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Pictured: "Sun Drop Froot Loops," by Terry Thompson, on display at the SFMOMA Artists Gallery. (Anne Harnagel / Los Angeles Times)
You've been to San Francisco. You know not to call it "Frisco," not to expect ample parking, not to forget your sweater. You know the Powell Street cable cars run through Union Square and where to find the Golden Gate Bridge. You know that most days, the Oakland Airport works as well as SFO, sometimes better. But for a small city (about 7 miles by 7 miles), San Francisco changes fast, especially the restaurants. If your itinerary is dominated by reassuring old favorites (Union Square, again! City Lights books, again!), you may be missing a lot. To remedy that, six of us fanned out across the 49 square miles in late fall and early winter, using public transportation — bus (www.sfmta.com) and BART (www.bart.gov) — and scoped out 49 listings of sweet spots in the city that are new, newly transformed or just underappreciated. (Of course, we ended up with more than 49.) We're also offering more than a dozen suggestions for hotels that won't break your personal bank. The lists of sights and accommodations aren't complete by any means, so we welcome your ideas and suggestions at email@example.com.
Levi Strauss heir: A Feb. 24 article about places to visit in San Francisco mentioned Billionaires' Row in Pacific Heights. Among the residents mentioned was Levi Strauss heir Peter Haas, whose name was misspelled in the article as Peter Haus. —
Golden Gate Park
NightLife at the Academy, the California Academy of Sciences. These people put a buzz in biology. On NightLife Thursday nights, the museum goes adults-only, with thumping music, crazy lights, multiple bars and table tennis. (Who knew that Berlin-style table tennis was such a big thing in the city?) You'll likely find a DJ or live band in the building's central dining area, near an exhibition of California ground squirrels. Sometimes there are spiked snow cones. Tickets are usually $12 for nonmembers. The party goes 6 to 10 p.m. Then you'll need to find another. 55 Music Concourse Drive, Golden Gate Park; (415) 379-8000, https://www.calacademy.org.
— Christopher Reynolds
Fly-casting pools. Aside from the bison roaming nearby, these fly-casting practice ponds might be the most surprising and alluring park attraction in America. The casting pools draw world championships and expert anglers from the members-only lodge nearby. But the facility is also open to the public at no charge. Free lessons (and lunch) on the second Saturday of each month, starting at 9:30 a.m. In the heart of Golden Gate Park; https://www.ggacc.org.
— Chris Erskine
Conservatory of Flowers. The conservatory is a symphony of plant life. Through its 16,000 whitewashed panes of glass, the sun shines on hibiscus, bromeliads, ferns, taro plants, water lilies, lotus and more. Catch a tour with a docent at 11 a.m., 12:30 or 2:30 p.m. and learn, as I did, about such weird specimens as the Dracula orchid. "It was not named for Bela Lugosi," docent Judy Fayollat told my group. "The fellow who found it thought it looked like a little dragon." Dracula derives from draco, Latin for dragon, she said. That might give you a little chill, except there are places in the conservatory where it's 85 degrees and hotter — nice on a chilly day and remember, you're in San Francisco, so when isn't it? The only thing that breaks the harmonious atmosphere are the explosions at one end of the building. A special exhibit celebrating the city's Gold Rush years (through April 14) comes complete with recorded blasts, but its trolleys, trains and ships that move and hoot and "smoke" could keep younger folks engaged. It's included with admission: $7 for adults, $5 for kids 12-17, college students and seniors 65 and older, $2 for kids 5-11 and free for kids 4 and younger. Open 10 a.m.-4 p.m. Tuesdays-Sundays. 100 John F. Kennedy Drive; (415) 831-2090, https://www.conservatoryofflowers.org.
— Catharine Hamm
Hamon Tower, the De Young Museum. The museum's ninth-floor observation deck offers a vertigo-inducing 360-degree view of the western end of San Francisco, including the upper-most spires of the Golden Gate Bridge. Take several laps around the perimeter to scope out the sights through the floor-to-ceiling windows, stop at the book store and then head downstairs to visit the rest of the museum. 50 Hagiwara Tea Garden Drive, Golden Gate Park; (415) 750-3600, deyoung.famsf.org. Admission to the tower is free, but the De Young is $10 for adults, $6 for youths 13-17 and college students with ID.
— Anne Harnagel
Outer Richmond
Lands End. Start with views and history at the Lands End Lookout Visitor Center (opened in 2012) on the city's western edge. Then prowl the ruins of the Sutro Baths. Next, nip into the Cliff House for a pricey ocean-view meal or to nearby Louis' for a cup of red chowder. But you want to raise a sweat, so head northeast for about a mile on the much longer Coastal Trail, amid big trees and views of the Golden Gate Bridge and Marin Headlands. Then double back. Lands End Lookout, 680 Point Lobos Ave.; (415) 426-5240, https://www.parksconservancy.org/visit/park-sites/lands-end.html.
Tee Off Bar & Grill. Divey and delicious neighborhood joint with an inspired spin on pub grub, including its renowned mac 'n' cheese. Rotating menu includes kangaroo burgers and crab empanadas. All the way out in Outer Richmond, but a terrific pit stop for drinks and dinner after a day at Ocean Beach or a sunset hike along Lands End. Open 365 days a year, and among the friendliest, most-fetching places in town. Most entrees $10-$20. 3129 Clement St.; (415) 752-5439, https://www.teeoffbarandgrill.com.
The Presidio
Golden Gate Bridge Plaza. To mark the structure's 75th anniversary last year, local and federal agencies joined to make upgrades and additions to the plaza where tour buses stop. Besides a new gift shop, there's a green screen photo op, so even in soupy fog, you can get a doctored photo of yourself atop the bridge's rigging under a clear blue sky. (It's $20 for two 5x7 prints.) To leave the tour-bus crowd behind, descend a short trail to the Warming Hut, near water's edge. There you'll find a little pier, another great view and a shop-café with a better selection and better food than up the hill. The plaza stands at the S.F. end of Golden Gate Bridge. (415) 921-5858, https://www.goldengatebridge.org.
Walt Disney Family Museum. Visitors with small children (no strollers allowed) who are expecting a theme park-like experience might be better off elsewhere. Instead, this museum (a former Presidio barracks) is tailored for die-hard fans who expect no less than a scholarly look at Disney's life and work, presented in 10 galleries. Still, there's lots of fun here — check out the enormous model of Disneyland and the console TVs playing reruns of "Wonderful World of Color." Be forewarned: My cab driver had never heard of the museum but insisted it was in Golden Gate Park. On certain evenings, the museum hosts Animate Your Night, an after-hours party with entertainment and cocktails. 104 Montgomery St., the Presidio; (415) 345-6800, https://www.waltdisney.org. GPS'ers will need the 94129 ZIP Code. Without it, you will be directed to Montgomery Street in the Financial District. Open 10 a.m.- 6 p.m. Wednesdays-Mondays. Adults $20, seniors/students $15,children ages 6-17 $12.
Fort Mason
Fort Mason Center, https://www.fortmason.org, a complex of refurbished and repurposed military buildings, is home to small art galleries, museums, theaters and other arts groups, as well as restaurants and a bookstore. The two rooms of the Mexican Museum showcase only a small fraction of its 14,000 artworks and artifacts from ancient to contemporary times. The Tequila Don Julio Collection, a recent acquisition, features the work of Mexican and Mexican American artists in a variety of media and materials. Favorite piece: Julio C. Morales' "Lowrider Mambo," an exuberant sculpture made with car rims and drum stands. Building D; (415) 202-9700, https://www.mexicanmuseum.org. Open noon-4 p.m. Wednesdays-Sundays. Free. The SFMOMA Artists Gallery, an offshoot of the San Francisco Museum of Modern Art, skips the Warhols and Picassos in favor of upcoming and established Bay Area artists whose works are offered for sale or rent. Proceeds benefit the artists as well as support the museum's exhibitions and programming. Building A; (415) 441-4777, https://www.sfmoma.org/visit/artists_gallery. Open 10:30 a.m.-5 p.m. Tuesdays-Saturdays. Free. Folks fed up with our here-and-now society will find inspiration at the Long Now Museum and Store. It's run by the Long Now Foundation, which seeks "to provide a counterpoint to today's accelerating culture" and "foster long-term thinking." On display are large, sculptural 1/4-scale prototypes of pieces of its 10,000-year clock being built on West Texas land owned by Amazon founder Jeff Bezos. Building A; (415) 561-6582, https://www.longnow.com. Open 10:30 a.m.-5 p.m. Mondays-Fridays, 11 a.m.-6 p.m. Saturdays and Sundays. Free. The Museo Italo Americano has no permanent collection but instead hosts three or four exhibits a year celebrating the contributions of Italian Americans. On display through March 10 is a dual exhibit by two Sicilian American artists and teachers: "A Retrospective: Paintings From 1984 to the Present" by Joe Oddo and "Sicily Revisited" by Jean Marchese Gallagher. Its gift shop offers a selection of Murano glass jewelry, Deruta ceramics and children's books in Italian. Building C; (415) 673-2200, https://www.museoitaloamericano.org. Open noon-4 p.m. Tuesdays-Sundays. Free.
Fisherman's Wharf
City Guides. Exploring a city can be an expensive pastime. But not with City Guides. This nonprofit organization celebrates San Francisco by offering scores of free walking tours each week to help you discover the landmarks, legends and lore of the city. I tried the Fisherman's Wharf tour with Bethel Watt, one of 300 volunteer guides, and enjoyed two hours of behind-the-scenes revelations about this world-famous destination. Several different tours are offered daily, even in winter, covering various parts of the city. Most last 90 minutes to two hours. https://www.sfcityguides.org.
