit – the axillary area – are involved, that does represent spread beyond the breast, but if it stays in the local lymph node areas, it’s not technically called a metastatic or Stage 4 breast cancer. So, metastatic breast cancer would have traveled beyond the breast and those local lymph nodes, and some common sites would be to the bone, to the lungs, to the liver, less commonly – at least, up front – to the brain, and it could also travel to other lymph node groups beyond those just in the armpit and the local chest wall area as well.

Katherine:   

What about subtypes? How are they determined?

Dr. Gralow:   

The main way that we subtype breast cancer right now is based on the expression of estrogen and progesterone receptor, the two hormone receptors, and the HER2 receptor, the human epidermal growth factor receptor. So, to date, those are the most important features when we subtype, and so, a tumor can either express estrogen and progesterone receptor or not, and it can overexpress or amplify HER2 or not, and if you think that through, you can come up with four different major subtypes, in a way, based on estrogen receptor positive or negative and HER2 positive or negative.

When all three of those are negative, we call that triple negative breast cancer, and that’s about 18-20% of all breast cancers as diagnosed in the U.S. And then, when all three are positive, we sometimes call it triple positive, and the reason that we subtype is because we know that those different subsets act differently and that we have different drugs to treat them with, and we’ve got great drugs in the categories of hormone receptor positive and HER2 positive, and increasingly, some recently hope in a new drug approval or two in triple negative breast cancer as well.

Katherine:     

For a patient to get diagnosed, what are the essential tests?

Dr. Gralow:  

So, we’re talking about metastatic breast cancer here, and in the U.S., maybe up to 10% or slightly less of breast cancer is technically Stage 4 or metastatic at diagnosis. That means at the time we first found it in the breast, it had already spread beyond. So, an important thing that we’ll do with a newly diagnosed breast cancer is especially if there are a lot of lymph nodes are involved or the patient has symptoms that might say there’s something in the bone, liver, or lung is staging.

So, we’ll use scans – maybe a CAT scan, bone scan, or PET scan – and we will look at whether the disease has gone beyond the breast and the lymph nodes, and if so, where. So, maybe 8-10% of breast cancer diagnosed in the U.S. already has some evidence that it has spread beyond the breast, but the most common way that metastatic breast cancer happens is that a patient was diagnosed possibly years and years ago, treated in the early-stage setting, and now it comes back, and that is the most common presentation for metastatic breast cancer, and sometimes that can be due to symptoms.

As I said, if it comes back in the bone, maybe that’s bone pain. If it’s in the lung, it’s a cough. There are symptoms. Sometimes, it’s because we’ve done a blood test or something and we find some changes there.

And so, when a breast cancer has recurred, it’s really important to document that it’s really breast cancer coming back, first of all, and so, if we can, we generally want a biopsy, and we want to stick a needle in it if it’s safe to do, and look and verify that it looks like breast cancer, and also, it’s really important that we repeat all those receptors that we talked about from the beginning because it can change.

So, a cancer up front 10 years ago could have been positive for estrogen receptor, but the only cells that survived – mutated, changed – were estrogen receptor negative, so what comes back could be different. So, it’s really critical to get that biopsy, repeat the estrogen/progesterone receptor and HER2, and also, in an ideal world, now that it’s 2020 and we’re moving more toward genomics, to do a full genomic profile and look for other changes and mutations that could drive our therapeutic options.

So, staging, knowing where the cancer is, getting a good baseline by understanding where it is and how big it is so that we can follow it and hopefully see that it’s responding to treatment, and then, repeating all of the biology components so that we know what the best options are for treatment are really critical.

Katherine:  

Right. How can patients advocate for a precise breast cancer diagnosis, and why is that important?

Dr. Gralow:    

Well, all those things I just mentioned are key. Knowing exactly where it is so that we can monitor it – for example, if the cancer has come back in the bones, we would add what we call a bone modifying agent, a drug like zoledronic acid or denosumab – Zometa or – which can suppress bone destruction from the cancer, but if it’s not in the bone, we wouldn’t add that.

And, we want to have a good look everywhere so that we can see if it’s responding because sometimes, the tumor can respond differently in one area than another. Also, I think it’s really important to know what your treatment options are by doing that biopsy, getting a full panel, and looking at potentially hundreds of genes that could be mutated, deleted, or amplified so that we know what our treatment options are.

And, we’re not going to use all the treatment options up front, so it’s helpful for knowing that if this treatment doesn’t work or is too toxic, what are the second-line or third-line options? So, we make sure that there’s what we call good staging up front so we know where the cancer is, and then we make sure that we’ve looked at it as best we can in 2020 with all the genomics.

That would give us the best chance of being tailored – individualized – to the tumor. Sometimes, if we can’t biopsy it, like with a needle that would go into a liver spot, then increasingly, we’re looking at what we call liquid biopsies, and that can be drawing the blood and seeing if we can find parts of the tumor, whether it be the DNA or the RNA that’s floating around in the blood, and sometimes we can get that information out of the blood as well.

Katherine: 

All right. Dr. Gralow, when you meet with patients, what are some of the more common misconceptions that you hear related to diagnosis?

Dr. Gralow:  

Well, I think people do confuse – especially at an early diagnosis – that the metastases, the travel to the local lymph nodes, is not the same as a metastatic breast cancer, so we spend some time talking about how it’s still curable and not considered a distant metastasis if the lymph nodes are in the armpit or up above the collarbone, and so, that’s something that we spend some time talking about.

This whole term of “metastatic recurrence” – unfortunately, when you start looking online and get your information from Dr. Google, you read right away that it’s no longer curable, and in 2020, yes, that’s true. That’s probably the most specific statement that we can make. We are not going with curative intent, which means we treat for a defined amount of time, and then all the disease goes away, and we stop treatment, and then you go on with your life, and it never comes back. That would be cure.

But, I think it’s really important to point out that much of metastatic breast cancer can be highly treatable, and what we hope to do – and certainly, at least a subset of metastatic breast cancer – we want to convert it more to what we would call a chronic disease, and so, think of it more like hypertension, high blood pressure, or diabetes. These are diseases that we generally don’t cure with treatment, but that we can control with drug therapy, which sometimes has to be adjusted, and if we don’t control it, we can get some bad complications.

So, that’s not all metastatic breast cancer, unfortunately – we can’t convert all of it do something where we can use a therapy for a long time that keeps it in check and where you have a pretty good quality of life – but we’re hoping that more and more, we’re getting targeted therapies and more specific treatments to patients so that we can convert more patients to a more chronic kind of situation.

Katherine:

So, it’s something that patients live with.

Dr. Gralow:  

Right.

Katherine:  

Many people are confused about genetic testing. They often think that it relates to ancestry or physical traits like hair and eye color. What’s the role of genetic testing in breast cancer?

Dr. Gralow:    

Well, you can do genetic testing of the patient’s inheritance, which is how most people think of genetic testing, and that’s actually really important and increasingly important in metastatic breast cancer to do your own inheritance. Have you inherited a gene that was associated with how your cancer developed? Because now, we actually have a class of drugs called PARP inhibitors that are approved for tumors that have a BRCA1 or BRCA2 mutation with them. Most of those mutations were inherited, but not all. Sometimes they can develop as well.

So, now, when my patient – if she didn’t previously have genetic testing for an inherited risk for breast cancer either coming from mom or dad’s side of the family, a lot of people do have that up front, especially if they’re younger at diagnosis or they have a lot of family members with breast cancer. If she didn’t have that genetic testing done previously, at the time of the metastatic occurrence, I’m going to recommend that that be done because knowing if the cancer is associated with one of these DNA repair genes – BRCA1, BRCA2, some other genes – we have a new treatment option, which is an oral pill that actually is highly effective if the tumor has a mutation in one of these.

But, we can also – so, that’s genetic testing of the patient’s own DNA, but we can also do what we call genetic testing – or genomic testing, if you will – of the genes of the cancer. What were the changes in the DNA at the gene level that caused a normal breast cell over time to develop into a cancer cell that’s now growing without responding to our body’s checks and balances? So, what were those mutations, deletions, or amplifications in the tumor itself?

