David Mutch: We are going to go ahead and start answering questions. I think I said that before. Does anyone in the audience have any questions?

Audience: I want to know if the clinical trials are specific to women who have had hysterectomies? If they are not, for those women who are still fertile or wanting to have opportunities to conceive, what is the damage, or potential damage or ramifications from the chemotherapy used in these trials? Thirdly. For those of us who have LMP as a borderline where chemo does not respond but are at greater risk for recurrence, are there trials available for that population?

David Mutch: First the LMP issue is early stage LMPs, or tumors of low-malignant potential, the GOG data is pretty clear.

Audience: But I wasn't and I have recurred with a secondary LMP diagnosis. So I want to know are there trials out there? I've gone through chemo already.

David Mutch: For recurrent tumors of low-malignant potential, to my knowledge, no unless it's changed to malignancy.

Audience: My diagnosis has changed from my recurrence. And then to the original question about the clinical trials. Have the majority of these women had full, complete hysterectomies or are they still potentially fertile and able to conceive, and what is the damage or any damage to fertility? Meaning, if they've gone through chemo and they are in these trials, will their eggs be at risk for more damage or their ability to conceive?

David Mutch: We will sort of pass it down. Chemotherapy does in fact affect the ovaries, sometimes patients who have ovarian preservation and undergo aggressive chemotherapy often can become menopausal. That data is best in patients with breast cancer who are treated. The older the patient is or closer to menopause the more likely they will be induced to go through an early menopause, but the affect then on the oocytes is unclear. Though, there are some trials for quote, "chemoprevention," where young women's ovaries are suppressed-the theory is that if you can suppress the ovaries there will be a higher likelihood that they will become quiescent and less damage will be done to the ovary during chemotherapy. I don't know if the POD, Pediatric Oncology Group, has those prospective studies going on or not. I know that it was proposed four to five years ago and then in fact it was accepted, but I don't know if that trial is accruing patients or not. This would be in Pediatric.

Audience: There is not a lot of data then on the effects of women who still are fertile, who would still have an ovary or tube in trying to conceive. There doesn't seem to be any data that I'm aware of to let women know to make conscious decisions. Could this be affecting their child?

Panel: There's not a whole lot of data out there now. It was just within the last decade or so where more attention has been paid to issues of survivorship. One would be fertility after treatment. In ovarian cancer, for the most part, the ovaries are removed because of the disease. So for the ovarian clinical trials, that is a little bit less of an issue. A lot of the data that we are going to see coming out of pediatric groups are actually childhood cancers. Especially cancers being treating in ovulating girls that you'll actually see long term effects and that data is being collected, I'm sure we will see that in the next couple of years.

Audience: I'm just concerned because there are a lot of younger women, women under 40 who still have not conceived, that are trying to conserve their fertility, even going through chemo and whatever means by surgery or debulking to save as much as they can to try to conceive. I guess my concern is that I'm in that predicament and I've gone through recurrence and still have an ovary for that purpose.

Bethan Powell: If you can get pregnant.

Audience: I've already done that.

Bethan Powell: If a person is able to get pregnant, is menstruating, is ovulating, there are studies that show any significant difference in the offspring. I think that was part of your question. There actually are some studies on carboplatinum and platinum and there are large studies on leukemia patients and various other chemo that have not documented increased anything in the offspring.

David Mutch: The Canadian Group had a bunch of questions and we will go through them. There are 20 of them. I don't think we will get through all of them.

Canadian Group: What's the current thinking regarding clear cell ovarian cancer? A report in 2000/2001 by Dr. Markman seemed to indicate that clear cell ovarian cancer appears not to have any worse prognosis than other epithelial cancer cell types depending on stage. Please expand on this particular subject.

David Mutch: Well my expansion would be that I don't think that's true. I think that clear cell carcinoma carries with it a worse prognosis. In that, recurrent clear cell and clear cell ovarian cancer tends to respond less well to chemotherapy than other epithelial ovarian cancers. I think the majority of data supports that.

