Our Services / Gynaecologic Oncology

Advancing the Fight Against Ovarian Cancer

The number of women diagnosed with ovarian cancer in Australia increased from 833 in 1982 to 1,266 in 2007 [1]. An estimated 1,488 women are expected to be diagnosed with ovarian cancer in Australian in 2015 [2]. 75% of women with ovarian cancer present at an advanced stage (stages III / IV) with disseminated abdominal disease and ascites.

Screening

Presently, there is no evidence that population screening for ovarian cancer is of any benefit in reducing mortality from this disease. Even with combined tumour markers and imaging, overall survival is not improved whilst intervention rates are increased where 10 laparotomies or laparoscopies need to be performed to find one cancer. However, screening may have a role in high-risk populations, such as a strong family history, gene mutation carriers, and Ashkenazi Jewish women.

Initial Cytoreductive Surgery

The amount of residual tumour deposits after surgical management of ovarian cancer has been consistently shown to predict survival. Each 10% increase in maximal cytoreduction was associated with a 5.5% increase in median survival time [3]. With 75% of this disease presenting at stage III / IV with ascites and abdominal deposits of tumour on bowel, liver, diaphragm, and other abdominal organs, surgery to achieve optimal debulking may be radical, extensive and potentially morbid.

This surgery, in addition to the removal of the ovaries and uterus, often involves a bowel resection, omentectomy, diaphragmatic, and subsegmental liver resection. Deciding on whether a patient is a candidate for such a surgical approach should be made after careful consideration of other co-morbidities and following discussion in a multidisciplinary team meeting. Optimal debulking to nil macroscopic visible disease in selected patients, remains the gold standard of care in ovarian cancer patients.

Figure 1. Overall survival of secondary debulking by amount of residual disease. CL, confidence limits; NA, not applicable. Reprinted from International Journal of Gynecology and Obstetrics, Vol. 108, Schorge JO et al, “Secondary cytoreductive surgery for recurrent platinum-sensitive ovarian cancer," pp. 123-127, Copyright 2010, with permission from Elsevier.

Intraperitoneal Chemotherapy

Adjuvant chemotherapy has traditionally been administered intravenously. However, recent randomized studies have shown that combination intravenous and intraperitoneal chemotherapy delivered via a port directly into the abdominal cavity achieves better progression free (18.3 vs 23.8 months P=0.05) and overall survival (49.7 vs 65.6 months P=0.03) [4].

This improvement in survival only applies when initial cytoreductive surgery has achieved an optimal debulking with no residual disease >1cm. Intraperitoneal chemotherapy was associated with more side effects at the time of treatment when compared to intravenous-only treatments, but the quality of life was equivalent at 12 months after treatment.

Neoadjuvant Chemotherapy with Interval Debulking

In patients whom we predict may not achieve optimal debulking at the initial cytoreductive surgery, neoadjuvant chemotherapy should be strongly considered. This approach involves three cycles of chemotherapy followed by interval debulking surgery; then, a completion of a further three cycles of chemotherapy – this approach has been shown to achieve similar progression free and overall survival with less morbidity [5].

Initial treatment with chemotherapy may reduce tumour volume to allow less radical surgery in order to achieve optimal debulking. Complete resection of all macroscopic disease, whether performed as primary treatment before chemotherapy or as interval debulking surgery after neoadjuvant chemotherapy, remains the objective because complete resection of all macroscopic disease (at primary or interval surgery) is the strongest independent variable in predicting overall survival.

Targeted Therapy

Any use of targeted therapy for ovarian cancer is still classified as experimental and is not standard practice. Whilst trials are still underway, evidence is slowly emerging that there are several classes of drugs that may be effective against ovarian cancer.

Preliminary studies of chemotherapy with angiogenesis (growth of blood vessels) inhibitor drugs such as bevacizumab (Avastin) have shown improved progression free survival but not overall survival from ovarian cancer [6]. PARP Inhibitors may have some utility in ovarian cancers related to the BRCA mutation [7].

On-going Follow-up

There is limited evidence to show that intensive follow-up of any gynaecological cancer improves outcomes. This is counter-intuitive as one would think that earlier detection of recurrences might improve outcome.

Certainly there is no role for frequent CT scans as radiation from CT scans may be harmful. A recent large multi-centre randomized control trial compared whether to follow-up ovarian cancer patients who are asymptomatic with blood tumour markers or not – it showed that patients followed up with routine blood tumour markers lived just as long as those who did not have frequent blood tests; however, those who did have the blood tests had a poorer quality of life [8]. Patients who had regular blood tests had their recurrences discovered earlier, but despite earlier re-treatments with chemotherapy, there was no survival advantage, more side effects and poorer quality of life.

