About 5.4% of women with cancer in Bulgaria have ovarian cancer. Ovarian carcinoma is responsible for 5% of deaths among gynecological tumors, let’s talk about it with Dr. Angel Yordanov. He is part of the team of the Oncology Clinic at the “Dr. Georgi Stranski” UMBAL, Pleven. He graduated from Medical University – Sofia in 2003. In 2009 he acquired a specialty in obstetrics and gynecology. Since 2020, he is the main assistant in the Department of Obstetrics, Medical University – Pleven. His professional and scientific interests are in the field of laparoscopic gynecological surgery, modern surgical treatment of malignant diseases of the female reproductive system, vulvar cancer, operative gynecology. He is a member of the Bulgarian Society of Obstetrics and Gynecology, the Bulgarian Association of Oncogynecology (BAOG), the Bulgarian Association of Minimally Invasive Gynecological Surgery (BAMIGH). – How common is ovarian cancer, Dr. Yordanov? What are the latest data and what conclusions can be drawn? For Bulgaria, according to data from the Bulgarian Cancer Registry for 2014, ovarian cancer or ovarian carcinoma is in fifth place in terms of frequency among oncological diseases in women. During this period, there were 800 new diagnoses, making 5.4% of all women with cancer. In Bulgaria, ovarian cancer is the sixth most frequent cause of cancer-related mortality in women. The number of newly diagnosed cases worldwide has decreased annually since the 1980s: for the period 2007-2017, the incidence of ovarian carcinoma decreased by about 1.6% per year, and the related mortality by 2.3% . In Bulgaria, the situation is not among the best in Europe. The incidence rate in Bulgaria from ovarian cancer is 17.8 per 100,000 and is above the European average of 15.8 per 100,000. The mortality rate from ovarian cancer in Bulgaria is 11.3 per 100,000 and is also higher than the average for Europe, which is 10.7 per 100,000 five-year survival is lower in Bulgaria at every age when compared to the average values ​​in Europe. The reasons for the decrease in the incidence of ovarian cancer worldwide are many, but perhaps the most important are the improvement of imaging methods, in particular ultrasound diagnosis and its accessibility to the patient, the use of different tumor markers, selection of high-risk groups and the active their follow-up and imposition of oncoprophylactic surgery. The significantly worse results for Bulgaria are due to the late seeking of medical help, the non-use of genetic tests to determine the high-risk groups to be subjected to preventive screening and, accordingly, surgery. – What disease is ovarian cancer? If you have to answer in one sentence – ovarian cancer is a systemic disease that most often occurs in the epithelial cells of the ovary or fallopian tubes. Ovarian cancer has the highest mortality rate among gynecological tumors and is responsible for 5% of carcinoma-related deaths.Unfortunately, most cases are diagnosed in advanced stages, because ovarian carcinoma can be asymptomatic for a long time and its early detection is more of a coincidence than a regularity. – What are the risk factors for the development of ovarian cancer? In general, risk factors are divided into modifiable and non-modifiable, with factors that increase and those that decrease the risk of developing ovarian cancer. Nonmodifiable risk factors are age and sex, family history, Ashkenazi ancestry, genetic factors, for example, mutations in the BRCA genes. Modifiable factors increasing the risk are: obesity, smoking, endocrine factors and hormone replacement therapy in menopause, lifestyle. Modifiable risk-reducing factors are: pregnancy, salpingectomy, risk-reducing surgery, long-term use of oral contraceptives. It is obvious that we can influence some of these factors and our efforts should be directed there. – What are the treatment options for ovarian cancer? What does the choice of therapeutic approach depend on and how does it proceed? There are treatment standards that cover each stage separately. The treatment of ovarian carcinoma is multidisciplinary and multimodal. The behavior of each patient with suspected ovarian cancer is determined by a multidisciplinary oncology committee, which analyzes all clinical indicators and decides on a therapeutic behavior in the specific case. Any choice of treatment approach should, whenever possible, be based on the highest level of evidence and the highest degree of recommendability, supported by national evidence-based clinical practice guidelines. Treatment for ovarian carcinoma includes surgery, systemic chemotherapy and targeted therapy, and much less frequently, other modalities such as radiation therapy may be considered. – What are the chances of preserving a woman’s fertility? What does this depend on? Fertility can be preserved only in a limited number of cases, which, unfortunately, are more of an exception. This can be done in women with a desire to preserve fertility and under the age of 40, in whom the disease is in the first stage, the tumor is highly differentiated and has a non-aggressive histology. Even with a decision to preserve fertility, the decision is confirmed intraoperatively after careful operative staging; only with proof of the first stage and appropriate histology can the patient’s reproductive function be preserved. In countries where assisted reproduction with donor cells is allowed, it is possible to preserve only the uterus and remove the ovaries. This gives better oncological security for the expectant mother. There are many debates with arguments “for” and “against” fertility-preserving surgery for ovarian carcinoma, but given the data of pregnancy rates between 60 and 100% and spontaneous abortions in up to 30%, this surgery is increasingly entering the practice.International guidelines recommend performing this type of surgery only in tertiary specialized centers where follow-up is significantly more intensive. – What are the principles of modern surgical treatment of ovarian cancer in the third and fourth stages? What is characteristic of preoperative and postoperative treatment? The main rule is to be as radical as possible in the primary operative intervention. We should aim to leave no visible lesions, as survival has been shown to depend on the size of residual tumors – the smaller the better. Therefore, the treatment