— Rosemary McClure
Boudin Museum and Bakery Tour. Passersby can stop and gaze through the street-level plate-glass windows of the demonstration bakery, but bread buffs will head upstairs to a gem of a small museum that recounts the Boudin Bakery history, which dates to 1849 and its founding in San Francisco. Check out the whimsical mobiles made with bread loaves shaped like sea critters, then watch the dough "dump" and the hundreds of loaves roll past on the conveyor belt. Stop first for a bite to eat (shrimp salad sandwich on a baguette, $9) at the Boudin Bakery Café on the ground level and get $1 off the $3 museum admission. 160 Jefferson St.; (415) 928-1849, https://www.boudinbakery.com.
San Francisco Maritime National Historic Park. Tap into this city's colorful seafaring history with a visit to the Maritime National Historic Park, near Aquatic Park. Besides a museum packed with interactive displays, the park's visitors center offers an opportunity to listen to sea chanteys, read a sailor's personal journal and check out vintage equipment. Free. 499 Jefferson St.; (415) 447-5000, https://www.nps.gov/safr/index.htm.
Hyde Street Pier. Ahoy, matey. Check out the fleet of historic vessels at Hyde Street Pier, near the Powell and Hyde streets cable-car turnaround. Visit the tall ship Balclutha, an 1886 square-rigger that rounded Cape Horn 17 times, and the Eureka, an 1890 steam ferry boat. Even if you don't want to tour the boats ($5 adults, free for supervised children under 16), the views of the bay and Golden Gate Bridge are phenomenal. (415) 561-7169, https://www.nps.gov/safr/historyculture/historic-vessels.htm.
Sidewalk cocktails. Looking for an inexpensive Fisherman's Wharf lunch? Try the chowder-in-a-sourdough-bread-bowl ($5.75) or sidewalk seafood cocktails ($4.75-$9) sold outside the pricey tourist restaurants. Avoid the overhead by ordering at the counter and taking a stroll through the inner or outer lagoons of Fisherman's Wharf, where you can sit on a bench and see docked fishing boats; one of them may have caught your lunch that morning.
Museums-in-motion. Tourists queue up in long lines to ride San Francisco's famous cable cars without realizing they can jump aboard another fun form of transportation: a historic trolley. The city's streetcars, nicknamed museums-in-motion, are vintage trolleys imported from around the world. Along with the cable cars, they form a steel triangle of tourist-friendly rails that deliver riders to Fisherman's Wharf, Union Square, Chinatown, Coit Tower and other famous locales. Fare: $2 adults, 75 cents for youth and seniors. Info: https://www.streetcar.org/museums-in-motion.
Telegraph Hill
Filbert Steps. Three stunning segments of steps soar from Sansome Street to Coit Tower. Take your time, and on either side of the rustic wooden stairs you'll see gorgeous homes — many Art Deco — with lovely gardens. At the top take in stunning city views and wander the perimeter of 210-foot-tall Coit Tower, with its murals from the 1930s, or ride an elevator to the top for a bird's-eye view of the city. From the bottom, it's a 15-minute walk to the Embarcadero.
— Jessica Gelt
Nob Hill/Russian Hill
Lombard Street, on foot. This famously curvy hillside block of Lombard Street (between Hyde and Leavenworth streets) is better for walkers than drivers. Either hike up Russian Hill or arrive by the Powell/Hyde cable car line (www.sfmta.com/cms/mfleet/cablecar.htm). That way, you can linger and enjoy the views down Hyde to Alcatraz and down Lombard to Coit Tower, and you need not scramble for parking. And it's fun to hear the chorus of foreign languages as tourists hop off the cable car and make their way down the winding street. From the bottom of the hill, it's an easy stroll to Washington Square.
Seven Hills Restaurant. Owner-chef Alexander Alioto, scion of one of San Francisco's noted political and culinary families, opened this cozy (just 38 seats) storefront restaurant in 2010. A starter of Parmigiano-Reggiano chips ($4), drizzled with 20-year-old balsamic, took the edge off while waiting at the even tinier bar. The house-made tortelli with wild mushrooms ($21), sauced with brown butter and thyme, were light and silky, but left me lusting after my neighbor's country-style pork chop with duck fat-roasted potatoes ($27). 1550 Hyde St.; (415) 775-1550, https://www.sevenhillssf.com. Open 5:30-9:30 p.m. Tuesday-Thursdays and Sundays, 5:30-10 p.m. Fridays and Saturdays. Reservations a must.
Swan Oyster Depot. Open for more than 100 years, this seafood shack nabbed top Bay Area seafood honors in a Zagat survey last year. The narrow room has only counter seating and is rarely without a line out its doors. Snag a seat and order from a wall menu of fresh oysters, clams and clam chowder as well as shrimp, prawn, crab and lobster seafood salads and cocktails. Meals come with a hunk of chewy sourdough bread and butter and are best consumed with a glass of cold, crisp white wine. The family-run business boasts some of the friendliest service in the city. Most items $10-$20. 1517 Polk St.; (415) 673-1101.
Tonga Room & Hurricane Bar. A mid-20th century icon of tiki style, the Tonga Room is in the historic Fairmont Hotel atop Nob Hill. Its lagoon — the hotel's former basement swimming pool — sports a floating stage where bands perform amid faux rainstorms. Patrons nosh on Pacific Rim fare such as Mongolian beef, Singapore noodles and orange chicken. Tiki drinks are elaborate, brightly colored and deadly strong. Happy hour (5-7 p.m. Wednesdays-Fridays) is a great time to visit. $19-$36. 950 Mason St.; (415) 772-5278, https://www.tongaroom.com.
North Beach
Beat Museum. Eight bucks gets you into this small museum stashed in a used book and record store. It pays homage to Neal Cassady, Jack Kerouac, Allen Ginsberg and other Beat Generation luminaries with homemade displays and cracked glass cases packed with books, manuscripts, photos and other ephemera, as well as the odd license plate and brown and tan plaid jacket worn by Kerouac. A new addition is the 1949 Hudson, still dusty and dirty, used in the recent "On the Road" movie. 540 Broadway; (800) 537-6822, https://www.kerouac.com 10 a.m.-7 p.m daily, except Christmas and New Year's. Adults $8, students $5.
Freddie's Sandwiches. Little neighborhood sandwich shop in North Beach has been drawing locals since 1926. Choice of breads, but the most popular is the soft sourdough. At $5.95, the Italian combo might be the best deal in town. Even the 6-inch can serve two. No ambience and limited seating, so grab lunch and head to the water. Sandwiches $6 and up. If heaven had a deli.... 300 Francisco St.; (415) 433-2882.
Café Divine. This spot has a tremendous location facing Washington Square Park and a great, airy feel. (It's also a good fallback if the breakfast/lunch line is too long at Mama's, a block away.) Sidewalk tables. Frequent live music, including accordion Mondays. Breakfast, lunch and dinner, with dinner entrees about $13-$20. 1600 Stockton St.; (415) 986-3414, https://www.cafedivinesf.com.
The Bike Rental District. Want to cover the waterfront or the Golden Gate on two wheels? You'll find the Bike Rental District (that's our nickname, not theirs) near the foot of Lombard Street. On this short stretch of Columbus Avenue, near the Joe DiMaggio Playground and North Beach Pool, three bike rental places compete: Bike & Roll San Francisco (899 Columbus Ave.; [415] 229-2000, https://www.bikethegoldengate.com); Columbus Cyclery (801 Columbus Ave.; [415] 561-9999, https://www.gobikeit.com) and Dylan's Tours (782 Columbus Ave.; [415] 932-6993, https://www.dylanstours.com).
Chinese Historical Society of America Museum. Designed by architect Julia Morgan, this sturdy brick building opened in 1932 as the Chinese Young Women's Christian Assn. Exhibits in the main gallery, the YWCA's gymnasium, recount the role of the Chinese in the history of San Francisco and the nation. Among the poignant displays is a small suitcase containing an immigrant's meager possessions: a hat, parasol, pipe, comb and chopsticks. 965 Clay St.; (415) 391-1188, https://www.chsa.org. Open noon to 5 p.m. Tuesdays-Fridays, 11 a.m.-4 p.m. Saturdays. Free first Thursday of the month. Adults $5, students/seniors $3, children ages 2-17 $2.
Chef Jia's. Let others wait in line at the more renowned, more expensive House of Nanking next door. Locals on a budget, or tourists with an eye for value, go to Chinatown for Chef Jia's, where dishes are offered sautéed or deep fried. This nondescript joint has only a dozen tables, and much of the business is neighborhood carry-out. But among the scores of storefront spots lining competitive Kearny Street, this is a standout, mostly for the food's freshness. Chicken dinners feature only breast meat. Try the honey chili chicken. And the five spices duck. From $6.95. 925 Kearny St.; (415) 398-1626.
Union Square
Burritt Room & Tavern. Inspired by film noir, this dining room and bar feature curtained booths and photos of old San Francisco. The bar gets loud. The restaurant stays pretty quiet (especially behind those booth curtains). Burritt Alley, just behind the tavern, is where Sam Spade's partner gets gunned down in "The Maltese Falcon." Owner-chef Charlie Palmer opened the restaurant in April 2012. The neighborhood is unlovely — near Union Square, but on the gritty block just before Stockton Street becomes Stockton Tunnel. (Upstairs from the tavern is the Mystic Hotel, another 2012 venture of Palmer's, 417 Stockton St.; (415) 400-0561, https://www.burritttavern.com. Dinner mains from $26.
Café de la Presse. Across the street, Chinatown begins. Around the corner, Union Square beckons. Upstairs, the Hotel Triton ushers guests into rooms papered with Kerouac excerpts. And in this busy, casual café, you can scan the global newsstand, then settle in among a local/global crowd for a bistro-style meal. 352 Grant Ave.; (415) 398-2680, https://www.cafedelapresse.com. Dinners mains from $19.
