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Ca-125 trend on treatment.

In an effort to improve oncologic outcomes, investigators have attempted to capitalize on molecular aberrations identified in LGSOC specimens. Most recently, the utilization of MEK inhibitors have been explored due to noted activation of the mitogen-activate protein kinase (MAPK) pathway in LGSOC. A phase II trial evaluating Selumatib activity in women with recurrent LGSOC (GOG 0239) demonstrated a 15% overall response rate, catalyzing the development of phase III trials examining alternate agents in this setting (Farley et al., 2013). A phase III study evaluating Trametinib vs. physicians choice chemotherapy in patients with recurrent or progressive LGSOC (GOG-281) has closed to accrual and will help guide further management with these targeted agents. Furthermore, efforts to identify appropriate patient subsets based on molecular profiling are ongoing. In context of the above, optimal management of these relatively chemotherapy-resistant tumors due to their low-grade nature remains an active area of investigation.

CT scan November 2017, illustrating interval decrease in size of the right adnexal mass to 1.6 cm × 1.6 cm.

2. Case

Low grade serous ovarian cancer (LGSOC) is a rare subtype of serous epithelial ovarian cancer, comprising approximately 10% of all cases of serous carcinoma. The majority of women are diagnosed with advanced stage disease, despite its slow growth. Treatment options for advanced disease include neoadjuvant chemotherapy followed by interval surgical cytoreduction or primary surgical resection followed by adjuvant therapy as well as maintenance hormonal therapy (National Comprehensive Cancer Network, 2019). Adjuvant therapy traditionally consists of combination platinum and taxane based chemotherapy, although response rates are limited, and may include concurrent/maintenance hormonal therapy. Even with advanced stage at diagnosis, patients with LGSOC have an improved prognosis when compared to their high grade serous counterparts, with median overall survival of approximately 100 months reported, reflective of a protracted clinical course (Gershenson et al., 2015).

In July 2017, CT imaging was repeated and she was found to have a decrease in the size of the bilateral adnexal masses and mesenteric and pelvic lymphadenopathy, which was confirmed by clinical exam. Her mesenteric and omental carcinomatosis remained stable. Genomic profiling of her primary surgical specimen was ordered at this time and no molecular aberrations were identified. She was seen for follow up in September 2017, four months after starting initial treatment, and repeat imaging in November 2017 continued to show a dramatic reduction in her disease burden, with near complete resolution of all previously identified lesions ( Fig. 3 ). On her most recent interval assessment in December 2018 she continues to show a response to therapy. She is clinically asymptomatic with a performance status of 0, which is unchanged from her performance status at time of diagnosis.

CT scan May 2017, illustrating a right adnexal mass measuring 5.8 cm × 5.0 cm.

Perhaps most provocative is the recent report that 40% of Americans believe that use of CAM is sufficient for the management of cancer (National Cancer Opinion Survey, 2019). In addition, 22% of Americans with a history of a cancer diagnosis and 38% of family caregivers share this belief. However, a recent study evaluated overall survival and adherence to treatment in patients receiving conventional cancer treatment with or without CAM for cancers considered curable. Patients who used CAM had significantly decreased overall survival when compared to those who did not, and also had higher rates of refusal of standard therapy (Johnson et al., 2018). Notably, this risk of death is linked to the refusal of therapy and not to the use of CAM itself. This demonstrates the importance and need for transparent, open discussions with patients regarding current available therapies, expected outcomes, and alternatives that patients may be seeking or have not yet disclosed.

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