So, we’ve got the patient’s genetics, we’ve got the tumor’s genetics, and both of those come into play when we’re making our best treatment recommendations and trying to understand what the right approach is.

Katherine:       

How is testing administered?

Dr. Gralow: 

So, for our inherited testing, those gene changes can be found in every cell in the body, so we can do that from a simple blood test where we just look at the blood cells. We can actually do it with our sputum and with a cheek swab, even. You can get enough of the DNA from the inside of the mouth to do that.

For a tumor’s genetics, we need some of the tumor, so that’s either done with a biopsy into the metastatic site or, as I mentioned before, increasingly, we’re exploring the potential for a liquid biopsy – so, drawing some blood and then trying to find pieces of the tumor that are shed into the blood.

Katherine:      

What advances have there been in testing?

Dr. Gralow: 

Well, it used to be – just going back a couple of years ago – that we didn’t do a lot of this genetic testing or genomic profiling of the tumor because we didn’t have many – the term is an “actionable mutation.” So, if we found something, would we do something with it? Did we have a drug we could use to do it? But, more and more and more, even in breast cancer, we’re finding actionable mutations that would drive therapy.

For example, in estrogen receptor positive breast cancer, we have a new class of targeted therapies called PI 3-kinase inhibitors – a drug called alpelisib or Piqray was approved in the last couple of years in that category – and it only is effective in estrogen receptor positive breast cancer that has a mutation in the PI 3-kinase gene. So, that would be something we’re looking for in the tumor’s genes, and actually, we need to know that there’s a mutation to even get the drug approved for treatment because it doesn’t work if you don’t have that mutation.

Increasingly, we’re finding some changes that can happen in the estrogen receptor gene and the HER2 gene, interestingly, so that you can have estrogen receptor expressed on your tumor, but over time, that tumor might develop an estrogen receptor mutation so that it stops responding to certain drugs that target the estrogen receptor.

And so, that’s called an ESR1. That’s the name of the estrogen receptor gene – an ESR1 mutation – and that would tell me probably not going to respond as well to a drug in the class we call aromatase inhibitors, but might respond better to a drug in the class that we call the selective estrogen receptor degraders like fulvestrant or Faslodex, is the name of a drug in that class.

We’re also finding that you can have what we call activating mutations in HER2, and they can be present whether the tumor overexpresses HER2 or not, and we’ve got some ongoing clinical trials looking at if the tumor doesn’t have extra HER2 on its surface – so, it doesn’t have extra HER2 protein, but at the gene level, it’s got an activated HER2 gene – we can use certain types of HER2 therapy to treat it, and we’re testing that right now in clinical trials.

So, could we even use some HER2 drugs even though technically, the tumor would be classified as HER2 negative? So, fascinating increasing information that we’re understanding, and I also mentioned before we can inherit mutations in genes such as BRCA1 and 2, but fascinatingly, the tumor can acquire those mutations. Even if we didn’t inherit a mutation, we can see mutations in the BRCA1 and 2 gene – we call those somatic as opposed to germline mutations. So, “germline” means it’s in every cell in your body, but “somatic” means the tumor somehow acquired this over time.

And so, we’ve done – we just presented some very early results of a trial, and we’re expanding this trial, looking at if you didn’t inherit a BRCA1 or 2 mutation, so technically, you don’t qualify for a PARP inhibitor, but if the tumor acquired a mutation and we can prove that with testing the tumor’s DNA, then we have seen responses from these PARP inhibitors, so that opens up another whole class of treatments, and there are other DNA repair genes that actually may be qualified as well that we can inherit or that can be acquired by the tumor.

So, more and more, we’re doing this genomic profiling, and it is leading to results that would give us possible treatment options.

Katherine:  

Dr. Gralow, the goal of this program is to provide the confidence and tool for patients to advocate for the essential tests to get best care personalized to them. Are there specific tests that patients should make sure they have?

Dr. Gralow:  

Well, there are a lot of assays out there to do this genomic profiling or genetic testing of the tumor, so I don’t promote any one. Various institutions do it and do it well, various companies do it, but I think every metastatic patient should have the tumor looked at in this kind of profiling.

I also think every metastatic patient should advocate for having a biopsy of their cancer, and if a biopsy cannot be done safely in the recurrence, then see if they could get a liquid biopsy – have blood drawn to find it. So, I think that patients should be asking about this. Sometimes, insurance won’t always cover it, and so, my job as a treating physician is to advocate for that, to do an appeal.

More and more, because we have so many actionable mutations in breast cancer now, I’m not having insurance decline, but occasionally, it does, and then it’s our job as the healthcare providers to make the case that yes, this will impact the patient, and yes, it should be covered by insurance.

Katherine:  

You’ve been referring to a number of terms. Patients may have heard the BRCA or “braca” that relate to breast cancer in genetics. Would you give us an overview of common mutations in breast cancer?

Dr. Gralow:    

So, of the mutations that we can inherit, the first two that were discovered were BRCA1 and BRCA2, and for all breast cancer – not just metastatic, but all breast cancer – we think that maybe 5-10% of breast cancer is the direct result of the inheritance of a strong gene that gives you a high – not 100%, but a high likelihood of developing breast cancer.

So, for BRCA1 and 2, these two genes are associated predominantly with breast and ovarian cancer, and if you live out your normal lifespan, you could have up to a 75-80% chance of getting one of those two cancers, and breast cancer being more common. Also, some association with some other cancers including, interestingly, prostate cancer, which we’re learning more about.

So, BRCA1 and 2 are the most common, and they tend to be found – because they have such a high association with the risk of breast and ovarian cancer, they tend to be found in families that have a lot of other breast cancers, and also breast and ovarian cancer presenting at a younger age. So, you’ve inherited a gene that leads to a high predisposition, and the cancer occurs earlier.

So, whereas the average age of diagnosis of breast cancer in the U.S. is 61-62 most commonly, in a patient who’s inherited a BRCA1 or 2 gene mutation, it’s closer to 40-42 – so, a lot younger. And then, there are a variety of other genes that can be inherited that are either much less common or have a weaker link. So, for example, there are genes called CHEK2 or PALB2, ATM, P53 – I just mention that because some of the listeners will potentially have one of those mutations or have heard it. Those are either rarer or they’re associated with a weaker chance of getting cancer.

So, those might be more commonly found in a family that doesn’t have a lot of cancer in it because a carrier – the mother or the father – and their other relatives would have maybe only a 30% chance of getting breast cancer in some cases. So, there would be a lot of carriers who don’t get cancer.

So, as I mentioned earlier, I think it’s really important – especially right now in metastatic breast cancer – that pretty much everybody, even if you didn’t have a strong family history, even if you weren’t diagnosed at a young age, get tested because if we find one of these inherited mutations, we now have some additional treatment options, especially right now, approved for BRCA1 or 2, but clinical trials going on for many of these other genes.

Katherine: 

How do these mutations affect disease progression and prognosis?

Dr. Gralow:          

So, most of the genes I’ve mentioned – in their normal state, they’re critical, actually. They’re called DNA repair genes, and their job in our life is when we accidentally make a mistake when we’re replicating our DNA and two cells are dividing, if there’s a mistake in the DNA, they go in and repair it. And, we’ve got all kinds of mechanisms to try to prevent mutations from happening as cells divide, and BRCA1 and 2 are a key part of that, and so, they’re fixing it.

So, if you inherit a mutation in one of those genes, you still have some ability to repair any routine mistakes that are being made, but over time, you have less ability, and then, if you get a cancer that has a deficiency in BRCA1 or 2, those cancers can be more sensitive to certain kinds of chemotherapy that affects DNA repair.

So, for example a class of chemotherapy agents called the platinum drugs – carboplatin and cisplatin – may be more effective in BRCA1- or 2-mutated cancers, also more generally in triple negative breast cancer because they can be more similar to BRCA1-mutated cancers in a lot of ways.

So, to go back to your original question, once a cancer has developed in a patient who has a BRCA1 or 2 mutation, we treat that cancer for what it is. So, it might have developed estrogen – have estrogen receptor on the surface or HER2, so we treat it as the subtype that developed, and actually, the chance of cure is just the same for BRCA1-associated breast cancer as it would be for one that doesn’t have a BRCA.

