Advancements in Ovarian Cancer Screening and Treatment

thank you everybody for coming tonight for this program on advancements in treatment and screening for ovarian cancer this is a key part of a double program that we're doing this year for ovarian cancer awareness month we'll be holding directly after this we'll be holding integrated cancer survivor celebration so whether you're survivor survivor just you know part of this group tonight we'd love to have you there party forum I'm you there in cancer program director and chair and this big fan of party over Harry's are very helpful and manager we also have our program manager Maggie Nicholas Alexander with make and we're so glad to have changed from force for we love working with horse so we're really glad we're able to work with a horse herb in New York here on this program and I really want to thank dr. repeat for the series the third year has done this presentation went too far for this group and we really appreciate this time for those of you that don't know dr. Levine he's a gynecologic oncologist he's the head of a quadric oncology era and when he went down he's also the head of their research library their kind of logic recent research laboratory so we're really [Applause] all right prevention and treatment of ovarian cancer progress both in both regards and I'll try to maybe talk for like 45 minutes and have plenty of time for questions and sticking around afterwards for things that aren't appropriate for formal questions but we'll talk about the origins of ovarian cancer cancer genetics prevention of ovarian cancer and new treatment approaches probably the first three thing about 25% each let's see oh I got my little thing here let's see if this works almost almost okay so ovarian cancers do not begin in the ovary we lose some of I recognize a lot of familiar faces thank you for coming back again so some of you may have heard some of this before so you may heard some of this on the OCR OCR a webinar from July so some would be review somebody new and updates but ovarian cancers do not begin in the ovary they mostly begin in the fallopian tube and that's the most common type called high-grade serous and they also can grow out of something called endometriosis which is a cause of infertility and a cause of pelvic pain when some parts of the lining of the uterus called the endometrium can settle in the pelvis or on the ovaries that is very common but it's not very common that that turns into cancer and that's called clear cell carcinoma and endometrioid carcinoma of the ovary which sounds like and no metrium which is inside the uterus because that's where the cells actually come from so they all involve the ovary and so we call them ovarian cancer and we'll continue to call them ovarian cancer because otherwise it's too confusing for doctors and patients but but from like a biologic perspective the actual cell where the cancer you know with a cell the cancer cell first sort of lived when it was growing up is not actually the ovary so we think and you see that here so as I mentioned they're not one disease and I like to say you know these different types of ovarian cancer are as different as lung cancer and breast cancer they're both right here but no one's gonna confuse them and think that the same cancer so ovarian cancers are all in the pelvis but they really come from different organs just like breast cancer in lung cancer and when we look at that and I'm just looking to see if there's a stick because these pointers don't work so we used to have a stick around here to point to things but I can't find the stick so I'll try my high-power pointer but the point basically is that a portion of its magic a portion of ovarian cancer is inherited and come from mutations in genes called brca1 and brca2 which you're probably familiar with and we'll get into that a little more in a minute there's a couple other genes that can also increase the risk of ovarian cancer but only a few and those are called rad51 C rad51 D and grip one and there's a question about a gene called pal b2 and there's a lot of other genes that people are getting tested for nowadays that probably don't cause an increased risk of ovarian cancer some of them could cause an increased risk of breast cancer and I'm not gonna necessarily talk about that today so ovarian cancer you can see that again you can see here the cancers high-grade serous endometrial ear cell so most cancers are high grade serous this is certainly the most aggressive type and people are probably familiar with that endometrium clear cells are also very serious cancers but they are more likely confined in or near the ovary when they're diagnosed so they're more likely to present at an earlier stage and therefore are a little easier to treat than a cancer that has left the ovary or pelvis at the time of diagnosis and I just checked my time here okay so a big reminder is that all women with any type of ovarian cancer should have genetic testing for brca1 or 2 mutations this is a blood test or a saliva sample and if you have a first-degree relative relative someone with ovarian cancer and that person has not been tested for these genes than as a first-degree relative which is a sister daughter or parent mother you should then be tested for these genes but the better person to test is someone who has cancer and that can be very informative because if you have a mutation anyone who's related to you by first-degree relationships like a mother daughter or a mother daughter or sister has a 50% chance of carrying that mutation that mutation increases your risk of ovarian cancer over the course of your lifetime between 20 and 40% and we can do lots of things to prevent people from getting ovarian cancer if we know that they have an inherited mutation the blood - it's a blood test that's covered by insurance Maran I'm sorry though that lost my train of thought for a second other point was that if you have tests if you have cancer and you have testing and you don't have one of these mutations the chance to any of your family members you can come and feel free to come up here if you want if it's more comfortable if you don't have any of these mutations your family is probably not at risk and so it can do a lot to sort of help family members either not be worried about ovarian cancer or actually do something to prevent ever getting ovarian cancer and just to be clear and just a reminder there's different types of mutations the type of mutation I've just been talking about are called germline mutations because they are in every cell of your body and they are inherited and the germline mutations are the ones that you can pass on and that's what we test for in a blood test somatic mutations are in the tumor that's what people often think when they say molecular testing or maybe genomic testing so the inherited mutations we often talk about genetic testing and there is some overlap in the terms but blood tests saliva sample you're testing for a mutation you most likely got from a family member like a mother or a father don't forget that men can pass all these mutations on men generally don't get these cancers although nowadays we are discovering relationships between brca1 and 2 mutations and pancreatic cancer prostate cancer and male breast cancer those cancers are all more rare and obviously there's different approaches to each of those cancers and so I'm not planning to talk about that too much but we are obviously a g1 oncologist taking care of gynecologic cancers and so in this regard men can pass all these genes down but they're less likely as a as a gender to get the cancers that that women get a breast and ovarian cancer so again germline mutations are can be inherited and you could pass them down somatic mutations they're just in their tumor you can't catch them you can't give them to anybody they're just what created a cancer to become a cancer but we can test for them now with different types of sequencing and other sort of molecular techniques that we'll talk about and these BRCA mutations they can be inherited or they can be just be local to the tumor so they can be germline or they can be somatic so if you didn't know these terms and you want to learn one thing tonight it's the two terms of germline versus somatic they're very important and so if you can't get to a facility like NYU we come up here if you want over here if you can't get to a facility like NYU you can have genetic testing from your living room under a program called magenta which is a clinical trial that's not out of MD Anderson in Texas it's probably gonna be closing later this year and basically we're trying to figure out is it as good to have genetic testing over the internet by a qualified company we're working with a company called color genomics and they do video counseling they do telephone counseling which has been shown to be as good and we're trying to figure out do you really need a telephone genetic counselor or could you watch a video online and still you know get all the information that you need I want to clarify these are genetic testing companies for medical purposes a bunch of them I have no bias towards any of them I like many of them some I don't like quite as much but the ones that are common are myriad Ambree gene DX color genomics and there could be one or two others that I'm forgetting just out of lack of memory