Maiden Lane. Don't blink or you might miss this alley off of Union Square, between Post and Geary. Once the city's scandalous red-light district, it now sports San Francisco's largest concentration of luxury retail shops, including Hermès, Gump's, Chanel and a host of other high-end stores. Be sure to visit Britex: four floors of every kind of fabric imaginable and thousands of styles of buttons. Maiden Lane also has a handful of outdoor cafes and its own opera singer, tenor Robert Close, who has been entertaining visitors for 25 years. https://www.visitunionsquaresf.com/about_union_square/maiden_lane/.
The Tenderloin
Saigon Sandwich. Banh mi lovers, rejoice. Saigon Sandwich is a tiny gem of a storefront along a gritty (but swiftly gentrifying) stretch of street in the Tenderloin that serves some of the best Vietnamese sandwiches in the city at rock-bottom prices. Step inside and order to go at the counter; there are only two seats at the front of the room. Choose roast chicken, roast pork, meatball pork or tofu, or opt for mixed roast pork and chicken pâte — a particularly decadent mouthful. Sandwiches come on a thick baguette, are slathered with tangy aioli and piled with cilantro, carrots and jalapeño peppers. $3.25-$3.75. 560 Larkin St.; (415) 474-5698.
Moulin Rouge Restaurant. Moulin Rouge serves breakfast as it was meant to be: inexpensive, flavorful and satisfying. The place is narrow and dim and sports the Toulouse-Lautrec-influenced décor of a previous incarnation. However, an elderly Asian husband-and-wife team now runs it as a no-frills American breakfast and lunch cafe. He takes the orders, and she cooks the food to order at a grill visible to the restaurant. The cream cheese-stuffed French toast and strawberry pancakes are luscious, and the organic ham and eggs — thick strips of savory grilled ham and crispy-edged fried eggs — are a house specialty. $5-$8. 887 Geary Blvd.; (415) 928-0158.
Civic Center
Books Inc. at Opera Plaza. Perhaps because of that drab name, Books Inc. is the best independent Bay Area bookshop chain you've never heard of. With a history dating to 1851, it has a dozen locations — including one in Opera Plaza on Van Ness Avenue that makes a perfect stop for browsing before a show at the War Memorial Opera House or after a stroll around City Hall. The shop has a nice kids section in back, a well-stocked magazine section in front, and an adjoining Peet's coffee outlet. Also, there's a busy Philz Coffee spot just across the street. 601 Van Ness Ave.; (415) 776-1111, https://www.booksinc.net.
Just for You Café. This sassy diner — a sign on a front window warns, "We reserve the right to pour coffee on your cellphone" — attracts locals, students, artists and other creative types in need of its huge beignets (three for $4.75) or other New Orleans and Mexican specialties ($8.50-$9.25). It's way off the tourist track in the Dogpatch neighborhood east of Potrero Hill, but well worth the trek for breakfast or lunch. 732 22nd St.; (415) 647-3033, https://www.justforyoucafe.com. Open 7:30 a.m.-3 p.m. Mondays-Fridays, 8 a.m.-3 p.m. Saturdays-Sundays.
Workshop Residence. Behind the bright blue facade is a creative think tank, opened in 2012, that pairs visiting artists and designers with local manufacturers to create affordable, appealing textiles, housewares, apparel and other objects. Artists are selected for stays of several weeks to several months and have use of the workshop/gallery and its small staff. An added perk is the upstairs apartment, where artists literally live over the store. The end result of all that creativity is sold in the gallery and online, with profits split with the artist. Last fall, Jim Isermann was artist in residence, fashioning lowly moving blankets into vibrantly hued wall hangings and furniture coverings. 833 22nd St.; (415) 285-2050, https://www.theworkshopresidence.com. Open 10 a.m.-6p.m. Tuesdays-Saturdays.
Mission District
Foreign Cinema. Great food, cool movies. The kitchen turns out elegant California-Mediterranean cuisine and a tall, whitewashed patio wall serves as movie screen. (Titles run in 2012 included "La Vie en Rose" and "The Brother From Another Planet.") Images can be murky, but the food is Technicolor, the ambience singular. Dinner nightly (entrees $20-$29) and weekend brunches. The adjoining Laszlo bar (2526 Mission St., [415] 401-0801) serves up dim, trendy atmosphere with an indoor balcony where you can pretend you're a Hungarian secret agent. (You can also order from the Foreign Cinema menu.) 2534 Mission St.; (415) 648-7600, https://www.foreigncinema.com.
St. Vincent Tavern & Wine Merchant. This long, lean space opened in May — yet another restaurant in the booming Mission District — and is going gangbusters. St. Vincent is the patron saint of wine and vinegar makers, and the wine list is a key attraction here. Menu is California-centric with global influences (entrees $24-$30). Besides reservations (which fill fast), there are 25 first-come, first-served seats at the stainless steel bar, chef's counter and communal table. Owner is sommelier and author David Lynch, not to be confused with that other David Lynch. 1270 Valencia St.; (415) 285-1200, https://www.stvincentsf.com.
Savanna Jazz. Need a place to unwind? Try this cozy, affordable retro jazz club set amid the taquerias of the Mission District. Live music five nights a week, with covers starting at $5. Thursday night jam sessions draw all levels of musicians, and the house band, led by trumpeter Eddie Ramirez, really kicks, blending traditional jazz and popular standards. Hearty burger and steak menu starts at $10. 2937 Mission St.; (415) 285-3369, https://www.savannajazz.com.
Paxton Gate. Oddities galore crowd this curiosity shop known for taxidermy, occult and other quirky novelties. Stuffed animals, from bats ($65) to bisons ($1,800), hang from the walls. Or browse for books, shells, fossils or plants. 824 Valencia St.; (415) 824-1872, https://www.paxtongate.com.
Precita Eyes Mural Arts and Visitors Center. Precita Eyes, which was founded in 1977 by area artists, is a community-based arts center that acts as a de facto curator of the Mission District's culturally resonant street art. Choose one of three walking tours to explore the rich variety of expression on display on the neighborhood's walls. The Classic Mural Tour includes an informative slide show as well as a talk on the history of murals and the state of the city's contemporary mural movement. More than 80 murals can be seen in an eight-block radius of the center. Tours from $15 to $20. 2981 24th St.; (415) 285-2287, https://www.precitaeyes.org.
Castro Theatre. Built in 1922 by Bay Area architect Timothy L. Pflueger, this historic landmark is a grand movie palace still in operation.. Designed to resemble a Mexican cathedral, the theater has seating for more than 1,400, a vintage Wurlitzer organ and a massive Art Deco chandelier dating from 1937. It once showed first-run movies, but now it's mainly an art house with a mix of classic and contemporary programming. A recent calendar included films as diverse as Fellini's "8 1/2," "Argo" and "Ghostbusters." 429 Castro St.; (415) 621-6120, https://www.castrotheatre.com.
Lower Haight
Two funky food joints are down the block from each other, in the chronically interesting, ungentrified Haight. Two Jack's Nik's Place is an oddly named but friendly soul food shack that's been in the family since 1977. Try the world-class fresh fish plates (from $7.50), black-eyed peas ($2) or oyster po-boy ($7.50). 401 Haight St.; (415) 431-6290, https://www.twojacksniksplace.com. Down the street, you'll find Memphis Minnie's, featuring some of the best barbecue on the West Coast. Zero in on the brisket. In the mood for ribs? Fine, but try the brisket too (smoked 18 hours). 576 Haight St.; (415) 864-7675, https://www.memphisminnies.com. Entrees $12-$21.
Pacific Heights
Billionaire's Row. Since the late 19th century, the city's wealthiest families have built spectacular mansions with beautiful views in exclusive Pacific Heights. How expensive? An eight-bedroom hilltop mansion at 2901 Broadway recently sold for more than $28 million, a bargain considering it originally was listed at $58 million. Among the neighbors (about 2700 to 2900 Broadway) are Oracle Chief Executive Larry Ellison, Getty Oil heir Gordon Getty and Levi Strauss heir Peter Haus. You can check out the homeowners' amazing views from the Lyon Street steps at Broadway, where you can also see Sen. Dianne Feinstein's $16.5-million house, which backs up to the stairway.
Swedenborgian Church of San Francisco. You may be tired from the walk if you arrive on foot at this national historic landmark in Pacific Heights, but time spent in this island of solitude, completed in 1895, will revive you. Its interior glows with the richness of its redwood walls. A fireplace in the back, whose andirons rise to become small crosses, puts you in mind of burning love, not the fires of hell. The religion grew out of the works of Swedish philosopher Emanuel Swedenborg, who abandoned his work as a scientist to contemplate Scripture. Whether you agree with him or find yourself far distant, the words of "Commonplace Blessings," to which a prayer book fell open on a late Friday afternoon, ring true and well: "Accept, oh Lord, our thankfulness for the countless commonplace blessings that surround us, so familiar that we often ignore them…so abundant that when we begin to count them our complainings are shamed into silence." The church is trying to establish public hours for visitation, but for now, you can call ahead or knock on the door from 1-6 p.m. Mondays-Fridays. Services are at 11 a.m. Sundays. 2107 Lyon St.; (415) 346-6466, https://www.sfswedenborgian.org.
Kabuki Springs & Spa. This place is a little like life itself: It's had its ups and downs. Since its acquisition by hotel group Joie de Vivre, it's in an up period. It's been refreshed, which is how you'll feel when you emerge from a communal or private bath, maybe coupled with a massage. Communal baths cost $22 weekdays, $25 weekends. Women take the plunge Sundays, Wednesdays and Fridays; the men Mondays, Thursdays and Sundays. Tuesdays are co-ed (bathing suits required). I tried the private bath/shiatsu massage Bliss package for $155. This is the spa place for nonspa (and nonrich) people. Massage and private bath packages begin at $120. 1750 Geary Blvd.; (415) 922-6000, https://www.kabukisprings.com.