But, the chance of getting a second breast cancer – a totally new breast cancer – would be higher unless you chose to remove both of your breasts and the bulk of your breast tissue. So, decisions like surgery – if you had a known BRCA1 mutation, we’d treat the cancer you have now aggressively and for cure, but when you talk about your surgery options, we’d say doing more aggressive surgery, like removing both of your breasts – that’s not gonna improve your chance of surviving the cancer you have now, but it will markedly reduce the chance of getting a second breast cancer.

So, you could consider that as an option for surgery – not to improve your chance of this cancer, but to reduce the chance of another breast cancer. So, your surgery decisions might be impacted by knowing your BRCA1 or 2 mutation. And then, clearly, if you had metastatic breast cancer, knowing if you had the option of a PARP inhibitor, one of the drugs in that class could be – you could have a different treatment option for drug therapy.

Katherine: 

Well, Dr. Gralow, what other factors should be taken into consideration with a treatment route?

Dr. Gralow:   

I always like to think of the treatment decision as relying on three factors, and the first relates to the tumor factor, the cancer factor.

So, we talked a lot about the biology, the estrogen receptor, the HER2, the genomic profiling. So, that’s critical, but there are two other components that we need to really strongly consider when trying to devise the right treatment regimen. One of those is patient factors, and not just the patient’s genetics, but are they pre- or post-menopausal?

What is the age? Where are they in life? Are they young with young kids? Are they working, and is that an important priority for them? Are they older and with grandchildren, and they don’t need to work? What is it that would be critical? What are the patient’s priorities here, and what are their fears, what are the things they would – what would be really important as we plan a regimen? And so, the patient factors which would be patient priorities and where they are in life right now.

And then, there’s factors related to the treatment itself, which would include not just how effective it is, but – and, this is really important when trying to decide regimens – what are the side effects of a regimen? For some patients, hair loss is a big deal, and we can put it off as long as possible – maybe choosing the first couple regimens don’t cause hair loss sometimes.

But, for other people, that doesn’t matter to them. For some, we have oral – some regimens, and that could keep them out of the infusion room, and others actually – I’ve had patients who actually like coming into the infusion room regularly so that they can review the side effects and get the reassurance provided by it. So, we’ve got different route of administration of the drugs, different side effects. If you already had, for example, a neuropathy – a numbness/tingling of fingers and toes – from treatment that you might have gotten for early-stage disease, we’d probably want to avoid drugs where that’s their major side effect in the metastatic setting and that would increase that even further.

We’ve got some drugs that cause a lot of toxicity to our GI system – nausea, vomiting, or diarrhea – and other drugs that don’t. And so, understanding what symptoms the patient already has and actually tailoring the treatment based on some of the side effects of the drug could also be done, as well as how they’re administered. So, again, patient factors, tumor factors, and then, factors related to the treatment itself all come into play when we make decisions.

Katherine:    

There have been so many advances in breast cancer research. What are you excited about in research right now?

Dr. Gralow: 

Well, every single drug that’s been approved, every single new regimen that’s been approved in breast cancer is the direct result of clinical trials, and this is a major part of my career, is to help patients get access to clinical trials and run important clinical trials that could lead to new discoveries – is this regimen better? What’s the toxicity?

Because until we have a cure for breast cancer, we need to do better, and we need to research better treatment options. So, doing trials, having access to clinical trials where you can participate, help move the science forward is key.

I think where we’re moving with breast cancer is the more we’re understanding the patient and the tumor, the more we’re realizing every single breast cancer is different, actually, and whereas when I started my training 20-plus years ago, breast cancer was breast cancer – we weren’t even using HER2 yet, we were just learning how to use estrogen receptor, and we kind of treated everything the same – now, we’re subsetting, and subsetting, and subsetting. Even in triple negative breast cancer now, which is about 18-20% of breast cancer, we’re subsetting.

Does that triple negative breast cancer have PD-L1, which is associated with being able to get immunotherapy drugs? Does it express androgen receptor? Because sometimes, even a breast cancer that doesn’t have estrogen or progesterone receptor can express the androgen receptor, like prostate cancer, and we can use some prostate cancer drugs. So, even triple negative breast cancer we’re subsetting and subsetting, and could that triple negative breast cancer be associated with a BRCA1 or 2 mutation, and then we can use the PARP inhibitors?

So, I’m actually really excited about that we’re learning more and more, and subsetting, and not treating breast cancer as one size fits all, and if we can better tailor the treatments to the patient and the tumor, that we are going to get to the point where I can tell my patients yes, we can get cures in metastatic breast cancer.

Katherine:    

For patients who may be hesitant to speak up – to advocate for themselves in the process – I’m gonna start again. For patients who may be hesitant to speak out for themselves and advocate for their own care and treatment, what advice do you have?

Dr. Gralow:   

You have a whole team who’s behind you, and I’m the MD on the team, but I’ve got a nurse practitioner, and a nurse, and a scheduler, and a social worker, and a nutritionist, and a physical therapy team, and financial counselors. I’ve got a whole team who works with me. And so, a patient might be hesitant to speak up during the actual appointment with their physician. It’s a short amount of time. I would recommend come into it with written-down questions because things go fast. You don’t get a lot of time with your doctor.

Things go fast, but don’t come in with 25 questions, either. Pick your top few that you want to get taken care of this visit because if you come in with 25 or 30, you’re gonna lose the answers to most of them. Maybe bring somebody with you who’s an advocate and a listener for you who could be taking notes, so you can process and you don’t have to write it down, or ask if you can record it. It’s really important if you’re newly diagnosed or maybe there’s a progression and you’re going on a new treatment. That’s okay too.

But, I would also say you have a whole team behind you, so sometimes, if you don’t have time or if you’re hesitant to speak up in your doctor’s visit, you can ask the nurse, or maybe you can ask the social worker for help, even. See if there’s support groups around.

Interestingly, we’ve got a peer-to-peer network where patients can request to talk to somebody else who’s matched to them by some tumor features, and their stage, and things like that. Maybe finding somebody else who’s gone through something similar, and somebody independent to talk to instead of relying on your family.

It can also be really helpful to talk to a therapist or a psychologist about your fears, and sometimes, you want to be strong for your family, strong for your children and all, but you need a safe space with somebody that you can just express your fears and your anger if that’s what’s going on, or your depression or anxiety to while you’re trying to hold a strong face for others in your family. So, I would encourage patients to look at who is the whole team and talk to the other members of the team as well, and sometimes, they can help advocate.

Also, find somebody who might be able to come to your appointments with you, somebody who will help you advocate or remind you – “Didn’t you want to ask this question?” – or be another set of ears that you can process it with afterwards.

Katherine:     

Dr. Gralow, we’ve covered a lot of useful information today for patients. Thank you so much for joining us.

Dr. Gralow:    

Thank you, Katherine.

Katherine:       

And, thank you to all of our partners. To learn more about breast cancer and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Katherine Banwell.

Cancer, COVID, and Change

“There’s something to be said for not being a patient,” one of my doctors said.

“It feels so good,” I said during our telemedicine appointment, “to be away from the hospital for eight weeks in a row.” It’s the longest hospital break I’ve had since being diagnosed with cancer last summer. Before mid-March, I’d been to four to ten medical appointments every month. Being a cancer patient felt like a full or half time job. Because of the pandemic, I’m now treated by my oncology team from the comfort of my own home.

I don’t miss shuffling from room to room or floor to floor and sitting in waiting rooms for hours. I love not needing to ask for rides or take cabs or public transportation while my white counts are low. I don’t miss being poked,  prodded, weighed, and measured or having my vital signs documented in hallways while removing my coat, wig, and shoes. I love not having to roll up sleeves for the vials of blood to be drawn or to pull down my pants so the doctor can put a stethoscope to my belly and bowels.

Because of the increased health risks at hospitals, new access to telemedicine, and flexibility around clinical trial protocols, I can see my oncologist, face to face, through Zoom. Questions can be answered ,via email, a text, or a phone call. Clinical trial drugs are overnighted to me.

