Barbara A Goff  美国华盛顿大学妇产科学

　　Barbara A Goff，美国华盛顿大学妇产科学系主任、教授，弗莱德·哈钦森癌症研究中心副研究员。其专业为妇科肿瘤的外科治疗、机器人手术、化疗、卵巢癌临床试验和早期检测。

　　<Oncology Frontier>: What are current clinical practice and research hotspots in gynecological oncology？

　　Prof. Goff: I think the biggest hot topics in gynaecologicalcancer， particularly ovarian cancer，really surround new targeted therapies， so we are seeing therapies that specifically target certain pathways， like women who have BRCA mutations. There arespecific drugs that work extremely well in this group of patients.We are seeing anti-androgenic drugs that have really great activity， so I thinkone of the most exciting things in terms of hot topics ingynaecologicalcancer is new targeted therapies that are becoming available every day and that we are seeing these clinical trials on.

　　I also think that we are seeing great advances in surgery， particularly the minimallyinvasive surgical techniques that are allowing women to have very extensive operations but with only very tiny incisions， much less pain and better outcomes.I think， specifically with ovarian cancer， we are still trying to look at what is the role of intraperitoneal chemotherapy， what is the role of dose-dense chemotherapy， and how can we maximize the survival for these patients.

　　《肿瘤瞭望》：请您介绍一下目前在妇科肿瘤的临床实践和研究方面的研究热点

　　Goff教授：新兴的靶向治疗相关问题，是目前妇科肿瘤，尤其是卵巢肿瘤治疗领域中最热点的问题，现在已经研发成功了特异性针对某些通路，例如BRCA突变的靶向治疗方法，对这类患者，现在已有疗效很好的特异性药物。我们还发现，抗雄激素药物有很高的活性。因此我认为在靶向治疗或者说是妇科肿瘤治疗领域里，最让人兴奋的事情之一就是，每天都有患者能用上新型靶向治疗，相关临床试验正在开展。

　　同样，我们也目睹了在手术治疗上取得的巨大进步，尤其是微创手术技术的应用，使得在手术治疗范围相当广泛的同时，仍具有创伤小、疼痛轻、恢复快的优点。另外，我认为特别是对卵巢癌的治疗，腹腔内化疗、剂量密集型化疗以及如何最大程度上延长患者的生存期，都是我们目前正在探索的问题。

　　<Oncology Frontier>: Ovarian cancers are usually diagnosed at an advanced stage and have poor prognosis. Are there better approaches for ovarian cancer screening， to detect earlier， treat earlier and improve prognosis?

　　Prof. Goff: Yes， so that’s an excellent question. There have been several prospective randomized trials that have evaluated very different screening techniques. Unfortunately， most of these trials have not shown that there is an improvement in the mobility or the mortality. Right now， the screening protocol that has probably the best chance of being successful is the screening program that comes from the UK collaborative study where women are been screened with a CA125s and having that analyzed with a risk of ovarian cancer algorithm (ROCA).I think that is probably going to be the strategy that is most likely to be successful although we are still waiting for those final results to be reported. People continue to look for other markers for ovarian cancer， but unfortunately， we’ve not been very successful in identifying other markers， which is why I think it’s very important for women and practitioners to understand what the early symptoms of ovariancancer are.Those include bloating， increased abdominal size， feeling full quickly， difficulty eating andurinarysymptoms. Those can all be symptoms of ovarian cancer and while a lot of womenwillhave those symptoms and don’t have ovarian cancer， it is important to know that research that we’ve done in the United States shows that those symptoms are predictive of havingovarian cancer. So it is important for women to understand that if they have these symptoms and that these symptoms persist for more than 3 weeks， and that they occur almost daily or every other day， that theyshould see their physician and let them know that they have concerning symptoms.

　　《肿瘤瞭望》：卵巢癌诊断时常分期较晚，预后差。有什么好办法对早期卵巢癌进行筛查，达到早诊早治改善预后的作用呢？

　　Goff教授：曾经有几项前瞻性随机试验对几种不同的筛查方法进行评估，遗憾的是大多数的试验结果并未显示出对患者临床发病率或死亡率的改善。

　　就目前的筛查方法来看，一项来自英国合作研究的筛查方案（ROCA）有望成为早期成功筛查卵巢癌的方法，此方案主要筛选妇女的CA-125，以此评估卵巢癌的发病风险，我认为这个筛查方案最有希望成功，目前我们仍在等待此方法的最终研究结果。

　　一直以来人们都在寻找卵巢癌的特异性肿瘤标志物，但均未取得显著进展，这也是为什么对于女性及临床医生而言，了解卵巢癌的早期症状非常重要。例如腹胀、腹围增加、饱腹感、进食困难、泌尿系统症状等，这些都可以成为卵巢癌的症状，当然也有许多女性出现了这些症状，但却没有卵巢癌。

　　我要提醒大家重视的是，我们在美国做的一项研究显示：所有这些症状都预示着卵巢癌的发生，因此女性了解自身是否出现这些症状很重要。如果这些症状持续出现超过3周，几乎每天或每隔一天就会发生的话，这些患者应该赶快就医，向医生告知她们已出现相关症状。

　　<Oncology Frontier>: Which gynecological malignancies are recommended to have screening tests according to evidence in hand? And in what population the screening should be performed?

