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Gynecologic cancer treatment: Based in science, filled with hope - 05/21/2008

Denise McMillen, 52, continues to defy ovarian cancer. It’s been eight years since her diagnosis and hope remains a steady companion, fueled by regular chemotherapy sessions.

“One of my main goals in life is to get my kids to a point in life where they’re self-sufficient,” McMillen says of her children, Sami, 14, and Scott, 17. A busy mother and company controller, McMillen doesn’t view her cancer as an excuse, having worked, health permitting, throughout treatment.

Just looking at her, one wouldn’t suspect she’s in chemotherapy — she’s got all her hair. But, as McMillen quickly points out, the drug Avastin® doesn’t make your hair fall out. This marks her fifth round of chemotherapy since 2000. McMillen lost her hair three times with prior chemotherapy drugs, and wore a wig “mostly because my kids wanted me to look normal.”
McMillen credits her survival to her treatment team at The Hospital of Central Connecticut.

Whispering symptoms
As is typical with ovarian cancer, McMillen’s wasn’t diagnosed until it had advanced. Hers was at stage three.
Often referred to as the cancer that “whispers,” ovarian cancer is the deadliest gynecologic cancer. Its symptoms, including increased abdominal pressure, bloating and frequent urination, are experienced at some point by most women, yet persistent with ovarian cancer, says Joel Sorosky, M.D., chief of Obstetrics/ Gynecology.

There’s no widely accepted screening for the cancer, which is fairly common in meno-pausal years and occurs more frequently with advanced age. A doctor who suspects it may conduct a pelvic exam and order detection tests, such as a C125 blood protein test, a CT scan, or a transvaginal ultrasound.
“The earlier you go through menopause, the lower the incidence of cancer,” Sorosky says. Ovarian cancer, will strike nearly 22,000 women in the United States this year, according to the American Cancer Society (ACS).

McMillen, of Tolland, noticed she was bloated and urinating more frequently back in 2000; her primary care physician diagnosed a urinary tract infection. When treatment failed, she saw her obstetrician/gynecologist who ordered a C125 test, sonogram and CT scan.
“The tech was so nervous when she was looking at it,” McMillen recalls of the sonogram. “I could see her hand shaking.”
Days later, McMillen got the call confirming what she would only call the “Big C.”

She was referred to HCC gynecologic oncologist James Hoffman, M.D., who conducted surgery to remove her uterus, ovaries, fallopian tubes, omentum (fatty apron attached to the stomach), and all visible cancer. She then started chemotherapy at the George Bray Cancer Center, and after just one round of treatment McMillen was in remission for three years. She and her husband, Dick, told their children that “‘Mommy had cancer but it’s in remission.’ I never let them know there was a possibility it would come back, even though Dr. Hoffman said there was a 90 percent chance it would.”

“Most people have some cancer left, not visible (after surgery). That’s why we give chemo after surgery, to try to lengthen remission time,” says Maureen Bracco, APRN, an oncology clinical researcher at HCC. “Unfortunately, it kills some of the good cells. That’s where we get the side effects, lowered blood counts, hair loss, potential nausea.” For many patients, anti-nausea medications are effective.

The ‘gold standard’ in treatment
As a Gynecology Oncology Group (GOG) site under the National Cancer Institute, the hospital has participated in drug trials for more than 25 years. Most trials are for endometrial, ovarian and cervical cancers, but also include vulvar and vaginal cancers.

Hoffman, principal investigator, and Bracco direct the Central Connecticut GOG group, comprised of The Hospital of Central Connecticut, the University of Connecticut, and Hartford, Middlesex, and St. Francis hospitals.
“They have improved the quality of life,” says Bracco of the trials which provide qualifying and consenting patients with the newest treatments and established care standards.
“GOG is our gold standard. By participating in GOG we are helping to shape the standard of care for women with gynecological cancer,” she adds.

Nationally, says Hoffman, about 2 percent of gynecologic cancer patients volunteer for GOG trials. The New Britain General campus has a 30 to 40 percent participation level. “In all the years I’ve done this,” he says, “I don’t recall a single patient who volunteered who didn’t come away thinking it was a good thing to do.”