I enjoy the time and money I’m saving and the convenience of getting all care from home. But I also miss the real-life hugs, handshakes, and high fives that used to come with seeing the clinical team in person.

COVID Challenges

Many cancer patients are losing jobs, homes, loved ones, and health insurance. For those newly diagnosed with cancer, surgery, scans, and treatments must be done all alone. Those in active treatment are often terrified of catching COVID-19 while immunocompromised. Others are afraid hospital visits will expose our family members to COVID.

It’s startling how much hospital protocols and procedures have changed. When I look back or think about what comes next, I worry. I hope the pictures and stories below capture what it’s like to be an oncology patient and how swift and severe the COVID-related changes over the last few months have been and continue to be.

From Person to Patient

My partner drove me to the hospital on the morning of my surgery. We checked in before 6a.m. and waited, with others, in the lobby.

Eventually, we were called up and walked, single file, through halls by someone escorting us to the pre-op area. Each one of us was assigned a bed (pictured) and a nurse (not pictured). The photo is of the pre-op area.

My partner got to visit me before surgery. He was there when the surgeon, nurses, fellows, and anesthesiology came to prepare me for surgery.

If surgery were scheduled today, my partner wouldn’t be able to stay with me.

The Shock of a Post-Op Diagnosis

This is me in post-op. My partner took this photo on his phone and was able to share it with my family and friends to let them know I made it through surgery. They were worried because it went hours longer than expected.

In the photo, I’m high as a kite and happy to be alive. I’ve just downed the iced coffee my partner snuck in (as planned and with permission from the nurse). In the photo, I am still in shock that my surgery was five hours long, it’s afternoon, and that cancer was found. I don’t yet know how serious my diagnosis will be. That will come twelve hours after surgery when the surgeon explains my cyst was actually a cantaloupe-sized cancerous tumor, aggressive, advanced, and usually chronic. Mercifully, my partner is with me as she explains that she had to do a total hysterectomy, removing ovaries, fallopian tubes, lymph nodes, and my omentum and lays out the timeline for chemotherapy.

My partner held my hand and crawled into my bed to hold me while I sobbed. But he provided far more than essential emotional support. He helped me stand and keep my balance, helped me get to my first trip to and from the restroom. He was there to advocate for me when I dozed off and to get the nurse when my call button went unanswered. He was the one who provided my loved ones with updates. He was the one who snuck my favorite health foods to help “wake up” my digestion enough to allow me to be discharged after one day.

It’s hard to imagine what that traumatic and challenging day would have been without him. I can’t imagine recovering from major surgery and receiving such devastating news alone but it’s what many diagnosed with cancer during COVID now endure.

At-Home Adjusting & Recovery:

Going home after surgery is comforting and scary. My right leg was giving out from under me because my obturator nerve “got heat” during my surgery. I had trouble standing in the shower or lifting my right leg onto the bed or into a car. I had extensive swelling and bruising on my right side and pelvic area and had a bit of a reaction to the bandage tape. I didn’t know what was normal. And after a phone call to the hospital, I was asked to come back in for a check-up.

Today, I’d either have had a telemedicine appointment or need to decide if an in-person visit with a medical professional is worth possible exposure to COVID. These are the types of decisions we are all facing but it’s especially scary when one is already vulnerable and fighting for life.

Early Treatment: Chemo Buddies are Not Optional

Getting chemotherapy infusions is time-consuming, scary, and intense. Everyone reacts differently to the many drugs given with chemotherapy (such as Benadryl, steroids, Pepcid, and anti nausea drugs). Everyone reacts differently to the chemotherapy, marked hazardous,  that require the nurse to wear gloves, masks, and protective clothing to prevent contact in case of accidental spills. Some drugs make you sleepy, and parts of your body numb. Others make you feel amped, wired, and agitated.

Some cause nauseous, headaches, or allergic reactions, immediately and others not for days or weeks.

Having a chemo-buddy like Beth was a huge help. She was the one who asked for window seats in the infusion center, who made sure I got warm blankets. She massaged my feet and reminded me to listen to guided imagery. She sat with me in waiting rooms as we waited for my labs to come back to make sure my white and red blood counts weren’t too low, my liver counts not too high, and that the chemo was making my tumor marker scores go down.

She was the one who touched the elevator buttons for me, the one who walked me to the car and handed me off to my fiancé at the end of the day. She was the one who got me water, coffee, or snacks.

I felt safer whenever I had a chemo buddy with me and Beth would also take notes and make sure I didn’t skip any of my questions just because the oncologist seemed in a hurry.

Beth was not only a source of support but provided an extra pair of hands to plug in my iPhone, to hold my bags, food, or books. She was the person I could share tears, laughs, and heart to hearts with. She listened as I worried about my daughter, as I struggled to balance work and parenting.

She was there to support me as I talked endlessly about healthy eating, fasting, supplements, and complementary medicine. But the greatest comfort of all was knowing she would be there if passed out, fell, or had an allergic reaction to all the treatment drugs. At my last treatment, I was alone and Beth at home. It was hard.

In-Between Hospital Visits: Public Services & Personal Support

 

Social distancing during treatment is hard even for introverts like me who need a lot of alone time. When physically weak, short visits with loved ones who bring food, hugs, and gifts are life-affirming and life-changing.

Those who show up do so for cancer patients as well as our families. They help us to take care of our kids, partners, pets, plants, and housework. They help us manage as we face fear and loss, whether losing jobs or body parts, or hair and having few or no visits is hard. Today, barber shops where we might get our heads shaved are closed.

The wig shops and stores we go to for hats and head coverings are often closed.

We can’t go out to eat with loved ones, or do yoga on good days. We can’t have parties for our loved ones to create normalcy or new rituals. We can no longer go out in the public either. We can’t do things such as sitting alone writing in a journal and drinking a smoothie when swallowing food is too hard.

We can’t travel to remind ourselves there is still beauty and magic in the world and to enjoy our loved ones and lives as much as possible.

These are not all small things or luxuries in coping with the brutal effects of cancer treatment and chemotherapy. They can change the cancer and recovery experience and all that helps keep us strong. 

Later Treatment

We need others when we are sick. We might need help standing, walking, or eating. We might need rides, treatments, or blood or platelet transfusions. We might need help articulating symptoms and side effects. To have fewer in-person visits when so medically vulnerable can be anxiety-producing.

We also have less in-person celebrations with our clinical teams when we finish a line of chemotherapy or have a cancer-free scan. We no longer have informal pet therapy either with the cheerful and cuddly animals of friends, family, and neighbors.

I can’t imagine going to chemo alone, depleted, and with low white counts.

The increased risks, vulnerabilities, and lack of human company and tactile comforts feels indescribably epic.

Maintenance Treatment & Clinical Trials

My immunotherapy infusions (or placebo) have been put on hold for the past two cycles. I asked if I could remain in my clinical trial if I refused to come to the hospital for treatment until the risk of getting COVID is decreased. Luckily, I’ve been allowed to stay home. Clinical trial protocols, in general, are much more flexible as a result of the pandemic. My medication (or placebo pills) are mailed to me. Before March, in-person prescription filling was required and always took hours.

However, I’ve been weighing what I’ll do if I have to weigh virus-related risks against the possible benefits of clinical trial treatment. If I’m required to be treated at the hospital I may drop out of the trial. This is one of the many difficult decisions oncology patients often face but it’s made more complicated because of the coronavirus. .

Have Some Changes Been for the Good?

The losses, challenges, and changes are worrisome and real. That said, not all the COVID-related changes for oncology patients are bad. The whole world is wearing masks, staying home, socially distancing, and worrying about health, wellness, death, and dying.

Instead of being stared at when I wear a mask, I’m now in good company, because much of the world is doing the same. Many of us are consumed with health issues and worried about health, mortality, and immune functioning.

To be reminded, once again, that health and life aren’t guaranteed to anyone, that we are all facing mortality, and must appreciate every day we have, is strangely comforting. While I’m reminded of our collective vulnerability, to hear health concerns, risks, and challenges confronted as the world and nation’s collective concern is a reminder that none of us are being personally picked on for failing at being human, we are just, in the end, all excruciatingly fragile and mortal.