Certainly there are some limitations to this study, including the non-utility of secondary debulking surgery. These patients were mostly re-treated with chemotherapy without surgery, and secondary optimal debulking surgery prior to further chemotherapy for recurrent disease has been shown to improve survival compared to chemotherapy alone.

References

1.	Australian Institute of Health and Welfare & Australasian Association of Cancer Registries 2010. Cancer in Australia: an overview, 2010. Cancer series no. 60. Cat. no. CAN 56. Canberra: AIHW
2.	Australian Institute of Health and Welfare 2010. Gynaecological cancer projections 2010-2015. Cancer series no. 53. Cat. no. CAN 49. Canberra AIHW.
3.	Bristow et al. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2002) vol. 20 (5) pp. 1248-59
4.	Armstrong et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. New England Journal of Medicine (2006)
5.	Vergote et al. Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer. The New England journal of medicine (2010) vol. 363 (10) pp. 943-53
6.	Burger RA, Brady MF, Bookman MA, et al. Phase III trial of bevacizumab in the primary treatment of advanced epithelial ovarian cancer, primary peritoneal cancer, or fallopian tube cancer: a Gynecologic Oncology Group study. J Clin Oncol 2010;18s:946s (LBA 1).
7.	Chan and Mok. PARP inhibition in BRCA-mutated breast and ovarian cancers. Lancet (2010) vol. 376 (9737) pp. 211-3
8.	Rustin et al. Early versus delayed treatment of relapsed ovarian cancer (MRC OV05/EORTC 55955): a randomised trial. Lancet (2010) vol. 376 (9747) pp. 1155-63

Our Services / Gynaecologic Oncology

Dr Jason Tan, raised and educated in Perth, received his medical degree from the University of Western Australia in 1998. Thereafter, he completed six years of specialist training in obstetrics and gynaecology and was a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in 2007. He undertook further training and completed his fellowship in advanced gynaecological endoscopy at Monash Medical Centre, Melbourne, in 2008.

Dr Tan trained further for three years to subspecialise in gynaecological oncology at Mercy Hospital for Women, Melbourne; Queensland Centre for Gynaecological Cancers, Brisbane; and Ariake Cancer Research Centre, Tokyo, Japan; and completed the gynaecological oncology subspecialty training in 2010. In addition to that, he completed his fellowship in upper gastrointestinal surgery and bariatric surgery, at Sir Charles Gairdner Hospital in 2011.

Dr Tan’s special interest is surgical management of cancer, particularly in radical debulking surgery, and he specialises in laparoscopic management of gynaecological cancer. He sees patients with cancers of the ovaries, fallopian tubes, cervix, uterus, vulva and vagina. Besides that, he also sees patients with benign gynaecological conditions requiring complex surgery, such as severe endometriosis, fibroids and complex pelvic masses as well as investigation and management of abnormal Pap smears.

Dr Tan pioneered the robotic surgery for gynaecology and gynaecological oncology in Western Australia with the da Vinci System, further enhancing the legacy of minimally invasive surgery pioneered in Perth by the late Dr Tony McCartney. Robot assisted approach is advantageous in highly complicated procedures due to the better vision and dexterity, offered by the robotic instrumentation.

Dr Tan founded the WOMEN Centre, a leading multidisciplinary private centre for women’s health in Western Australia, in 2014. The specialists at WOMEN Centre provide a truly collaborative approach to patient care in order to ensure the best outcome possible and patients regaining their quality of life after treatment.

Besides his practice at WOMEN Centre, Dr Tan devotes his time to the public health service as consultant gynaecological oncologist at King Edward Memorial Hospital, which includes the teaching and training of medical trainees and junior doctors. He is also the current lead clinician for gynaecology and gynaecological oncology for the Western Australia Cancer and Palliative Care Network and a clinical senior lecturer at University of Notre Dame and University of Western Australia as well as preceptor at various surgical skills development workshops.

Qualifications and Training

2011	Fellowship in Upper Gastrointestinal Surgery and Bariatric Surgery – Sir Charles Gairdner Hospital
2010	Gynaecological Oncology Subspecialty, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (CGO)
2008	Fellowship in Advanced Gynaecological Endoscopy – Monash Medical Centre
2007	Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG)
2005	Member of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (MRANZCOG)
1998	Bachelor of Medicine, Bachelor of Surgery – University of Western Australia (MBBS)

Dr Tarek Meniawy manages all aspects of general medical oncology and also subspecialises in gynaecological malignancies, and melanoma. Besides his clinic at WOMEN Centre, Dr Meniawy devotes his time to Sir Charles Gairdner Hospital, King Edward Memorial Hospital and University of Western Australia as a clinical senior lecturer.

