Diagnosis, treatment and burden in advanced ovarian cancer: a UK real-world survey of healthcare professionals and patients.

Aim: Little is known regarding uptake of epithelial ovarian cancer (EOC) treatments or patient burden in UK real-world practice.Methods: Cross-sectional surveys of patients with advanced EOC and healthcare professionals (HCPs).Results: 101 HCPs and 142 patients participated. Time from initial primary care consultation to diagnosis was ∼7 weeks. 83% patients were offered hereditary genetic testing, with 89% uptake. 53% HCPs reported surgery was performed ≤1 month in non-neoadjuvant setting. Surgery delay negatively impacted patient quality of life (61%), mental health (89%), and surgical outcomes (63%). 56% patients received active first-line maintenance treatment; patients on active surveillance had greater emotional/psychological distress.Conclusion: Treatment delays and low uptake of active first-line treatment should be addressed. Emotional support must be readily accessible throughout treatment.

What is this article about? New treatments for ovarian cancer mean that patients could be treated and live with the disease for many years. However, not much is known about the treatments that are actually received by patients with ovarian cancer in real-life. These surveys were done to learn more about the treatment and experience of patients with ovarian cancer in the UK.What were the results? 101 healthcare professionals (HCPs) and 142 patients took the surveys. The surveys found that patients usually waited about 7 weeks from their first GP visit to diagnosis of ovarian cancer. Half of HCPs reported that patients had surgery within 1 month of the decision that surgery was needed. HCPs reported that delays in surgery had a negative impact on patient quality of life, mental health, and the success of the surgery. After finishing their first line of chemotherapy, about half of patients had a maintenance treatment to control their ovarian cancer and give them as long as possible between recurrences. The remaining patients were not given treatment but were watched for further signs of cancer. Patients on maintenance treatment experienced less emotional/psychological distress than those managed by watchful waiting.What do the results of the study mean? This survey shows that more needs to be done to make sure that patients with ovarian cancer in the UK are diagnosed and treated quickly and offered the right treatment. Emotional support should be available to patients during their treatment.

Combined Laparoscopic Uterine Artery Occlusion and Myomectomy versus Laparoscopic Myomectomy: A Direct-Comparison Meta-Analysis of Short- and Long-Term Outcomes in Women with Symptomatic Leiomyomas.

OBJECTIVE: To ascertain the efficacy and safety of laparoscopic uterine artery occlusion (LUAO) during laparoscopic myomectomy (LM) on intra- and postoperative morbidity and to assess its impact on leiomyoma recurrence rates. DATA SOURCES: MEDLINE, Scopus, Web of Science, and Cochrane Database were searched for relevant references from inception until December 2018, in line with PRISMA guidelines. METHODS OF STUDY SELECTION: Two authors screened for study eligibility and extracted data. Randomized controlled trials (RCTs) and observational studies (OSs) comparing short- and long-term morbidity of LM with or without LUAO were included. The modified Jadad score and the methodologic index for nonrandomized studies were used to evaluate the quality of RCTs and OSs, respectively. TABULATION, INTEGRATION, AND RESULTS: Twelve studies encompassing 750 LM and 873 LUAO-LM cases were included in the meta-analysis. The studies were of moderate quality. LUAO-LM appears to significantly decrease intraoperative blood loss, postoperative hemoglobin drop, and blood transfusion rate. A trend toward shorter hospital length of stay was demonstrated, whereas no significant difference in operation duration was observed. The combined procedure seemingly contributes to lower recurrence rate. No LUAO-related complications were reported. Moderate to high heterogeneity was observed for few outcomes. CONCLUSION: This is the first meta-analysis to date to provide a convincing overview of efficacy and safety of LUAO-LM. Although a medium risk of bias warrants some caution with interpretation of the results, LUAO-LM seemingly improves intra- and postoperative outcomes in women with symptomatic leiomyomas.

