Interview with Dr. Marcela del Carmen on Diagnosis and Treatment of MMMT

The following transcript is from an interview between Dr. Marcela del Carmen (MDC), a leading GYN Oncologist from Mass General Cancer Center in Boston and Diane Redington (DR), a woman with a GYN Carcinosarcoma (also known as MMMT) who is seeking to motivate researchers to advance the science and uncover knowledge about carcinosarcoma and find a cure for this cancer. On January 5, 2017, Diane conducted a series of interviews with Dr. del Carmen on the topic of Carcinosarcoma. This interview discusses diagnosis and treatment of MMMT.

Dr-Marcela-del-CarmenMarcela G. del Carmen, MD, MPH is a graduate of the Johns Hopkins School of Medicine. She completed a residency in gynecology and obstetrics at Johns Hopkins Hospital and a fellowship in gynecologic oncology at Massachusetts General Hospital. She graduated with a Masters in Public Health from the Harvard School of Public Health.

Dr. del Carmen was on the faculty at Johns Hopkins before returning to join the faculty at Massachusetts General Hospital. Dr. del Carmen is board certified in Obstetrics and Gynecology and Gynecologic Oncology. She is a Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School. Dr. del Carmen is also Chief Medical Officer of the Massachusetts General Physicians Organization.

Dr. del Carmen is a fellow of the American College of Obstetricians and Gynecologists and also of the American College of Surgeons, and a full member of the Society of Gynecologic Oncology, the International Gynecologic Cancer Society, and the New England Society of Gynecologic Oncologists. Dr. del Carmen has been a member of the Ovarian Cancer Committee of the Gynecologic Oncology Group and currently serves on several committees in the Society of Gynecologic Oncologists.

Dr. del Carmen’s research interests include the surgical treatment of gynecologic malignancies, specifically ovarian cancer, the management of rare gynecologic tumors and improving access to health care services for underserved populations.  Dr. del Carmen has been a principal investigator of clinical trials evaluating novel therapies in the treatment of ovarian cancer, as well as the design of a novel device for delivery of intra-peritoneal catheter

1. What do I do if I am diagnosed with this cancer? (DR)

Dr. del Carmen, when a patient is diagnosed with a gynecological carcinosarcoma or MMMT, it’s pretty devastating. So, what we’d like for you to talk about is, “What do you do when you receive this diagnosis? How do you find a team to help you make a decision on which direction to go in? And then we’d like for you to talk a little bit about treatment based on the stage that you’re diagnosed at and the kind of things that you should consider when you’re trying to make treatment decisions.”

Find an Expert Team (MDC)

Sure, so first of all, I think the most important thing that a patient can do to advocate for her care is to really go to a place that has expertise in dealing with gynecological cancers. When you think of gynecological cancers, specifically cancer of the ovary, it is defined, irrespective of cell type, by the National Cancer Institute [NCI] as being a rare cancer. So already, you are beginning to see how you’re not going to have every hospital, every physician, is going to be able to offer the appropriate expertise around care. When it comes to cancer of the ovary treatment, again, irrespective of cell type, there are data, largely out of the United States, that show that your outcome, how long you live and how well you live during that time is really, really contingent on who takes care of you. So finding that expert team of doctors and clinicians who are going to take the lead in helping you make decisions about your care is probably the most critical piece to your care and to the ultimate outcome of your cancer treatment.

Carcinosarcoma is rare. (MDC)

With regards to carcinosarcoma, that is defined as being an exceedingly rare form or cell type of cancer of the ovary or cancer of the uterus. When you look at all women that develop ovarian cancer or uterine cancer, fewer than 5% of those patients will have this particular cell type. The cell type is tricky to treat because it is pretty aggressive based on its inherent biology. These tumors are basically comprised of a combination of what we call epithelial carcinoma – these are your regular “garden variety” serous ovarian and endometrial ovarian cancer, for example – and then the second component of the tumor is a sarcoma type. So this combination of epithelial carcinoma and sarcoma is what makes it “triple MT” [MMMT] or a carcinosarcoma, and these tumors tend to be aggressive in how quickly they spread and then how refractory [resistant] they can be sometimes to surgical and systemic treatment or chemotherapies.

