“Ovarian cancer – previously known as the silent killer – is not so silent anymore”: Meet Professor Christina Fotopoulou

According to Cancer Research UK, approximately 7,500 women are newly diagnosed with ovarian cancer. Unfortunately, many women are undiagnosed for months because the symptoms are similar to those of other conditions. Professor Christina Fotopoulou is a gynaecological oncology surgeon at Queen Charlotte's & Chelsea Hospital and a leader in the field of ovarian cancer. Here, she discusses the diagnosis and treatment of ovarian cancer and how both have evolved over time, and how she is helping to fight the disease through research.

Tell us about your role.

At Queen Charlotte’s & Chelsea we are a tertiary referral centre, so we see women from all over the UK who come to us seeking a second or third opinion due to challenging presentation of the disease. Alongside my team, my role is to support and operate on these women, when appropriate. I am also the chair for gynaecological cancer surgery at Imperial College London and in this role, I lead on research to find solutions to defeat ovarian cancer.

Ovarian cancer will affect approximately one in 55-75 women, so it is much rarer than breast cancer for example which affects 1 in 8 women. It was known as the silent killer because many of the symptoms – abdominal bloating, irregular bowel moments and pain – resemble menopausal symptoms or those of irritable bowel syndrome (IBS). GPs and other generalist healthcare professionals might not immediately diagnose ovarian cancer and many women get undiagnosed for months before they reach us. Therefore, it is important that we do not dismiss any persistent, newly appearing symptoms and that we acknowledge how difficult the journey of many women has been before they reach a specialist. It is our responsibility to explain available treatment options and associated risks so that patients can make an informed decision on what is the right course of action for them.

What are the risk factors for ovarian cancer?

The main risk factors for ovarian cancer are older age, being overweight, postmenopausal hormone replacement therapy, endometriosis, early start of menstruation and late menopause, and never having been pregnant. Moreover, genetic risk factors are crucial; if someone for example inherits a harmful variant of the BRCA1 or BRCA2 gene. We know that approximately 25-30% of epithelial ovarian cancer patients (the most common type) will be BRCA mutant and approximately half of these patients will have a negative family history. The National Institute for Health and Care Excellence (NICE) and NHS England have now established routine genetic testing in all patients with high grade, non-mucinous epithelial ovarian cancer, even in those who have a negative family history.

What inspired your career within this field?

My father – he is a general surgeon in the University of Athens, and he used to help the gynae oncologist with their procedures in Athens. As a child I was always fascinated by how surgical efforts and expertise could change the fate of these women and I wanted to do the same.

Nowadays, I still look up to my mentors from my days at the Charité University Hospital of Berlin; key opinion leaders in the field and of course I am inspired daily by my children.

How has the field of gynaecological oncology evolved throughout your career?

I am fortunate to be considered one of the leading experts in this field and I have been involved in the development of national and international guidelines on how to diagnose, treat and follow up the disease. I also teach surgical advances all over the world, so I am constantly exchanging knowledge with other colleagues in the field.

Previously, many patients were deemed inoperable but now we can improve the quality and length of life for these women. We have learnt that even though the disease will reoccur in most women, patients will benefit from maximal removal of their tumours. Our aim is to make ovarian cancer a chronic disease whereby even in the cases where we can’t cure it, we can control it.

Surgical expertise has evolved massively over the years and NICE has now recognised the importance of surgery and new guidance issued in April 2023 reiterates and reinforces this.

On a systemic level, we have learnt that chemotherapy alone is not enough. After chemotherapy, patients will now go on a longer-term maintenance treatment with targeted new agents like PARP inhibitors which target the BRCA gene so that patients can live longer even if the disease returns.

Tell us more about your research.

With funding from Imperial Health Charity, my team and I are trying to decode the spatial and temporal heterogeneity of ovarian cancer. What does this mean? Ovarian cancer will affect the entire abdomen and will take the shape of multiple tumours. We are trying to understand whether all these tumours inside one patient have the same profile.

We have found that on a genetic and drug resistance level, these tumours are not the same and this is called heterogeneity. This makes treatment challenging and what makes this even more complex is that the disease changes over time so if it returns, the profile of the tumours will be different. Therefore, a single site biopsy is not enough – we need to profile multiple tumours from the abdomen to have a more representative picture and treat the disease more effectively.

I am supported by an amazing research team. Together, we combine our knowledge to meet the unmet needs of how to diagnose and treat ovarian cancer. Through this collaboration, we can practically revolutionise any ideas that we have for new treatments and advances for the betterment of the patient. As a surgeon, I also have the privilege of working with clinical nurse specialists and medical oncologists so that we have a more holistic approach of how to care for patients with ovarian cancer.

Congratulations on recently receiving the International Gynaecologic Cancer Society (IGCS) Award for Outstanding Achievement in Gynaecologic Oncology Surgery. Tell us about this award.

The International Gynaecological Cancer Society (IGCS) and the European Society of Gynaecological Oncology (ESGO) are the largest societies of gynae oncology internationally. They host annual awards, and I was humbled to receive this esteemed award from IGCS in recognition of my work developing national and international guidelines and surgical quality indicators; homogenising surgical care for patients with ovarian cancer; establishing centres for surgical expertise, and for my research.

Still, regardless of all scientific achievements and awards, my greatest achievement remains to be able to tell a woman that her surgery has gone well when it finishes. Nothing beats this. And by inputting into national and international guidelines, I can help women on a much larger scale by improving standards of care globally.

What is your key takeaway for women reading this?

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