YakiniQ Café. It's in Japantown, true, but the fare here finds its influence in many countries. Doesn't matter what country it's from, though, if it hits the spot on a cold and dreary day. Say yes to the sweet potato latte ($3.50). It's like drinking pumpkin pie. Or grab a sandwich (banh mi, perhaps, or caprese served on baguettes, $8.95, including salad), macaroons, shaved ice (more Asian than Hawaiian $5). It's like a gastronomic world tour without leaving Japantown. 1640 Post St.; (415) 441-9291.
Daiso Japan. If you're a fan of 99 cent stores, welcome to Daiso Japan, a slight step above both in price (most items $1.50) and merchandise. Because, really, who doesn't need an earbud spool? A pig soap dish? A contact lens case shaped like a tube of lipstick but with openings at each end for the lenses? (Turns out I didn't — this one doesn't work well unless you're wearing soft, slightly bendable lenses.) Browsing is free if you can resist. 22 Peace Plaza, No. 400; (415) 359-9397. If that doesn't make you smile, the Sanrio store may. The tending-toward-pink array of merchandise featuring Hello Kitty has made a fortune for Sanrio, has made fans out of millions children and adults, and has made some folks want to run screaming in the other direction. Well, meow. Also free if you avoid putting your paw in pocket, pulling out wallet. No. 315 Peace Plaza West Mall; (415) 614-2700. Need something more manly? You could try Soko Hardware, which has the tools you need for any project and also an array of Japanese home décor items whose grace contrasts with the testosterone of the tools. 1698 Post St.; (415) 931-5510. For quirky and fun, there's New People, which says K-pop has nothing on J-pop. (Take that, Psy!) Besides an underground cinema, the light, bright center has quirky stores and merchandise to match, some Goth, some triumphs of modern design, all interesting. 1746 Post St.; (415) 525-8630.
Nichibei Kai Cultural Center tea house. If you're in San Francisco on April 13 or 14, you can attend the spring tea ceremony and discover this treasure of culture and construction. The framework for the two tea rooms, one large for groups and one small, was built in Kyoto, Japan, brought to San Francisco and completed in the mid-'80s. The entrance to the small tea room is a story unto itself: It's purposely small so that a samurai, for whom the tea ceremony was originally developed, would have to leave his sword outside. The beautiful cedar, cultivated to have few knots, is planed, not sanded, and the intricate joinery speaks of old-world craftsmanship. The décor, which is subtle, changes with the season. 1759 Sutter St.; (415) 921-1782.
Paper Tree. If you aren't a fan of origami before you enter Paper Tree, you will be after, especially if you run into Linda Mihara, international origami artist. She'll share more about her work when she's not helping customers in search of origami, papers, books and other art supplies. A small area displays the creations of Mihara as well as Robert Lang, Brian Chan and Bernie Peyton, whose artistry is a complex mix of geometry and genius. It's a rich experience, and browsing is free. 1743 Buchanan Mall; (415) 921-7100, https://www.paper-tree.com
Benkyodo Co. This is Japantown's version of the corner coffee shop — friendly and warm with regulars who talk weather and politics — except that its pastries are not the day-old Danish you might find at Mel's but fresh and delicious Japanese mochi. Apple manju and pink habutai (mochi with lima bean) were among my favorites. It's a good, if slightly sinful, breakfast — to go if you must. $1.10-$1.25, cash only. 1747 Buchanan Mall; (415) 922-1244, https://www.benkyodocompany.com
For the record, 5 p.m. Feb. 28: This article refers to Levi Strauss heir Peter Haus. His name is actually Peter Haas.


text:
Pill or liquid form (oral)
Inhaled form
Corticosteroid and beta2-agonist combination
Inhaled corticosteroids are usually delivered using a
inhaler (MDI) but are also often available for dry
powder inhalers (DPI).
Corticosteroids decrease inflammation in
the airways (reducing swelling and
mucus production), making breathing easier.
corticosteroids may be used to treat
chronic obstructive pulmonary disease (COPD) when
symptoms rapidly get worse (COPD exacerbation), especially when
there is increased mucus production.
Inhaled corticosteroids may be used to treat stable symptoms
of COPD or symptoms that are slowly getting worse. Inhaled corticosteroids may
decrease the number of COPD exacerbations in people with severe COPD,
particularly those with
chronic bronchitis and frequent exacerbations.
Corticosteroids may be useful for people who have
asthma as a component of their disease.
Research results on oral corticosteroids for COPD exacerbations show that:
Research on inhaled
Studies report that combining an inhaled corticosteroid
with a long-acting beta2-agonist resulted in:
Combining a corticosteroid with a beta2-agonist and an
anticholinergic improved:7
But people who used fluticasone combined with a
beta2-agonist were more likely to get
It is not possible to predict who will improve
with corticosteroid therapy. Lung function tests (spirometry) can
be done before and after using the medicine, to learn if it has helped.
All medicines have side effects. But many people don't feel the side effects, or they are able to deal with them. Ask your pharmacist about the side effects of each medicine you take. Side effects are also listed in the information that comes with your medicine.
Here are some important things to think about:
The possibility of side effects
increases as the dose of the medicine increases. Side effects are less likely
to occur when you use the inhaled form of the medicine.
Common side effects of oral corticosteroids include:
Oral corticosteroids also may increase blood sugar level,
which may lead to a type of diabetes caused by the medicine (secondary diabetes). If you already have diabetes, it
may make the diabetes harder to control.
Common side effects
of long-term use of oral corticosteroids include:
Common side effects of inhaled steroids
The U.S. Food and Drug Administration (FDA) has
reported that salmeterol may make breathing more difficult. If your wheezing
gets worse after taking salmeterol, call your doctor right
Using a device called a
spacer with your metered-dose inhaler and rinsing your
mouth with water and spitting the water out after inhaling should reduce these
side effects.
See Drug Reference for a full list of side effects. (Drug
Reference is not available in all systems.)
Inhaled corticosteroids are
preferred to oral corticosteroids for long-term treatment of COPD, because they
cause fewer side effects. But low-dose inhaled steroids do not always work as
well as high-dose oral steroids.
Long-term treatment with oral
corticosteroids is not recommended.8 Although
long-term treatment with inhaled corticosteroids reduces the frequency of COPD
exacerbations in some people, the long-term risks and whether the benefit is
worth the risks of long-term treatment is not known.2
Most doctors recommend that everyone using an inhaler also use a
spacer. Use of a spacer is especially important when
using an inhaler containing a steroid medicine. But you should not use a spacer with a dry
powder inhaler (DPI).
Medicine is one of the many tools your doctor has to treat a health problem. Taking medicine as your doctor suggests will improve your health and may prevent future problems. If you don't take your medicines properly, you may be putting your health (and perhaps your life) at risk.
There are many reasons why people have trouble taking their medicine. But in most cases, there is something you can do. For suggestions on how to work around common problems, see the topic Taking Medicines as Prescribed.
If you are pregnant, breast-feeding, or planning to get pregnant, do not use any medicines unless your doctor tells you to. Some medicines can harm your baby. This includes prescription and over-the-counter medicines, vitamins, herbs, and supplements. And make sure that all your doctors know that you are pregnant, breast-feeding, or planning to get pregnant.
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.
Complete the new medication information form (PDF)(What is a PDF document?) to help you understand this medication.
CitationsSingh JM, et al. (2002). Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease. Archives of Internal Medicine, 162: 2527–2536.Alsaeedi A, et al. (2002). The effects of inhaled corticosteroids in chronic obstructive pulmonary disease: A systematic review of randomized placebo-controlled trials. American Journal of Medicine, 113: 59–65.McIvor RA, et al. (2011). COPD, search date April 2010. Online version of BMJ Clinical Evidence: http://www.clinical evidence.com.Highland KB, et al. (2003). Long-term effects of inhaled corticosteroids on FEV1 in patients with chronic obstructive pulmonary disease. Annals of Internal Medicine, 138: 969–973.Calverley P, et al. (2003). Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: A randomised controlled trial. Lancet, 361: 449–456.Hanania NA, et al. (2003). The efficacy and safety of fluticasone propionate (250 micrograms)/salmeterol (50 micrograms) combined in the Diskus Inhaler for the treatment of COPD. Chest, 124: 834–843.Aaron SD, et al. (2007). Tiotropium in combination with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease. Annals of Internal Medicine, 146(8): 545–555.Global Initiative for Chronic Obstructive Lung Disease (2011). Global Strategy for the Diagnosis, Management, and Prevention of COPD. Available online: http://www.goldcopd.org/uploads/users/files/GOLD_Report_2011_Feb21.pdf.
Last Revised:
November 29, 2011
Healthwise Staff
Medical Review:
E. Gregory Thompson, MD - Internal Medicine & Ken Y. Yoneda, MD - Pulmonology
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subset: commoncrawl


text:
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Incidence and Mortality
Estimated new cases and deaths from ovarian cancer in the United States in 2012:[1]
Several malignancies arise from the ovary. Epithelial carcinoma of the ovary is one of the most common gynecologic malignancies and the fifth most frequent cause of cancer death in women, with 50% of all cases occurring in women older than 65 years.[2] Approximately 5% to 10% of ovarian cancers are familial, and three distinct hereditary patterns have been identified: ovarian cancer alone, ovarian and breast cancers, or ovarian and colon cancers.[3] The most important risk factor for ovarian cancer is a family history of a first-degree relative (e.g., mother, daughter, or sister) with the disease. The highest risk appears in women with two or more first-degree relatives with ovarian cancer.[4] The risk is somewhat less for women with one first-degree and one second-degree relative (grandmother or aunt) with ovarian cancer.