this is not to be confused with 23andme and ancestry.com those are those are entertainment testing those are sort of testing for fun I think there's another word I'm forgetting but those are not genetic testing despite what you've read about 23andme it's not genetic testing for cancer risk they're for entertainment purposes they're for seeing if you're really European or African or Asian or whatever you want to do with that and to you know maybe look at your risks of developing diseases which is very uncertain and very inaccurate so those are entertainment testing we do not recommend those you obviously can do those from your living room but that's not what we're talking about you could do them for fun if you want they're only 99 dollars or whatever but this is also actually this study is free for people who are at somewhat increased risk but a company like color or Ambree they all have sort of remote genetic counseling and it's real genetic testing it goes to the same company that we send our samples here to all those companies and and you can do that if you live in an area and I just for example say North Dakota where you might not have a genetic counselor within a reasonable distance and so we now and if you have family members so if you have ovarian cancer you have a mutation or someone you know needs to be tested they don't live New York City it can be done so get him back to the fallopian tube this is a little depiction from US paper we had in the Wall Street Journal about a year or two ago just showing how the cancer cells kind of grow from the fallopian tube and they fall on top of the ovary so the ovary is like like like a supermarket it's got all the nutrients and all the food the cancer cells need to grow and so the cancer the cells fall on top of the ovaries so it's cancer on the ovary or cancer of the ovary I'm sorry it's cancer on the ovary not cancer of the ovary but the ovary is a great place for the cancers to grow so so the cancer needs the ovary that's why we call it a varying cancer but if it comes from the fallopian tube you know that opens up a lot of various special opportunities for screening and prevention so how do we know that we're right we don't know that well right because we're not always right we pretty sure that we're right but we're not always as smart as we think we are but what we've done is we've taken these cells from the fallopian tube and also cells from the cancers and we can look at their mutations we look at a mutation called p53 which is in almost every high-grade serous ovarian cancer and the exact mutation that that that we have over there is the same in the fallopian tube the very earliest cancer cells you can come up here if you want plenty no need to make yourself comfortable the exact mutation that's in the very early parts of the cancer or we call a precursor lesion is also in the tumor and that's pretty good genetic evidence that this is the origin of the cancer as well if we take a tumor or a person who has cancer and we take the fallopian to him a look inside of it about 50 to 60 percent of the time we will see a very early precursor lesion in the fallopian tube we never see that in the ovary we can sort of tell where the cancers beginning and it begins right from the fallopian tube and I can talk about later why it's not a hundred percent it's only 50 or 60 percent so the fallopian tube is likely the site of origin for many or most high-grade serous carcinomas probably not every single one but most of them ovarian cancer screening which I didn't really talk about with ultrasound or measuring a ca-125 to see if someone has early ovarian cancer has not really worked don't forget screening means you're trying to find something what are you trying to find you're trying to find cancer you're trying to find real cancer cells at an early stage but it's still cancer if you screen someone and find a cancer that person still has cancer now it's a much more curable cancer than if it was bigger or harder to treat but you're screening for cancer prevention means we want someone to never ever get cancer if we find the cancer early that person still probably getting chemotherapy if you never get cancer you're not getting chemotherapy and and everything else and so we want to prevent cancers but would also let the screen cancers we're really good at preventing cancers now in high-risk women who have BRCA mutations through birth control pills and risk reducing surgery where really bad at detecting ovarian cancer early and working really hard on that I think last year I've talked about a biosensor we're developing that's almost ready for human trials I'm not going to talk about that tonight but in my laboratory we do lots of research on both on both prevention and also precision medicine other things so screening doesn't work it's recommended against for the general population so if you're not at high risk which mostly means you have a mutation in your family and you're just someone who says I don't want to get ovarian cancer I'm just gonna have a sonogram maybe once a year maybe twice a year that's harmful that person will end up in the operating room with an unnecessary operation the more likely than not at some point develop a complication and you do enough of these someone's gonna have a really bad complication who never needed anything in the first place so we recommend against ovarian cancer for the average risk population for the high-risk population the jury is out so it's something to consider I recommend it from any of my patients for some people we don't we have a little discussion so we don't know the answer and the high-risk population feel free to have a seat if you want anywhere but it's recommended against for the average risk population in the high-risk population so if you have a BRCA mutation we recommend that around age 40 for brca1 and 45 for brca2 that we strongly recommend that women have their ovaries and fallopian is roofed that has dramatically reduced the chance to get an ovarian cancer it also puts women into premature menopause which is not great so 30% of high-risk women do not follow our standard recommendation that used to be made by white men and now is made by lots of women and men together but you know 30% of people do not follow those recommendations and that's a problem so we need to come up with better screening and prevention approaches our professional societies suggest that maybe we should just take out the fallopian tube and if it comes from the fallopian tube when you take it out that'll be great the ovaries make hormones that prevents menopause the fallopian tube is simply a meeting place for eggs and sperm so once you're done having kids the fallopian tube is completely unnecessary it doesn't serve any purpose except for allowing people to get pregnant so if you're done having kids you could take out the fallopian tube and essentially no one would be the wiser obviously there's a small risk with those procedures but that would be much better than having to take out the ovaries however this approach is completely unproven and untested so because of that I just want to remind you this is called bilateral South injecting me it's being done I do it a lot and we have a long discussion but it's it's a possible way to reduce the risk of ovarian cancer but it's unproven and experimental today so this is the idea in the United States according to the CDC women in the early 40s recent recent data 2015 30 percent of women across this country in their early 40s have had their tubes tied or a tubal sterilization which is depicted over here we cut the tubes we tie them we do lots of things to the tubes and therefore the eggs and the sperm can't meet up but you can't get pregnant and that's a contraceptive approach but imagine if we just took out the fallopian tube then the fallopian tube wouldn't be there and it couldn't turn to cancer sounds great we should do it it might work it might work really well it might not work maybe the maybe the early you know cancer cell here has already you know fallen onto the ovaries so what I call the horses out of the barn maybe a normal fallopian tube cell is sitting on the ovary which I called the supermarket which is all the food and nutrients and the normal cell will turn into cancer later on when it's already on the ovary I don't know I don't think that's gonna happen a lot but I have no idea so the point is that while it sounds really nice that we should just take out the fallopian tubes this would be a revolutionary approach we don't know so we have to test it and it's really hard to do so it's a really great idea but it's unproven and I think it probably will work I think it's probably much better than not having the ovaries and fallopian tubes taken out so just doing screening which I told you doesn't work very well take it out the fallopian tubes is probably much better than that but still unproven so we have a study called the wisp study it's open at these centers including NYU the wisp study is for women who don't want to have their ovaries and fallopian tubes out and they just want to have their fallopian tubes out and we're trying to see you know what does that do does it actually prevent menopause which it should but until we can prove that we're actually correct in that women feel you know just as healthy and have no menopausal symptoms you know we need to demonstrate