duration of postmenopausal hot flushes

Average American women become menopausal around age 51 years old.   Some women experience hot flushes younger when they have their ovaries removed surgically for various reasons.   In the Study of Women Across the Nation (SWAN), the median duration of hot flash symptoms was 7.4 years.  This duration is longer than the currently recommended duration for treatment of symptoms (maximum 4 to 5 years to minimize excess breast cancer risk).

We postulate that the increase risk of breast cancer is due to the progestin part of hormone replacement therapy.  When women still have uterus and experience menopause, they are usually prescribe both estrogen and progestin.  The progestin seems to reduce risks of uterine cancer but with prolonged usage may incrase risk of breast cancer.

Thus, do discuss with your physicians and health care providers of risks and benefits of hormone replacement therapy.

Reference:

Avis NE, Crawford SL, Greendale G, Bromberger JT, Everson-Rose SA, Gold EB, Hess R, Joffe H, Kravitz HM, Tepper PG, Thurston RC, Study of Women’s Health Across the Nation (SWAN).  Duration of menopausal vasomotor symptoms.  JAMA Intern Med. 2015;175(4):531

Removing your fallopian tubes may decrease your risk for ovarian cancer

Research has shown that the majority of ovarian cancer arise from fallopian tubes, not ovary.  You may happen planning to have your uterus removed (hysterectomy) for non-cancerous reasons (fibroid, pain, excessive bleeding, etc).   And if you are a young woman, most of your surgeon would recommend preservation of your ovary/ovaries while removing your uterus.  A 2015 paper from Obstetrics and Gynecology journal showed that concurrent prophylactic removal of your fallopian tubes could reduce your ovarian cancer by 50%.

The removal of your fallopian tubes usually take only a few extra minutes.  Most surgeons do not even charge extra to do this.  There is a small risk of compromising blood perfusion to the ovary.   Please discuss with your surgeon if you plan to have hysterectomy for benign (non cancer) reasons.

Reference:
Kwon JS, et a.  Costs and Benefits of opportunistic salpingectomy.   Obstet Gynecol 2015
Falconer H, et al. Ovarian cancer risk after salpingectomy.  JNCI 2015

New HPV vaccines to prevent genital dysplasia and cancer (available start Feb 2015)

Human papilloma viruses (HVP) are known to cause cancers.  In the genital areas, HPV cause the majority of cervical cancer (>90%) and some vulvar, vaginal, anal and penile cancers.   In 2015, there is a new HPV vaccine called 9valent HPV vaccine (from Merck).   In the past, there were 2 HPV vacciness covering HPV 16,18 and HPV 16,18,6,11.  This new vaccine covers 9 different HPV types thus further protect patients from potential genital cancers.

This new vaccine, similar to the previous HPV vaccines, are administered at 0, 1-2 months, and then 6th month (3 doses).  Vaccination can be started as early as 9 years old to age 26 (females) and 21 (males).  Men who have sex with men and immunocompromised men (HIV) can be vaccinated up to age 26.

You could find out more information from CDC.gov or your physicians and other health care providers.

Morcellator (tissue grinder) and uterine fibroid and risk of spreading cancer

With wide spread surgical practice using robot or laparascopy hysterectomy, many surgeons have to work with large uterine mass.  Most of these uterine mass are fibroid (benign smooth muscle tumor).   Thus, the surgeons would use a morcellator (like a grinder) to make the uterine mass smaller so they could be removed laparascopically (without making large surgical skin incision).

Unfortunately, not all uterine masses are fibroid and it is difficult to tell before surgery which one actually has uterine cancer.   If you use the morcellator on uterine cancer, then you may have the cancer spreads on your pelvis and abdomen.   Because of some rare cases that have occurred, many surgeons are becoming more cautious about using morcellators.   Please discuss with your surgeon if you have large uterine mass and you are about to undergo hysterectomy.  You may want to choose open abdominal approach than laparascopic or robotic hysterectomy.

Chemotherapy before surgery in patient with ovarian cancer

In some patients with ovarian cancer, unfortunately,  the cancer spreads widely that surgery cannot remove most of the tumor.   A randomized trial reported of using neoadjuvant chemo (chemo before surgery) first for 3 months to shrink tumor to smaller size, then surgery.   In my experience, this approach works especially well on patients with a lots of tumor and ascites (fluid in abdomen) which put patient at high risk for surgical complications.   Some patients, due to extensive tumor, may need longer than 3 months of neoadjuvant chemo.  Although chemotherapy itself has its own side effects, some patients seem to better tolerate surgery after, rather than before chemo.

If you have widespread ovarian cancer with ascites, you may want to discuss this neoadjuvant chemotherapy approach with your doctor.

Reference:
Vergote I. et, al.  New England Journal of Medicine. September 2010

Recurrent ovarian cancer

Unfortunately, patients with ovarian cancer often have their disease recurred.   As I discussed earlier, we divide the patients into platinum sensitive (have not seen carboplatin or cisplatin in the last 6 months) or platinum resistant (resistant to carbo or cisplatin).   The prognosis is better with platinum sensitive disease.   The treatment usually consists of doublet chemo (2 agents) rather than single agent based on ICON4 study.   The most common combination would be carboplatin and paclitaxel (Taxol) since ICON4 study showed that this combination has survival advantage compared to other platinum based chemo.   Other choices are carboplatin + Doxil or Carboplatin + Gemzar (please note that none of these have survival advantage in comparison to their control arm).

In platinum resistant, we don't use cisplatin or carboplatin.  But paclitaxel, doxil, topotecan, oral etoposide (VP 16) are active.   Recently, the West Clinic published a study using abraxane and avastin on patient with platinum resistant which showed about 50% response rate.  To the best of my knowledge, this is the highest response rate ever documented in medical literature.

Reference:

Phase II clinical trial of bevacizumab with albumin-bound paclitaxel in patients with recurrent, platinum-resistant primary epithelial ovarian or primary peritoneal carcinoma.

Tillmanns TD, Lowe MP, Walker MS, Stepanski EJ, Schwartzberg LS.

Gynecol Oncol. 2013

Using plain water to kill ovarian cancer

Ovarian cancer is the 2nd most common gynecologic cancer in the United States with the highest mortality in all-gynecologic cancers.   Optimal removal of most tumor during initial surgery has been shown to improve survival rate.  The presence of exfoliated ovarian cancer cells in the peritoneal cavity after ovarian cancer debulking surgery is well recognized.  These cells are viable and can grow back again.

We have just completed research showing plain water killed these cancer cells effectively.   We grew ovarian cancer cells in plates.  Then we bathed them in normal saline (same concentration as plasma/blood).   In this concentration (we call it isoosmolar), cancer cells continue to grow.   Then, we place some of these cells in water for 30 minutes.   The water, which is hypoosmolar (less salt concentration), diffused into the cancer cell wall and ruptured the cancer cells.   

We are currently writing this research paper and will submit for publication.   Now, we cannot use this finding yet on patients.  We need to go thru multiple studies in animals and human before we could use it.   But my prediction is to use water into abdomen after ovarian cancer surgery may improve survival.   Currently, we do the same thing using intraperitoneal chemotherapy.  I think water would be less toxic than chemotherapy in patients.  lets keep our finger cross.