Dr Meniawy received his medical degree from Cairo University, Egypt; in 2000 and undertook postgraduate physician training at the Princess Alexandra Hospital, Brisbane. He had further training in medical oncology at Royal Perth Hospital and Sir Charles Gairdner Hospital, and was awarded the Fellowship of the Royal Australasian College of Physicians in 2011. He is a member of the Western Australia Gynaecological Cancer Service and the Western Australia Melanoma Advisory Service.

Dr Meniawy has a keen interest in research and is actively involved in clinical trials including early studies of novel therapies, and large international studies in gynaecological cancer and melanoma. He has a particular interest in tumour immunology and immunotherapy, which have resulted in major breakthroughs in cancer therapies in recent years.

In 2016, Dr Meniawy was awarded a Doctor of Philosophy by the University of Western Australia for his studies on the effects of targeted anti-cancer therapies on the immune system. He is also an active member of the Australia and New Zealand Gynaecological Oncology Group, a not-for-profit organisation, dedicated to gynaecological cancer research.

Qualifications and Training

2016	Doctor of Philosophy – University of Western Australia (PhD)
2011	Fellow of the Royal Australasian College of Physicians (Medical Oncology)
2000	Bachelor of Medicine, Bachelor of Surgery – Cairo University (MBBS)

Dr Paul Cohen is a gynaecologist with special interests in gynaecological oncology and the management of menopausal symptoms in women who have undergone treatment for cancer (including breast, colorectal, haematological and gynaecological cancers).

Dr Cohen completed his medical degree at the University of Oxford in the United Kingdom, and subsequently undertook specialist training in obstetrics and gynaecology in Auckland, New Zealand. He was granted Fellowship of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in 2010 and undertook full time research in the molecular biology of ovarian stromal tumours, for which he was awarded a Doctorate in Medicine by the University of Auckland in 2011. Thereafter, he undertook an additional three years of fellowship in gynaecologic oncology in Brisbane, Newcastle and Sydney, and relocated to Perth in 2013.

Dr Cohen currently works as a gynaecologist and a clinical senior lecturer at King Edward Memorial Hospital, and contributes his expertise to the Western Australia Gynaecological Cancer Service and the Menopausal Symptoms After Cancer Clinic, where he has been actively involved in research and teaching.

Dr Cohen is also the director of gynaecological cancer research at St John of God Subiaco Hospital, where he oversees a number of research projects and supervises undergraduate, Master and PhD students. He is an adjunct professor at the Institute for Health Research, University of Notre Dame, Fremantle.

More information here for gynaecological cancer research at St John of God Subiaco Hospital.

Qualifications and Training

2011	Doctorate of Medicine – University of Auckland (MD)
2010	Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG)
2002	Diploma Obstetrics and Medical Gynaecology – University of Auckland (Dip Obs)
2001	Master of Arts in Physiological Sciences – University of Oxford (MA Oxon)
2000	Bachelor of Medicine, Bachelor of Surgery – University of Oxford (BMBCh)
1997	Bachelor of Arts in Physiological Sciences – University of Oxford (BA)

Dr Stephen Lee - Obstetrician and Gynaecologist

Dr Stephen Lee manages all aspects of general obstetrics and gynaecology, with special interests in advanced laparoscopic surgery, complex gynaecological problems and fertility.

Before relocating to Perth, Dr Lee completed a two-year laparoscopic gynaecology fellowship under the mentorship of Dr Catarina Ang, Head of Gynaecology 1 Unit at Royal Women’s Hospital in Melbourne, an accredited training site of the Australasian Gynaecological Endoscopy and Surgery Society (AGES). During the fellowship, Dr Lee was able to perfect a wide range of minimally invasive gynaecology skills and was invited to speak at AGES and AAGL (American Association of Gynaecologic Laparoscopists) conferences to present his research.

Prior to his fellowship, Dr Lee completed basic obstetrics and gynaecology training at Monash Medical Centre in Melbourne. Subsequently, Dr Lee was a research fellow under the guidance of Associate Professor Sue Walker and Associate Professor Stephen Tong, at The Mercy Hospital for Women and University of Melbourne, investigating intrauterine growth restriction. Thereafter, he travelled to England to work as a clinical fellow in urogynaecology at Nottingham University Hospital under the supervision of Consultant Urogynaecologist Dr Paul Hooper.

