De bekendste en meteen ook meest voorkomende kanker bij vrouwen is borstkanker. De dodelijkste vorm van gynaecologische kankers is echter diens minder bekende broertje ovariumkanker. Vijf jaar na een nieuwe diagnose van borstkanker is nog ongeveer 90 procent van de patiënten in leven, waar dat voor ovariumkanker gemiddeld de helft is. Bovendien zal ongeveer tachtig procent van deze patiënten hervallen na een eerste diagnose. Eens hervallen is genezing zo goed als zeker niet meer mogelijk.
Bij nieuw gediagnosticeerde ovariumkanker is chirurgie de basispijler van behandeling, terwijl de rol van chirurgie in de setting van herval al langer een bron van discussie is. Met de recente publicatie van twee grote studies (GOG213 en DESKTOP III), die een eventueel langere overleving na herbehandeling met chirurgie onderzochten, breekt een moment van kritische toetsing en evaluatie aan.
Kanker alomtegenwoordig
Een kennis of naaste gediagnosticeerd met kanker, is eerder de regel dan de uitzondering. In 2018 werden maar liefst 70.468 nieuwe diagnosen van kanker geregistreerd. Concreet betekent dit dat ongeveer één op drie mannen en één op vier vrouwen deze diagnose krijgt voor hun 75ste verjaardag. Kanker is alomtegenwoordig in onze maatschappij en dat zorgt er ook voor dat veel tijd en geld voor wetenschappelijk onderzoek wordt vrijgemaakt voor deze veelzijdige ziekte.
Niet alleen wordt gezocht naar innovatieve therapieën, ook huidige therapieën worden kritisch geëvalueerd. Gezien de hoge hervalpercentages binnen eierstokkanker, vaak in combinatie met de ongeneeslijkheid van de ziekte, is naast een zo lang mogelijke overleving kunnen bieden, het behoud en verbeteren van de levenskwaliteit de hoofdprioriteit.
Nieuwe studieresultaten
De behandeling van eierstokkanker bij herval bestaat steeds uit chemotherapie, vaak in combinatie met chirurgie. De gebruikte chirurgische techniek bij eierstokkanker noemt men debulking. Deze uitgebreide chirurgie met uitruiming van alle aanwezige tumornesten in de hele buikholte vergt een zeer langdurige en nauwgezette operatie, waarbij ook vaak de verwijdering van verschillende organen nodig is. Patiënten die dit ondergaan, staan voor een lange revalidatie met verschillende (vaak definitieve) ongemakken zoals diarree en mindere opname van voedingsstoffen met nood aan voeding via infusen. Deze chirurgie is dus enkel te verantwoorden indien die ook de levensverwachting verlengt en/of de last van symptomen vermindert.
Hoewel alle ogen gericht waren op de recent gepubliceerde studies, werd geen eenduidig antwoord gevonden op de vraag of patiënten met hervallen ziekte debulking chirurgie moeten krijgen en zo ja, voor welke patiënten dit de beste therapie is. Beide studies trokken een verschillende conclusie over een mogelijk overlevingsvoordeel wanneer patiënten vergeleken werden die wel of net geen chirurgie ondergingen. Uit beide studies bleek een overlevingsvoordeel voor patiënten bij wie alle zichtbare (en zelfs microscopische) tumoren werden verwijderd, vergeleken met vrouwen die chirurgie ondergingen maar bij wie nog tumorresten achterbleven.
De juiste setting
Deze resultaten laten ons dus wat op onze honger zitten, maar één conclusie blijkt alvast getrokken: het verwijderen van alle tumornesten is van cruciaal belang wanneer besloten wordt tot chirurgie over te gaan. Concreet betekent dit dat vóór het uitvoeren van de ingreep moet worden bepaald of een patiënte een geschikte kandidate is. Er moet vooraf bepaald worden of de voor- en nadelen van de ingreep tegen elkaar opwegen en een inschatting van de haalbaarheid van totale verwijdering van tumoren moet gebeuren. Daarnaast is een getrainde chirurg met kennis van zaken en voldoende ervaring essentieel.
Een algemene trend binnen onze moderne gezondheidszorg is de centralisatie van bepaalde zorg en ingrepen, met het oog op het voorzien van kwalitatievere patiëntenzorg en ziektebehandeling. De grote voordelen van centralisatie zijn onder andere specifieke expertise, de mogelijkheid tot wetenschappelijk onderzoek, specifieke evaluaties, trainingen (zowel voor artsen als paramedisch en verzorgend personeel) en de uitrusting van het centrum waarin de ingrepen gebeuren. Hoewel de voltooide studies geen pasklaar antwoord gaven op de selectie van patiënten, bleek eens te meer de nood aan secure en gespecialiseerde aanpak.
Wat brengt de toekomst?
Het gebrek aan een duidelijk antwoord zorgt echter ook voor heel wat nieuwe vragen. Met nieuw onderzoek komen ook nieuwe methoden om kanker vroeg op te sporen (denk maar aan screening door mammografie en echo bij borstkanker of uitstrijkjes voor baarmoederhalskanker) en nieuwe therapiemogelijkheden in beeld. Enkele van deze nieuwe moleculen zijn PARP inhibitoren en bevacizumab, die respectievelijk een doelgerichte kankertherapie op DNA niveau en op niveau van bloedvoorziening voor een kankercel zijn. Met deze nieuwe medicatie hopen wetenschappers een nieuwe behandeling van eierstokkanker te vinden, die minder bijwerkingen heeft en dus minder belastend is op de levenskwaliteit van de patiënt.
Nieuwe medicatie die minder zware bijwerkingen heeft dan chemotherapie en uitgebreide chirurgie, die patiëntes een comfortabelere behandelingsperiode geeft, die van eierstokkanker een chronische maar controleerbare ziekte maakt, klinkt wetenschappers (en patiënten) als muziek in de oren. Het blijft belangrijk om vrouwen die hervallen met eierstokkanker te behandelen met aandacht voor ziektecontrole enerzijds en levenskwaliteit anderzijds. Of chirurgie een rol speelt in de behandeling moet steeds heel persoonlijk per patiënte bekeken worden.
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