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Case history

image An 80-year-old woman presented with a 3 month history of abdominal swelling, pain, breathlessness, fatigue and loss of appetite. Her past medical history included significant hearing impairment, depression since the death of her husband, and osteoarthritis. She lived alone with no close friends or family. She rarely left the house because of increasing abdominal pain, low mood and anxiety in relation to difficulty communicating due to a hearing deficit. She regularly missed meals. Her performance status (PS) was 2.

On abdominal examination, ascites was clinically detectable and confirmed by an ultrasound scan. A right-sided pleural effusion was clinically evident. Blood tests demonstrated normocytic anaemia (Hb 95 g/l), normal renal function and low albumin (27 g/l). A CT chest, abdomen and pelvis scan demonstrated diffuse peritoneal stranding with large-volume ascites, a pelvic mass and a large right pleural effusion. No other visceral disease was noted. CA-125 tumour marker was elevated at 12,672 U/ml.

Ascitic and pleural fluid was drained and sent for cell block examination, which confirmed adenocarcinoma. Biopsy of the pelvic mass confirmed high-grade serous adenocarcinoma. Based on pleural involvement, this patient was diagnosed with stage IV ovarian cancer.

The patient did not attend her first oncology clinic appointment, as she was unable to get to the hospital. The gynaecology cancer specialist nurse was unable to communicate with her over the telephone. The patient attended her rebooked oncology appointment 2 weeks later, unaccompanied.

What are the goals of treatment for this patient?

What is the evidence base to support the patient's treatment options?

What is the role of bevacizumab?

How do the patient's comorbidities affect her cancer treatment options?

How does the patient's social isolation affect her management?

What are the goals of treatment for this patient?

The aim of treatment is to prolong overall survival (OS) and progression-free survival (PFS) whilst improving and maintaining the patient's quality of life. This patient has a high-grade serous ovarian carcinoma and has a good chance of deriving clinical benefit and improved survival with a combination of chemotherapy and debulking surgery.

What is the evidence base to support the patient's treatment options?

Optimal (no residual disease) debulking surgery in specialist gynae-oncology surgical centres has consistently been shown to significantly increase OS and PFS regardless of age.1,2 A decision had to be made as to whether the patient should proceed directly to primary debulking surgery or whether she should receive neoadjuvant chemotherapy and interval debulking. A randomized trial comparing these strategies showed that the neoadjuvant chemotherapy approach was non-inferior.3

Platinum agents have been the backbone of first-line chemotherapy regimens for the last 40 years in advanced ovarian cancer. It has been demonstrated that the addition of paclitaxel to platinum treatment improves OS.4-6 Results from a phase III trial comparing the efficacy of paclitaxel and carboplatin versus paclitaxel and cisplatin were ...

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