“I feel like I’ve been slow-dancing with death since last summer but now I feel less alone,” I told my friend Kathy. “It’s like others have joined you on the dance floor,” Kathy said. “Yes,” I said, which once again makes me feel like a person rather than a patient and there’s something to be said about not being a patient….


Resource Links:

  1. The National Cancer Institute  guide: Coronavirus: What People with Cancer Should Know.
  2. American College of Surgeons: (ACS) Guidelines for Triage and Management of Elective Cancer Surgery Cases During the Acute and Recovery Phases of Coronavirus Disease 2019 (COVID-19) Pandemic
  3. Sample of patient visitation changes hospitals have implemented from Mass General Hospital.
  4. Telehealth at Dana Farber.
  5. Coronavirus (COVID-19) Update: FDA Issues Guidance for Conducting Clinical Trials

Ovarian Cancer: What You Need to Know with Dr. Chad Michener

This podcast was originally published by the Cleveland Clinic on April 23, 2010 here.

Ovarian Cancer: What You Need to Know with Dr. Chad Michener

How common is ovarian cancer and how do symptoms typically present? What are the risk factors? How is ovarian cancer diagnosed and treated? Join Chad Michener, MD as he answers these questions and many more.

Podcast Transcript:

Scott Steele:  Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Hi and welcome to another episode of Butts & Guts. I’m your host, Scott Steele, the chairman of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And we’re very glad today to have Dr. Chad Michener, who is the interim chair for the department of sub specialties in women’s healthcare. Chad, welcome to Butts & Guts.

Chad Michener:  Thanks, Scott.

Scott Steele:  So we always like to start out this with a little bit of background about our guests. And so tell us a little bit about where you’re from. Where’d you train and how did it come to the point that you’re here at the Cleveland Clinic?

Chad Michener:  Long story, actually, so I actually grew up in Springfield, Ohio, one of four kids. I had three sisters. Regular high school, thought I was actually going to go to art school, and kind of out of the blue decided that wasn’t going to be a great stable choice for me. So I went to college with no real plans and kind of just fell into medical school. And then on through went into training for obstetrics-gynecology, and then really enjoyed the surgical aspect. So did a cancer training fellowship at Cleveland Clinic, actually, and then stayed on board for the last 15 years.

Scott Steele:  Fantastic. Well, we’re lucky to have you here. So today we’re going to talk a little bit about ovarian cancers. So give us the 50,000-foot view of ovarian cancer. What is it, and how does it affect the daily lives? What are some symptoms?

Chad Michener:  So ovarian cancer is one of the unfortunate diseases that we find late. So it’s about 23,000 cases a year. We see, unfortunately, about 14,000 women die because we don’t often find it early. And it’s really because of the symptoms don’t always show up until pretty late. So the symptoms are pretty vague. So it kind of fools patients. It fool’s physicians sometimes because it’ll show up as bloating, nausea, I can’t really eat, I have heartburn, relatively new symptoms for patients. And so oftentimes, they’ll go down the pathway of, “Oh, you have an ulcer,” or things of that nature. And so there’s a little bit of a delay in diagnosis there, but generally speaking, we’ll still find that in stage three or stage four about 75% of the time.

Scott Steele:  So we use a lot of these terms, stages this and that. Before we get to the actual staging of it, talk to me a little bit about risk factors. There’s a lot of risk factors with every cancer. Are there risk factors associated with ovarian?

Chad Michener:  So most of the risk factors are things that are not typically preventable. So there’s no big family component; although, about 25% are going to be genetic when you really do all the genetic analysis on patients. However, there are some things that can be protective. So people who have been on birth control pills, it can reduce their risk by 40 to 50% after using those for five years. Having children is protective, breastfeeding is protective. Essentially, anything that limits the number of menstrual cycles a woman has in her lifetime, is things that can decrease that as much as possible. Things you don’t really have control over are what age they start having menstrual cycles or how many years they have menstrual cycles. So the little things in between become important.

Scott Steele:  So when you have these type of symptoms, is it spread all over the place, or how do you differentiate between what is “normal” and what is something that’s concerning? Is there any one of those symptoms that are real red flags that you would say to the women to get in and see their doctors?

Chad Michener:  So not any one symptoms. So they actually looked at studies of healthy women going in for breast screening versus women with pelvic masses that were benign and then, of course, a group of ovarian cancer patients, and the symptoms were actually fairly similar. The big difference was is that patients with ovarian cancer, the symptoms were relatively new to them and they happen more days than not over the course of three or four weeks. So if you’ve got new symptoms that aren’t going away, they’ve been lasting for three or four weeks, they’re there most days, it’s probably worth a discussion; although, a lot of times it’s not going to be ovarian cancer. It’ll be sort of the more common other things.

Scott Steele:  Okay, so I’m a woman. I’m experiencing these symptoms. I’m going to come into your office for an appointment. What can they expect during that appointment and how is this diagnosed?

Chad Michener:  So most times they’re going to do a pelvic exam and a regular exam on the abdomen. If they don’t find much there, or let’s say they feel maybe there is some fullness or thickening in the pelvis, then usually that’ll be followed with an ultrasound. And then depending on what the ultrasound shows, they may get more imaging to follow. We don’t often use markers to look for this because most times the marker can be nonspecific, so it can be elevated for other things, essentially.

Scott Steele:  And by a marker, you mean blood tests?

Chad Michener:  Blood tests, yeah. So in this case, most times we’re talking about a blood test called a CA 125. We don’t use it for screening because it can be elevated for other reasons. But in somebody who has, say, an ovarian cyst or a pelvic mass, that may be a test that follows up to the ultrasound results.

Scott Steele:  And so you have to have a tissue diagnosis in many of these cancers. Is there something that you do to get a tissue diagnosis to confirm that it’s ovarian cancer?

Chad Michener:  So we do, if it looks like there’s a lot of spread already and we’re not quite sure that that’s what it is. Sometimes we’ll do a biopsy that the radiologist will do, using a CT scan or an ultrasound to guide their biopsy. But oftentimes, we’ll actually take patients to the operating room to make the diagnosis ourselves, particularly if it just looks like an ovarian cyst, maybe with some other questionable features. And most times that’ll be done with a laparoscopy, so a little incision through the belly button with a camera. And then they can put in a couple extra working channels to take out cyst, take out the ovary, and then get a diagnosis that way.

Scott Steele:  So before we go into the actual treatment, and let’s just say that they’re facing this operation that you’re talking about, is there anything that women can do to prepare themselves for that operation?

Chad Michener:  Nothing particular. It’s obviously a little scary for them. So trying to just sort of do normal routine stuff is helpful. There will be sort of things that will follow the day before surgery. We’ll have them be on a liquid diet rather than on a kind of heavy diet so that it can kind of clean stuff out through the intestines and make surgery potentially a little bit easier. But other than that, nothing really per se that we get patients ready for.

Scott Steele:  So in other cancers, you have radiation therapy, oncology, you have surgery, you have chemotherapy up front, chemotherapy afterwards. What’s the initial therapy for ovarian cancer? And as you lead into that, can we go back to that concept you talked about, about staging? What are the different stages of it?

Chad Michener:  So stages of ovarian cancer. As a general rule, you’re going to have stage one, which is just confined to the ovary and there’s a little sub stages of that. Stage two would be that it’s outside of the ovary but still confined to the pelvis itself, so it hasn’t spread into the abdominal cavity at all. Stage three would be abdominal involvement, and that can be really anything. It tends to spread on the surfaces of the organs. And so you’ll see little implants, and they can cover the intestines, the liver, a fatty apron called the omentum that hangs off to the intestines is a very common site that we see. And then anything that’s either inside of one of those organs, let’s say there’s a cyst in the liver that’s involved or if it’s in the chest, then it would be a stage four.

Treatment is based on those stages. So if we think it’s confined to stage one, or at least it appears to in surgery, then we do a staging operation where we would take out the ovary, usually the uterus and the other ovary as well. And then we would do lymph node biopsies. We would biopsy the omentum and then biopsy different sites in the abdominal cavity where we often see spread and then followed by chemotherapy in most but not all cases. Advanced stage disease, we spend a lot of time up front getting imaging, sometimes getting biopsies before going to the operating room, to figure out what the diagnosis is and how much involvement there is, to decide if we think we’re going to be able to remove all of the tumor surgically.