that so this study has the primary objective of improving sexual function and menopausal symptoms compared to women who have their ovaries and fallopian tubes out again it's run out of MD Anderson we're one of ten centers it's probably going to close by the end of the year and it's a very good proof of principle study but it won't tell us if it actually prevents people from getting and or dying of ovarian cancer and so we've been working for about ten years on another study to figure out who would you study if you want to prove efficacy which means it's effective and it actually works well who would you study you can't study everybody because if you're 55 or 60 in menopause you want to take out just the fallopian tube because you'd want the ovary and fallopian tube to both come out because the ovaries aren't making as many hormones and menopause as I do before menopause and when you do a study you have to have two groups and you want to show that one group gets less cancers and the other group so who do you study you study brca1 carriers because brca1 carriers have about a 1% risk per year of getting ovarian cancer if we studied brca2 carriers no one really gets cancer before the average age of menopause which is about 51 there may be a couple of cases here and there which is why we recommend brca2 carriers to have ovaries and fallopian tubes taken out at about age 45 but we can't use that population in a study so we have to study premenopausal brca1 carriers and then how do we answer the question well what's better than what so we do something called a non-inferiority study if we say let's just take out the fallopian tubes we want to make sure it's not worse than our standard of care we don't need it to be better because the procedure is better so we don't need it to work any better because taking out the ovaries and fallopian tubes works well we don't want it to be worse that's called non-inferiority so how do we design such a study so we go back to a prospective study of a five or six major cancer centers that pooled their data together and when they were first figuring out does taking out the ovaries and fallopian tubes prevent cancer they had to ask that question and study it and they found out the answer was yes and how well did it work well over the course of the study period 99% of women who had a brca1 mutation and had their ovaries and fallopian tubes taken out did not get cancer so 1% of people got cancer and so we're saying well if we can just take out the fallopian tubes and 98% of people will still not get cancer that's pretty good it's pretty good for for us is it good for you well that's a discussion is 1% versus 2% vs. menopause you know but at least we can quantify it so we're designing a study to say is taking out just the fallopian tubes almost as good as just taking out the fallopian tubes ovaries and to do that we have a study through a cooperative group which has a long title here but basically it's comparing the two arms and since the title is very long we do the acronym so it's called so ROC and so we have the so ROC study that's been approved by the National Cancer Institute by the division of cancer prevention there's a protocol that's undergoing sort of some tweaks and revisions and we hope this study will be open next summer and it's gonna be open across this entire country a Canada Japan Korea Australia some places in South America to start with and then we'll open up to other places in Europe who are not part of this direct co-operative group not that we're discriminating against Europe we just have this group that includes all those countries already and so we're gonna do that women will self select South injected me or tubes and ovaries so just the tubes or tubes and ovaries we're gonna follow them for up to 20 years we're gonna do different surveys to see to measure medical decision making and estrogen deprivation symptoms we're going to recommend that people who don't have their ovaries out have them out at the appropriate age and we're going to see how people follow those recommendations and it's gonna take 10 years to accrue or collect or enroll 2262 premenopausal brca1 carriers that's about 230 people a year across multiple countries and then we follow them for a total of 16 years so in 16 years we'll know the answer that's a long time but it's an important question if we do better and we have Europe join us and we have 400 people per year we'll get our answer maybe 10 years but maybe 10 years from now when I have a lot of gray hair I'll be saying to someone you know you just need to have your fallopian tubes taken out you won't go into menopause and we're gonna prevent your ovarian cancer you know and that would be great so so we'll figure this out it's a question that has to be asked and we hope that we can we can figure that out we think we can do it I'm gonna skip some of this stuff because I'm getting long winded so the take-home message is that um ovarian cancer start in the fallopian tubes we have mouse models to suggest this is correct Souths injected me is is a feasible idea it's unproven and experimental so we're doing it with a proper you know counseling and this clinical trial will give us an answer at some point at least in my children's lifetime so moving on I'll spend the rest of the next 20-25 minutes talking about treatments and if you have any questions of a prevention or screening and write them down put them on your iPad we'll answer them at the end keep them in the back of your mind so you don't forget them but we'll do all that stuff at the end but now we'll talk about treating ovarian cancer in just one second okay so the normal treatment of ovarian cancer is to do a big operation take it all the cancer that we can see with the naked eye give chemotherapy and have someone go into remission the best scenario is when we can take out all the cancer all the cancer we can see with the naked eye people can get a full course of chemotherapy and then we monitor them with ca-125 that you're familiar with this is the actual three-dimensional picture of the protein shown in two dimensions on the flat screen but this is ca-125 this is a CT scan we monitor people and too frequently the cancer comes back and then we give other treatments treatments work very well we certainly can cure some people with advanced stage ovarian cancer but we certainly can treat all people with ovarian cancer our treatments are definitely getting better people are definitely longer people are definitely being better than they were five 10 20 years ago I can't tell you for sure that we're curing a larger number of women so their cancer never ever comes back we have a lot of studies asking that question because to know that question you have to have a lot of people who you follow for a long time but the good news is we're really talking and studying ten-year survivors now so the typical thing is you know the 5-year survival rate is this and this and this we don't care about that we have a lot of people who are living to five years now we have a number to many people who are not but we have a lot of people living at five years but we're focusing on ten years and of course we want to focus on infinity years but we really are in our professional societies now we only really talk about ten yet we don't talk about five years survivors anymore we talk about 10 years survivors I have a lot of people living beyond 10 years both with cancer and without cancer and I'll tell you one study we did that was biased and sort of self selected we looked at people with advanced stage of Internet cancer who were alive at ten years or more and so it's not everyone of course but of the people who are alive ten years or more about 40 percent of people had surgery chemo and nothing else and about twenty percent of people had surgery chemo maybe one recurrence and nothing else and about 40% of people were on and off chemo for for a long time one of my good friends from Australia we were just at a major ovarian cancer conference last weekend in Atlanta called the ASC our special conference and ovarian cancer and and and me my colleagues when I when I was at Memorial sloan-kettering before I moved to NYU three and half years ago we came up with a term called one-and-done which means you get your initial treatment and that's it and he came up with a couple other terms because everyone's cancer sort of behaves differently so he came up with the term called grumbling disease we're like ca-125 it's kind of going up and down and if this is you you're in the doctor's office like oh my god what's going on in the dark so I don't really know what going on and you're kind of the doctor said just wait let's see what's going on you're like well I want to know I want to know will you just say let's wait and the cancer kind of does company that's probably your own immune system kind of responding to the cancer and that's that's not bad you know and that goes on for a long time the other type is people who respond to platinum chemotherapy which everyone gets initially multiple times so for the Platinum we give platinum cancer goes away cancer comes back we give more platinum that's called multiple platinum responses and then the last group is sort of progressive platinum resistance which is something obviously working very hard on where platinum works for a while then platinum doesn't start to work