Methylation of MYLK3 gene promoter region: a biomarker to stratify surgical care in ovarian cancer in a multicentre study.

BACKGROUND: Survival benefit from surgical debulking of ovarian cancer (OC) is well established, but some women, despite total macroscopic clearance of disease, still have poor prognosis. We aimed to identify biomarkers to predict benefit from conventional surgery. METHODS: Clinical data from women debulked for high-stage OC were analysed (Hammersmith Hospital, London, UK; 2001-2014). Infinium's HumanMethylation27 array interrogated tumour DNA for differentially methylated CpG sites, correlated to survival, in patients with the least residual disease (RD; Hammersmith Array). Validation was performed using bisulphite pyrosequencing (Charité Hospital, Berlin, Germany cohort) and The Cancer Genome Atlas' (TCGA) methylation data set. Kaplan-Meier curves and Cox models tested survival. RESULTS: Altogether 803 women with serous OC were studied. No RD was associated with significantly improved overall survival (OS; hazard ratio (HR) 1.25, 95% CI 1.06-1.47; P=0.0076) and progression-free survival (PFS; HR 1.23, 95% CI 1.05-1.43; P=0.012; Hammersmith database n=430). Differentially methylated loci within FGF4, FGF21, MYLK2, MYLK3, MYL7, and ITGAE associated with survival. Patients with the least RD had significantly better OS with higher methylation of MYLK3 (Hammersmith (HR 0.51, 95% CI 0.31-0.84; P=0.01), Charité (HR 0.46, 95% CI 0.21-1.01; P=0.05), and TCGA (HR 0.64, 95% CI 0.44-0.93; P=0.02)). CONCLUSIONS: MYLK3 methylation is associated with improved OS in patients with the least RD, which could potentially be used to determine response to surgery.

Risk of Ovarian Cancer Relapse score: a prognostic algorithm to predict relapse following treatment for advanced ovarian cancer.

OBJECTIVE: The aim of this study was to construct a prognostic index that predicts risk of relapse in women who have completed first-line treatment for ovarian cancer (OC). METHODS: A database of OC cases from 2000 to 2010 was interrogated for International Federation of Gynecology and Obstetrics stage, grade and histological subtype of cancer, preoperative and posttreatment CA-125 level, presence or absence of residual disease after cytoreductive surgery and on postchemotherapy computed tomography scan, and time to progression and death. The strongest predictors of relapse were included into an algorithm, the Risk of Ovarian Cancer Relapse (ROVAR) score. RESULTS: Three hundred fifty-four cases of OC were analyzed to generate the ROVAR score. Factors selected were preoperative serum CA-125, International Federation of Gynecology and Obstetrics stage and grade of cancer, and presence of residual disease at posttreatment computed tomography scan. In the validation data set, the ROVAR score had a sensitivity and specificity of 94% and 61%, respectively. The concordance index for the validation data set was 0.91 (95% confidence interval, 0.85-0.96). The score allows patient stratification into low (<0.33), intermediate (0.34-0.67), and high (>0.67) probability of relapse. CONCLUSIONS: The ROVAR score stratifies patients according to their risk of relapse following first-line treatment for OC. This can broadly facilitate the appropriate tailoring of posttreatment care and support.

Epigenetic Regulation of the Homeobox Gene MSX1 Associates with Platinum-Resistant Disease in High-Grade Serous Epithelial Ovarian Cancer.