If we think that that’s going to be not possible or unlikely, then oftentimes, we’ll start chemotherapy as our first treatment after a biopsy diagnosis and then plan surgery after a few rounds of chemotherapy. So that’s called neoadjuvant chemotherapy. In surgery, we’ll do what we call a debulking operation. We’ll go in, we’ll take out everything possible that we can, and sometimes that can be done laparoscopically. Sometimes it has to be done as a large open incision. And then, if we’re able to shrink everything down surgically, we actually can offer hyperthermic intraperitoneal chemotherapy, or often called HIPEC, and that actually has been associated with better outcomes in people who have neoadjuvant chemo therapy first.

Scott Steele:  That’s kind of honed down in some specifics there. So what can women expect with chemotherapy? And when you talk about a few cycles, how long is that? What side effects do they get from that? Is their hair going to fall out, or is it something that they can tolerate well? If they’re having that bloating, does that get better?

Chad Michener:  Yeah. So chemotherapy for ovarian cancer generally comes in three-week cycles, so 21 days. And sometimes that’ll be weekly treatments, sometimes be just once every three week treatments. It’s actually a fairly tolerable regimen, but there are common side effects such as hair loss. Some people will experience some nausea, but not a lot of vomiting with that regimen. They can get constipation or diarrhea. It’s pretty variable, but those can be side effects of our anti-nausea drugs. And then sometimes people were experienced neuropathy, so they get numbness or tingling in their hands or their feet. And that can be reversible over time, but we do watch that carefully because one of the drugs is associated with neuropathy more than others. After three cycles of that, so nine weeks, we would get another set of cat scans and then decide if it’s something that we can take to the OR at that point.

Scott Steele:  So when you go to the operating room and you’re trying to get out this tumor or multiple tumors in there, is it something that you have to take out other organs? Do people wake up? Do they have to wear a bag? What does that surgery all involve?

Chad Michener:  Yeah, generally speaking it’s going to be hysterectomy, and then the tubes and the ovaries, the omentum commonly. And then the other organs that can be involved oftentimes can be the appendix, the spleen, the intestines, whether that be small intestine or large intestine. And probably about 20% to 30% of patients will have some sort of a intestinal surgery during their debulking operation, most commonly the colon that sits behind the uterus. But most times, we’re able to take that out, put the colon back together, and there’s no ostomies or bags that patients would have to wear. Probably less than 5% of the time, we’ll end up doing a colostomy or an ostomy that is a temporary in most cases. Once in awhile it will be permanent, but that’s a very, very small percentage of patients.

Scott Steele:  So one of the things we know is that there’s different biologies associated with not only just classes of tumors, but within each class of tumor, individual variations exist. So there was a study that recently came out regarding a more of GI cancers about the HIPEC that you talked about, that heated intraperitoneal chemotherapy, that showed that HIPEC wasn’t as advantageous as just getting the tumor out alone. If I heard you right, that HIPEC’s a little bit different beast in terms of the ovarian cancer. What is the role of HIPEC, and who would be a candidate for HIPEC versus just the debulking surgery?

Chad Michener:  So HIPEC for ovary cancer, in fact, is actually relatively new. It’s not done in a lot of centers. And so we’re still trying to figure out exactly who the best patients are for this. As a general rule, we haven’t used it based on cell type. So if it’s an epithelial ovarian cancer, whether it’s serous or mucinous or clear cell or endometrioid, all of those patients are potential candidates, assuming that they’re having a good response to chemotherapy and they have a near complete or near complete debulking surgery. We don’t often use it for what we call germ cell tumors or stromal tumors, which we typically will see in younger women, kind of different population. We don’t know that, say, mucinous tumors are better, which is commonly what it was used for for GI tumors. But I think we just don’t have the data yet. So we kind of offer it to everybody who we’re doing a debulking operation on who’s had chemo up front because there is a survival advantage there, at least in the one study.

Scott Steele:  So how long can women expect to be in the hospital after this? Is it a pretty safe surgery to recover from?

Chad Michener:  Yeah, people do pretty well. So all complications, including wound infections or anything of that nature, bladder infections, you’ll see that in somewhere between 15% and 20% of patients, usually minor complications. Major complications like blood transfusions and things, readmissions to the hospital, retake backs to the operating room, usually we’ll only see that in about 5% of patients depending on the center. Most times, they’re in the hospital for anywhere from about three to 10 days. And it really depends on how much is done in surgery. If there’s bowel surgery or not bowel surgery, if they have a large transfusion for bleeding, they have to go to the ICU, they’ll end up staying longer in the hospital. But I think, as a general rule, people will be usually home within three to 10 days.

Scott Steele:  And do they have to get follow up chemotherapy?

Chad Michener:  Yeah, so if they started with chemotherapy, then usually we’ll finish with three more cycles of chemotherapy, so an additional nine weeks. And we generally try to start that three or four weeks after surgery. If they didn’t get chemotherapy up front and we just took them for a debulking surgery, or if they had early stage disease, then usually they’ll get all of their chemotherapy after, which usually consists of six cycles of chemotherapy.

Scott Steele:  One of the things that you had mentioned was a little bit about the younger women population was a little bit different group, but can you talk a little bit about … I’m sure this does affect some younger women. Is there a role for kind of preserving fertility or egg freezing or anything like that? And also, is there a role for genetic testing?

Chad Michener:  So fertility in younger women, we do try to preserve, in fact. And if it is, let’s say, a germ cell tumor, so a different form of ovary cancer, usually affects women in their teens, twenties, not so common after the thirties. Oftentimes, you can take one ovary out, do the biopsies for lymph nodes and things, and leave the other ovary. Oftentimes, do chemotherapy and then they’ll still maintain their fertility afterwards. There are some other things you can do. We’ll usually have them see one of our infertility experts and talk about either protective drugs for the ovaries during chemotherapy or we do offer them the potential to go through a cycle of intro vitro fertilization, freeze eggs, freeze embryos if we think they have time for that. Or sometimes I’ll actually harvest and freeze part of the ovarian tissue as well. So that would be that group.

It’s harder to do in people with advanced disease, obviously, because they’ve got disease covering a lot of areas. So typically, we won’t recommend fertility preservation in that specific sense. But sometimes we’ve taken out ovaries, left uterus behind if the uterus doesn’t look involved, and then there’s ways to do donor eggs and things like that for fertility in the future if they do well. The second question was genetic testing. And for that we actually offer genetic testing to all of our women with epithelial ovarian cancer, so the more classic ovarian cancer that we talk about, because about 20% to 25% of people will have some gene mutation in their family.

And that becomes important for two reasons. One is that that can be passed on about half of the time, so with each pregnancy there’s a 50% chance of passing that gene on. And then secondly is we actually utilize that as part of our treatment now with a group of drugs called PARP inhibitors, and those are oral medications that are taken either with or most times following chemotherapy, and they have a specific function in patients with BRCA mutations or similar mutations. And so it becomes an important part of the treatment paradigm for those patients as well.

Scott Steele:  What if you have a woman out there that says, “Listen, I don’t get this because I get a yearly pap smear.”

Chad Michener:  Yeah, that’s a common misconception. I think that people think they’re getting checked for this all the time when they go for their pap smear, and pap smears are really meant to look for cervical cancer and that’s it. It is true, once in a while we’ll find either a fallopian tube or and ovarian cancer or even sometimes an endometrial cancer, but it’s not designed for that. In fact, most people who have endometrial or ovarian cancer have a normal pap smear at the same time that they get diagnosed. So it’s not really for that.

Also on pelvic exams, sometimes people don’t have large masses. So they can have lots of disease scattered all over the abdominal cavity, and the ovaries can actually feel quite normal. And that’s because we lump ovarian cancer in with something called fallopian tube cancer, but also with one called primary peritoneal cancer where the majority of the disease is in the lining surface of the abdominal cavity, but really doesn’t involve the ovaries much at all. And so you can have normal exam and then three months later show up with bloating, nausea, and then be diagnosed with ovarian cancer.

