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Melanie Cole (Host): Ovarian cancer can be difficult to detect, especially in the early stages. My guest today is Dr. Larry Puls. He's a gynecologic oncologist at Greenville Health System. Welcome to the show, Dr. Puls. How common is ovarian cancer?

Dr. Larry Puls (Guest): In the United States this year, there will be about 22,000 cases, more or less. That would put it at number 8 on the list as far as cancers go in the U.S. So, it's not the most common but it's a reasonably common cancer.

Melanie: Are there certain risk factors that would predispose a woman to ovarian cancer?

Dr. Puls: What we do know about the disease is this: there is clearly a group of women--and that number is climbing. It's now probably somewhere between 20% and 30%--who are predisposed to this cancer from genetics, something they had inherited either from their mother or their father. And, in those families we tend to see a clustering of ovarian cancer and breast cancer in these women. So, that certainly makes up one subgroup. Another subgroup that we know to be true is women who have what we call “incessant ovulation”, meaning the more cycles a woman has in her lifetime, the more likely she is to get ovarian cancer. We can prove that because if you can give a woman the birth control pill for five years, you lower her risk by almost 50% that she won't get ovarian cancer in her lifetime. There are other theories. One other is that there is a suggestion that there may be some outside chemicals or issues in the culture that, indeed, women can pick up and get exposure to that may ascend through the uterus and cause some increased risk to ovarian cancer. But, beyond that, it's not really associated with dietary issues and lot of other common things we might think of. So, what I'm saying is that a lot of these things are somewhat vague really as to what causes it.

Melanie: And, in that history component, with the genetic component, when you say you see the clusters in families, is that related to the BRCA gene? Is there genetic testing now for ovarian cancer?

Dr. Puls: Yes. So, in 1994 they isolated the BRCA family mutations but it has grown a lot. There is no question, it is the most common one of all--the BRCA1 and BRCA2 mutations. But, there are others now. The HNPCC gene and others that are now associated with ovarian cancer. So, originally, we thought this number was going to come in around 9-10% of ovarian cancers were related to the gene. That number is now over 20% and climbing as we begin to find more and more of these genes.

Melanie: Are there any symptoms? It’s been called the “silent cancer” by some. Are there any symptoms that women would come up with that would send them to see their doctor in the first place?

Dr. Puls: Of course, here's the very difficult question. The two most common symptoms are things that most women would say they complain of anyway. So, number one is bloating. I mean, if you literally ask 100 women, “How many of you have periodic bloating?” most of them would raise their hand. But, what I try to express to my patients is it's not just "bloating", it's change over time. So, what your baseline is, is whatever it is, but then it really begins to ramp up. And, the reason women get bloating is because these cancers make fluid as a byproduct. So, many women, by time they are diagnosed, almost look pregnant because of the fluid. The second most common complaint is intestinal changes. So, it can be intermittent constipation and/or diarrhea. But, again, if you ask a lot of women they are going to say, “Well, I've got that as well.” So, what I try to stress to my patients is its change over time. So, whatever your baseline bowel habit is, it gets a lot worse than that. You find that you're taking 10 laxatives a day to try and get your bowels to move. That’s a problem and that needs to be looked into. So, those would be the two most common complaints that we would see.

Melanie: And, as we know, we have had our PAP smears and our mammograms. Is there any screening tool available for ovarian cancer?

Dr. Puls: So, there have been a number of big trials done, the latest of which was just published out of London. Over 200,000 women were in that screening trial and what they used was a blood test we call CA-125. They used a form of ultrasound called “transvaginal ultrasonography”, which is a probe which is used basically to measure ovary size. And, unfortunately, even in that big trial, though they were able to identify a lot of ovarian cancers, the ultimate question is, did it make a difference? In other words, did it save lives? And, I think most people would probably say that it didn't make a big impact. So, I hate to say, as we all do, that we probably don't have great screening for this cancer as of right now.

Melanie: Then, how is it diagnosed?

Dr. Puls: So, unfortunately, most of the time when we find these cancers, it's the symptoms that I have already named: the bloating. They get the bowel changes. They ultimately see that their internist who ends up referring them to a gastroenterologist who ends up referring them, ultimately, to radiology to get a CAT Scan and by the time we get a CAT Scan, oftentimes these cancers are very advanced when we find them and we've already found that the cancer has spread and moved to places we wish it hadn't moved to. That's a very difficult place for us to cure those patients.

Melanie: So then, what treatments are available if it's caught early enough? Or, even if it's not, what kind of treatments, what's the first line of defense you do for women with ovarian cancer?

Dr. Puls: What I'm going to say is a basic generalization but, as a general rule, the first thing we do is we operate on patients. So, we take the cancer out of the patient. That usually ends up meaning--not always--but it usually ends up meaning we do a hysterectomy. We take the ovaries out and then we do a number of other biopsies of things we call “lymph nodes” and so on to look and see if the cancer has spread or moved on. Once we complete that portion of it, the surgical piece, most women, though not all, but most, go on to get chemotherapy, meaning we give medicines through their veins in their arm to treat the cancer. But, also, as well, in this particular cancer, one of the unique things about what we do in a treatment is that we oftentimes give chemotherapy into the belly itself. We call that “intraperitoneal chemotherapy” and it is highly effective. Difficult to take but, nonetheless, highly effective. And so, it's generally a combination of surgery and chemotherapy is how we treat these cancers today.

Melanie: And, I was going to ask you about HIPEC and hyperthermic intraperitoneal chemotherapy. So, that can be done at the same time as the surgery. Yes? Then, do you follow it up with standard chemo? Or, is the HIPEC generally enough for the short term?