In most families affected with the breast and ovarian cancer syndrome or site-specific ovarian cancer, genetic linkage has been found to the BRCA1 locus on chromosome 17q21.[5,6,7]BRCA2, also responsible for some instances of inherited ovarian and breast cancer, has been mapped by genetic linkage to chromosome 13q12.[8] The lifetime risk for developing ovarian cancer in patients harboring germline mutations in BRCA1 is substantially increased over the general population.[9,10] Two retrospective studies of patients with germline mutations in BRCA1 suggest that these women have improved survival compared with BRCA1 mutation-negative women.[11,12][Level of evidence: 3iiiA] The majority of women with a BRCA1 mutation probably have family members with a history of ovarian and/or breast cancer; therefore, these women may have been more vigilant and inclined to participate in cancer screening programs that may have led to earlier detection.
For women at increased risk, prophylactic oophorectomy may be considered after the age of 35 if childbearing is complete. In a family-based study among women with BRCA1 or BRCA2 mutations, of the 259 women who had undergone bilateral prophylactic oophorectomy, two of them (0.8%) developed subsequent papillary serous peritoneal carcinoma, and six of them (2.8%) had stage I ovarian cancer at the time of surgery. Of the 292 matched controls, 20% who did not have prophylactic surgery developed ovarian cancer. Prophylactic surgery was associated with a higher than 90% reduction in the risk of ovarian cancer (relative risk [RR], 0.04; 95% confidence interval [CI], 0.01–0.16), with an average follow-up of 9 years;[13] however, family-based studies may be associated with biases resulting from case selection and other factors that may influence the estimate of benefit.[14] (Refer to the Evidence of Benefit section in the PDQ summary on Ovarian Cancer Prevention for more information.) After a prophylactic oophorectomy, a small percentage of women may develop a primary peritoneal carcinoma, similar in appearance to ovarian cancer.[15] The prognostic information presented below deals only with epithelial carcinomas. Stromal and germ cell tumors are relatively uncommon and comprise less than 10% of cases. (Refer to the PDQ summaries on Ovarian Germ Cell Tumor Treatment and Ovarian Low Malignant Potential Tumor Treatment for more information.)
Ovarian cancer usually spreads via local shedding into the peritoneal cavity followed by implantation on the peritoneum and via local invasion of bowel and bladder. The incidence of positive nodes at primary surgery has been reported to be as much as 24% in patients with stage I disease, 50% in patients with stage II disease, 74% in patients with stage III disease, and 73% in patients with stage IV disease.[16] In this study, the pelvic nodes were involved as often as the para-aortic nodes. Tumor cells may also block diaphragmatic lymphatics. The resulting impairment of lymphatic drainage of the peritoneum is thought to play a role in development of ascites in ovarian cancer. Also, transdiaphragmatic spread to the pleura is common.
Prognosis in ovarian cancer is influenced by several factors, but multivariate analyses suggest that the most important favorable factors include:[17,18,19,20,21]
For patients with stage I disease, the most important prognostic factor is grade, followed by dense adherence and large-volume ascites.[22] DNA flow cytometric analysis of stage I and stage IIA patients may identify a group of high-risk patients.[23] Patients with clear cell histology appear to have a worse prognosis.[24] Patients with a significant component of transitional cell carcinoma appear to have a better prognosis.[25]
Although the ovarian cancer-associated antigen, CA 125, has no prognostic significance when measured at the time of diagnosis, it has a high correlation with survival when measured 1 month after the third course of chemotherapy for patients with stage III or stage IV disease.[26] For patients whose elevated CA 125 normalizes with chemotherapy, more than one subsequent elevated CA 125 measurement is highly predictive of active disease, but this does not mandate immediate therapy.[27,28]
Most patients with ovarian cancer have widespread disease at presentation. This may be partly explained by relatively early spread (and implantation) of high-grade papillary serous cancers to the rest of the peritoneal cavity.[29] Conversely, symptoms such as abdominal pain and swelling, gastrointestinal symptoms, and pelvic pain often go unrecognized, leading to delays in diagnosis.[30,31,32] (Refer to the PDQ summaries on Pain and Gastrointestinal Complications for more information.) As a result of these confounding factors, yearly mortality in ovarian cancer is approximately 65% of the incidence rate. Long-term follow-up of suboptimally debulked stage III and stage IV patients showed a 5-year survival rate of less than 10% with platinum-based combination therapy prior to the current generation of trials including taxanes.[17] By contrast, optimally debulked stage III patients treated with a combination of intravenous taxane and intraperitoneal platinum plus taxane achieved a median survival of 66 months in a Gynecologic Oncology Group trial.[33] Numerous clinical trials are in progress to refine existing therapy and test the value of different approaches to postoperative drug and radiation therapy. Patients with any stage of ovarian cancer are appropriate candidates for clinical trials.[34,35] Information about ongoing clinical trials is available from the NCI Web site.
Related Summaries
Other PDQ summaries containing information related to ovarian epithelial cancer include the following:
The following is a list of ovarian epithelial cancer histologic classifications.
(Refer to the PDQ summary on Ovarian Low Malignant Potential Tumor Treatment for more information.)
In the absence of extra-abdominal metastatic disease, definitive staging of ovarian cancer requires laparotomy. The role of surgery in patients with stage IV disease and extra-abdominal disease is yet to be established. If disease appears to be limited to the ovaries or pelvis, it is essential at laparotomy to examine and biopsy or to obtain cytologic brushings of the diaphragm, both paracolic gutters, the pelvic peritoneum, para-aortic and pelvic nodes, and infracolic omentum, and to obtain peritoneal washings.[1]
The serum CA 125 level is valuable in the follow-up and restaging of patients who have elevated CA 125 levels at the time of diagnosis.[2,3,4] While an elevated CA 125 level indicates a high probability of epithelial ovarian cancer, a negative CA 125 level cannot be used to exclude the presence of residual disease.[5] CA 125 levels can also be elevated in other malignancies and benign gynecologic problems such as endometriosis, and CA 125 levels should be used with a histologic diagnosis of epithelial ovarian cancer.[6,7]
Definitions: FIGO
The Féderation Internationale de Gynécologie et d'Obstétrique (FIGO) and the American Joint Committee on Cancer (AJCC) have designated staging to define ovarian epithelial cancer; the FIGO system is most commonly used.[8,9]
Treatment options:
In two, large, European trials, European Organization for Research and Treatment of Cancer-Adjuvant ChemoTherapy in Ovarian Neoplasm (EORTC-ACTION) and International Collaborative Ovarian Neoplasm (MRC-ICON1 [NCT00002477]), patients with stage IA and stage IB (grades II and III), all stage IC and stage II, and all stage I and stage IIA clear cell carcinoma were randomly assigned to adjuvant chemotherapy or observation. Data were reported individually and in pooled form.[12,13,14]
The EORTC-ACTION trial required at least four cycles of carboplatin or cisplatin-based chemotherapy as treatment. Although surgical staging criteria were monitored, inadequate staging was not an exclusion criterion. Recurrence-free survival (RFS) was improved in the adjuvant chemotherapy arm (hazard ratio [HR], 0.63; P = .02), but overall survival (OS) was not affected (HR, 0.69; 95% confidence interval [CI], 0.44–1.08; P = .10). OS was improved by chemotherapy in the subset of patients with inadequate surgical staging.
The MRC-ICON1 trial randomly assigned patients to six cycles of single-agent carboplatin or cisplatin or platinum-based chemotherapy (usually cyclophosphamide, doxorubicin, and cisplatin) versus observation and had similar entry criteria to the EORTC-ACTION trial; however, the MRC-ICON1 trial did not monitor whether adequate surgical staging was performed. Both RFS and OS were significantly improved; 5-year survival figures were 79% with adjuvant chemotherapy versus 70% without adjuvant chemotherapy.
The pooled data from both studies indicate significant improvement in RFS (HR, 0.64; 95% CI, 0.50–0.82; P = .001) and OS (HR, 0.67; 95% CI, 0.50–0.90; P = .008). These pooled data provide for an OS at 5 years of 82% with chemotherapy and 74% with observation, with a 95% CI in the difference of 2% to 12%. An accompanying editorial emphasizes that the focus of subsequent trials must be to identify patients who do not require additional therapy among the early ovarian cancer subset.[15][Level of evidence: 1iA] Optimal staging is one way to better identify these patients. Except for the most favorable subset (patients with stage IA well-differentiated disease), Gynecologic Oncology Group (GOG) trials, and the evidence above, which is based on double-blinded, randomized controlled trials with total mortality endpoints, support treatment with cisplatin, carboplatin, and paclitaxel (in the United States).
In future trials, the Ovarian Committee of the GOG has opted to include patients with stage II disease in advanced ovarian cancer trials and not to include further study of patients with stage I disease at this time.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I ovarian epithelial cancer and stage II ovarian epithelial cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Treatment options for patients with all stages of ovarian epithelial cancer have consisted of surgery followed by chemotherapy.
Patients diagnosed with stage III and stage IV disease are treated with surgery and chemotherapy; however, the outcome is generally less favorable for patients with stage IV disease. The role of surgery for patients with stage IV disease is unclear, but in most instances, the bulk of the disease is intra-abdominal, and surgical procedures similar to those used in the management of patients with stage III disease are applied. The options for intraperitoneal (IP) regimens are also less likely to apply both practically (as far as inserting an IP catheter at the outset) and theoretically (aimed at destroying microscopic disease in the peritoneal cavity) in patients with stage IV disease.