Scott Steele:  So what’s on the horizon for the treatment or diagnosis of ovarian cancer?

Chad Michener:  So the Holy grail would be screening, right? So we don’t find it early. So if we could find a great screening test where we could find patients in early stage, it’d be wonderful because survival rates for stage one cancers are actually pretty great. The problem with finding it late is that survival rates aren’t as good. And so the research is been looking for a new marker for a long time. As I said, CA 125, not really that specific, so you can’t use that to screen kind of a normal population of women because there’s a lot of what we call false positives. So people get a positive test, they don’t actually have ovarian cancer, they have anything else. Inflammation of anything in the abdominal cavity or in the chest can cause that number to go up. So that’s one of the big things that lots of people are pushing for.

On the treatment side, I think everything is going, as with most cancer, to targeted therapies, things other than chemotherapy. And so hyperthermic chemotherapy, it was one of them, and I think that’s still a work in progress. We’re still trying to figure out how to fit that in. And then with targeted therapy, most of our trials now contain not only chemotherapy but either PARP inhibitors, other targeted inhibitors, and actually sometimes immunotherapy or a combination of those. So that’s where all the research is going currently.

Scott Steele:  Well, that’s fantastic stuff, and we’re glad to have you here. This one hits particularly close to home as my mother passed from it. So, Chad, we are going to just kind of wind up with a few quick hitters for you. So what’s your favorite sport?

Chad Michener:  Gee, I would say college football to watch. To play, I like to run as my primary mode of activity.

Scott Steele:  Favorite meal?

Chad Michener:  I would say steak, believe it or not.

Scott Steele:  And what’s the last nonmedical book that you’ve read?

Chad Michener:  The last one I read was a book called Driving Miss Norma, which was actually interesting, about a cancer patient. And we had visitors here at Cleveland Clinic that were the authors of that book, and they took their 90-year-old mother around the country in an RV and did a lot of visiting things for a lady that actually had an endometrial cancer, so an aggressive form. She chose that over doing treatment for her cancer, but kind of a fun read, a lot of things that they did, a lot of pictures. So that was actually a really fun, great book.

Scott Steele:  Fantastic. And tell us one thing you like about being here in Cleveland.

Chad Michener:  The thing I loved about being here, I did my fellowship here and actually chose to stay because there’s a lot of collaboration here. And even since I started 15 years ago, the Cleveland Clinic has grown tremendously. There’s a lot of great relationships here, a lot of colleagues that I work with frequently. And so I thought it would be a great place to work from a family standpoint. Cost of living is great, as you know from living here. And there’s really a lot of stuff to do, so it actually is quite a fun city to be in. And so we’re super glad that we stayed.

Scott Steele:  Well, that’s fantastic. And so for more information about ovarian cancer, please download our guide by visiting Cleveland Clinic.org/G-Y-N-O-N-C, that’s Cleveland Clinic.org/gynonc. And to make an appointment with a Cleveland Clinic specialist, call (216) 444-6601. That’s (216) 444-6601. Chad, thanks for joining us on Butts & Guts.

Chad Michener:  Right. Thanks, Scott. Appreciate it.

Scott Steele:  That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.

Finding Support in Unlikely Places

This blog was originally published by Cancer Today by Patricia Anne Ward here.

WHEN I WAS DIAGNOSED ​with stage IC ovarian cancer in February 2018, my life came to a screeching halt. It was the first life-threatening health issue I’d ever faced in my 70 years of life. Despite my fear and anxiety, I knew I didn’t want my cancer or treatment to define me as a person. Honoring that wish turned out to be much easier in theory than in practice, as even a well-intentioned question like “How are you?” served as a reminder of my circumstances.

There were also some insensitive remarks that cut far deeper. One person told me, for example, that God never gives us too much to handle. Another described how cancer was a blessing reserved only for the strong—if this is true, I’d much rather be weak. Someone else suggested my cancer was a result of some transgression to God and that I should make amends.

Despite being surprised by these comments, I understood. People say a lot of things when they are faced with the uncomfortable concept of mortality. And my cancer was a tangible reminder of what we all know and ignore: Each of us has a finite amount of time.

It was shortly after I started losing my hair, a side effect of chemotherapy, that I began noticing others were uncomfortable around me. Some family and friends even avoided making eye contact when talking to me. Others used text messaging to avoid uneasy verbal conversations. With no one in my immediate circle undergoing cancer treatment, I felt alone.

That’s when I started discovering support in the most unlikely places. In the pickle and condiment aisle at the grocery store, a woman turned to look at me, a wide smile across her face. Not too long before our meeting, that woman wore a cap just like mine. She shared that she was two years out of treatment and her scans were still “clean.” We spoke for a bit, tearing up. I held hands with this kind stranger for a few moments. We hugged, wished each other well and went our separate ways.

At a clothing store, another woman stopped me after spotting that cap, which gave my cancer away. Apologizing first for interrupting, she then told a familiar tale of symptoms, diagnosis, surgery, treatment and the worst part: waiting. Still, she was approaching the five-year mark since her diagnosis with no evidence of disease. Speaking from a place of vulnerability but also strength, she described how her cancer had helped her to become more compassionate, a virtue that she would surely lean on, since her husband had been newly diagnosed with cancer. As we said goodbye, I promised her I would stay positive and upbeat—and strangely I wasn’t lying.

All through my treatment, chance encounters with people who knew what I was experiencing came to me just when I needed them. I saw these people as angels, and still do. They came with no judgement or preaching. There was no awkward response or agenda. Our connections were palpable.

There were other signs: I found feathers everywhere, next to my car in a parking lot, the floor in the garage or at the park. One simply blew in on a breeze and landed right at my feet. And each time I made a discovery of these gifts from nature, a sense of warmth and protection would envelope me. I have always believed in angels; I found it encouraging to think that they believed in me too.

For now, my treatments are over. My hair and eyebrows are growing back. My recovery continues. There will be more doctor appointments, more exams, and more wondering about and praying for a future with no more cancer. I’ve changed too. I am smarter, kinder and less quick to judge. When I am out of the house, I scan my surroundings for people like me—signs of treatment, signs of fear—to offer an encouraging word. I don’t know what the future holds, but I can’t help but believe that I am going to be OK. 

Patricia Anne Ward of Gaylord, Michigan, is a retired human resources administrator and supervisor who has been married to her husband, Richard, for 30 years. She is the former president of a local animal welfare group, Friends for Life of Otsego County. Her proudest title is survivor.​

November 2017 Notable News

All cancer, on a very basic level, is the same. It is the uncontrolled growth of cells. However, each type of cancer varies greatly and that is why early detection and individualized treatment is so important for patient health and survival. Fortunately, research breakthroughs come along every day that help pave the way to successful, individualized treatment.

A breakthrough in breast cancer research has come from an unlikely place, reports al.com. For his winning science fair project, high school senior Kenneth Jiao researched breast cancer and made a discovery that may help stop the spread of the disease to other organs. Through his research, Kenneth discovered that the CHD7 gene and it’s molecular processes may prevent metastasis. Kenneth’s project was inspired by a breast cancer scare his mother had a couple of years ago. His mother’s tumor turned out to be benign, but the worry and fear Kenneth felt during that time motivated him to look for ways to prevent the disease. Kenneth earned a $3,000 scholarship for his win and is moving on to the final round of competition in Washington, D.C. where he could end up winning $100,000 in scholarship money. You can learn more about Kenneth and his science fair experience here.

Researchers may have found an easier way to find successful, individualized cancer treatment by experimenting on tiny replicas of unhealthy cancer cells called tumoroids, reports economist.com. The tumoroids, which were developed from the cells of eight liver cancer patients, are unique in that they contain only cancerous cells. Traditionally cultured cells are often mixed with healthy cells, which can affect the results of the genetic analysis. Along with gaining a better understanding of the cancerous cells, the research team is using the tumoroids to test anti-cancer drugs. The hope is that, eventually, replicas will be made of individual patients’ cells which will then be examined and tested to determine personalized treatment options. Find more information about the tumoroid research, here.