Typically, each chemotherapy program for ovarian cancer means treatment once every three weeks for 18 weeks. Endometrial cancer patients may have a similar regimen, often after a hysterectomy.

Most women with early stage endometrial or cervical cancers are candidates for minimally invasive hysterectomy, says gynecologic oncologist Amy Brown, M.D. Smaller incisions help reduce hospitalization and recovery. Ovarian cancer most often requires traditional, open surgery. Throughout cancer treatment, patients’ physical and psychological responses are closely monitored. The hospital’s Wolfson Palliative Care Team of diverse healthcare specialists may assist patients with symptom management and discussion regarding healthcare decisions, finances, and advanced care planning.

A cancer patient may also receive radiation therapy at the hospital’s American Savings Foundation Radiation Oncology Treatment Center. Treatment for endometrial, cervical and vaginal cancer usually includes five weeks of external radiation beam therapy and three to five treatments of brachytherapy, which provides a high dose of radiation delivered using a cylinder placed within the vagina near the tumor. Each treatment is about 10 minutes. Vulvar cancer most often uses external beam treatment. This fall, the hospital will offer the Novalis® shaped-beam surgery system, which delivers highly focused radiation for varied cancers, including gynecologic.

Cancer origins and screening
With early detection through Pap smear tests, cervical cancer is relatively rare, says Sorosky, and will be diagnosed in about 11,000 women in the U.S. this year, according to the ACS. Primarily viewed as a sexually transmitted disease, it presents in viral form, the human papillomavirus. If it advances to cancer, a hysterectomy and possibly radiation and chemotherapy may be required. Gardasil®, the new cervical cancer vaccine, works to prevent precancerous symptoms which could otherwise manifest into cancer, Sorosky says. Even rarer cancers are vaginal and vulvar, usually detected through precancerous lesions.

Some cancers, including ovarian, says Brown, have a genetic predisposition which may be picked up on a BRCA genetic test. However, only up to about 10 percent of breast and gynecologic cancers are thought to be caused by a genetic mutation.
There is no screening for endometrial cancer, which affects the uterine lining and is also known as uterine cancer. It often strikes women after age 50 and is more common in obese women, perhaps triggered by increased estrogen, Sorosky says.

Last spring, Fatima Mancini, 41, thought she had a vaginal infection, although her menstrual cycles had been irregular. When treatment for the suspected infection wasn’t working, ultrasound results prompted a dilation and curettage, which showed endometrial cancer. Further radiologic imaging established stage four cancer.
“The first thing that went through my head was, ‘I’m going to die.’ That was it. It was a long journey from there,” says Mancini.

She went to Hoffman who started her on chemotherapy in May 2007 before a hysterectomy last September, and four weeks of post-operative radiation, all at HCC.
Chemotherapy took its toll on Mancini, of Waterbury, who worked, when able, as a patient care assistant at a local hospital.
“You go through a lot of changes, like losing your hair. That was a big thing,” says Mancini, whose long, black hair was cut short before her first chemotherapy treatment, and then shaved after it started falling out.

Today, Mancini credits medical advances, strong faith and family support, including from her mother, Lucy Matos, who visits from Portugal, for bringing her back to health.
“Sometimes I just don’t feel like I had it (cancer),” says Mancini. “It was something I was going through. I did think, ‘why me?’ After that, it was like, you have it, deal with it. You do what you have to do to survive.”

‘A nest of spiders’
“It’s like having a nest of spiders in you,” was how one ovarian cancer patient described the disease. “They’re watching you and when you turn your head they sneak in. They leave spider eggs behind and then they pop up again.”

This vivid description highlights cancer’s dramatic impact and recognizes one of six processes — admitting cancer’s presence — ovarian cancer patients go through, according to Bracco, whose thesis studied long-term ovarian cancer survivors.

Many patients are helped by the hospital’s social work and pastoral care services and Living with Cancer support group.
McMillen, a support group member since 2000, continues to visualize hope during treatment. “My visualization was always Jesus with a sword and killing every cancer cell. It still is. I feel that when I go to chemo what’s going into my body is going to help me.”
“Hope,” says Hoffman, “is part of everyone’s prescription.”