Julian Schink: I think of clear cell carcinoma particularly as a bad actor. There are actually two separate types of clear cell carcinoma. The one that is associated with an increased incidence of blood clots seems to be a more aggressive tumor that is less likely to respond to chemotherapy. The response of the University of Wisconsin to this problem has been to offer to these patients more aggressive than standard therapy whenever possible. The advantage we have in clear cell carcinoma over papillary serous carcinoma is it much more frequently stays in the pelvis. So, you can in a sense target your therapy to the pelvis. We still give standard chemotherapy, albeit, I have concerns because in one published series the response rate was only 34 percent, but we still give standard chemotherapy. I will offer patients additional therapy with radiation if they've had a good response and they are willing to undergo that.

David Mutch: Any other questions?

Audience: If you have chemotherapy…. [Inaudible]

Panel: My philosophy is never let the treatment be worse than the disease, and that is an important thing to live by. We know that when we treat up front, after the diagnosis is made, the best response that we can get is the best chance for the patient to have a very successful outcome, so we tend to be very aggressive at that point in time. That means aggressive surgery and aggressive drug. Not everybody can take that. Not everybody can tolerate it and it is not our goal to kill people before the disease will ever catch up to them. So it's an evolution often times where you don't know what your bone marrow capacity will be perhaps, and you give one line of drug and it's just too toxic. We have to make smart changes to try to be aggressive without the types of toxicity that you are describing.

Bethan Powell: I think Skip raised earlier the idea of patient care being a team and that would be a place where that value could be applied. Listening to the patient is very important. But also, if you know the bigger picture and the patient doesn't, then talking to the patient about hope or telling them that this is short term. It is possible that some people get very discouraged with the symptoms in the short term, but if they know the potential for a brighter future or it being short term, that's something to help influence the patient, I think.

Panel: Remember to that when you have side effects to chemotherapy, dose modifications can be made, such as dose reduction and adding on other tools to help women go through the chemotherapy, other drugs to boost their bone marrow, their platelets, white counts, red counts, those types of things. We know that once, for example, if women get anemic, certain women get very, very tired and just by simply doing a blood transfusion or try to prevent it by giving a drug, for example, Procrit, that actually their energy will get better and they will have a natural improvement in their quality of life. You have to negotiate with your physician and let him or her know how you are feeling so they can alter your treatment.

Panel: Could we ask that you use a microphone? The reason I suggest that is that I'm told that this is being transcribed so that other people can read what the answers are, but they can't transcribe it if you don't use a microphone.

Audience: I'm not quite clear on what consolidated treatment is. I have been symptom free for about four years. I wasn't sure whether you were suggesting that at some point that you go back in to look to see if there has been a recurrence, or whether you just leave well enough alone.

Panel: Acutally, nobody's sure what consolidation therapy is. My definition is that it is a treatment. It doesn't even have to be chemotherapy, although we are mostly focused on chemotherapy. So it's a treatment, chemo, hormones, or some other drug or radiation that is given to the patient with the goal of eliminating tumor that we can't detect-microscopic tumor, quiescent tumor, whatever. It is a principal that was developed in the treatment of hematogenous malignancies, so leukemia, lymphoma, and was shown in those diseases to improve outcomes. Albeit, in those cases with a lot of toxicity sometimes the consolidation that is used in leukemia and lymphoma is bone marrow transplant. Bone marrow high-dose therapy was attempted in solid tumors like in ovarian cancer and breast cancer and has not been shown to improve survival. That doesn't mean that the concept of consolidation doesn't work; however, what it means is that high dose therapy doesn't work in Gyn cancers yet, as we know of. There is gradually, slowly mounting data though to suggest that as one strategy for women with ovarian cancer, because we've got to admit that at least half and maybe two-thirds of the women have a complete response to their initial therapy have their cancer come back. That's not a new cancer. That means it was never gone. So, consolidation therapy is a treatment directed at those microscopic cells to shut them down once and for all. That's all it is. We don't know what the right one is yet. It's got to be part of our research plan. That's kind of a strong statement.