About 70 percent of women diagnosed with the most frequently occurring type of ovarian cancer are diagnosed with an advanced stage of the disease, but according to cancer.gov new research may help to change that. A new study reveals that the most common ovarian cancer, known as HGSOC, may begin as lesions in the fallopian tubes several years before the start of ovarian cancer, which means there is a potential for early detection. The new study supports and expands on a study done ten years ago that identified fallopian tube lesions in women with the BRCA1 or BRCA2 mutations. The evidence now shows that HGSOC originates from the fallopian tube lesions whether the BRCA mutations are present or not. Not all ovarian cancers originate from the fallopian tube lesions and more research needs to be done, but there is hope for the possibility of early diagnosis and prevention. More details about the study and further research can be found here.

There are thousands of species of bacteria that live in and on our bodies and the ones living in our stomach, our stomach microbiome, may be a major factor in the risk of tumor development, according to new research reported by worldwidecancerresearch.org. The study shows a link between the microbial diversity of the stomach and varying health conditions — some cancerous and some not — and while many factors are involved in gastric cancer development, the study shows that the stomach microbiome may be one of those factors. Understanding and being able to change stomach bacteria may one day lead to the prevention or treatment of stomach cancer. Learn more about the exciting microbiome discovery here.

Check back next month for more exciting breakthroughs and in the meantime, keep up with the latest at PEN here.

5 Lessons Learned from an Ovarian Cancer Survivor

Editor’s Note: Blog written by MyLifeLine.org founder and ovarian cancer survivor, Marcia Donziger. She shares 5 of the lessons learned after she was diagnosed with ovarian cancer at age 27. 


marcia-photo

Marcia Donziger

In 1997 I was 27, happy, free, and traveling the world as a flight attendant. Newly married and ready to have a baby, I felt strong and invincible. My future was unfolding just as I expected it to. Until the symptoms appeared ever so subtly. Squeezing cramps around my waist. It hurt to pee. After a few weeks, I marched my invincible self into my doctor’s office, told her I diagnosed my own bladder infection, and may I please have antibiotics.

She decided to investigate a little further. After an ultrasound, she discovered a grapefruit-sized tumor growing on my left ovary. “Could it be cancer?” I asked. “No,” my doctor assured me, “you’re too young to have cancer.”

Surgery was scheduled to remove my “benign tumor.” I was excited to get it over with, so I could go on with my life and have babies. After 5 hours of surgery, I woke up in the recovery room, my body uncontrollably thrashing in pain. My doctor hovered over me and broke the news, “I’m sorry. You have ovarian cancer. You’ve had a complete hysterectomy. We took everything out.”

What I heard loud and clear was “Cancer. You can’t have children.”

The diagnosis came as a shock. Stage IIIC ovarian cancer had taken over my abdomen, resulting in an emergency hysterectomy that I was not prepared for. The intense grief hit immediately. The loss of my fertility was most crushing. I had always wanted to be a mom.

Halfway through chemo treatments, I celebrated my 28th birthday, but there wasn’t much to celebrate. My marriage was dying. Cancer puts tremendous stress on a couple. Some couples can handle it together like champs. We didn’t. We divorced 1 year from the date of my diagnosis.

After treatment ended, I looked in the mirror to see what was left. I was 28 years old, ravaged physically and emotionally, divorced, and scared to date as a woman unable to have children. Who would love me now?

Now, almost 20 years later, I feel strong again (although not invincible).

With the benefit of time and perspective, I’ve distilled that traumatic cancer experience into 5 life lessons:

  1. Trust grandma’s reassurance, “This too shall pass.” As an ovarian cancer survivor herself, my grandma is living proof of this timeless wisdom. Stressful events don’t have to be permanent. We don’t have to be victims. Although cancer is extremely painful and unwelcome, the bright spot is we are forced to build character traits such as resiliency, emotional courage, and grit.
  2. Create your own joy in the midst of crisis. There are ways to uplift yourself during the chaos of cancer treatment. For example, I took a pottery class throughout my chemo months to find solace in distraction and art, which helped soothe my soul and ease the journey. What would make you happy? Do some-thing just for you.
  3. Stop doing what you don’t want to do. If you were doing too much out of obligation beforehand, try to change that. You are only obligated to make yourself happy. No one else can do that for you. The key is to use this wisdom to prioritize your time and honor yourself, so you can be healthy for others. Drop what doesn’t serve you. Drop the guilt. Life will go on.
  4. Connect with others. The emotional trauma is hard to measure in a medical test, but it’s real. Anxiety and depression can go hand-in-hand after cancer—it did for me. In response to the emotional challenges I experienced, years later I founded MyLifeLine.org Cancer Foundation to ease the burden for others facing cancer. MyLifeLine.org is a cancer-specific social platform designed to connect you with your own family and friends to ease the stress, anxiety, and isolation. Gather your tribe on MyLifeLine. You are not alone.
  5. You are lovable after cancer. No matter what body parts you are missing, you deserve love just as you are. Cancer tore down my self-esteem, and it took significant effort to build it back up. I am dedicated to personal and professional growth now. Look into your heart, your mind, your spirit. Try fine-tuning your best character traits, like generosity or compassion. Never stop growing and learning. We are not defined by the body.

To wrap up my story—I learned that when one door closes, another opens. Today I am the proud, grateful mother of 11-year-old twin boys. Born with the help of a surrogate mom and an egg donor, my dream finally came true of becoming a parent. Where there is a will, there is a way. Never give up on your dreams!


About MyLifeLine.org: MyLifeLine.org Cancer Foundation provides free websites to connect cancer patients with family and friends so patients feel supported. To learn more about how MyLifeLine.org can help you or someone you know affected by cancer, please visit www.mylifeline.org.

The Effects of Chemo and Ovarian Cancer

Real ovarian cancer patient experiences shared privately at Treatment Diaries. Making sure you feel less alone navigating a diagnosis is important. Connecting you to those who can relate and provide support is what we do.


Had my first chemo January 20th. LOVE the pre-chemo “cocktail” they give. Relaxed me so much I slept through most of it. First four days after were fine. Next four, lots of nausea and threw up a few times. Doctor added two more anti-nausea meds and finally got it under control.

Using two chemo drugs; Carboplatin and Taxotere.

Two weeks after the first chemo my hair started falling out. Nausea and vomiting I can handle. Being tired a lot I can handle. Fingertips tingling I can handle. Hair falling out by the handful……..that was just demoralizing!

I put up with it for two days. Then, we shaved my head. I do mean WE. Went into work and sold raffle tickets. Winning ticket pulled got to shave my head! It was hilarious! Got pictures and lots of video. Plus, raised $322 to help with expenses, which I really needed.

My “work son”, Andrew, was the winner. Worked out good that way, I think. His mother is going through chemo for breast cancer, started losing her hair and shaved her head. He was having a hard time dealing with that. Shaving my head seemed to give him a new perspective.June TD quote

I freely admit, if I’d shaved my head at home by myself, I’d have bawled my eyes out the whole time. But, doing it at work made it easier. Everyone was cracking jokes and laughing….it was more like celebrating a milestone than doing something that was a reminder of something bad.

One thing I’ve noticed is that the “stubbies” don’t fall out as easy once they die as full strands do. Then, when I put on a scarf or hat, they get shoved down in the hair follicle and it’s uncomfortable. BUT, I found a great fix for it: LINT ROLLER! Yes, after my shower, I stand in front of the mirror and take a lint roller to my head. And laugh myself silly the whole time!

Turns out, I don’t look bad bald. So, I’ve opted not to bother with a wig. I use a scarf or hat outside, but go au natural indoors. And, I have to admit, I love how much time I’m saving in the shower! Especially on the days when I have no energy!

Second chemo was February 10th. Used my chemo port for the first time as well as an IV. That was interesting. And they gave me some kind of IV anti-nausea meds since the first dose hit me pretty hard. Worst side effect this time was that it messed with my taste buds. For about 10 days, all I could taste was sweet stuff. Couldn’t taste meat or spicy anything. Talk about frustrating! Grrrrrrrr!!!!!!!

Took the long way home afterward. Was stopped right next to a police officer at one light. He had about as much hair as I do right now. So, he’s looking over at me, I’m looking over at him…..we both were grinning at each other. Very cute moment.