Surgery has been used as a therapeutic modality and also to adequately stage the disease. Surgery should include total abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy and debulking of as much gross tumor as can safely be performed. While primary cytoreductive surgery may not correct for biologic characteristics of the tumor, considerable evidence indicates that the volume of disease left at the completion of the primary surgical procedure is related to patient survival.[1] A literature review showed that patients with optimal cytoreduction had a median survival of 39 months compared with survival of only 17 months in patients with suboptimal residual disease.[1][Level of evidence: 3iA] Results of a retrospective analysis of 349 patients with postoperative residual masses no larger than 1 cm suggested that patients who present at the outset with large-volume disease and achieve small-volume disease by surgical debulking have poorer outcomes than similar patients who present with small-volume disease.[2] Gradual improvement in survival with decreasing residual tumor volume is likely. Although the association may not be causal, retrospective analyses, including a meta-analysis of patients receiving platinum-based chemotherapy, have found cytoreduction to be an independent prognostic variable for survival.[3,4]
A study led by the European Organization for the Research and Treatment of Cancer (EORTC) Gynecological Cancer Group, together with the National Cancer Institute of Canada (NCIC) Clinical Trials Group (EORTC-55971 [NCT00003636]) between 1998 and 2006 included 670 women with stage IIIC and IV ovarian, tubal, and primary peritoneal cancers.[5] The women were randomly assigned to primary debulking surgery followed by at least six courses of platinum-based chemotherapy or to three courses of neoadjuvant platinum-based chemotherapy followed by so-called interval debulking surgery, and at least three more courses of platinum-based chemotherapy. Methods included efforts to ensure accuracy of diagnosis (vis-à-vis peritoneal carcinomatosis of gastrointestinal origin) and stratification by largest preoperative tumor size (excluding ovaries) (<5 cm, >5 cm–10 cm, >10 cm–20 cm, or >20 cm). Other stratification factors were for institution, method of biopsy (i.e., image-guided, laparoscopy, laparotomy, or fine-needle aspiration), and tumor stage (i.e., stages IIIC or IV). The primary endpoint of the study was overall survival (OS), with primary debulking surgery considered the standard.
Median OS for the primary debulking surgery was 29 months, compared with 30 months for patients assigned to neoadjuvant chemotherapy. The hazard ratio (HR) for death in the group assigned to neoadjuvant chemotherapy followed by interval debulking, as compared with the group assigned to primary debulking surgery followed by chemotherapy, was 0.98 (90% confidence interval [CI], 0.84–1.13; P = .01 for noninferiority).[5][Level of evidence: 1iiA] Perioperative and postoperative morbidity and mortality were higher in the primary-surgery group (7.4% severe hemorrhage and 2.5% deaths, contrasting with 4.1% severe hemorrhage and 0.7% deaths in the neoadjuvant group). The strongest independent predictor of prolonged survival was the absence of residual tumor after surgery. The subset of patients achieving optimal cytoreduction (≤1 cm residuum) whether after primary debulking surgery or after neoadjuvant chemotherapy followed by interval debulking surgery had the best median OS.
For the past 3 decades, the Gynecologic Oncology Group (GOG) has conducted separate trials for women whose disease has been optimally cytoreduced (most recently defined as ≤1 cm residuum) and for those who had suboptimal cytoreductions (>1 cm residuum). The extent of residual disease following the initial surgery is a determinant of outcome in most series [1,2,3,4] and has been used in the design of clinical trials, particularly by the GOG.
On the basis of these findings, the standard treatment approaches are subdivided into the following:
Treatment Options for Patients With Optimally Cytoreduced Stage III Disease
IP chemotherapy
The pharmacologic basis for the delivery of anticancer drugs by the IP route was established in the late 1970s and early 1980s. When several drugs were studied, mostly in the setting of minimal residual disease at reassessment after patients had received their initial chemotherapy, cisplatin alone and in combination received the most attention. Favorable outcomes from IP cisplatin were most often seen when tumors had shown responsiveness to platinums and with small-volume tumors (usually defined as tumors <1 cm).[6] In the 1990s, randomized trials were conducted to evaluate whether the IP route would prove superior to the intravenous route. IP cisplatin was the common denominator of these randomized trials.
The use of IP cisplatin as part of the initial up-front approach in patients with stage III optimally debulked ovarian cancer is supported principally by the results of three randomized clinical trials (SWOG-8501, GOG-0114, and GOG-0172).[7,8,9] These studies tested the role of IP drugs (IP cisplatin in all three studies and IP paclitaxel in the last study) against the standard IV regimen. In the three studies, superior progression-free survival (PFS) and OS favoring the IP arm was documented. Specifically, the most recent study, GOG-0172, resulted in a median survival rate of 66 months for patients on the IP arm versus 50 months for patients who received IV administration of cisplatin and paclitaxel (P = .03).[9][Level of evidence:1iiA] Toxic effects were greater in the IP arm, contributed to in large part by the cisplatin dose per cycle (100 mg/m2) and by sensory neuropathy from the additional IP as well as from the IV administration of paclitaxel. The rate of completion of six cycles of treatment was also less frequent in the IP arm (42% vs. 83%) because of the toxic effects and catheter-related problems.[10]
Notwithstanding these problems, IP therapy for patients with optimally debulked ovarian cancer is receiving wider adoption, and efforts are under way by the GOG to examine some modifications of the IP regimen used in GOG-0172 to improve its tolerability (e.g., to reduce by ≥25% the total 3-hour amount of cisplatin given; a shift from the less practical 24-hour IV administration of paclitaxel to a 3-hour IV administration). A Cochrane-sponsored meta-analysis of all randomized IP versus IV trials shows an HR of 0.79 for disease-free survival and 0.79 for OS, favoring the IP arms.[11] In another meta-analysis of seven IP versus IV randomized trials that were conducted by Cancer Care of Ontario, the relative ratio (RR) of progression at 5 years based on the three trials that reported this endpoint was 0.91 (95% CI, 0.85–0.98) and the RR of death at 5 years based on six trials was 0.88 (95% CI, 0.81–0.95).[10]
Treatment Options for Patients With Suboptimally Cytoreduced Stage III and Stage IV Disease
Cytoreductive surgery
The value of interval cytoreductive surgery has been the subject of two large phase III trials. In the first study, performed by the EORTC, patients subjected to debulking after four cycles of cyclophosphamide and cisplatin (with additional cycles given later) had an improved survival rate compared with patients who completed six cycles of this chemotherapy without surgery.[12][Level of evidence: 1iiB] The GOG-0162 trial was designed to answer a very similar question but used the then-standard paclitaxel-plus-cisplatin regimen as the chemotherapy.[13] This trial did not demonstrate any advantage from the use of interval cytoreductive surgery. The divergence of results may be caused by the efficacy of the chemotherapy obscuring any effects of interval cytoreduction, the wider use of maximal surgical effort at the time of diagnosis by U.S. gynecologic oncologists, or unknown factors. Although many patients with stage IV disease also undergo cytoreductive surgery at diagnosis, whether this improves survival has not been established.
Systemic chemotherapy
First-line treatment of ovarian cancer is cisplatin, given IV, or its second-generation analog, carboplatin, given either alone or in combination with other drugs. Clinical response rates from these drugs regularly exceed 60%, and median time-to-recurrence usually exceeds 1 year in this subset of suboptimally debulked women. Trials by various cooperative groups in the subsequent 2 decades addressed issues of optimal dose-intensity [14,15,16] for both cisplatin and carboplatin,[17] schedule,[18] and the equivalent results obtained with either of these platinum drugs, usually in combination with cyclophosphamide.[19] With the introduction of the taxane paclitaxel, two trials confirmed the superiority of cisplatin combined with paclitaxel to the previous standard of cisplatin plus cyclophosphamide; however, two trials that compared the agent with either cisplatin or carboplatin as a single agent failed to confirm such superiority in all outcome parameters (i.e., response, time-to-progression, and survival) (see Table 2).
Nevertheless, for patients with ovarian cancer, the combination of cisplatin or carboplatin and paclitaxel has been used as the initial treatment (defined as induction chemotherapy) for several reasons:
Since the adoption of the platinum-plus-taxane combination as the standard nearly worldwide, clinical trials have demonstrated:
In this large study consisting of 84% to 87% of patients with the Féderation Internationale de Gynécologie et d'Obstétrique stage III disease, as expected, the extent of cytoreduction was an important prognostic factor in OS. Results of PFS in patients with residuum greater than 1cm, less than or equal to 1 cm, or microscopic were 13, 16, and 29 months, respectively; whereas for OS, the results were 33, 40, and 68 months, respectively.[26]
Consolidation and/or maintenance therapy
In an effort to improve on the modest results achieved in suboptimally debulked patients (in contrast to those achieved after optimal cytoreduction and IP therapy), trials of consolidation and/or maintenance therapy have been carried out with drugs that contribute to the treatment of recurrent ovarian cancer. Presently, not one of the treatments given after the initial platinum/paclitaxel induction has been shown to improve survival; these treatments include the following:
A GOG-178 study of 277 patients compared three doses versus twelve doses of monthly paclitaxel given every 4 weeks following a clinically defined complete response at the time of completion of platinum/paclitaxel induction. However, the study was stopped early because of a very significant difference in PFS (28 months vs. 21 months).[33][Level of evidence: 1iiDiii] Subsequent updates of this data have raised the possibility that a subset with low CA 125s might show a survival benefit.[35] A trial to confirm the value of maintenance with taxanes versus observation is being conducted by the GOG.
A smaller Italian study entered 200 patients over 7 years who were randomly assigned to either 12 similar courses of monthly paclitaxel or observation; patients were in clinical complete response (n = 95) or pathologic complete response (n = 105) after induction therapy at the time of their random assignment.[34] Sensory neuropathy was the most prominent toxicity and was grade 2 in 21.3% of the patients and grade 3 in 6.7% of the patients. The median PFS for the maintenance paclitaxel arm was 34 months (95% CI, 20–43 months) and 30 months (95% CI, 17–53 months) for the observation arm. Neither PFS nor OS differences were significant.[34]
An accompanying editorial points out the weaknesses of both studies in order to draw conclusions (both stopped early and were noninformative for survival endpoint).[36] Also, although both studies addressed the issue of maintenance paclitaxel administered monthly, the patient populations differed. This was reflected by the considerably better outcome in both arms of the Italian study. Taken together, paclitaxel maintenance is of unproven value and requires validation by the ongoing and larger GOG-178 study cited above.