Audience: Along those lines, in Dr. Trimball's presentation he mentioned that one of the questions that is salient at this time is, should we try other drugs with different mechanisms of action? Following nine seemingly very affective rounds of carboplatinum, six with Taxol through taxotere, my little lay person brain was thinking along those lines and I really pushed to be put immediately on Doxil or topotecan, or etoposide, or Gemzar, or something that might have another mechanism of action, though I appear to be in remission. Because I have a Stage IIIC, I know the stats. I couldn't get anybody to go along with my plan. The best that I could get was taxotere alone as a consolidation treatment, which I did for another seven rounds. This was prior to SWOG-178, so I thought I was thinking very well there. Now I'm facing a recurrence. The taxotere was not effective. That is my one lingering doubt. Should I have really traveled and thought and found someone that would put me on another severe chemo, and maybe could we have eliminated what cells remained?

Panel: You gave a better, more articulate explanation of why we should do consolidation therapy than I did. But you also point out the problem. Neither you nor I know what the drug should be. We have a problem.

Bethan Powell: The difficult part is you were forced to make a decision without data, and now get to look back and say, what if I had done something different? Going into it, I understand what you're saying, "I want to live, give me anything, I want to live, give me more." There are studies in breast cancer that show that more is actually equivalent on survival and higher on toxicity. If we have studies then we can answer that question. It is possible, at this point we don't know, that if you had made the other decision and gone and gotten treatment that you might have ended up with a serious complication and still be where you are today.

Audience: Right, and that's the exact rationale that was given behind the refusal to, and it wasn't an adversarial situation. I have an excellent Gynecologic oncologist here in New Orleans, and I actually had five other opinions, all very good ones. I'm familiar with that rationale. But, my question is, I should have asked Dr. Trimball because he is the one who brought up the question of, should we use other mechanisms of action? I'm wondering what's next with that. Is there anybody trying to put together a study to do, not just Gemzar, it seems like wimpy doses to me, I might be wrong, but, "Hey hit me with the Doxil. Hit me with something tough even though, yes I did carbo, I did Taxol." Is there anybody who wants to do that? Who's going to do that?

Panel: The answer to that question is, yes, and there have been proposals. There was a proposal at the most recent GOG meeting for a consolidation trial, and people are looking at non-cross resistant drugs for those trials, and the problem is we have a lot of drugs to choose from and getting consensus on which should be in that regimen is the challenge that people are facing now. There is a lot of discussion on that issue. And, to take it a step farther, it is also, there are drugs that don't kill tumors but might stop tumors from growing that people want to study in consolidation. So the answer to that is yes.

Audience: Thank you.

David Mutch: Let's answer a couple of these questions that the group came up with. The second question is. There is confusion regarding the language of the term survival in ovarian cancer women. With the recent advent of carboplatinum and Taxol are we correct to say that with improved surgical techniques and newer chemotherapies, and/or radiotherapy that actual survival rates have increased and not simply the disease free period between relapses?

Well, survival is the duration of life. That's the definition of survival. So, the survival rate is increasing if the disease free interval increases. Not exactly. The question that you're asking is, are we increasing the cure rate so that the disease does not come back? What do you think? I think that in some patients we are doing a little better meniscally in terms of curing patients, but more importantly, and I hate to use this term, but ovarian cancer is sort of becoming a chronic disease. More recent studies, as Dr. Schink showed, the median survival exceeds five to seven years. Think of other chronic diseases such as kidney disease or heart disease. I don't think the median survival in patients like that is of that duration. The biggest impact that we are making is making people live with their disease longer.

Panel: I don't think there is any question that we are making headway. It's incremental, it's small. If you look at NCI data over the last forty years it's statistically significant. If you measure between the year 2000 and 2001 it isn't. But over time we're making a big difference. Other people in health care have this problem. It's very hard to show any single one intervention is statistically significant. It's a packaged deal. Our incremental efforts to optimally debulk patients, get them their aggressive chemotherapy in a timely fashion and stay on treatment has clearly left us with a much larger fraction then we had when I started this business fifteen years ago of people who are alive at five years. So we're definitely making headway, but we also have a long way to go. If we're running a race we haven't gotten to the halfway point yet.