　　Prof. Goff: Right now， the only gynaecologicalcancerwhere there are formal recommendations for screening would be cervicalcancer， and I think what’s exciting is that there are now several different approaches to screening cervical cancer. There can be the conventional pap smear. There can be co-testing with pap smear and HPV.And there can now also be primary HPV screening which we think may have even higher sensitivity for detecting cervixcancer. I think that’s very good news to reduce the incidence of cervixcancer. For the other gynaecologicalcancers， at least in the United States， there is no formal recommendation for screeningfor ovarian cancer in the general population. Screening is not recommended because it’s been associated with an increased riskof harm from screening rather than benefit， so we currently do not screen women for ovarian cancer in the general population， but we do encourage women and practitioners to talk about symptoms and understand what some of the earlywarning signs can be from ovarian cancer. For women who have genetic mutations who are at higher risk for ovarian cancer (those with BRCA1 or BRCA2mutations)， we are still recommending prophylactic risk-reducing surgeryfor those patients to try to prevent ovarian cancer.Finally for endometrial cancer， there are no formal recommendations for screening， but the good news is that most women with endometrialcancer will have early warning symptoms. Usually they will have post-menopausal bleeding， or for women who are not menopausal，they will have heavier than normal bleeding or bleeding in between the periods.So for any women with abnormal bleeding who is over the age of 40， we recommend that they have an endometrialbiopsy to make sure that they don’t have endometrial cancer.

　　《肿瘤瞭望》：现有的循证医学证据支持对哪些妇科肿瘤进行筛查？分别针对什么样的人群？

　　Goff教授：迄今为止，妇科肿瘤中只有宫颈癌是常规建议临床筛查的，欣慰的是目前宫颈癌的筛查可采用多种不同的方法。一般采取巴氏涂片和HPV检测联合筛查，同时初级HPV的筛查或许能提高宫颈癌检测的灵敏度，这对降低宫颈癌的发病率来说是个很好的消息。

　　对于其他妇科肿瘤，并没有正式的临床筛查推荐建议，至少在美国是这样。我们不推荐一般人群进行卵巢癌的筛查，因为筛查所带来的风险可能大于其带来的益处，但是我们鼓励女性和临床医生了解和讨论卵巢癌的一般症状及特殊症状。

　　携带相关基因突变（BRCA1或BRCA2突变）的女性罹患卵巢癌的风险更大，我们不建议其进行预防性切除手术以预防卵巢癌的发生。

　　对于子宫内膜癌，也没有正式的临床筛查建议，但幸好对于大多数这类患者来说，一般都会早期出现预警症状。通常她们会出现绝经后出血，或者非绝经期妇女出现月经量较前增多或经间期出血，因此对于年龄大于40岁出现不规则出血的女性，我们均建议其进行子宫内膜活检以排除子宫内膜癌。

　　<Oncology Frontier>: What is the standard of care for advanced Ovarian Cancer?

　　Prof. Goff: The standard care for advanced ovarian cancer first involves a decision as to whether or not a woman should have upfront surgery or whether she should have  neoadjuvantchemotherapy. If the surgeon feels that they can resect all of the disease， then we strongly recommend that women have primary debulkingsurgery with the goal of removing all of the disease. In those patients， I think the best option is to treat either with intraperitoneal chemotherapy or to treat with dose-dense chemotherapy. I think that is the standard of care at this point in time. We don’t recommend maintenance therapy at this point in time， nor do we use upfront anti-androgenictherapy， although there are some people who are using that approach.That approach has not been shown to be associated with an improved cure rate， so for those reasons we don’t use them.

　　《肿瘤瞭望》：晚期卵巢癌的标准治疗是什么？

　　Goff教授：对于晚期卵巢癌的标准治疗首先涉及到一个重要的决定，即患者是应该行前期手术治疗还是应该选择新辅助化疗。如果外科医生评估后可以手术切除所有病变，那么我们强烈建议其进行以根治性切除为目的的实体瘤切除手术，以期达到无病生存。对于多数晚期的卵巢癌患者，我认为最好的办法或我认为的晚期卵巢癌的标准治疗是进行腹腔内化疗或剂量密集型化疗。我们并不推荐在晚期进行维持治疗，也不推荐使用抗雄激素治疗——尽管现在有许多人采用这种治疗方法，但这种方法并不增加治愈率，因此我们不使用这些治疗方法。