and so those are kind of like four models of ovarian cancer and and that's sort of the basics and so how do we improve upon the basics we're doing a lot of improvement and I'm gonna show you some data that's been published in the past presented at national meetings over the past year that sort of takes various drugs and makes them work better and so maybe I'll just go back for a second before I talk about the data I'll just make a comment about clinical trials and so clinical trials are great and they're great for patients except for weak what we call like the first and human trial this is the trial like people come in the office and I sort of hate to use this term but they're like I don't want to be a guinea pig so first and human when you're taking a brand-new drug that's that you know I don't want to like equate humans to guinea pigs I think that's insulting all sorts of things but the first human trial it's probably not gonna work and that's really a trial I have nothing else I'm gonna try this just for the heck of it and it may be right it may be wrong and may be good for some people it is how we develop drugs and all these drugs that people are getting we're at that point someday so people might want to do it to help the future etc that's not a lot of our clinical trials it's almost none of them most clinical trials nowadays take the standard treatment that is a very reasonable treatment that you that someone would probably get anyway and adds another drug to see if it works better and so the opportunity is you're gonna get the next best drug we know how it works and you're gonna get a treatment that's gonna be better than what the standard would be that's great what's the risk you added another drug you add a little toxicity and so there may be a little toxicity we may not fully know all the toxicity when we combine drugs together and we may find out the additional drug doesn't help so then you've got the toxicity without any benefit so that's the balance so clinical trials are great because they're very well regulated there's a very strict sort of recipe that we follow and there's an opportunity to get something that works better and the cost is there may be more toxicity and may not be a big deal may be you know a little more fatigue or it could be something that's you know a big deal and we think we know what those toxicities are but since it is a clinical trial again we're not always as smart as we think we are and so you know we have an idea there are a few trials sort of get closed for safety and a number of them get closed for not working but clinical trials those type of clinical trials are really what most of us talk about we say you know you really should go on a clinical trial it's a great opportunity the other thing clinical trials do it gets you access to a drug that we might like to give to you that we can't give to you because it's not commercially available so that's the other benefit of clinical trials so clinical trials are great we have 24 or 25 gynecologic oncology clinical trials open here NYU we have four eight twelve trials for ovarian cancer and we have more Phase three trials open here than any other Medical Center in the tri-state area so what if clinical trials taught us this is a clinical trial for a rare type of ovarian cancer called Carson or sarcoma it is a fairly aggressive subtype it also develops in the uterus and so the question was we used to give a very toxic regimen called ifosfamide and taxall would like to give carbo and taxol which is much less toxic which is commonly given for regular ovarian cancer is that just as good and so they compared those two arms and they actually enrolled 600 people which we thought we never could do for sort of a rare tumor they compared the two treatments and they basically found out that they're the same so that's good so again this was called a non-inferiority trial because we already had a stander so we're not looking for something that was better we're looking for something that was the same but less toxic there's another type of clinical trial you know we don't want things to be better we want them to be well they're better but want them to be better from a quality of life perspective it would be and in fact there was a suggestion that it also worked better which was not the purpose of the trial but it's not a bad thing when the treatment looks better and so this is now our standard for these rare aggressive types called carcinomas this was interesting trials so I told you that you know the goal of and I should take a step back the standard treatment is a big operation followed by chemotherapy to take it all the cancer when we can do that so there's two main situations where we cannot do that one is if someone is not physically fit to tolerate a big operation these operations as some of you know if you've had them can easily be six hours I've done many ten-hour operations a couple of 12 to 14 hours it's a big deal that's like running a marathon so I can run a 5k I cannot run a marathon but if you put my body through a marathon I'd probably make it I think but if you know if you're you know maybe you know have you no history of heart disease or something else you know a big operation can be very dangerous and so there are some people who have poorly controlled diabetes maybe some heart problems they can't tolerate a six to ten hour operation so that would be dangerous and the other type of times we know to the operation is that this cancer we can't take out so--that's operator dependent I can do some things other people can't do maybe there's someone who due to something I can't do I have friends who help me with things I can't do that I'm not trained to do but there are still things that that we that are just unreasonable we can't take out a lot of ovarian cancer from the chest you know there are certain times we can look inside someone and find out that the intestines are too involved to remove we can't take out all the intestines because we just can't do that even though we technically know how to do that it's not you know the right thing to do so what if the cancer is too advanced we also can't do an initial operation and that's when we give chemotherapy so we give chemotherapy first that's called neoadjuvant chemotherapy we give a couple cycles of chemotherapy the cancer gets smaller we then do an operation and give more chemotherapy so the question here is in older women who what they call our vulnerable which means they have some characteristics that make us concerned about whether they can tolerate a big operation and get back to all of their normal activities you know should they have an operation at all or should they just get chemotherapy and what kind of chemotherapy should that be and so these are some of the things we look at we look at activities of daily living can you go to the store can you address yourself bathe yourself can you you know sort of take care of yourself we look at anxiety and depression and nutritional status with albumin and white blood cell counts and this is a score that's been worked out by other people who I don't know but it talks about basically it's called a geriatric vulnerabilities stored it's basically the health assessment women who I think are 70 years or older and this is a fair number of people who get ovarian cancer and so the question was what type of chemotherapy should they get so we often think this is a patient who might be a little bit sick we're just gonna give them the carboplatin we're not gonna give in the tax all because the two drugs together is a little more harsh than just one drug and we think the Platinum drug is the most important drug and so this compared just the Platinum versus the Karbo and the platon given in different combinations to see if one might be just as good but better tolerated and much to our surprise because this was done very commonly much to our surprise which we'll get to in a second forty patients will put into each of the arms one thing to keep in mind surgery was not part of this trial but two-thirds of women either never had operation or had an operation that was quote unsuccessful so we do lots of operation one take out all the cancer we will use all of our information to predict that we can take it all the cancer but if we can't and if we leave a lot of cancer behind we actually haven't helped somebody but since it's so important to try to do that we do that for a lot of people and in our hands here or NYU about 80% of the time or more we are able to take out all the cancer we don't want to withhold a very useful operation from eighty percent of people but we don't get it perfectly right but in this study only seven to ten percent of people had all the cancer taken out because they're already studying a group of people who are older and may not tolerate a big operation etc so so there was a lot a lot of great surgery being done in this study which is why people you know we're on this study to figure out the chemotherapy differences and in fact you know fifty to sixty percent of people receive all the chemotherapy so that was great but what we learned is that the single agent carboplatin was actually much worse and so this was a common thing that people were doing they were they were they were receiving single agent carboplatin because we thought well that's good enough and it wasn't and so ever since this came