Screening Proposed For Women At High-Risk For Ovarian, Fallopian Tube Cancer

Women with a high risk of ovarian or fallopian tube cancer who are unwilling to undergo risk-reducing salpingo-oophorectomy might benefit from a screening protocol

medwireNews: Researchers believe that a screening protocol based on the risk of ovarian cancer algorithm (ROCA) and transvaginal sonography (TVS) may be suitable for women at high risk of ovarian or fallopian tube cancer who are not yet willing to undergo surgery.

The phase II UK FOCSS (United Kingdom Familial Ovarian Cancer Screening Study) findings suggest that interpreting serial CA-125 results with TVS where necessary offers a “high sensitivity” screening protocol, the investigators say.

Moreover, the protocol resulted in a significant stage shift in the diagnosis of cancer, although the team admits that “it remains unknown whether this strategy would improve survival in screened high-risk women.”

Women with an estimated lifetime risk of ovarian or fallopian tube cancer of at least 10% who had previously participated in phase I of the UK FOCSS, testing annual CA-125 screening plus TVS, were invited to join phase II.

Over a median of 4.8 years, 4348 patients had their serum CA-125 blood levels checked every 4 months and their risk of malignancy calculated using the high-risk ROCA, based on age and menopausal status.

Nineteen invasive ovarian or fallopian tube cancers were detected within a year of last screening, including one prevalent screen-detected high grade stage IIIc tumour at first screen and 12 incident screen-detected cancers diagnosed thereafter. The remaining six occult cancers were diagnosed during risk-reducing salpingo-oophorectomy (RRSO) but no symptomatic interval cancers were detected.

In addition, 18 women were diagnosed more than 1 year after their last trial screening, including 13 symptomatic tumours, two detected at RSSO and three identified at an annual screening.

More than half (52.6%) of the cancers diagnosed within a year of last screening were stage I or II, including 38.5% of the screen-detected tumours and 83.3% of the occult cancers. By contrast, just one (5.6%) of the tumours diagnosed more than a year after last trial screening was stage I or II.

Thus, stage IIIb or IV disease at diagnosis was found in 36.8% of patients diagnosed during screening versus 94.4% of those diagnosed at least 1 year after screening ended.

And all but one (94.8%) of the patients whose cancers were diagnosed during screening had no residual disease after surgery compared with 72.2% of the 18 cancers diagnosed after screening ended.

Screening was modelled to be 94.7% sensitive for cancer detection at 1 year, with positive and negative predictive values of 10.8% and 100%, respectively.

“In those not ready or willing to undergo surgery, multimodal screening using ROCA every 4 months and TVS (at an interval determined by the ROCA), with regular discussions about the effectiveness of RRSO, appears to be a better option than symptom awareness alone”, suggest Ian Jacobs, from University of New South Wales Australia in Sydney, and colleagues.

The authors emphasise in the Journal of Clinical Oncology that “RRSO remains the treatment of choice” in this patient population, adding: “Such screening should not be viewed as an alternative to surgery, but it does seem to offer a better chance of avoiding a diagnosis of advanced incompletely resectable [ovarian cancer/fallopian tube cancer] in the interim.”

Reference

Rosenthal AN, Fraser LSM, Philpott S, et al. Evidence of stage shift in women diagnosed with ovarian cancer during phase II of the United Kingdom Ovarian Cancer Screening Study. J Clin Oncol; Advance online publication 27 February 2017. DOI: 10.1200/JCO.2016.69.9330

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