After two relapses!

*Only for medical professionals to read and refer to the National Cancer Prevention and Control Promotion Week.
Professor Zhang Bingzhong from the Department of Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University is specially invited to answer questions for patients with ovarian cancer.

Ovary is an important organ that maintains female reproductive and endocrine functions.
It is located deep in the pelvic cavity, and early lesions are not easy to detect.

The incidence of ovarian cancer is not the highest among tumors of the female reproductive system, but the mortality rate ranks first.
The reason is that its early symptoms are not obvious, and most patients are already in the advanced stage when they are discovered.

Therefore, ovarian cancer is called the "silent killer" of women, and has shown a trend of getting younger and younger in recent years.

In 2019, the 43-year-old Ms.
Jinhui was diagnosed with advanced high-grade serous ovarian cancer.
She experienced two recurrences after the initial surgical treatment and is still undergoing active treatment.

Ms.
Huang Jinhui told the “medical community” about her illness: In early January 2019, I was diagnosed with high-grade serous ovarian cancer stage IV.
After a series of ups and downs, I was transferred to the Department of Gynecology and Oncology of Sun Yat-sen Memorial Hospital.
Into regular treatment.

I remember that on December 29, 2018, due to bowel, abdominal distension, hiccups and other discomforts, an internal medical examination at a hospital near my home revealed a 5mm liver nodule and effusion around the liver by B-ultrasound.

However, various examinations at two city-level hospitals failed to find the cause, and the PET-CT examination was finally arranged to be diagnosed as cancer.

In only ten days, I went from being a "live and kicking" person who can work and live normally to a tumor patient who can't even eat food.

Due to the usual lack of medical knowledge and popular science, I don't understand high-grade serous ovarian cancer at all.
In addition, the disease progressed rapidly.
At that time, my thoughts were very negative, I couldn't eat, I couldn't sleep, I was panicked, and I was a little resistant to treatment! Accompanied by his family, on January 11, 2019, he was transferred to Professor Lu Huaiwu from the Department of Gynecology and Oncology of Sun Yat-sen Memorial Hospital. He quickly formulated a surgical plan for me, and on January 17, 2019, the operation was carried out smoothly.

In March 2020 and January 2021, Ms.
Jinhui experienced a relapse respectively.
She has a lot of knowledge about the disease of ovarian cancer, and she has some new doubts about her current treatment.

During the National Cancer Prevention and Treatment Week, the "medical community" specially invited Professor Zhang Bingzhong from the Department of Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University and Ms.
Huang Jinhui to have an in-depth conversation on the diagnosis and treatment of ovarian cancer, so as to help more ovarian cancer patients understand the disease and improve Confidence in treatment.

On April 20, 19:00-20:00, scan the QR code of the poster to watch the live broadcast↓↓↓What are the treatments for advanced ovarian cancer? Moderator (Ms.
Huang Jinhui): After the diagnosis of advanced ovarian cancer, what are the treatments? Professor Zhang Bingzhong: Because the ovaries are small and hidden deeply, early ovarian cancer usually does not have any symptoms.

Through physical examination, relatively early ovarian cancer can be found.

The vast majority of ovarian cancer patients go to the hospital because of bloating, and some patients go to the internal medicine department because of dyspepsia, and then find ovarian cancer.

Approximately 70% to 75% of patients are in the advanced stage when they see a doctor.

After discovering ovarian cancer, the extent of the lesion must first be clarified.
PET-CT scans are usually used to determine the organs involved.

For patients with a wide range of lesions and incomplete imaging examinations, it is recommended to perform a comprehensive laparoscopic exploration, which can visually see the situation from the upper abdomen to the pelvis.

It is very important to completely remove the tumor in the first operation.
If there are residual lesions after the operation, even chemotherapy will not have a good effect in the later stage.

For patients who can be completely resected, cytoreductive surgery can be performed directly.

If the scope of the lesion is wide, or the tumor affects an important location, it is difficult to complete the resection, then the tumor tissue can be taken for pathological examination.

Chemotherapy is performed first, that is, neoadjuvant chemotherapy.
After the tumor has shrunk and the lesions have become fewer, the intermediate tumor cytoreductive surgery is performed. For patients who directly undergo cytoreductive surgery, usually 6-8 times of chemotherapy are given after surgery; for patients who have received neoadjuvant therapy before surgery, 4-6 times of chemotherapy are given after surgery, and the total number of treatment courses is also 6 8 courses.