out just this past summer we're now trying not to just give single agent carboplatin to anybody and it also shows that people who are older and quote vulnerable or kind of maybe a little bit frail they can tolerate full doses of chemotherapy and there's no reason to kind of cut back on the dose just because the doctor might be afraid this person's not going to tolerate it just shows that people really can tolerate the chemotherapy that we give for ovarian cancer and so everyone should get two drugs together really if at all possible and this was a very very important study and because of this study and because so few people actually had proper surgery and still did pretty good we kind of questioned the role of surgery and so this is a study that's being planned it's not open it's very controversial we have some internal discussions going on with our national national groups and basically the question is and I won't read all this but the question is could you just have chemotherapy and do just as well as getting chemo and surgery and chemo so not for everybody but if you maybe you can't have that big operation do need an operation all who wants an operation if you don't need operation and so this is basically saying for people who are going to get chemotherapy first after the first three cycles of chemotherapy there's a randomization to surgery versus no surgery and then we see how people do and so this is controversial because surgery is like a baseline or a hallmark of ovarian cancer you know and it's probably very important for many people but this be some people where it's not helping that much and so so this study I hope we could do it and and and learn from that so moving on the sort of the exciting types of drugs you may have heard about if you're keeping up with the field are basically PARP inhibitors and just to summarize PARP inhibitors work very well for anyone with ovarian cancer who has a brca1 or 2 mutation they're fda-approved for that reason and we give that all the time to people who have brca1 or 2 mutations and they probably don't work so well on their own for people who don't have brca1 or 2 mutations and so we're trying to make them work better by combining PARP inhibitors with other sorts of treatments the other thing you've heard of is immunotherapy or sometimes called checkpoint blockade immunotherapy does not work very well for ovarian cancer by itself and we've just learned that so if anyone's been on an immunotherapy trial we didn't know that but we now know now that for ovarian cancer it doesn't work very well by itself but when we combine it with other types of drugs it works much better and that's where all of our trials are going now and so we're very excited about that we have seen much more benefit when we combined it we're not sure how how big of a benefit it is and how much we can push that benefit to make it work even better and so that's where a lot of the studies are happening now so this study was basically asking a very interesting question about PARP inhibitors in women who do have BRCA mutation mutations whose cancer has come back and the question is if your cancers come back and you have a BRCA mutation should you just get a PARP inhibitor which is a pill or should you get regular chemotherapy and get a PARP inhibitor later because we're so tied to chemotherapy for ovarian cancer it's really hard to like not give chemotherapy when we can and so this study enrolled 250 women this is called a 1 to 2 randomizations there's twice as many people getting the investigational drug the PARP inhibitor as getting chemotherapy so it's a two-to-one randomization and what they found is that in the brca population which I believe is over here yep actually I didn't show that here but in the brca population there was no benefit forget that this different study so what they found is in the brca populations all beer SIA carriers in the brca population the PARP inhibitor actually worked better than the chemotherapy and so now for people with recurrent disease who have a beer stay mutation the option can be pop inhibitor or chemotherapy and we could figure out which one which one to give first so that was a really important study and this slide I put in this to remind you that PARP inhibitors a pill take it once a day or twice a day that's really easy you don't to come in the office but it's real chemotherapy it's real chemotherapy in a pill form and what you can see from this teal bar that nice they made a teal in that teal bar you can see that 21 percent of people up Harpe inhibitor had grade 3 anemia which is a type of anemia that can require a blood transfusion so now we talked about getting a PARP inhibitor like a maintenance therapy and I always say you know do you want to take a part inhibitor versus you know go lie on the beach you know because if you're not any treatment you might go to the beach if you're not a proper hitter maybe you go to the beach but you're gonna be tired a little nauseous you might need a blood transfusion it's well tolerated and of course if it works we certainly want to do that but they're real drugs that are real side effects and 20% of the time there's you know real anemia that sometimes needs a blood transfusion so you know just important for people to understand it really works and it's a real drug it's not just like I'm taking a Tylenol every day it is great that it works in a pill form and and it's a big advance and it's also great you know that it works so that's the solo 3 study let's see there we go so this this is the day's so so in recurrent cancer that's platon sensitive this studies comparing just to par pin hibbett ER versus a PARP inhibitor and what's called an anti-angiogenic inhibitor or Bevis ism AB which goes by the commercial name Avastin it's a also a veg F antibody and it blocks the blood vessels if you block the blood vessels the tumor can't get nutrients and then the cancer cells will die and this works and so in this study the question is if you have recurrent ovarian cancer again the question is we don't want to give regular chemotherapy can you just get a PARP inhibitor or can you get a PARP inhibitor with bevacizumab are the anti-angiogenic inhibitor and will that work just as well and again 40 or 50 people in each arm and this is the fascinating point here so this is what I was confused the previous slide in the BRCA population because PARP inhibitors worked so well in the BRCA population adding that second drug didn't do anything and we've seen this in a couple of trials so if you have a B or C area sociated cancer the PARP inhibitor works really well you don't need something else but in the non BRCA population adding the bebés is amad made a dramatic difference and PARP inhibitors don't really work so well in the population of women who don't have a BRCA mutation but when you add bevacizumab to that it works quite well and then I asked myself I said well are you just seeing the effect of the Bevis ISM app because these people didn't get Bevis is a map but in fact the Bevis is amad which also works it actually works twice as well combined with the PARP inhibitor so this is a nice option at the two drugs that actually don't work that great on their own but you put them together and they have what's called synergy it's not just taking the effects of the two drugs and adding them which would be additive you actually get an improved benefit which is called synergy which is actually what we're looking for when we do these trials I was explaining to you how you take some drug and you add another drug we don't just want to put them all together because then we can give them separately if we give them separately we decrease the toxicity if we give them together we increase the toxicity so it only makes sense to do that if you get more than what's called additive so one plus one should equal 3 if one plus one equals two we should do one and then one and not together but if one on one equals three then we want to do that together that's called synergy and so this is another option this again shows you the same thing the anemia in the dark red and blue bars again about 20% PARP inhibitor and high blood pressure when you give Bevis isn't that because it's known that when you target blood blood vessels which regulate your blood pressure your blood pressure goes up so if you've received bevacizumab your blood pressure's probably gone up we know people need blood pressure treatments we have cardiologists who work with us because we are pretty good at managing blood pressure and we're a lot better at managing blood pressure than we are managing ovarian cancer so we want to use the drugs that really target ovarian cancer and then deal with the blood pressure which we can do it's a pain it's not easy but we can do that and so that's the conclusion of that study this is another very exciting study of a drug called Len bat nib you might have read about it yesterday because it was just FDA approved for endometrial cancer limb bat nib also targets blood vessels and other things that make cancer grow it's called a tyrosine kinase inhibitor so it targets sort of different receptors that make cancer cells active and here it gets given with taxall which is a traditional chemotherapy agent the question is if you give tax all plus - this new drug this is the classic trial so give me an taxol is a very good chemotherapy agent