Dr Lee devotes his time to the public health service as a consultant obstetrician and gynaecologist at King Edward Memorial Hospital. He is keen on improving the education and training of general practitioners, with an interest in women’s health, and budding obstetricians and gynaecologists.

Dr Lee earned his Bachelor of Medicine, Bachelor of Surgery from the University of Melbourne, and he is a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. In his spare time, he likes to cycle, play tennis and practise Chinese martial art.

Qualifications and Training

2013	Master of Business Administration, Melbourne Business School, University of Melbourne
2012	Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG)
2010	Member of Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (MRANZCOG)
2007	Postgraduate Diploma in Management, Melbourne Business School, University of Melbourne
2002	Bachelor of Medicine, Bachelor of Surgery – University of Melbourne (MBBS)

Dr Fred Busch - Obstetrician and Gynaecologist

Dr Fred Busch manages all aspects of general obstetrics, including high-risk obstetrics, and gynaecology.

Dr Busch’s special interests in gynaecology include advanced laparoscopic surgery (including hysterectomy and endometriosis), hysteroscopic surgery, pelvic floor repair and incontinence surgery, menorrhagia management, and colposcopy.

Dr Busch received his medical degree from the University of Stellenbosch in South Africa. He trained in the United Kingdom for paediatrics, ear nose and throat surgery, and obstetrics and gynaecology before relocating to Australia. He undertook the integrated obstetrics and gynaecology training program at King Edward Memorial Hospital and was granted Fellowship of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in 2007.

Qualifications and Training

2007	Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG)
2001	Australian Medical Council Equivalency Examinations
2000	Diploma of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (DRANZCOG)
1993	Bachelor of Medicine, Bachelor of Surgery – University of Stellenbosch (MBChB)

Dr Su Hamid - Obstetrician and Gynaecologist

Dr Su Hamid manages all aspects of general obstetrics up to 20 weeks of pregnancy and general gynaecology.

Dr Hamid’s special interests in gynaecology include colposcopy and management of abnormal Pap smear, endometriosis, ovarian cysts, Polycystic Ovarian Syndrome (PCOS), fibroids, pelvic pain, incontinence (including urodynamics) and pelvic organ prolapse, menstrual problems, painful intercourse, post coital bleeding, post-menopausal bleeding, vulval conditions, gynaecological cancer assessment and diagnosis, family planning, infertility assessment, and menopause management.

Dr Hamid graduated with a first class honours in Bachelor of Medical Sciences in 1990 and Bachelor of Medicine and Bachelor of Surgery in 1992, from the University of Nottingham in the United Kingdom. She has been working in obstetrics and gynaecology since 1993 and was granted membership to the Royal College of Obstetricians and Gynaecologists (United Kingdom) in 1998. She completed her Specialist Certificate of Training in Obstetrician and Gynaecologist in 2004 and obtained fellowship of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in 2008. After her move to Australia in 2003, she has worked in Perth, Melbourne and Geraldton. She is multilingual and can consult in Malay and English fluently.

Dr Hamid was born in Malaysia and moved to the United Kingdom where she studied and worked for 20 years before moving to Australia with her family; drawn by the quality of life and abundance of sunshine here. In her spare time, she enjoys working out in the gym and cycling.

Qualifications and Training

2008	Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG)
2004	Specialist Certificate of Training, Obstetrician and Gynaecologist
1998	Member of Royal College of Obstetricians and Gynaecologists (MRCOG)
1992	Bachelor of Medicine, Bachelor of Surgery – University of Nottingham (BM BS)
1990	Bachelor of Medical Sciences – University of Nottingham (B Med Sci)

Dr Jeremy Tan - General, Upper Gastrointestinal and Bariatric Surgeon

Dr Jeremy Tan completed his Bachelor of Medicine, Bachelor of Surgery (MBBS) at the University of Western Australia in 1999. He went on to undertake specialist training is general surgery and was awarded Fellow of the Royal Australasian College of Surgeons in 2007. He further subspecialises in upper gastrointestinal surgery and bariatric surgery after completing his fellowship for both at Sir Charles Gairdner Hospital in 2007.

Dr Tan attends obstetric and gynaecological operations where there may be concurrent surgical problems such as hernias or diseases that involve the bowel. He also contributes his expertise in gynaecological cancer surgery where the tumour deposits are in anatomical locations that require the expertise of a surgeon with extensive upper gastrointestinal surgical experience for a complete resection of tumour.

