Organization of care and access to clinical research

Patients with ovarian cancer require special care.
The management of this disease involves multiple specialists. Their interventions must therefore be coordinated to be effective.
The start of management should assess the general condition of patients and the extension of the disease in the abdomen.
Ovarian cancers very often lead to a deterioration in general condition, with malnutrition, transit and eating disorders. In addition, this disease occurs frequently in older women. It is therefore essential to check that the treatments (major surgery and chemotherapy) can be tolerated.
Clinical examination and simple biological data such as albuminemia or hemoglobin level provide important information. Renutrition should be systematically considered if major surgery is planned. For more complex cases, the use of renutrition specialists is necessary. Elderly women should benefit from an onco-geriatric consultation which will assess the feasibility of treatments.

The extension of the disease is assessed by biological tests such as the rate of markers (CA 125) and especially by imaging. The scanner of the chest, abdomen and pelvis is the reference examination. It makes it possible to list the affected areas, to look for damage incompatible with surgery, or associations of damage making complete removal of the disease illusory.
The scanner must be performed and interpreted by radiologists trained in the management of ovarian cancer. Images should be viewed with surgeons and medical oncologists who are also trained in the treatment of this disease. It is essential that each case be discussed by these different specialists before any treatment, in order to decide on the most suitable sequence for the patient (surgery then chemotherapy or the reverse).

A laparoscopy can complete this assessment. It makes it possible to precisely assess the severity of the abdominal involvement and predicts the possibility of performing complete excision of the disease by surgical intervention. It also makes it possible to take biopsies which will confirm the diagnosis of ovarian cancer and its histological type. It is indeed important to make the difference with ovarian metastases from another cancer (breast, colon, etc.), or an ovarian cancer of rare histology which requires different treatments. These biopsies are also useful for biological characterization of the tumor (search for BRCA gene mutation in the tumor, search for instability of microsatellite loci, etc.).
A second meeting again brings together radiologists, surgeons, medical oncologists and pathologists to define the best possible care, taking into account the general condition of the patient, the histological type and the extirpability of the disease.< br>
If an intervention is decided, it must be carried out quickly after an anesthesiology check-up and renutrition. A stay in an intensive care unit or in surgical resuscitation is necessary during the first days. These operations are indeed long (4 to 8 hours), involve multiple gestures and very often bowel resections.

Conversely, if the treatment begins with chemotherapy, it must begin quickly. In this case, an intervention is to be carried out after three or four chemotherapy sessions. It is therefore necessary from the outset to plan the clinical, biological and radiological assessment which will be carried out at the end of this chemotherapy; as well as the operating date of the "interval surgery". A new discussion of the patient's file must take place in order to verify the response to chemotherapy and the operability. Otherwise, delays can be detrimental.

Patient follow-up, screening and management of possible relapses have a similar overall organization.
Other specialists also participate in the treatment of patients: psychotherapists, psychiatrists, geneticists, supportive care doctors, etc. Their intervention must be thought out in this complex circuit.

Access to clinical research is also paramount.
The realization of clinical research “protocols” (or therapeutic trials) is fundamental. It makes it possible to advance treatments by making them more effective or less toxic with equivalent effectiveness. This is true for medications, as it is for surgical procedures.
Clinical research benefits the patients of tomorrow, but also the patients of today. It has in fact been shown that the services which carry out clinical research have better results than the others and that the patients who take part in these protocols have a better prognosis. Finally, these trials allow access to new molecules that generally bring hope.
Personalized medicine, which aims to adapt the treatment to the biological characteristics of the tumour, can only develop by carrying out protocols studying the effectiveness of a drug based on biological data. We are at the beginning of this new approach, which will need multiple trials before being used in routine.

The structures that treat women with ovarian cancer must therefore be specialized, trained and offer access to clinical research.