Audience: After my fourth use of Doxil I'm developing terrible mouth sores and the skin on my hands changes colors and they became dry and cracked. Can I expect the same effects after ensuing Doxil?

David Mutch:

Audience: But it will come back.

David Mutch: It's unlikely that you'll have no toxicity. You can minimize the toxicity by the techniques I described. You may talk to your doctor and his/or her nurse. They are usually pretty good. I wish mine were here.

Audience: Use frozen peas on the hands. Use frozen peas on the hands for three to five days. I'm serious it will help. You hold it.

Audience: A young woman I know was told that by having fertility treatments to get pregnant that there is a very real possibility of developing ovarian cancer. Is that correct?

Panel: Well one of the well-studied theories on ovarian cancer is ovulating too much--just over a reproductive lifetime. I think Dr. Randy Burchuk has classified that by counting ovulations over reproductive life. I think if you target infertility treatment itself, looking at brief bursts of ovulation induction using Clomid, Pergonal, which gives you lots of ovulations per cycle, there has not been any definitive studies that have said that yes indeed it does increase your risk. So in a theoretical basis it makes sense that it might, but when you look at women who have had fertility treatment it is not statistically significant.

Panel: I was handed a question. Explain radiofrequency ablation, can it be used for ovarian cancer in the liver?

It is easier for me to say yes it can, and don't ask me to explain it. Radiofrequency ablation is where they put a very small wire into the tumor using CT guidance or ultrasound guidance and then a radiofrequency, electric current destroys the tumor cells and it does it in concentric fashion, outward from that electrode and you can predict how far it's going to go. If you put that electrode in the right places in the tumor, you can kill the tumor. It is a very exciting treatment option. I have experience in using it, and for patients with disease only in the liver, it works. But recognize that's a very small fraction of people with ovarian cancer, but for those people it is a treatment option as long as vital structures are not involved and there aren't to many tumors.

David Mutch: I have one of the set questions here. Are there any indications that we are seeing more late recurrences and what is the effect on the ultimate survival rates?

Panel: Yes and yes. What we have to keep in mind is that even though women go into prolonged remission it can be difficult to say, cure. All of us have taken care of patients who have been in remission for months and years, and the reason that they need to continue to see Gynecologic oncologists, even five years out, is that we have all had patients who have recurred further than five years out and even further than ten years out. There is always that possibility. As we get into more consolidation concepts, and we get into more combination chemotherapies using Taxol carbo and switching over to Doxil and switching over, as we do more sandwich combinations, it will be interesting for us to see, not only if the remissions are longer, but if the survivals are even longer, not only for five or ten, but on and on. Did I answer the question?

David Mutch: The fourth question. We understand that early stage ovarian cancer, Stage IA and IB, except clear cell and mucinous, do not require chemotherapy?

David Mutch: Sometimes. I think it depends on the presentation. A Grade IA, if the patient was properly staged, certainly the literature indicates that it might be safe to watch that patient. I think Grade 2 is sort of a gray area, and most people would treat Grade 3.

David Mutch: Do we believe that Stage I subcategorized needs to be revised more accurately to define this particular Stage?

David Mutch: I think they have been refined in IA, IB and IC.

David Mutch: What is your analysis of the recent action in Icon I publications?

David Mutch: Boy, you don't want to hear my opinion on Icon I, I don't think. Icon I is a bad paper. It was a bad study. Basically anyone who had a cancer and the doctor thought it was an ovarian cancer, was treated with chemotherapy. There was no staging. There were no controls for patient variables. Basically my view is that the British government wanted the study to be published in that way so that they didn't have to pay for additional chemotherapy in other patients. That is my opinion of it. Other people can comment.

