State of the Science
State of the science: Contemporary front-line treatment of advanced ovarian cancerThe ovarian cancer treatment landscape has transformed dramatically in the front-line setting in the past several years. A quarter of a century ago, platinum/taxane adjuvant chemotherapy was established as the new standard of care . Various additions to and adaptations of this backbone were studied including intraperitoneal (IP) chemotherapy, substitution of taxanes with other novel chemotherapeutics, dose-dense administration, and adding novel biologics including bevacizumab to platinum/taxane.
Stereotactic body radiotherapy for the treatment of gynecologic malignancies: Passing fancy or here to stay?Stereotactic body radiotherapy (SBRT) is defined as the delivery of image-guided high-dose conformal radiation, in five or fewer treatments. SBRT is established as a treatment option for select disease sites (lung, prostate, pancreas, hepatocellular), and has recently emerged as a promising treatment option in the setting of oligometasatic disease. Retrospective evidence supporting the utility of SBRT in gynecologic malignancies continues to grow however, practice patterns are widely variable .
State of the Science: The role of HIPEC in the treatment of ovarian cancerInterest in intraperitoneal (IP)-based therapies for epithelial ovarian cancer (EOC) has grown over the past decade. Yet despite multiple theoretical and clinical advantages, IP therapy has not been widely adopted in the U.S. Recently, support for hyperthermic intraperitoneal chemotherapy (HIPEC) has increased. There have been numerous retrospective studies and meta-analyses that support the use of HIPEC in ovarian cancer [1–5]. Further optimism for HIPEC was based on the recent results of a phase III trial [5–9], but significant criticisms have been noted over the use of HIPEC [10–13].
State of the science: Uterine sarcomas: From pathology to practiceIn July 2019, the NRG Oncology Group held a Summer Symposium in conjunction with its Semi-Annual Meeting entitled “Uterine Sarcomas and Carcinosarcomas: From pathology to practice.” Invited faculty included experts in medical oncology, gynecologic oncology, radiation oncology, pathology, and radiology. Herein we summarize the presentations to guide practice surrounding uterine sarcomas.
An update on fertility preservation strategies for women with cancerWith rapid advancements in cancer therapy, reproductive age women are benefitting from overall improved survival rates . Invasive cancer occurs in approximately 1–2% of this population, with current five-year survival rates in the United States approaching 83% . Challenges remain in managing late effects of cancer therapy, including infertility and premature ovarian insufficiency (POI) . Women need timely reproductive-risk counseling and referrals to reproductive medicine specialists for consideration of fertility preservation (FP) prior to initiating cancer treatment, if desired, to increase their chance of having a child in the future.
State of the science: Evolving role of surgery for the treatment of ovarian cancerWhile surgery combined with systemic chemotherapy has remained the foundation of ovarian cancer treatment, the scope, timing, and overall philosophy surrounding surgical debulking has continued to evolve. There is abundant controversy regarding certain aspects of ovarian cancer management, including the role of neoadjuvant chemotherapy (NACT) and the timing of cytoreductive surgery. Over the past 3 decades, however, one factor has remained unchanged: volume of residual disease after debulking surgery is a strong prognostic factor in ovarian cancer, reinforcing the importance and relevance of surgical effort in the care of these patients.
Challenges in the identification of inherited risk of ovarian cancer: where should we go from here?The idea that a mutation in a single gene could lead to a high risk of breast or ovarian cancer used to be a radical idea. It was not until 1990 that Dr. Mary Claire King and her team localized a gene for hereditary breast cancer to chromosome 17q21 , which she named BRCA1. This discovery set off a race involving multiple research labs around the globe to clone and sequence the gene, ultimately ending in 1994 when a team led by Mark Skolnick became the first to do so [2,3]. Skolnick went on to found Myriad genetics, which then acquired a patent for the sequence of BRCA1, followed shortly the next year with a patent for BRCA2.
Hormonal strategies in gynecologic cancer: Bridging biology and therapyUpon ligand binding, the estrogen (ER) and progesterone receptors (PR) dissociate from chaperone proteins, dimerize, translocate to the nucleus and bind to specific chromatin sites [1,2] enhancing or repressing transcription in hormone dependent tissues. ER and PR are abundantly expressed in the female reproductive tract and mammary gland [3,4] and their expression levels and interaction with co-regulators dictate the robustness of signals, the specificity and context dependent actions in different tissues .
HPV vaccinationSince the introduction of the human papillomavirus (HPV) vaccine in 2006, the evidence regarding its efficacy and safety has continued to highlight its importance in cancer prevention. Despite the clear benefits of vaccination, patient perception, public health policy, and changing vaccine availability have impacted vaccine uptake in the United States. Moreover, the vaccination landscape has changed dramatically over the last several years due in large part to the release of a nine-valent HPV (9vHPV) vaccine in 2014, revisions to ACIP guidelines for vaccine dosing, and changes in state-level policies.
Enhanced recovery in gynecologic oncology – A sea change in perioperative managementFirst referred to as fast-track, or more recently, Enhanced Recovery After Surgery (ERAS®), a growing number of disciplines, including gynecologic oncology, have begun to challenge long-held beliefs about pre-, intra-, and postoperative management in the pursuit of perioperative optimization [1–3]. The most important tenets of enhanced recovery include nutritional optimization, maintenance of perioperative euvolemia, and opioid-sparing multimodal pain management. These measures have been shown in multiple surgical specialties to reduce length of hospital stay, improve patient satisfaction, reduce complications, reduce healthcare costs, and most importantly, hasten patient recovery [4,5].
Of mice and women - Non-ovarian origins of “ovarian” cancerA number of recent publications have presented competing views on origins of the heterogeneous group of epithelial malignancies currently classified as ovarian carcinomas (OCs) [1–8]. On one end of the spectrum, some have argued that OC is not ovarian in origin, but arises instead from Müllerian-derived extra-ovarian cells that involve the ovary secondarily. Others have been reluctant to embrace this view. Much of the debate has focused on the origin(s) of high-grade serous carcinoma (HGSC), the most common OC subtype and the one responsible for most deaths attributed to OC.