A joint approach gynaecological cancer surgery with Dr Tan facilitates the highest chance of optimal debulking with lower morbidity when the cancer require extensive surgical debulking in the upper abdomen. Dr Tan is also available for outpatient service such as vasectomy procedure at WOMEN Centre.

Qualifications and Training

2007	Fellowship in Upper Gastrointestinal Surgery and Bariatric Surgery – Sir Charles Gairdner Hospital
2007	Fellow of the Royal Australasian College of Surgeons (FRACS)
1999	Bachelor of Medicine, Bachelor of Surgery – University of Western Australia (MBBS)

Dr Tim Pavy - Specialist Pain Medicine Physician

Dr Tim Pavy, after graduating from the University of Adelaide, trained extensively in anaesthesia and intensive care in South Africa, Zimbabwe, England and Canada. He settled in Perth, in 1987, and is one of the key medical practitioners at King Edward Memorial Hospital, where he founded Australia’s first public Pelvic Pain Clinic in 2008.

Dr Pavy became a fellow of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists in 2000. His particular interests, on which he has published extensively and lectured at national, and international level, include anaesthesia and pain relief for pregnant women, and persistent pelvic pain.

Qualifications and Training

1988	Fellow of the Australian and New Zealand College of Anaesthetists (FANZCA)
1986	Fellow of the Royal College of Anaesthetists (FRCA)
1982	Diploma in Midwifery (Obstetrics) (Dip.Mid.COG)
1980	Diploma in Anaesthesia (DA)
1976	Bachelor of Medicine, Bachelor of Surgery – University of Adelaide (MBBS)

Dr Clayton Golledge - Physician in Infection Management and Clinical Microbiologist

Dr Golledge has more than 25 years of consultant experience as a Physician in Infection Management and Clinical Microbiologist. He trained initially in medicine at Princess Alexandra Hospital in Brisbane, Sir Charles Gairdner Hospital and Royal Perth Hospital. He subsequently completed his microbiology training at Royal Perth Hospital, Sir Charles Gairdner Hospital and Fremantle Hospital.

Dr Golledge did advanced training in infectious diseases at the City Hospital and Western General Hospital in Edinburgh and since 1991 has been a consultant at Sir Charles Gairdner Hospital and also consults at St John Of God Subiaco Hospital, Hollywood Hospital and Bethesda Hospital.

Dr Golledge was instrumental in setting up the inaugural Infectious Diseases Service at Sir Charles Gairdner Hospital and was also responsible for the Western Australia’s first Hospital In The Home Service through Sir Charles Gairdner Hospital.

Qualifications and Training

2011	Fellow of the Royal Geographical Society (FRGS)
2001	Fellow of the Royal College of Physicians (FRCP)
2000	Fellow of the Royal Society of Tropical Medicine (FRSTM)
1995	Fellow of the Australian College of Tropical Medicine (FACTM)
1991	Fellow of the Royal College of Pathologists of Australasia (FRCPA)
1990	Diploma of Tropical Medicine and Hygiene (DTM&H)
1980	Bachelor of Medicine, Bachelor of Surgery – University of Queensland (MBBS)
1977	Bachelor of Medical Science (BSc Med)

Dr Lesley Ramage - Women’s Health General Practitioner

Dr Lesley Ramage has more than 25 years of experience in women’s health as a general practitioner. She obtained her medical degree from Leeds University in the United Kingdom and completed her postgraduate general practitioner training in 1986.

Dr Ramage has worked in general practice since moving to Australia with her family in 1993. Since 2007, she has also held an appointment at King Edward Memorial Hospital where she consults in menopause and menopause symptoms after cancer clinics. She is actively involved in the teaching and training of medical undergraduates and doctors.

Dr Ramage holds a Postgraduate Diploma in Women’s and has been an invited speaker at a number of educational events. She regularly attends local, national and international scientific meetings to keep up to date with new developments in the field of women’s health.

Dr Ramage’s special interests include family planning and the management of menopause (both natural and following a diagnosis of cancer). She performs Pap smears and sexual health screening and provides osteoporosis and cardiovascular disease risk assessments.

Qualifications and Training

2006	Postgraduate Diploma in Women’s Health (PGDip Women’s Health)
1986	Family Planning Certificate
1986	Royal College of General Practice United Kingdom (RCGP)
1983	Bachelor of Medicine, Bachelor of Surgery – Leeds University (MBChB)