we give it to lots of people can we add something else to make it better and here this was a study of a couple of different types of cancers and there we go so this is the schema lomatin it like a lot of new drugs is also a pill it's real chemotherapy real side effects but it's a pill that's better tax sales tax all given once a week 30 19 patients had ovarian cancer only 7 had endometrial cancer so it's mostly an ovarian cancer study and the mutual cancer studies were done previously worked out very well which is why we expanded it to why we expanded it to ovarian cancer and what you can see is that people do get a high blood pressure because this type of drug also can target blood vessels and so there is high blood pressure this drug does give you diarrhea in fact the 8% diarrhea rates kind of on a low side because this drug does have some diarrhea which can be kind of a pain in the butt so to speak thank you for laughing at my joke and it also can lower blood counts etc but it works and so this is called a waterfall plot and basically the top line is kind of baseline and everything that's negative means tumors are getting smaller and so this is really good the red line at minus 30 is 30 percent shrinkage of tumor which is kind of our defined sort of success rate for whatever reason that means the drug is kind of worthwhile and you can see you know it's worked it works pretty well and so we're excited about that the blue bars are ovarian cancer the red bars are endometrial cancers and mostly ovarian cancer 70% of people actually had a response which is great and so this is safe and tolerable and this is live at nib with Pember lism AB and so so I'm sorry lomatin it with with taxol and so there's other evidence that suggests when you combine it with immunotherapy so that's called Pember lism AB is one of a couple types of immunotherapy so now we have an ongoing trial here and only at a few other centers were actually combined in Pember lism AB with live at nib for a varying cancer only after receiving three prior treatments for ovarian cancer so it's for what we call fourth line therapy so you've got three different regimens of chemotherapy and you still need something else this is the trial for you and we are just starting to put a few people on on this study but it's for fourth line ovarian cancer therapy the way clinical trials work if this trial is positive it'll go from fourth line to second line and then to first line as things start to get better and better so before I wrap up I just want to mention one more thing about PARP inhibitors there's another major conference going on in Europe and next weekend it starts and so PARP inhibitors have been tested sort of kind of all over the place we use it a lot for people again with BRCA mutations but the question is can you combine it with chemotherapy for people who may or may not have BRCA mutations and and another PARP inhibitor called the lip er rib which is one of the least studied PARP inhibitors just finished its first upfront trial where it's given in combination with taxol and carbo and there's a press release so I'm not divulging anything secret but there's a press release that came out a few weeks months ago explaining that was a positive trial and so that's another big and exciting addition to our ability to treat ovarian cancer it's possible that everyone will get a PARP inhibitor with taxol and carbo as initial treatment what we have to see next weekend when the data are actually presented is how positive is it is it a statistically you know significant trial but the actual benefit is something that we don't care about or is it a huge drop the mic type a benefit where you know it's it's it's really gonna make a difference and when we see the numbers we can sort of interpret it will also learn about the toxicities then we can kind of learn about the balance and discuss it with people and say you know is this something that we should be doing so I don't know the answer and we'll know that after next weekend so this is an example of types of clinical trials we have here just for ovarian cancer we have a neoadjuvant trial that is testing a immune modulating drug that we put directly into the belly and that's gonna be opening in the near future we've finished a trial of a immunotherapy with chemotherapy we now have an open trial for newly diagnosed patients that includes immunotherapy plus a PARP inhibitor so again we're trying to see how we could put these drugs together to make them work better and also make sure they're tolerable so this is open now PARP inhibitor checkpoint inhibitor immunotherapy and chemotherapy and this is a maintenance study so once you don't regularly mow therapy now instead of giving just a par pin hibbott or we give a power hitter again with immunotherapy because the PARP inhibitor is a standard of care for women of BRCA mutations but if you don't we need something better and so we think the PARP with the immunotherapy is likely to be helpful for disease that's come back if it's what's called platinum sensitive which I think people are familiar with we have a study of again a PARP inhibitor with immunotherapy and we have a study of a Parkin hibbett er in people whose tumors have a mutation that's not brca1 or 2 so it's one of those other types of mutations like rad51 C and D it's not proven how well the PARP inhibitors work and so this study is testing PARP inhibitors in those other genes where you can't actually get the PARP inhibitor through the FDA approved in decay which is only for brca1 and 2 and so this trial is seen how to expand the arena of PARP inhibitors to other women who have alterations that we think should should be useful for what's called platinum you know when they can't when the cancer doesn't respond to platinum anymore we need new options this is what I just talked about leviton and plus PEM bro for recurrent ovarian cancer this is again a part prohibitor and another checkpoint inhibitor and that's gonna be opening soon we have against sadirah nib which is like Bevis ism abbott targets blood vessels so again blood vessel plus a PARP inhibitor we have a immunotherapy trial on hold we have a really exciting trial here this is this is an antibody that affects both blood vessel formation and immunotherapy all in one shot and it affects the blood vessels in a really novel way and so that's combined with taxall in this trial here and we have another trial that's on hold right now but again it's a checkpoint it's a vaccine against against not ca-125 is a vaccine against something I'm forgetting obviously and DNA methyl transferase inhibitor so this is something called um this is this is a drug that that reactivates genes that are inactivated by something called methylation and this is a I think amok one vaccine it's a they're all like these real complicated drugs that we're all putting together it's run out of what Roswell Park and that's very exciting and let's see what's next here and so to wrap up chemotherapy combinations are showing great promise for both initial and recurrent cancers our progress is directly proportional to the success of clinical trials and the amount of funding we have for translational research so if you or any of your friends have an extra hundred dollars or an extra hundred thousand dollars please give them to my research laboratory NYU the National Cancer Society the American Cancer Society your favorite institution where your doctor or friends work we need to you know there's lots of funding for all the cancers that are more popular like breast cancer and lung cancer we need funding for the in cancer our progress is directly related to how much research funding we have and you may not have an extra dollar to your name but you might know somebody so we need people to realize how much progress we're making and how important the research is and we need all sorts of fund and our governmental funding goes down all the time and so any funding that we can get will help will help the cause and lives can be saved through genetic testing and cancer prevention clinical trials are not always successful we always learn we learn what drugs to give what drugs not to give and it's very important for everyone to live longer and better and all the standard treatments today they were in a clinical trial at some point we have lots of clinical trials here at the Perlmutter Comprehensive Cancer Center some of these slides I stole from people who gave presentations at national meetings and we always want to thank all the patients who actually do go on clinical trials we actually want 10% of our patients to go on clinical trials and here we have 14 percent of our patients who do go on clinical trials but that means most people don't why don't they it's hard it's hard for a patient to go on a clinical trial it's hard for a doctor to put someone on clinical trial we owe a lot we have paperwork anyway we have a lot more paperwork when we do clinical trials and it's hard for the institution to run clinical trials and we lose money I make a lot more money to do an operation then put in someone on a clinical trial and I love both but it's clinical trials are tough and so we have to do them because that's how we make things better and this is my group that helps us do both surgery and clinical trials this is our research lab over here these are our doctors at our Manhattan campus we