Dr. Puls: So, let's qualify this now. HIPEC has been looked at investigationally in ovarian cancer but is not used presently and is not recommended. Our Society's come up with a statement on that. I want to differentiate . So, HIPEC is giving chemotherapy in the abdomen but it's very different than this. So, that's given in operating suite and so on. What we are talking about is we put a catheter into the belly and then we administer it as an outpatient situation. It is not heated when we do it. It's given at room temperature and that's how we deliver it. It's given over 3 days over a 21-day period of time.

Melanie: So, it is vastly different than HIPEC.

Dr. Puls: Very different.

Melanie: So then, because people are hearing about this now in the media so I'm glad you cleared this up for us. Then, what follows? Is radiation generally required or not?

Dr. Puls: We generally don't use radiation and the reason for that is, unfortunately, most patients with ovarian cancer have got disease that's kind of spread out all over the belly. My analogy is it’s like leaves on the tree. The original tree was the cancer but when those leaves drop off, they spread around the abdominal area. So, radiation, is effective but only if it's in a spot. One particular spot we might consider using it but we rarely use it because most of the time, the disease is disseminated over the belly, meaning it's in multiple areas. And so, it's for that reason we generally cannot give radiation. So, it's generally a disease that's surgical and chemotherapeutic.

Melanie: Are you using targeted therapy at all for ovarian cancer?

Dr. Puls: We are, but not as much as we wish. We now have an open trial right now for vaccine therapies in which we are actually, when we harvest the cancer out of the patient, we develop vaccines for the particular patient. We have a trial open on that. We have 7 or 8 patients on that trial right now. We also, in BRCA mutation patients, have an open trial, looking at the use of what are called “PARP inhibitors”. Those are drugs that are very specifically targeted for a BRCA mutation patients. So, we are trying to do more and more of that but, at the present time, targeted therapy is not highly effective in ovarian cancer, though it is being developed and we have a lot of trials looking at targeted therapy at the present time.

Melanie: And, those trials are being done at Greenville Health System?

Dr. Puls: They are.

Melanie: And, do you recommend any certain support organizations for ovarian cancer?

Dr. Puls: Back in 1999, I was one of the original founders of what's called the “South Carolina Ovarian Cancer Foundation”. It is an organization based out of Greenville, though we have chapters in Charleston and Greenville. We have them all over the state—a very big patient support and so, what the organization is about is a number of things, but one of them is a support issue. So, when women get ovarian cancer, these ladies who have been down that road, who had the chemotherapy, who had treatment will oftentimes come and sit with new patients getting chemotherapy. They are there and available for information. You know, even to ask somebody, “How did I get this?” Or, “What do I do with this?” Or, “What sort of fix did you have?” Because women, obviously, would love to be able to talk to other people who have experienced it and kind of get a clear idea of what their experience was so that they know what it is they are getting themselves into. So the organization, if you go to SCOCF, which is South Carolina Ovarian Cancer Foundation, they have a nice website and all the contact information is there and it's a great support group that we have all over the state of South Carolina.

Melanie: So, wrap it up for us, Dr. Puls, in these last few minutes, about what women should know about ovarian cancer, their chances of getting it, their risk factors and, really, if there’s any way to prevent it and why they should come to Greenville Health System for their care.

Dr. Puls: So, at the end of the day, about 1 out of 70 women is going to get ovarian cancer in their lifetime. Unfortunately, the problem with this cancer is, of those women who get the cancer, well over half of them will die of their disease. So, obviously, the earlier we can treat it, the better because if you look at women who get ovarian cancer, and it's confined to just one ovary, meaning it's very very early, we can cure well over 90% of those patients. So, the earlier we find it the better we do. And so, we would love to be able to find those and as I've already said, we don't have a great screening tool. So then, what do I counsel my patients? I counsel them that what they ought to do is know their body, know the symptoms and, if they begin to have any questions, bring it up to their physicians because I'm amazed oftentimes at new cancer patients, how many of them will say, “I went to my doctor or I just thought this was an aging process and nobody would really listen to me.” So, if you're concerned it's something major is going on, that the constipation is ramped itself up a lot or the bloating is a lot worse, go seek some opinion about it. You can get it looked at. There are ways to get those looked at at that point in time, because the earlier we get it the better. So, 1) know your body; 2) no, unfortunately, there is not a great screening tool but most physicians will have a strong sense of what are the things that they would do to work you up if they had any questions; 3) if there's any question of genetics in your family, seek the pinion of your gynecologist because they can make a referral to a geneticist who can easily screen you for this and can tell you what your risks are for this particular cancer. So, I would argue, why us? We, obviously, do this a tremendous amount and there is no question that the tie to survival is tied to your gynecologist being involved in this and being very much involved in the surgery. And, also, having the availability of all of these studies. So, we have the only Phase One unit which is a first in human trials departments here in the upstate and we are very proud of that. So, we have a lot of the immunotherapies which you were mentioning that are becoming available through this trial department. And, it really takes, in the treatment of ovarian cancer, a support team. So, it's a matter of not just a physician but it's all the ancillaries involved in that, from the inpatient unit to the chemotherapy nurses to the research component to the support system involved. And so, wherever you go, it's important that you have that kind of team behind you which I truly believe we offer.

Melanie: Thank you so much for such great information, Dr. Puls. Thank you for being with us today. You're listening to Inside Health with Greenville Health System and for more information you can go to www.ghs.org. That's wwwghs.org. This is Melanie Cole. Thanks so much for listening.