Monitoring and managing recurrence in ovarian cancer

The following questions and responses have been lightly edited for grammatical purposes. 

1) What guidance do you have for monitoring recurrence?

Dr. Karlan: I think when you get into remission, and you understand the biology of ovarian cancer, you realize you’re always going to be on the lookout. That doesn’t mean living in fear. It means knowing your body and living your life to its fullest. Make the most of every day. Live with joy and purpose. We’ve even done studies in psychoneuroimmunology showing that those positive factors can support your immune system.

So what can you do? Know your body. Know what’s different for you. Are your clothes fitting the same? Are your bowel habits the same? What were the symptoms you had when you were first diagnosed? Was it that same type of pelvic discomfort?

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Try to put symptoms into context. If you travel, go on vacation, or change time zones, you might get a little constipated. If you come home and it goes away, that’s probably okay, but if something feels different, have a conversation. These days, with electronic medical records, you can often send a message to your physician and say, “Hey, this feels a little different.”

It takes time to figure out what your body feels like after treatment for ovarian cancer. You’ve had surgery, you’ve had chemotherapy, and things may feel different now. Your bowels may feel different. If you notice a change, I always say “persistent and progressive.” If it’s there every day and seems to be getting worse, call and make an appointment. Don’t just live with it.

For many ovarian cancer patients,[the biomarker] CA-125 can be a helpful barometer. Is it going up or going down? It’s not a one-to-one correlation with how much disease you have at any given time. Often, you’ll get down to low levels and then it goes up, and you get very concerned. It’s really about looking at trends over time.

2) What happens if ovarian cancer comes back?

Dr. Karlan: The reality is that ovarian cancer, especially when diagnosed at a late stage, often has many different clones of cells. We try to remove them all with surgery and chemotherapy. Even if one or two cells remain, over time, those cells can grow back into a tumor. Until we have reliable early detection, ovarian cancer will continue to recur.

The good news is that we now have a whole pharmacopoeia of treatments – chemotherapies and targeted agents – that can be used in this setting. A lot comes down to clinical judgment: which drug is right at which time?

I’ve had patients receive 10 different treatments. They’re alive more than a decade later, living with their ovarian cancer. They continue to travel, find joy, and achieve great things. They may need what I sometimes call “tune-ups” — treatments to knock the cancer back down — but they are living full lives.

I would tell patients that we have a long runway of treatment options. There will likely be something else. The key is having open conversations with your physician and your family about what’s right for you. What side effects are you willing to accept? What toxicities matter most to you?

None of these treatments, oral or IV, are completely free of side effects. How do you sequence them? Maybe you lost your hair with your first chemotherapy and you’re not ready to do that again. Maybe neuropathy has been a major issue, and you can’t tolerate a drug that worsens it. There’s a long list of factors to consider.

You’re living with all of this, and that’s why the conversation with your physician is so important. As someone who has cared for women with ovarian cancer for many years, I can honestly say it’s an exciting time. I’m able to offer and discuss many different options, and together we can make the best choice.

For more information on ovarian cancer types and biomarkers, check out part one of Dr. Karlan’s webinar recap.