Panel: For those of you who aren't familiar with this study, basically it suggested that we can get as bad of a result by using platinum by itself, as carboplatinum and Taxol. The problem of course is that if you take a totally nealistic approach and you just keep backing into it and saying, "no treatment, no treatment, no treatment," well then a little less treatment isn't any worse than no treatment. It's very frustrating. It's countered to my theme, which is, we made incremental progress in which it is very difficult to measure the increments, whether you move up in increments or down, but when you take the package deal of a more comprehensive aggressive approach, we end up with a group of patients who are much more likely to be alive five and ten years later.

David Mutch: Still today we see references to early stage ovarian cancer having a 90 percent to 95 percent survival rate which is not accurate. Will you be publishing in your literature a more accurate reflection, understanding that many early ovarian cancer women feel that they are not taken seriously when these results are quoted?

Bethan Powell: I'm not sure why it's not accurate?

Panel: It's because you have so many different categories in early stage. So lets assume you've got Stage IC clear cell for example, that would be given its own prognosis, and we know, I think you probably agree, that in that particular case, 90 percent to 95 percent is not accurate. I think that what they are looking for is, in Stage III we can say that survival rates are 25 percent, 30 percent, whatever. Stage I is more complicated, because it doesn't give enough credence to, I guess the cancers other than low-grade for example.

Bethan Powell: I think that's true. It is more complicated and certainly the textbooks would reflect that with the percentages attached to IA. Little asterisks about clear cell are going to be lower and closer to 70 percent. I think most Gyn oncologists would also make that distinction in discussions with the patient. If somebody was creating the impression that all Stage I ovarian cancers are 95 percent, I think that would be an inaccurate understanding.

Panel: I think a lot of confusion and a lot of issues being raised are questions designed to say; how can we understand what we should have? And can you say you should always have this and you should never have this? I think what has to be understood is that when we establish a relationship in that team approach with you, it is very important to recognize there are no "always" answers and there are no "never" answers. I tried to express this earlier-Individualizing each case and each story. You heard many different stories today, and that is extremely important. We had a lot of different stories today to help guide us in that. We can give you percentages based on those studies. As you heard from our colleagues, some studies are good, some studies are maybe not so good, and there are some flaws in it. We use it as guidance, but it's not an absolute. That brings up the importance of second opinions. Those studies help guide us to make recommendations and it would make you feel better to hear the same recommendation or maybe different ideas of recommendations based on ideas of each individual case. So, it's really hard for any of us up here to say, always, always or never, never in some of the specifics that you are asking.

Audience: There was an article in the Times Picciu and I tore it out, Sunday, January 5, 2003, and it mentions the chemical used called, Irofulven. Of course the article is saying it is a breakthrough for cancer and it mentions particularly advanced ovarian cancer. I went right away to the computer and came up with the manufacture of Irofulven. It's in a Phase II trial of refractory or recurrent advanced epithelial ovarian cancer. I just wanted to ask if the panel could comment on it at all?

Panel: I have some experience with Irofulven. It is a drug that is not yet approved by the FDA for use. It is being developed by a company called MGI in Minnesota and they are looking at it in ovarian cancer among other diseases. I know you had some discussion earlier about clinical trials. A Phase II trial means that they are endeavoring to establish what the response rate is. What the likelihood of measurable tumors shrinking is when you get this drug. And they are still in Phase II trial. There has been a suggestion that it is an active drug. That is kind of where we're at, and until these Phase II trials are completed it is kind of hard to get overly enthusiastic. It's another tool in the toolbox. We have others that are approved. What usually happens is, just like we heard about the hand/foot syndrome with Doxil, everyone of these drugs have their unique toxicities and how acceptable this drug ultimately will be to all of you is going to depend on how effective it is and the toxicities. We haven't defined them quite yet. But it isn't without toxicity, that's clear.

Audience: Are there any kind of guidelines or suggestions? How do you decide when you should possibly do a clinical trial? Going to the unknown as opposed to the drug that may be somewhat effective?

Panel: Excellent question. The question is how do I know whether I should be in a clinical trial or go with a known drug?