Two phase III trials (GOG-0218 [NCT00262847] and ICON 7 [NCT00483782]) have evaluated the role of bevacizumab in first-line therapy for ovarian, fallopian tube, and primary peritoneal cancers following surgical cytoreduction.[37,38] Both trials showed a modest improvement in PFS when bevacizumab was added to initial chemotherapy and continued every 3 weeks for 16 and 12 additional cycles, respectively, as a maintenance phase.
GOG-0218 was a double blind, randomized, controlled trial that included 1,873 women with stage III or IV disease, all of whom received chemotherapy—carboplatin (AUC 6) and paclitaxel (175 mg/m2 for six cycles).[37] Participants were randomly assigned to receive:
The women were enrolled with a primary endpoint of PFS; 40% of the patients had suboptimally resected stage III disease, and 26% had stage IV disease. There was no difference in PFS between the control group and the bevacizumab-initiation group. There was a statistically significant increase in PFS in the bevacizumab-throughout group when compared with the control group (14.1 vs. 10.3 months), with a HR of progression or death of 0.717 in the bevacizumab-throughout group (95% CI, 0.625–0.824; P < .001). Median OS was 39.3, 38.7, and 39.7 months for the control group, bevacizumab-initiation group, and the bevacizumab-throughout group, respectively. Quality of life was not different between the three groups. Hypertension grade 2 or greater was more common with bevacizumab than with the placebo. There were more treatment-related deaths in the bevacizumab-throughout arm (10 of 607, 2.3%) than in the control arm (6 of 601, 1.0%).[37][Level of evidence: 1iDiii]
ICON 7 randomly assigned 1,528 women after initial surgery to chemotherapy—carboplatin (AUC 5 or 6) plus paclitaxel (175 mg/m2 for six cycles)—or to chemotherapy plus bevacizumab (7.5 mg/kg for six cycles), followed by bevacizumab alone for an additional 12 cycles. The women were randomly assigned, and PFS was the main outcome measure; 9% of patients had early-stage, high-grade tumors, and 70% had stage IIIC or IV disease. Twenty-six percent had more than 1 cm of residual tumor prior to initiating chemotherapy. Median PFS was 17.3 months in the control group and 19 months in the bevacizumab group. HR for progression or death in the bevacizumab group was 0.81 (95% CI, 0.70–0.94; P = .004). Bevacizumab was associated with an increase in bleeding, hypertension (grade 2 or higher), thromboembolic events (grade 3 or higher), and gastrointestinal perforations. Grade 3 or greater adverse events were more common in the bevacizumab group. Quality of life was not different between the two groups.[38][Level of evidence: 1iiDiii]
A third trial, OCEANS (Ovarian Cancer Study Comparing Efficacy and Safety of Chemotherapy and Anti-Angiogenic Therapy in Platinum-Sensitive Recurrent Diseases [NCT00434642]), assessed the role of bevacizumab in the treatment of platinum-sensitive recurrences (see Table 3 for other trials in this setting). In this double-blind, placebo-controlled, phase III trial of chemotherapy (gemcitabine + carboplatin) with or without bevacizumab for recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer, 242 patients were randomly assigned per arm.[39] Median PFS for patients receiving bevacizumab was 12.4 months versus 8.4 months for those receiving a placebo. The effect of bevacizumab on HR to progression in patients assigned to the bevacizumab arm compared with placebo was 0.484 (95% CI, 0.388–0.605; P <.0001). Objective responses to chemotherapy were increased when combined with bevacizumab (78.5% vs. 57.4%; P < .0001).
In contrast to the first-line studies, treatment was allowed to continue beyond six cycles to ten cycles in responding patients, but there was no maintenance. A subsequent analysis will appear when additional survival data become mature; however, at the time of publication, differences in median survival were not apparent, and crossover from a placebo to bevacizumab had occurred in 31% of the patients. Bevacizumab-associated toxicities such as hypertension and proteinuria were more prominent than in the first-line trials, but feared safety issues, such as gastrointestinal perforations, did not occur during the study. Discontinuing treatment because of adverse events was more common with bevacizumab (n = 55 vs. n = 12 for placebo) but fewer patients discontinued treatment because of disease progression (n = 104 vs. n = 160 for placebo).[39][Level of evidence: 1iiDiii]
These three studies confirm the effect of improving PFS when bevacizumab is added to chemotherapy for ovarian cancer. In the OCEANS trial, the HR for progression was even more prominent than in the first-line trials, and a significant effect was seen when the bevacizumab and chemotherapy combination was extended beyond six cycles until progression. Without additional data, a statement about how bevacizumab should be used in ovarian cancer treatment is not possible because of the uncertain impact on OS, lack of clear delineation of who derives the greatest benefit, and prominent, associated toxicities.
At this time, the evidence does not support the use of bevacizumab as front-line therapy, because the gain in PFS comes with increased toxicity without improvement in OS or quality of life.
Treatment Options Under Clinical Evaluation
Information about ongoing clinical trials is available from the NCI Web site.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III ovarian epithelial cancer and stage IV ovarian epithelial cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Overall, approximately 80% of patients diagnosed with ovarian epithelial cancer will relapse after first-line platinum-based and taxane-based chemotherapy and may benefit from subsequent therapies; however, subsequent evidence questions this practice. Early detection of persistent disease by second-look laparotomies after completing first-line treatment is no longer practiced; when the outcomes in the 50% of institutions practicing such procedures were informally compared with the outcomes in those institutions not using such procedures, additional lack of support for them grew, as was found in the case for patients entered in GOG-0158.[1] However, the practice of close follow-up of patients completing treatment by serial CA 125s at intervals of 1 to 3 months was nearly universally adopted. In patients who are in clinical complete remission, increases in CA 125 from their initial treatment represent the most common method to detect disease that will eventually relapse clinically.
A trial by the Medical Research Council and European Organization for Research and Treatment of Cancer (MRC-OV05), which is now closed, examined the consequences of early institution of treatment for recurrence versus treatment delayed until clinical symptoms appeared.[2] Patients in clinical complete remission after platinum-based chemotherapy were registered and followed with CA 125s only and clinical visits. Upon detection of a twofold elevation over the normal range, patients were randomly assigned to disclosure of the result (and early treatment for recurrence) versus continued blinding and treatment upon development of signs and symptoms indicative of clinical relapse. The number of randomly assigned patients was to exceed 500 in order to yield a superior survival outcome at 2 years with early institution of therapy; this required 1,400 registrations, which were accrued between May 1996 and August 2005. Among 1,442 registrants, 29% continued to show no evidence of relapse, 19% relapsed without evidence of CA 125 doubling beyond normal or at the same time, and another 4% died prior to becoming eligible for random assignment. Registrants had stage III and stage IV disease in 67% of the cases, whereas these stages represented 80% of the randomly assigned patients. The median survival of all patients registered was 70.8 months.
Median survival for patients randomly assigned to early treatment (n = 265) was 25.7 months compared with 27.1 months for those patients in the delayed-treatment group (n = 264) (HR, 0.98; 95% CI, 0.8–1.2). The median delay in instituting second-line chemotherapy was 4.8 months, and the median delay in instituting third-line chemotherapy was 4.6 months. Treatments for second-line chemotherapy were comparable among the two groups (mostly platinum- and taxane-based), whereas third-line treatments were less often applied to the delayed-treatment group. The study concluded that there was no benefit in the detection of early presence of disease by CA 125; this is consistent with the failure of second-look surgeries to provide improved outcomes after early detection of persistent disease. Monitoring CA 125 levels in follow-up may play a role in identifying appropriate candidates for secondary cytoreduction, although this strategy awaits confirmation with a randomized trial.
Local Modalities: Surgery and Radiation Therapy
Cytoreduction is often employed,[3] but such intervention only now is being studied in the setting of a randomized clinical trial (GOG-0213). The role of radiation therapy in patients with recurrent ovarian cancer has not been defined.
Systemic treatment options for patients with recurrent disease are subdivided as follows:
Platinum-Sensitive Recurrence
Carboplatin was approved in 1987 for the treatment of patients with ovarian cancer whose disease recurred after treatment with cisplatin, based on improved survival with etoposide or 5-fluorouracil.[9] In a randomized, phase II trial of paclitaxel, a currently used second-line drug, the cisplatin-containing combination of cisplatin plus doxorubicin plus cyclophosphamide (CAP) yielded a superior survival outcome. This, and subsequent studies (see Table 3), have reinforced using carboplatin as the treatment core for patients with platinum-sensitive recurrences. Cisplatin is occasionally used, particularly in combination with other drugs, because of its lesser myelosuppression, but this advantage over carboplatin is counterbalanced by its greater intolerance. Oxaliplatin, initially introduced with the hope that it would overcome platinum resistance, has activity mostly in platinum-sensitive patients [10] but has not been compared with carboplatin alone or in combinations. With all platinums, outcome is generally better the longer the initial interval without recurrence from the initial platinum-containing regimens.[11] Therefore, on occasion, patients with platinum-sensitive recurrences relapsing within 1 year have been included in trials of nonplatinum drugs. In one such trial, comparing the pegylated liposomal doxorubicin (PLD) to topotecan, the subset of patients who were platinum sensitive had better outcomes with either drug (and in particular with PLD) relative to the platinum-resistant cohort.[12]
Several randomized trials have addressed whether the use of a platinum in combination is superior to single agents (see Table 3). A platinum-plus-paclitaxel combination yielded a superior outcome, in terms of response rates, PFS, and OS, in comparison to carboplatin as a single agent or other platinum-containing combinations as controls in an analysis of data analyzing jointly the results of three trials performed by the Medical Research Council/Arbeitsgemeinschaft Gynaekologische Onkologie (MRC/AGO) and ICON investigators (known as ICON4). Platinum plus paclitaxel was compared with several control regimens, though 71% used carboplatin as a single agent in the control, and 80% used carboplatin plus paclitaxel. Prolonged PFS (HR, 0.76; 95% CI, 0.66–0.89; P = .004) and overall survival (HR, 0.82; 95% CI, 0.69–0.97; P = .023) were improved in the platinum-plus-paclitaxel arm.[8][Level of evidence: 1iiA][5] The AGO had previously compared the combination of epirubicin plus carboplatin to carboplatin alone and had not found significant differences in outcome.