Through initial surgery and chemotherapy, most patients can achieve complete remission, that is, no tumors are found on imaging examinations, and blood test indicators are normal.

After the initial treatment, based on the results of the patient's genetic testing, a decision is made to maintain the treatment plan.

Is ovarian cancer easy to recur? What should be treated after recurrence? Moderator: Is recurrence of ovarian cancer more common? After recurrence, what kind of patients would benefit more from the second operation? For patients who have no chance of a second operation, how to develop a personalized optimal chemotherapy plan? Professor Zhang Bingzhong: Most patients with ovarian cancer can achieve complete remission after the initial treatment, but about 80% of patients will relapse, with an average recurrence time of about 18 months.

Maintenance treatment can delay recurrence and reduce the chance of recurrence.

After the initial treatment of patients with ovarian cancer, whether they are maintained or not, during the follow-up observation process, if tumor markers are found to be elevated, or imaging examinations reveal lesions, the diagnosis should be clear and the next treatment plan should be determined.

For recurrent ovarian cancer, there is currently no internationally recognized treatment plan.

There is a large study that after the recurrence of ovarian cancer, surgery combined with chemotherapy is equivalent to chemotherapy alone.

However, some scholars believe that surgery combined with chemotherapy can benefit patients who are more than 6 months away from the first treatment, are sensitive to chemotherapy, and have isolated tumor lesions and no ascites found on imaging examination.

At present, for patients who meet the above indications in China, re-cytoreductive surgery will be considered.

After re-cytoreduction, it is necessary to comprehensively assess whether the patient's physical condition can continue chemotherapy.

If the patient can tolerate chemotherapy, then continue to use the previous chemotherapy regimen, and the combination of anti-angiogenesis drugs can achieve the effect of "1+1>2".

The efficacy should be closely monitored after treatment.
The most commonly used ovarian cancer tumor markers are carbohydrate antigen 125 (CA-125) and human epididymal protein 4 (HE4). It should be noted that CA-125 is affected by inflammation and other factors, and HE4 is affected by renal function.

If chemotherapy leads to impaired kidney function, it will also affect H4 levels.

At present, it is believed that the tumor markers have decreased by more than 30% before chemotherapy is considered effective.

After each course of chemotherapy, the curative effect should be evaluated in time.

If the effect is not good, you can refer to the recommendations of the National Comprehensive Cancer Network (NCCN) to change the chemotherapy regimen.

For recurrent ovarian cancer, another genetic test may provide valuable information, because the patient's genetic status may have changed after the recurrence.

The appropriate treatment plan should be selected based on the patient's latest genetic test results.

Which patients can use targeted therapy? How to reduce the side effects of targeted therapy? Moderator: I would like to ask Professor Zhang, I am a BRCA1/2 germline gene negative patient.
Compared with those positive patients, is there any difference in the choice of targeted therapy drugs? How to prevent and reduce the side effects of targeted therapy, improve the efficacy, and improve the quality of life of patients? Professor Zhang Bingzhong: In recent years, the most advanced areas of ovarian cancer are targeted therapy and maintenance therapy.

After the patient has achieved remission after surgery combined with chemotherapy, continuing to use chemotherapy to maintain the therapeutic effect is not good, but the toxic side effects are greater.

In recent years, adenosine diphosphate ribose polymerase (PARP) inhibitors have proven to be a better choice for maintenance treatment of ovarian cancer.

We can be described as "love and hate" for BRCA gene mutations.

"Hate" is that BRCA gene mutations can cause tumors, and "love" is because for patients with BRCA gene mutations, PARP inhibitors such as olaparib and niraparib have good therapeutic effects.

In recent years, it has been discovered that regardless of whether patients have BRCA gene mutations, as long as homologous recombination repair defects (HRD) occur, maintenance therapy with PARP inhibitors is also effective.

The maintenance treatment plan is selected based on the results of molecular testing.
If the BRCA1/2 germline gene is negative, PARP inhibitors combined with anti-angiogenic drugs are generally selected for maintenance treatment. While paying attention to curative effects, we must also attach great importance to adverse reactions.