have a hospital in Brooklyn we have a hospital in Long Island and why a Winthrop this is our brand new hospital that's all single beds only single abetted Hospital in Manhattan and the newest Hospital Manhattan and so we have 13 GYN oncologist across the sort of small tri-state area and we get a lot of support from other foundations to do a research and that's it thank you for coming and that's a hotline if you need us we have a hotline right over there all right questions at all covered everything right so obviously for genetic testing it's all germline but for the treatment it's the same so we've learned that the PARP inhibitors which I think what you might be talking about the PARP inhibitors work just as well for BRCA however it gets into the cancer whether it's from germline or somatic the PARP inhibitors work for any type of BRCA mutation that's in the tumor it's quality any better versus blood testing the blood as opposed to the slide no saliva and blood should be the same you get more DNA out of blood so you might give us a live as sampling might tell you it's not good enough you may have to give another one but once they have the DNA it's since the germ line it's in every cell of your body whether it's your blood cell or your saliva really gives your is it's really inside of your cheek you really spitting out cheek cells when you give us a lava sample and so it doesn't matter what cell it comes from is every cell in your body just going so the inherited mutations can't change what we know about the mutations can change the testing we do 20 years ago wasn't as sensitive or as good as the testing we're doing now so if you've been tested more than 10 years ago you might want to consider more testing because we do those other genes that we test now if you've been tested five years or less it's probably the same and then five to ten some would have to look over the report to see what was done if we look at the report we can tell whether it's any different so that's that's that different decided to brca that genes gene patience might end up with ovarian cancer right so it's mostly Lynch syndrome which I didn't talk about and what we call Karev hereditary breast and ovarian cancer syndrome which is basically for ovarian cancer the five known gene the brca1 brca2 wrapped 51c rad51 d rip one maybe pal b to what she mentioned is something called Lynch syndrome which is a basically endometrial and colon cancer syndrome but it also has ovarian cancer in it and those and so the BRCA genes affect the way that DNA is repaired through something called homologous recombination where pieces sort of come out and get glued back together the other type of way that DNA can be repaired one of many ways is called mismatch repair where like something isn't read properly and there's a mismatch and these these genes proteins come in and fix that mismatch and those are basically four genes called mlh1 msh2 MS h6 and pms - and there's another gene called a p-- cam that's sort of related and those can cause hereditary colon cancer and endometrial cancer and sometimes ovarian cancer so those are covered on the panels they are more associated with endometrioid and clear-cell ovarian cancers they're not so much associated with high-grade serous ovarian cancer but it is something that we do as a matter of routine I just did not discuss it tonight but you are correct those are genes that can be associated ovarian cancer only did the PRC I didn't have a panel right so you were tested many years ago you would if you were tested five to ten years ago they would have been saying do you want a panel do not want a panel so the panels are more comprehensive so yes regardless of what kind of cancer it was cuz gonna have was high-grade serous it's probably not for one of the Lynch genes but if you only have brca1 and 2 you didn't have rad51 C and D I would say so what I didn't tell you guys is about 15 to 20 percent of ovarian cancer is inherited about three-quarters of that's from brca1 and 2 and so about you know maybe three to four percent is from the other genes and so you know that's substantial and so particularly if you have family members who could be at risk I would say you should go back for panel testing or something to consider [Music] leukemia in this population can be related to getting chemotherapy just so you know chemotherapy does have a 1% chance of giving you leukemia those particular genes so the brca1 and 2 genes can be related to other blood disorders called Fanconi anemia which is not exactly leukemia so I don't think they're directly for non affected members there should not be any higher incidence than the general population so what you're saying is if one sister has a BRCA mutation she's a high risk if one sisters does not have a BRCA mutation she's not at any higher genetic risk there is still a familial risk and this is more common in breast cancer so in breast cancer about five to eight percent of breast cancer is BRCA type related but there's also familial breast cancer which could be from either other genes that I didn't mention or things we don't know we think the familial ovarian cancer risk is much lower so I would say if two sisters one is BRCA one dozen I would say the one a dozen her risk of ovarian cancer is quite low it's also a little unusual to have a strong family history so you have a strong family history and a mutation that tracks with the cancers that families risk is probably due to the mutation if your was a lot of people at breast cancer and the families tested negative people still may be at increased risk of breast cancer that's what we call sort of uninformative testing if there's like three or four or family members with early onset breast cancer they've had genetic testing that's negative the family is still at risk for breast cancer if it's positive it's informative because that means the sister who has the mutation is at risk and the other one is not at risk so I would say the answer basically is you're not an increased population risk your first quest and chemo prevention so chemo really just means chemicals right and so for ovarian cancer the chemo prevention that works is the birth control pill so a birth control pill reduces the risk ovarian cancer by 30 to 50 percent that really is chemo prevention tamoxifen is a chemo prevention drug that can be used for breast cancer it doesn't prevent ovarian cancer but for ovarian cancer for someone who wants to do something and or doesn't want to have surgery birth control pills are great they prevent breast ovarian cancer more than a possibly slight increase of breast cancer but again if you're a carrier your risk of breast cancer is really high you got to be doing screening and MRIs and mammograms and so to reduce the risk of ovarian cancer by 30 to 50 percent is probably a good balance so anyone who's brca1 positive and pre menopausal should be seen a GYN oncologist at least for a consultation just to kind of make a plan the studies are open to anyone who qualifies which are the some age ranges and things like that but the wisp study is gonna be closing maybe at the end of this year we might have an extension magentas online it's open to the entire country so you don't need to be anywhere except your living room with an internet connection do to do magenta which is genetic testing the wisp study is a study comparing surgical prophylaxis or surgical risk reduction so if someone's interest in having some type of surgery and they came here we would ask them to be part of the study the study isn't actually studying the surgery the surgery is routine care this the the study is is studying people's sort of quality of life and it's basically involved surveys that come on to your iPhone or your computer and so we have that here it's open at the Centers I showed and then the study that we're gonna open hopefully the next summer will be open almost everywhere across the country once it open there'll be a big press where these share is gonna put it on their website a lot force is gonna have it on their website NCI is gonna have it so you're gonna hear a lot if you're in this community and you're here tonight you're gonna hear about that study when it's open I promise you okay very interesting thank you yes so so we have no screening yet for women at average risk but for prevention the things that really are in your control are basically taking birth control pills and being healthy which means activity proper weight proper diet the other thing that's kind of in your control is having children I mean I say that a little sort of jokingly I mean if you have more children your risk of ovarian cancer goes down people who come by that time people come to see me they're not really kind of you know deciding that so I mean yes it's in your control but usually it's not something you're actively gonna change but for daughters you know and and younger sisters taking birth control pill makes a lot of sense and I don't pass any judgment I'm trying to tell people how many you know kids they shouldn't have that was interesting study came out a couple days ago maybe in British Journal of cancer or something like that I was just at this conference this weekend where I had another study from up from a group at Harvard who showed the opposite so I'd really say the IUD ovarian cancer link is is unclear I don't think there's any risk I don't know