The COVID-19 epidemic in Poland has significantly affected access to doctors in Poland. This problem has also affected gynecologists, which translates into difficulties in cancer diagnosis, including ovarian cancer. “Patients who do not have specific symptoms or have the results of imaging tests that require further consultations, may have extended diagnostics there” – says prof. Paweł Blecharz.
- “We have many patients who postponed follow-up visits due to the epidemic”
- Expert: A characteristic and specific symptom is abdominal enlargement due to the accumulation of fluid, i.e. ascites. Depending on how the cancer grows, other symptoms may also appear
- The prognosis for Polish patients with ovarian cancer depends on many factors. «80 percent ovarian cancer surgery in Poland is performed in centers that do not have much experience in this field »
- You can find more up-to-date information on the TvoiLokony home page
Interview with prof. Paweł Blecharz, head of the Gynecological Oncology Clinic, National Oncology Institute Maria Skłodowskiej-Curie, Branch in Krakow
How does gynecological diagnostics look like in the era of coronavirus?
Access to specialists is difficult, especially when it comes to emergencies. In the entire healthcare sector, we also have a problem with access to emergency departments, where patients with the first or sudden symptoms of diseases, including gynecological cancers, often report. In addition, patients are now postponing research due to the pandemic.
Does this mean more difficult cancer detection, including ovarian cancer?
Yes. The diagnosis of ovarian cancer is long and requires a lot of research and consultation. When talking about ovarian cancer, we often talk about emergency situations, when the symptoms begin to cause so much discomfort that the patient feels forced to see a doctor. We also have many patients who postponed a follow-up visit due to the pandemic, and this fact made their disease more advanced than it could be if they regularly see doctors.
What are the symptoms of ovarian cancer?
A characteristic and specific symptom is abdominal enlargement due to the accumulation of fluid, i.e. ascites. Depending on how the cancer develops – whether in the form of a tumor or cells that detach from the ovary and implant in other organs of the abdominal cavity – there is a whole spectrum of symptoms (including menstrual disorders, abdominal pain, feeling fullness, nausea, belching). Ovarian cancer mainly affects postmenopausal women.
What is access to gynecological diagnostics during a pandemic?
Cancer centers continue to provide it. On the other hand, poviat or specialized multi-profile hospitals focus more on consultations within the HED. Therefore, patients who do not have specific symptoms or have imaging results that require further consultations may have extended diagnostics there. In the center where I work, we are waiting for such people. A patient who comes with a suspicion of a tumor of the reproductive organ and the results of imaging tests does not wait. It will be admitted on the same day, regardless of the pandemic situation, and then diagnosed and treated in the so-called fast path oncology (DILO card).
What diagnosis should a woman undergo if she has no disturbing symptoms but wants to know what is happening to her?
He has to start at the gynecology clinic. In addition to consultations and gynecological examination, the doctor should perform an ultrasound examination himself or refer the patient to it. The next stage is usually referral to the hospital for more extensive diagnostics (biochemical examination, computed tomography).
What is the diagnosis of ca-125 and he-4 biomarkers used for?
These serum markers have two main tasks. The first is to differentiate the nature of the changes in the ovary. Simply put, it comes down to whether we suspect the lesion is benign or malicious. The second task is to monitor the course of treatment in patients with ovarian cancer. When markers, especially marker ca-125, decrease, treatment is having an effect, and if not, therapy is likely to be ineffective.
And what is the importance of the diagnosis of BRCA gene mutations?
The effect of mutations in BRCA genes is twofold. If such a mutation is found in a healthy patient, it is a family with a high hereditary risk of ovarian and / or breast cancer. Such families should be included in more frequent prophylactic check-ups and supervision. They should also have access to surgical procedures that reduce the risk of developing the disease. A damaged BRCA gene in a woman’s body is like a ticking bomb. The easiest way to disarm it is to remove the appendages, i.e. fallopian tubes and ovaries. Secondly, breast removal may also be considered. We also consider this option in women without BRCA gene mutation, whose family includes ovarian cancer.
The second diagnostic option concerns a situation where the mutation is present only in a cancerous tumor of a woman without the BRCA mutation. During development, a tumor begins to mutate and has completely different genes than its host, i.e. humans.
What is the prognosis for Polish patients with ovarian cancer?