Bethan Powell: Usually clinical trials are clinical trials because they are asking a question that we don't know the answer to. So any time you see a national clinical trial there is usually an arm that's standard and the arm that is asking if this is a better approach or if this would work better. To me, any time there is a large national clinical trial it is worth considering, whether it's at the beginning of therapy or later on down the road. One of the problems you heard about today is that a lot of trials aren't done until patients have advanced disease. It is much harder to get responses. Clinical trials also aren't designed to not have a standard arm, and usually some modification of that if there is a standard therapy. So, you wouldn't have a trial that tested a known entity like carbo/Taxol against something completely unknown.

David Mutch: Is it correct to say, based on up-to-date literature, that early stage ovarian cancer is unstaged in approximately 15 percent to 30 percent of cases?

David Mutch: Well, if they are under staged then they are not early stage ovarian cancer. I think that's the point. If you don't aggressively stage the patient then you don't know what the stage is. So if you don't look at the lymph nodes then you won't know whether or not the lymph nodes are positive or not. Then you have the question of; do I need to treat this patient because she might have positive lymph nodes, or might have a positive diaphragm biopsy or might have a positive omentum? I would flip it around and say that if the patient is properly staged then no they're not under staged. The problem is that many patients with the diagnosis of ovarian cancer do not get staged properly and so we don't know their stage.

Panel: Unfortunately, and this was shown by a study that Ted Trimball published a few years ago, just a huge number, almost 85 percent to 90 percent of women with early staged ovarian cancer were not ideally managed at their first surgery.

David Mutch: Only 5.9 percent in that Muno study were. Early stage ovarian cancer.

Panel: Which means that most of those patients end up needing some other additional operation or treatment. The other answer to your question is, when it has been looked at, those women who were thought to have Stage I disease at their first incomplete operation, when you take those folks back and do a complete staging, 20 percent of the time you find additional cancer.

Bethan Powell: I think we've talked about ways to improve the management of ovarian cancer. In my mind there's probably one that could be done and may be in some ways the simplest and in some ways the hardest, but that is for Gyn oncologists to be present or available at staging surgeries where cancer is found. I personally believe that that would affect survival.

Audience: My concern is that the Gynecologists aren't getting the message. My wife has been actively involved in a group in Minnesota. Her best friend was diagnosed with ovarian cancer, and she had not been told, but we suggested very strongly before she got her surgery to have a Gynecologic oncologist available. And yet her Gynecologist told her, I can handle it. First of all, she didn't have a specialist on hand and it was ovarian cancer. Then the Gynecologist told her that she was Stage IC, and the Gynecologist told her that it was optimal for her to decide whether she wanted to have chemotherapy or not. I think, despite our efforts to indicate to some of our friends and relatives, that they are getting perhaps the wrong message from some of the Gynecologists out there.

Panel: First I think she is very fortunate to have you as a friend, and to have you there to help educate her. And I think it is very fortunate that when you heard that she might not even have had a IC, she might have been higher because she did not have the appropriate staging procedure, that you could then intervene. This is an ongoing battle for us and for you. We see and hear and take care of these patients every month with similar scenarios. We are doing the best we can to educate Gynecologists. The problem isn't always that they haven't been educated. Sometimes the problem is they do not want to listen. Am I going to get in trouble here, because it is being recorded? And the thing is that when I was practicing in Akron and Canton where there was four Gyn oncologists, and when I recently moved up to Cleveland where there is many more Gyn oncologists, I could not believe that the same pattern was there in a large center, a large city with two huge cancer centers-University Hospitals of Cleveland and the Cleveland Clinic-and I still see this every month. It's not right. The physician should always do the right thing. I applaud you for your efforts and we see it and we do the best we can, but people hear but people sometimes do not listen. Am I going to lose my license?