of ovarian carcinoma does not always begin with surgery. If complete removal of the tumor and all its lesions cannot be performed, the so-called delayed cytoreduction should be carried out – the patient undergoes 3-4 courses of chemotherapy, after which the surgical treatment is carried out in the second stage and chemotherapy is continued again. Chemotherapy is the tool that allows us to extend the lives of patients. The method of carrying out this type of treatment is specific and depends on many factors. – How often is secondary surgery required due to recurrence of metastases? This question cannot be answered unequivocally. This type of surgery has a very limited place only in strictly defined cases. If the disease recurs, chemotherapy is the treatment method and re-surgical treatment with complete resection of the tumor can be discussed – then this approach can be considered. – Can we talk about curing ovarian cancer? It is possible to talk about a cure in the early stages of the disease. Our goal in treating ovarian cancer is to prolong survival. A diagnosis of ovarian cancer should not be taken as a sentence – many women live with the disease for years. Just because it cannot be cured does not mean that there is no treatment. It is the same with arterial hypertension and diabetes mellitus: both are chronic diseases that cannot be cured. In the modern treatment of ovarian cancer, various types of treatment are now carried out – not only chemotherapy. After a different number of chemotherapy cycles, maintenance treatment is carried out, through which we increasingly achieve a significant prolongation of the survival of patients in the third and fourth stages of the disease. Published with the support of AstraZenecaTherefore, the treatment of ovarian carcinoma does not always begin with surgery. If complete removal of the tumor and all its lesions cannot be performed, the so-called delayed cytoreduction should be carried out – the patient undergoes 3-4 courses of chemotherapy, after which the surgical treatment is carried out in the second stage and chemotherapy is continued again. Chemotherapy is the tool that allows us to extend the lives of patients. The method of carrying out this type of treatment is specific and depends on many factors. – How often is secondary surgery required due to recurrence of metastases? This question cannot be answered unequivocally. This type of surgery has a very limited place only in strictly defined cases. If the disease recurs, chemotherapy is the treatment method and re-surgical treatment with complete resection of the tumor can be discussed – then this approach can come into consideration. – Can we talk about curing ovarian cancer? A cure can be talked about in the early stages of the disease. Our goal in treating ovarian cancer is to prolong survival. A diagnosis of ovarian cancer should not be taken as a sentence – many women live with the disease for years. Just because it cannot be cured does not mean that there is no treatment. It is the same with arterial hypertension and diabetes mellitus: both are chronic diseases that cannot be cured. In the modern treatment of ovarian cancer, various types of treatment are already being carried out – not only chemotherapy. After a different number of chemotherapy cycles, maintenance treatment is carried out, through which we increasingly achieve a significant prolongation of the survival of patients in the third and fourth stages of the disease. Published with the support of AstraZenecaTherefore, the treatment of ovarian carcinoma does not always begin with surgery. If complete removal of the tumor and all its lesions cannot be performed, the so-called delayed cytoreduction should be carried out – the patient undergoes 3-4 courses of chemotherapy, after which the surgical treatment is carried out in the second stage and chemotherapy is continued again. Chemotherapy is the tool that allows us to prolong the lives of patients. The method of carrying out this type of treatment is specific and depends on many factors. – How often is secondary surgery required due to recurrence of metastases? This question cannot be answered unequivocally. This type of surgery has a very limited place only in strictly defined cases. If the disease recurs, the treatment method is chemotherapy and re-surgical treatment with complete resection of the tumor can be discussed – then this approach can come into consideration. – Can we talk about curing ovarian cancer? A cure can be talked about in the early stages of the disease. Our goal in treating ovarian cancer is to prolong survival. A diagnosis of ovarian cancer should not be taken as a sentence – many women live with the disease for years. Just because it cannot be cured does not mean that there is no treatment. It is the same with arterial hypertension and diabetes mellitus: both are chronic diseases that cannot be cured. In the modern treatment of ovarian cancer, various types of treatment are already being carried out – not only chemotherapy. After a different number of chemotherapy cycles, maintenance treatment is carried out, through which we increasingly achieve a significant prolongation of the survival of patients in the third and fourth stages of the disease. Published with the support of AstraZenecadoes not mean that no treatment is given. It is the same with arterial hypertension and diabetes mellitus: both are chronic diseases that cannot be cured. In the modern treatment of ovarian cancer, various types of treatment are already being carried out – not only chemotherapy. After a different number of chemotherapy cycles, maintenance treatment is carried out, through which we increasingly achieve a significant prolongation of the survival of patients in the third and fourth stages of the disease. Published with the support of AstraZenecadoes not mean that no treatment is given. It is the same with arterial hypertension and diabetes mellitus: both are chronic diseases that cannot be cured. In the modern treatment of ovarian cancer, various types of treatment are already being carried out – not only chemotherapy. After a different number of chemotherapy cycles, maintenance treatment is carried out, through which we increasingly achieve a significant prolongation of the survival of patients in the third and fourth stages of the disease. Published with the support of AstraZeneca