PURPOSE: Although high-grade serous ovarian cancer (HGSOC) is frequently chemoresponsive, a proportion of patients do not respond to platinum-based chemotherapy at presentation or have progression-free survival (PFS) of less than 6 months. Validated predictive biomarkers of lack of response would enable alternative treatment stratification for these patients and identify novel mechanisms of intrinsic resistance. Our aim was to identify DNA methylation biomarkers of poor response to chemotherapy and demonstrate involvement of the associated gene in platinum drug cell sensitivity. EXPERIMENTAL DESIGN: DNA methylation was investigated in independent tumor cohorts using Illumina HumanMethylation arrays and gene expression by Affymetrix arrays and qRT-PCR. The role of Msh homeobox 1 (MSX1) in drug sensitivity was investigated by gene reintroduction and siRNA knockdown of ovarian cancer cell lines. RESULTS: CpG sites at contiguous genomic locations within the MSX1 gene have significantly lower levels of methylation in independent cohorts of HGSOC patients, which recur by 6 months compared with after 12 months (P < 0.05, q < 0.05, n = 78), have poor RECIST response (P < 0.05, q < 0.05, n = 61), and are associated with PFS in an independent cohort (n = 146). A decrease in methylation at these CpG sites correlates with decreased MSX1 gene expression. MSX1 expression is associated with PFS (HR, 0.92; 95% CI, 0.85-0.99; P = 0.029; n = 309). Cisplatin-resistant ovarian cancer cell lines have reduced MSX1 expression, and MSX1 overexpression leads to cisplatin sensitization, increased apoptosis, and increased cisplatin-induced p21 expression. CONCLUSIONS: Hypomethylation of CpG sites within the MSX1 gene is associated with resistant HGSOC disease at presentation and identifies expression of MSX1 as conferring platinum drug sensitivity. Clin Cancer Res; 22(12); 3097-104. ©2016 AACR.

Epigenetic mechanisms and therapeutic targets of chemotherapy resistance in epithelial ovarian cancer.

Epithelial ovarian cancer is the most lethal gynaecological cancer with the majority of patients succumbing to chemotherapy-resistant disease. Unravelling the mechanisms of drug resistance and how it can be prevented or reversed is a pivotal challenge in the treatment of cancer. Epigenetic mechanisms appear to play a crucial role in the development of inherent and acquired resistance in ovarian cancer. Aberrant epigenetic states can be reversed by drug therapy, and thus maintenance of epigenetic change is a potential target to halt or reverse chemotherapy resistance. This review explores the evidence that demonstrates that DNA methylation, histone modification, and microRNAs are associated with inherent and acquired chemotherapy resistance in ovarian cancer and the current challenges associated with this. We also explore current epigenetic therapies used in patients with drug-resistant ovarian cancer and future potential targets.

Poised epigenetic states and acquired drug resistance in cancer.

Epigenetic events, which are somatically inherited through cell division, are potential drivers of acquired drug resistance in cancer. The high rate of epigenetic change in tumours generates diversity in gene expression patterns that can rapidly evolve through drug selection during treatment, leading to the development of acquired resistance. This will potentially confound stratified chemotherapy decisions that are solely based on mutation biomarkers. Poised epigenetic states in tumour cells may drive multistep epigenetic fixation of gene expression during the acquisition of drug resistance, which has implications for clinical strategies to prevent the emergence of drug resistance.

A kink is not always a perforation: assessing Essure hysteroscopic sterilization placement.

OBJECTIVE: To highlight the fallacy of using a kink in the microinsert outline on plain abdominal x-ray as a marker for tubal perforation. DESIGN: Case report. SETTING: West London District general hospital. PATIENT(S): 36-year-old Asian woman requesting permanent sterilization. INTERVENTION(S): Essure hysteroscopic sterilization followed by abdominal x-ray, pelvic ultrasound, and laparoscopy. MAIN OUTCOME MEASURE(S): Absence of tubal perforation. RESULT(S): A patient presented with clinically suspected fallopian tube perforation 3 days after Essure hysteroscopic sterilization. Her transvaginal scan was inconclusive, but the plain x-ray demonstrated a kink within the left microinsert outline. Diagnostic laparoscopy did not identify a perforation, and bilateral tubal placement was confirmed after salpingectomy. CONCLUSION(S): This case highlights the difficulty of relying on imaging in the acute setting to establish a diagnosis of tubal perforation after hysteroscopic sterilization.