Panel: I just want to weigh in on this too, and I'm willing to say this and have this transcribed. I was interviewed. Mame magazine interviewed me about a year ago and asked me the same question, and two days ago I read what I said and I couldn't believe that I had the guts to say it. Three reasons. One is money, the second one is denial, and the third one is that these guys don't believe what we do makes a difference. So the money is an issue and it's okay to confront people over that. The denial comes from the fact that people look at a 40-year-old woman and can't believe that a cystic and solid mass actually is cancer, even though the data suggests, depending on what you look at, there's a 20 percent, 30 percent or 40 percent chance of it being cancer, they just refuse to accept that. So that's a huge problem. And the last problem is that a lot of these guys trained before there were Gyn oncologists and there was comprehensive staging of the disease and they never saw success. So, they don't believe in the process. You have to confront them, and you have to say are these the reasons? Which of those reasons are the barriers for referral and overcome them. I think they have to be confronted.

Bethan Powell: To some extent, in the sense that Gynecologist do ovarian cancer, they are competitive with us rather than necessarily partners. And this is something I feel that you can influence and change the standard of care as much as we can.

There's another thing, I felt, that has not been talked about and it's something that we as Gyn oncologist can do. I do feel very strongly that providing staging is really a simple thing that we can do that affects survival. In our community many of us are academic center based. If we say, all ovarian masses have to come into the academic center, many patients don't want to do that, and the docs likewise; only one out of ten of the masses they are managing is going to be cancer, practically, they can't send all ten people, so they take a chance, and it turns out that this is the one out of ten. We don't have a very good model for really addressing that issue. I think it's simplistic to say, refer them all to us. One of the things that some of us do is go to community hospitals and work in partnership with the Ob/Gyn there. That way there is access in the community to pretty straightforward one out of ten cases that need straightforward surgery, where an ovarian debulking Stage III case may be more appropriately managed at a cancer center because it's a bigger surgery. There is a lot of controversy about that, but I actually think that that might be a model that more women could get staged.

Audience: Do Ob/Gyn residents now as part of their training spend time with a Gyn oncologist? How recently did that come in to being?

Panel: It's a requirement in Ob/Gyn residency that they spend time on the Gyn oncology service. In my program it is 30 weeks, which they all feel is too much time. As long as our specialty has been there it's been the case. We've done a better and better job over the years. When I look at my colleagues who are in their 50's practicing in Wisconsin, I see people who clearly trained with someone who must not have been very aggressive, must not have debulked patients, clearly didn't stage ovarian cancer patients. Those guys just plain don't believe. It's very hard to get them to believe because they fulfill their own prophecy. They don't debulk patients and they send them to the medical oncologists who doesn't treat them very aggressively, and the patients don't do very well, and we fight with them, and fight with them, and fight with them.

Audience: You know it's not just physicians. I've been an RN in ICU for 30 years. I receive a magazine called Advance for Nurses. It may just be an East Coast publication. In November there was an article written by an RN with her Ph.D. who battled ovarian cancer. When the magazine arrived I was really excited to see what good was to be said in this nursing article. In it she did not mention Gyn oncologists at all. I couldn't get over to the computer fast enough. I e-mailed the editor of the magazine who contacted this woman who responded to me right away. Her response was too many women live in rural areas where they don't have access. I thought, here is this nurse with a Ph.D. and she's not even letting people be included to that link out there. It's not just physicians, it's a lot of people. It's shocking.

I think the thing is being not popular like the breast cancer people, is because the ten-year breast cancer survivorship is like 80 percent plus. We are starting to have more survivors now. The numbers are growing. We are still not as common of a cancer as breast cancer, but it doesn't mean the voices can't be as loud or louder. This is where we turn it back to you to help us get out there and educate. There are many ways to do that, through the Gynecologic Cancer Foundation, which is supporting this whole event that we work very hard for. There are ways to get into your community and help that. I'd say, lets shout louder and let's get popular.

Audience: I am going to tell a story to Cancer Weekly in November which is on the Internet and I published my e-mail address. It's ovariancancer@yahoo.com.

David Mutch: There are some booths downstairs that are run by advocacy groups. They would like you to visit their booths. I know that the ACOL, Ovarian Cancer On Line, Support Group has a lot more questions. I don't think we are going to be able to get to them, but I would be more than happy to find a time if you wanted to meet me sometime later to finish answering these questions. I think in the interest of time, I think we should probably close down.