The main adverse reactions of PARP inhibitors are fatigue and bone marrow suppression, and the dosage can be adjusted according to the patient's weight and bone marrow status.

Common adverse reactions of anti-angiogenic drugs include hypertension, abnormal renal function, hand-foot syndrome, and skin rash.

Therefore, according to the results of the patient's genetic testing, a treatment plan with good curative effect and tolerable should be selected.

Which patients can use immunotherapy? Moderator: I would like to ask Professor Zhang, what genetic tests and examinations need to be done if immunotherapy is used? Which patients benefit most from immunotherapy? When is it better to use immunotherapy? Professor Zhang Bingzhong: Under normal circumstances, immune cells will recognize and kill malignant tumor cells.

But if the signal link of immune cells recognizing tumor cells is abnormal, then the immune system will not be able to clear the tumor cells.

At present, the scope of immunotherapy is very wide, including immune cell therapy, immune checkpoint inhibitor therapy and improvement of tumor microenvironment.

Immune checkpoint inhibitors represented by PD-1/PD-L1 inhibitors have developed rapidly in recent years, and can be based on patients’ PD-L1 expression, DNA mismatch repair defects (dMMR), microsatellite instability (MSI) and tumors Mutation burden (TMB) indicators determine whether to use PD-1/PD-L1 inhibitors for treatment.

The current international guidelines recommend immunotherapy for the subsequent treatment of ovarian cancer.

If immunotherapy works, it can often last a long time.

In some patients, immunotherapy alone is not effective.
Combination of anti-angiogenic drugs, chemotherapy, radiotherapy or targeted therapy can be considered.

What should I do if diarrhea, constipation, and insomnia occur after surgery? Moderator: I did intestinal adhesion lysis + rectal mass removal + rectal anastomosis.
After the operation, I found that my intestinal motility was poor, my bowel movements were irregular, and I often had abdominal distension.
I needed to take laxatives.
This was after surgery.
Are side effects common? How to alleviate and improve? The quality of sleep after surgery has not been very good.
How can I relieve it or take some sleep-aiding drugs? Professor Zhang Bingzhong: Ovarian cancer often has a large area of ​​tumor, which affects organs such as the intestine and liver. In order to remove the tumor tissue as much as possible during surgical treatment, it may also cause damage to the intestine, and even remove part of the intestine.

Different segments of the intestine function differently, and corresponding symptoms such as constipation and diarrhea may appear after surgery.

However, as long as you maintain good work and rest habits, diarrhea, constipation and insomnia will be gradually relieved.

When the patient has symptoms of discomfort after the operation, it is necessary to communicate with the doctor in time.

We will provide patients with corresponding psychological counseling and use medications when necessary.

In addition, nutritional supplementation is very important after surgery.

It is possible that the nutritional concepts of many patients are inconsistent with modern medicine, and modern medicine still cannot fully understand whether some "tonics" are effective.

High-quality protein should be supplemented after surgery, such as eggs, milk and meat products, which can enhance resistance, promote body recovery, and relieve symptoms of discomfort.

In addition, proper physical exercise can also effectively improve the above discomfort symptoms.

Professor Zhang Bingzhong hopes that the female compatriots will care for their bodies, and no matter how busy they are at work, they must undergo a quality physical examination.

Once a tumor is found, it is necessary to maintain an objective and calm attitude, communicate with the doctor, and actively cooperate with the treatment.

Any medicine may have side effects, so be aware of it rationally and treat it calmly.

I hope that everyone will go through each stage safely, and strive to achieve complete remission, and delay and reduce recurrence.

Expert profile Zhang Bingzhong, Chief Physician, Associate Professor, Doctoral Tutor, Director of Gynecological Oncology, Deputy Chairman of Guangdong Primary Medicine Gynecological Oncology Branch, Standing Committee Member, Gynecological Oncology Branch of Guangdong Anticancer Association, Member of Gynecological Oncology Group, Guangdong Medical Association, Guangdong Precision Medicine Association Member of the Gynecological Oncology Branch Member of the Standing Committee of the Guangdong Gynecological Minimally Invasive Society "Chinese Journal of Practical Gynecology and Obstetrics", "Modern Obstetrics and Gynecology", "Journal of Sun Yat-sen University", "New Medicine" Editorial Board