they thought that it increases ovarian cancer that's good it does decrease the risk of endometrial cancer it's a great contraceptive approach it's very safe nowadays the ones from olden days gave infections but the ones now are very safe and so it's a really good product and I give it to a lot of people I use it to treat some endometrial cancers so I don't them as a danger does it prevent or reduce the risk of ovarian cancer I'm not sure the data is really next what that's one goal for what other breath oh okay so you do a couple things so if you're in the New York area any of the major medical centers have a genetic counseling program it sounds like mine that's not mine on mute so if you have a reason so if you either have cancer or have a strong family history any of the academic centers will be happy to see you we have a genetics number we can give it to you you can call and make an appointment if you're just average risk most of us now are doing what what's called group counseling just to kind of give education and have testing one controversy is whether every woman in the whole world should have testing because we're gonna find some people at high risk and do things about that and that's controversial but if there's a if you're not at you know low risk any place will be happy to test you also get a test down line so if you're if you have any sort of family history you could do the magenta study it's still open you go online and register and you spit in the cup and they send it back and forth but any any Center will do tests and it's really easy in New York City if you live in kind of a remote area you have to go online to get it done does that make sense I might have been that something that somebody said but I had a question if I'm not BRC okay right and my foundation testing came back with no a genetic propensity is there anything that's out there for preventive for reoccurrence I'm in remission remission so Hagrid says yeah basically that's called maintenance therapy you want to maintain the remission so for the BRCA carriers we're using PowerPoint hibbett errs we have studies going on so one study I showed is that when people have just finished their initial treatment we have a maintenance study of both immunotherapy and PARP therapy together to see if we'll keep keep keep that away but that's for people who basically as someone's finishing up their treatment we discussed that and they kind of go right on to that so if you've been in remission more than a few months you want to qualify for that study yeah you're probably gonna be out of that window so again I would just say lifestyle things the one thing I didn't mention that people always find I think fascinating if you have a good social support system and you're happy your cancer will stay away and so this was tested by a friend of mine MD Anderson in animals and we actually can make the animals have a social support system or we can isolate them we can also make the animals happy or not and so in the exact same antics we can control everything animals and it's proven in animals that if you have a good social support system and you're happy or not depressed your cancer stays away when we control for everything else you say well that's animals so another colleague of mine did that in humans we can actually measure hormone levels of stress and people who had lower stress hormone levels also had the cancer stay away longer we can't control everything in humans maybe their stress levels were lower because their cancer was away right maybe their stress levels were lower for reasons we don't know and so it's not a perfectly controlled study but the evidence would suggest that a good social support system and Happiness will actually help help as much as possibly keep your cancer away and maybe everyone should have a pet maybe they should a mouse people say Braca but it's really BRCA yes yeah should I go to still be tested if you have ovarian cancer and your if you're negative you're negative so if you're negative and you have proper testing not done at one of those other companies we talk but at a good company and let's say you had the whole panel done you know you can decide whether you want to go back and have panel but if you're negative you've nothing to pass down so that's the beauty of genetic tests if you have ovarian cancer and your tests and negative you all of your children are a population risk which is 1% so I see a lot of people who say my mom would ovarian cancer should I take my ovaries out I say no we take a family history we make sure the patient or somebody had genetic testing but as they say everyone with ovarian almost everyone ovarian cancer has a mother sister or daughter and they're not all at high risk right so I'm I just saw someone whose mom was 40 years old with breast cancer and that doesn't meet the qualifications for even genetic testing there's only one person in some algorithm so yeah once you're negative you're negative and your kids can't inherit what you don't have in addition of seven years just I did not have the panel done at this point again it's something to consider yes there are some people who will pick up a mutation that could have been related to your cancer and then your daughter would be tested for that and have a 50/50 chance if it's better for you to be tested if you were not available to be tested then she would be tested but it's much better because you're informative if you have a rad 51c mutation she can be tested exactly for that mutation has a 50/50 chance if we test you we know you're negative then that's great if you were not able to be tested and she was only testing was negative either you had a mutation she didn't inherit or you never had a mutation we don't know so testing the person who has the cancer is always better when that's possible there was a big history I'm the father of your toy is going like existence and grandmother's and will that that would be you know but if I'm not saying but if the person has ovarian cancer it's gonna be in that person so you you know you your dad may not have had cancer but the person who has cancer is the right one to test because then we know like we have a baseline if you don't know you can inherit it from mom or dad that's absolutely true but it's always better to test the person who has cancer that's kind of the us is that we talk about variant of uncertain significance is that what you mean right so a view so so we're really good at sequencing now because we've developed a lot of really cool technology that the outpaces our knowledge and so you know all of us so I'm one in every three hundred of our nucleotides is different so like you may have blue eyes I might have hazel eyes you know these are all variations and so you sequence you find a lot of variations the v us does mean absolutely nothing we completely ignore them and our job my job is to tell other doctors to ignore them and not make people a little crazy so if you have V us you just ignore it when we do enough sequencing we're gonna find these things when we go back years later and learn about their significance and can classify them 90% of the time they get classified is to call benign or unimportant so most of those things that we say we don't really know once we get enough data to know they become negative sometimes a gonna positive so what you can do is you can take your report and wherever you are testing every year or two you can contact them and say hey any updates on my mutation and they can say oh it's become benign oh now it is important what you'd want to know most of the time they'll say we still don't have any more information but mostly the place says even the companies you can call them and say could you check if there's any new information I recommend people do that about every two years you know most people don't but it's certainly a reasonable thing to do how are we doing on time we till 7:00 okay good I think there was one or two more questions so colon cancer ovarian cancer are unrelated except through Lynch syndrome and so whoever the doctor is would would decide whether the colon cancer could be familial and then then that person may or may not have genetic testing but typically most colon cancers are not related to each trial is different some excluse many will exclude some include carcinoma sarcoma is a very unique type that again for the trials you just sort of look at each trial for how we treat the disease we take you know what we know and interpret it as best as we think you know using our judgment but the trials have specific almost every trial will say carcinomas are included or they're excluded and more than more than half the time they're excluded which is unfortunate but we do have a few a few that are included this this latinum trial of fourth line I was talking about that does include crusto sarcoma some of the other that one trial where I couldn't remember ever you type a drug that includes Karno sarcoma so we have some that include and some don't all right well thank you very much I'll be around for a few minutes I appreciate coming happy palindrome day [Applause] and you're welcome you

Channel: NYU Langone Health

Views: 6,318

Rating: 4.8431373 out of 5

Keywords: NYU Langone, Perlmutter Cancer Center, Douglas Levine, ovarian cancer, cancer screening

Id: NeleZAdPzgA

Length: 79min 11sec (4751 seconds)

Published: Mon Oct 07 2019