Confirm the Diagnosis (MDC)

So, to address the first question, the first thing you need to say is you want to have an expert pathologist, somebody who does GYN pathology, day in and day out, look at the tissue slides to make sure that you have indeed been rendered the correct cell type and that your cancer is truly a carcinosarcoma, because many of these cancers are misclassified by pathology doctors who are not really experts. When you think about it, if you are talking about a cancer that occurs with a frequency of 5% of the time [of ovarian cancers], it’s going to take an expert pair of eyes to be able to make the accurate diagnosis.

So to me, the first part of it is making sure that if you have been diagnosed with a carcinosarcoma of the uterus or of the ovary, make sure that that diagnosis has been rendered by an expert gynecologic pathologist. And those pathologists usually live in tertiary care centers or cancer care centers, mostly affiliated to big academic centers. So whether it is the MGH or the Brigham, Sloan-Kettering, Hopkins, the Mayo Clinic, MD Anderson, but places where all they do, day in and day out, is read gynecological cancers as opposed to what happens in a lot of other places where a general pathologist is reading prostate cancer today, they’re reading colon cancer tomorrow and then the next day they are going to read ovarian cancer. So because of the rarity associated with this diagnosis, I think the first step is to make sure that you have a solid diagnosis based on expert pathology review.

Team of Experts (MDC)

I think after that, if it is indeed a carcinosarcoma, you really need to put together a team of experts who have a lot of experience managing these cancers.

Clinical trials can be tricky. They’re not for everyone. But for many patients they’re the right choice to make.

2. What is the Treatment for Carcinosarcoma? (DR)

Could you describe the treatment for carcinosarcoma based on when you’re diagnosed with it? There seems to be such broad variation depending on what treatment center you go to. I think you alluded to that. I think the quality of your treatment team is going to define how long you live. It could be a huge factor in your treatment.

The Staging Process (MDC)

For this cancer because of the inherent aggressive biology of them… so they can come up either from the uterus or from the ovary. Irrespective of how early the stage is, and these cancers I want to highlight, they’re staged surgically, for the most part.

Sometimes if we are not going to operate, we stage them clinically by imaging studies – usually chest, abdomen and pelvic CT or a PET CT.

But for the most part, when you’re talking about early stage carcinosarcoma, you’re talking about a tumor that is either confined to the uterus, if it’s coming from the uterus, or confined to the ovary, if it’s arising from the ovary. The information about that confinement, meaning that we know with 100% certainty that the cancer has not spread, is based on surgical findings.

Let me kind of walk you through a sort of generic patient experience in early stage tumors:

Metastatic Disease

For women that have metastatic disease up front, meaning that there is already a recognition by the clinician that the cancer has left its site of origin and it has spread at other places, the presentation of the patient can be different. They can present with something else and then as part of that something else, they have a workup [testing] that includes:

3. What’s the role of radiation? (DR)

Very Localized Therapy (MDC)
So, you have to think of radiation therapy in the management of cancers of the gynecological tract as very localized therapy. Surgery and radiation are similar in that they treat only an area that you are going to remove surgically or that you are going to irradiate specifically. So they are not meant to treat the entire body.

Side Effects

Benefit of Radiation

Other Considerations

4. So, if you have more extensive disease, radiation is probably not a good method. (DR)

MDC
That’s correct. As a general statement, that is right. There are always exceptions to any rule. And I think that if a patient comes in and they had an area that looks like a metastases but there was really nothing above that, and that you think you would get better local control by giving some radiation therapy, sometimes we tailor the radiation to only be in that particular specific spot of the body and try to shield more normal anatomy away from the radiation beam. But in general, I would say radiation is local treatment, it decreases the risk of a cancer coming back in that specific area of the body, but it doesn’t change the risk that the cancer would show up in another place outside of the area that you irradiated.

DR
Thank you so much for sharing your time and expertise with us.

Watch the video of the transcript