Preface

Worldwide, 204,449 new cases of ovarian cancer are diagnosed each year, with an estimated 124,860 disease-related deaths.1 In the United States, ovarian cancer is the leading cause of gynecologic cancer-related morbidity and mortality in large part due to the difficulty in detecting early-stage disease. One of the primary reasons that ovarian cancer is associated with such a significant burden of disease for the individual and for society is that it is a difficult disease to prevent, or at the very least diagnose in the early stages, when cure is still an attainable goal for the majority of patients. This volume discusses the full range of diagnostic and therapeutic considerations, including epidemiologic, pathologic, radiologic, surgical, and chemotherapeutic aspects. The volume is intended as a practical guide and overview to the diagnosis, staging, and management of patients with both early-stage and advanced-stage ovarian cancer.

Despite recent advances, the pathogenesis of ovarian cancer is still unclear, and one of the difficulties in studying ovarian cancer is the lack of a comprehensive tumor progression model. Ovarian cancer is a heterogeneous collection of tumors, which are primarily classified by cell type into serous, mucinous, endometrioid, clear cell, and Brenner (transitional) tumors corresponding to different types of epithelia in the organs of the female reproductive tract.2-4 The tumors in each of the categories are further subdivided into three groups—benign, malignant, and intermediate (borderline tumor, or low-malignant-potential)—based on their clinical behavior. On the basis of a review of recent clinical, histopathologic, and molecular genetic findings, a research team has proposed a new carcinogenesis model that reconciles the relationship of borderline tumors to invasive carcinoma, discussed in Chapter 2.

The epidemiology of ovarian cancer has been extensively studied, and the most clinically relevant observations are presented in this volume. It is known that the incidence of ovarian cancer increases with age. Epithelial ovarian cancer is predominantly a disease of perimenopausal and postmenopausal women, with 80% of ovarian cancers occurring after the age of 40. There are a number of demographic characteristics and factors related to reproductive history and health, including the so-called "incessant ovulation" theory and the associated effect of oral contraceptive use on reduction in risk, parity as a risk factor, and the interaction with infertility. Several environmental risk factors for ovarian cancer have also been targeted as potential contributors to pathogenesis. Perhaps the most significant known risk factor for ovarian cancer is a family history of the disease (or breast cancer) and the likelihood of a genetic predisposition. Approximately 10% of all ovarian cancers can be associated with a familial genetic predisposition. At present, the majority of hereditary ovarian cancers can be linked to two currently known syndromes, hereditary breast and ovarian cancer (HBOC) and hereditary nonpolyposis colorectal cancer (HNPCC).5,6 HBOC syndrome is associated primarily with an increased risk for breast cancer, while HNPCC is associated with an increased risk for colorectal cancer. The most up-to-date information on ovarian cancer family syndromes is presented in Chapter 3. In addition, the indications and options for genetic testing of women at risk for ovarian cancer are also covered in detail.

At the current time, there have been no studies that demonstrate sufficient efficacy for ovarian cancer screening in the general population. Therefore, ovarian cancer screening is not recommended for women at general population risk. However, the urgency of ovarian cancer screening is greater for women with BRCA1 and BRCA2 mutations, given the significantly increased risk of ovarian cancer among these women. In Chapter 6, the basic principles of cancer screening, the challenges associated with ovarian cancer screening, and studies of screening strategies in high- and low-risk populations are reviewed. Because of the challenges of early detection of disease and the fact that genetic testing and screening will identify only a minority of patients who will ultimately develop ovarian cancer, chemical or surgical ovarian cancer prophylaxis may be considered for selected women. The various options for ovarian cancer prevention are reviewed in Chapter 4.

Radiographic imaging is an integral part of ovarian cancer detection, diagnosis, management, and treatment follow-up. A number of imaging modalities are available, and a variety of new techniques, especially molecular imaging approaches, are being developed. Each imaging modality has its unique advantages and limitations; therefore, evidence-based use of imaging is essential for achieving the greatest possible benefit without over- or underuse of specific modalities. New developments in radiographic imaging of ovarian cancer and the associated clinical applications are covered in Chapter 5.

Surgery is a cornerstone of the diagnosis and treatment of ovarian carcinoma. The surgical goals differ based on the nature and stage of disease. For patients with apparent early-stage disease, the primary surgical objective is to obtain sufficient pathologic documentation of the true extent of disease through a rigorous staging procedure. Accurate staging information allows low-risk patients to safely defer adjuvant chemotherapy and identifies patients at high risk of recurrence as those who will benefit from systemic treatment following surgery. Unfortunately, approximately 65% of patients will be diagnosed with International Federation of Gynecology and Obstetrics (FIGO) Stage III (T3N0/1M0) or IV (any T, any N, M1) disease.7 For this group, the most important clinician-driven prognostic factors are the extent of residual disease following primary cytoreductive surgery and the administration of adjuvant platinum-based chemotherapy.8,9 The most critical considerations for surgical intervention and selection of a chemotherapy treatment regimen for patients with both early-stage and advanced-stage ovarian cancer are reviewed in Chapters 7 and 8.

This volume is intended for all clinicians caring for women with ovarian cancer, including attending surgeons and physicians, fellows, and residents in the disciplines of gynecologic oncology, medical oncology, and primary care. Ultimately, the optimal management of ovarian cancer is dependent on multiple factors, including demographic prognostic factors, the age and general medical condition of the patient, the extent of disease at the time of detection, the biologic aggressiveness of disease, and available access to an appropriately skilled multidisciplinary care team. We hope that you enjoy this volume and benefit from the extensive experience of the elite team of contributors who have authored its contents.

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