Much depends on where they will be operated on. 80 percent ovarian cancer surgery in Poland is performed in centers that do not have much experience in this field. The challenge in this disease is surgery, which is crucial for prognosis. Patients with ovarian cancer require not only the care of a gynecologist, gynecologist, oncologist and surgeon, but also a dietitian and psychologist. Therefore, they should be treated in specialized centers, as confirmed by scientific research.
How many women in Poland suffer from ovarian cancer?
We have approximately 3–3,5 cases of disease, which means that the average woman has a 1,5–2 percent risk of developing the disease. The prognosis is poor, as 5–30 percent of patients survive 35 years, and those who survive have relapses. The peak incidence is in the 60–65 years. age. The advancement of ovarian cancer in Polish women is much higher than in the West. However, it is not about the stage of the cancer, but about the fact that Polish women “carry” the disease for much longer and report later than in countries with greater health awareness.
How is this cancer treated?
Surgical treatment is not enough, because in most cases we are dealing with disseminated disease, which cannot be completely removed in this way. However, surgery increases the sensitivity of the disease to systemic treatment (chemotherapy), as well as to molecular treatments and targeted therapies. They are the greatest hope for treating ovarian cancer. Unfortunately, they are expensive and therefore introduced with a long delay.
What are PARP inhibitors and what role do PARP inhibitors play in treating ovarian cancer?
These are new drugs that inhibit the growth of neoplastic disease. They are used to maintain remission. They are particularly active in patients with BRCA gene mutation. Each patient with ovarian cancer should have this mutation tested, as it is estimated that up to 35 percent of ovarian tumors are associated with it (this mutation causes ovarian cancer, but its absence does not guarantee that a woman will not get the disease).
Therapy with PARP inhibitors is carried out at home, in the form of tablets. It is well tolerated and can be taken as long as the disease is under the control of the drug. Or until it becomes toxic.
How many indications for inhibitors are registered in Poland?
Access to inhibitors is limited in our country to patients with a mutation in BRCA1 / 2 genes, who had the so-called platinum-sensitive relapse. This means that the disease returned 6 months or more after the end of previous treatment, and patients undergoing chemotherapy had remitted from this relapse.
Unfortunately, we do not yet have the widespread availability of PARP inhibitors in first-line treatment, where the results of using these drugs are even better than in the treatment of relapses. We are awaiting such a drug program.
So what are the hopes for ovarian cancer patients?
The second PARP inhibitor entered the Polish market (the first – olaparib, the second – niraparib). The differences in their effectiveness are slight. Niraparib proved to be effective not only in patients with BRCA gene mutation, but in the entire group of patients. It would be ideal for women to have access to it, as it improves treatment outcomes by extending the time to next progression as well as the time between chemotherapy after the next progression. This effect is pronounced in the group with the BRCA mutation and in the group without the mutation. The registration of this drug is already a fact, and the reimbursement is a matter of – I hope – the next months, not years.
Is it also a chance for patients without the BRCA gene mutation?
There are countries where PARP inhibitors can be used today not only in connection with the mutation, but in the entire group of patients who have achieved remission either in the first line of treatment or in disease relapse.
What about ovarian cancer prevention?
If a woman has cases of ovarian and / or breast cancer, as well as colorectal or cervical cancer in her family history, she should consult a genetic clinic.
In the case of gynecological neoplasms, the most important thing is to test the BRCA1 / 2 gene mutation, which causes frequent occurrence of breast and / or ovarian cancers. It does not manifest itself in any way until it causes cancer. This test can be performed in genetic clinics that operate in each voivodeship city, usually at cancer centers or university hospitals. You can also make them on your own, commercially. A woman who develops ovarian cancer should undergo genetic testing. They are then free of charge.
What has changed in the treatment of ovarian cancer over the course of several decades?
Access to modern technologies and drugs has increased. But waiting for one drug to cure all sick women would be naïve. We have to use different medications at different times of the disease. We have a chance to cure cervical cancer completely. We are a bit slower with ovarian cancer, but it is the biggest challenge in gynecological oncology. That is why it concentrates the greatest efforts of the medical community and thanks to this we are making progress.
Can women visit gynecological examinations safely during a pandemic?
Absolutely, let’s not postpone health. By following the basic sanitary and epidemiological recommendations, you can successfully participate in medical appointments and medical procedures. So let’s not move them, because we will not regain the time lost in this way, and the disease from the early stage will move to an advanced stage, giving less chance of being cured.
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