Another trial by European and Canadian groups compared gemcitabine plus carboplatin to carboplatin. The PFS of 8.6 months with the combination was significantly superior to 5.8 months for the carboplatin alone (HR, 0.72; 95% CI, 0.58–0.90; P = .003). The study was not powered to detect significant differences in OS, and the median survival for both arms was 18 months (HR, 0.96; CI, 0.75–1.23; P = .73).[7]
Carboplatin plus paclitaxel has been considered the standard regimen for platinum-sensitive recurrence in the absence of residual neurological toxic effects. The GOG-0213 trial is comparing this regimen to the experimental arm that adds bevacizumab to carboplatin plus paclitaxel.
In a phase III trial, carboplatin plus PLD (CD) was compared to carboplatin plus paclitaxel (CP) in patients with platinum-sensitive recurrence (>6 months). The primary endpoint was PFS with a median PFS for the CD arm of 11.3 months versus 9.4 months for the CP arm (HR, 0.823; 95% CI, 0.72–0.94; P = .005).[13][Level of evidence: 1iiDiii] The CP arm was associated with increased severe neutropenia, alopecia, neuropathy, and allergic reaction; the CD arm was associated with increased severe thrombocytopenia, nausea, and hand-foot syndrome. Although OS data have not been reported, given its toxicity profile and noninferiority to the standard regimen, CD is an important option for patients with platinum-sensitive recurrence.
Platinum-Refractory or Platinum-Resistant Recurrence
Clinical recurrences that take place within 6 months of completion of a platinum-containing regimen are considered platinum-refractory or platinum-resistant recurrences. Anthracyclines (particularly when formulated as PLD), taxanes, topotecan, and gemcitabine are used as single agents for these recurrences based on activity and their favorable therapeutic indices relative to agents listed in Table 4. The long list underscores the marginal benefit, if any, generally conveyed by these agents. Patients with platinum-resistant disease should be encouraged to enter clinical trials.
Treatment with paclitaxel historically provided the first agent with consistent activity in patients with platinum-refractory or platinum-resistant recurrences.[14,15,16,17,18] Subsequently, randomized studies have indicated that the use of topotecan achieved results that were comparable to those achieved with paclitaxel.[19] Topotecan was compared with PLD in a randomized trial of 474 patients and demonstrated similar response rates, PFS, and OS at the time of the initial report, which was contributed primarily by the platinum-resistant subsets.[20]
Drugs used to treat platinum-refractory or platinum-resistant recurrence:
Other drugs used to treat platinum-refractory or platinum-resistant recurrence
This group includes drugs that are not fully confirmed to have activity in a platinum-resistant setting, have a less desirable therapeutic index, and have a level of evidence lower than 3iiiDiv.
Treatment Options for Patients with Recurrent or Persistent Disease
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent ovarian epithelial cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Stage III and Stage IV Ovarian Epithelial Cancer Treatment
Added text about the randomized, double-blind, phase III OCEANS (Ovarian Cancer Study Comparing Efficacy and Safety of Chemotherapy and Anti-Angiogenic Therapy in Platinum-Sensitive Recurrent Diseases) trial of chemotherapy with or without bevacizumab that assessed the role of bevacizumab in the treatment of platinum-sensitive recurrences for recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer (cited Aghajanian et al. as reference 39 and level of evidence 1iiDiii).
Added text to state that in the OCEANS trial, treatment was continued in a longer cycle in responding patients but without maintenance that would currently provide survival data and differences in median survival. Also added that bevacizumab-associated toxicities caused the discontinuation of treatment because of adverse events but fewer patients discontinued treatment because of disease progression.
Added text to state that the three studies confirm the effect of improving progression-free survival when bevacizumab is added to chemotherapy for ovarian cancer; however, additional data are needed to best determine how bevacizumab should be used in ovarian cancer.
This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of ovarian epithelial cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Ovarian Epithelial Cancer Treatment are:
Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
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Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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National Cancer Institute: PDQ® Ovarian Epithelial Cancer Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/treatment/ovarianepithelial/HealthProfessional. Accessed <MM/DD/YYYY>.
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Energy Costs Got You Down?
Now is the time to improve efficiency and productivity of existing motor systems
With the current economic climate putting a squeeze on capital budgets, now is the time to improve the efficiency and productivity of existing motor systems such as pumps, fans and air compressors.
According to a U.S. Department of Energy (DOE) study, the U.S. chemical industry consumed approximately 6.3 quads1 of energy in 2001. This amount represents approximately 6 percent of domestic energy use and about 19 percent of all U.S. manufacturing energy use for that year. DOE also estimates that greater attention to motor system management could reduce chemical plant energy consumption by as much as 18 percent.
Defining motor management
Motor management entails a variety of practices that capitalize on the benefits of premium-efficiency motors (lower operating costs and improved reliability) and best motor repair practices (maintain efficiency, optimal availability). It includes:
A decision-making protocol based on life-cycle costing for making purchase and repair/replace decisions.
Procedures to inventory and categorize motors.
Practical advice on making sure the optimal motor for critical applications will be available when needed.
Guidelines to ensure quality repair services.
Motor Decisions Matter, a national educational campaign, is working to spread the word about the benefits of motor management and premium-efficiency motors and to empower companies to adopt these practices. Campaign sponsors include motor manufacturers, utilities, energy-efficiency organizations, trade associations and governmentagencies. (For more information, see www.motorsmatter.org.)
Figure 1. Motor Systems Energy Use
Source: Xenergy study, 2001
Motor management importance
Over a motor's lifetime, its electric bill accounts for over 97 percent of its total cost. Less than 3 percent of the lifetime cost goes toward its purchase, installation and repair. For example, consider a 75-horsepower (hp) motor running at full load for 6,000 hours per year. A typical purchase price would be approximately $4,000. Over its 10-year life, however, that same motor would cost $220,000 to run (based on $0.075 per kilowatt-hour [kWh]).
It becomes apparent that small increases in efficiency translate into big savings. In this example, a one percent increase in motor efficiency translates into $2,800 in energy savings over that time ," nearly the cost of the motor.
Implementation of a motor management plan often improves productivity. The first step to plan implementation is to gain an understanding of your motor fleet and to catalog it. One of the benefits of this review process is that it quickly identifies applications with older inefficient motors and improperly sized motors that should be replaced based on their economic performance. The economic analysis also will indicate whether these motors should be replaced immediately or upon failure. Plants that have large motors and motors running critical processes stand to gain the most from the review in terms of economic return and reduced downtime.
Motor management also could reduce downtime attributed to motor failure. Premium-efficiency motors typically are constructed with superior materials and have more copper, tighter tolerances and longer warranties.
Figure 2. Motor System Energy Use within SIC 28
Source: Xenergy study, 2001
The management plan
Identification of appropriate applications for premium-efficiency motors is an important component of every motor management plan. An understanding of what motor efficiency levels are available and how to specify them is equally important.
Working closely with the National Electrical Manufacturers Association (NEMA), also a campaign sponsor, the Consortium for Energy Efficiency established a premium-efficiency specification and brand, called NEMA Premium, which motor manufacturers, distributors, repair shops, energy efficiency organizations and motor incentive program administrators now embrace. (For more information, see www.nema.org/premiummotors.)
Motor repair quality also is an important consideration when analyzing motor repair/replacement decisions. Proper evaluation requires a comparison of total repair costs (repair plus energy and life-cycle operating costs) with total replacement costs with a NEMA Premium motor (purchase plus energy and life-cycle costing) before you are able to determine which option will achieve the greatest economic return.
When the repair option is appropriate, you must exercise care to ensure all repairs do not deviate or deviate very little from the motor's original energy specifications because improperly performed repairs can decrease motor efficiency by as much as 2 percent. For more information about what constitutes quality repair and how to specify it for your motors, see the Electrical Apparatus Service Association (EASA) guidelines on best practice repair (www.easa.com, under Industry Resources).
Finally, motor management is about planning. Too often, repair/replace decisions are based on motor availability or short-term economics ," not long-range planning. Motor management provides the financial analysis tools you need to make good motor decisions and offers direction for developing cost-effective, pro-active purchasing and repair/replace policies. The Motor Decisions Matter Web site (www. motors matter.org) offers a motor planning toolkit to help you get started on development of your facility's plan.
Figure 3. SIC 28: Distribution of Motor Population and Energy (by hp)
Source: Xenergy study, 2001
Savings opportunities
Motor use accounts for 59 percent of all electricity used in manufacturing. The following information is taken from Small Chemicals and Allied Products Manufacturers: a Profile of Motor Energy Efficiency Opportunities, a study commissioned by the Consortium for Energy Efficiency and conducted by Xenergy in 2001. It gives an indication of where chemical processing plant personnel might find energy and related savings.
The chemicals and allied products industry (SIC 28) is the largest user of motor systems energy, accounting for 20 percent of the total industrial motor system energy use. See Fig. 1.
Within the chemicals and allied products industry group, SIC 28, the breakdown for motor system energy is even more pronounced, with four of the industries within this group comprising more than 75 percent of the total motor system energy use. See Fig. 2.
The distribution of motors within this industry group also is telling of the potential for increased motor efficiency, as the largest number of motors in the chemicals and allied products industry are those with hp levels between 1-5 (see Fig. 3), and the vast majority of all the motors in this industry are less than 50 hp.
As shown in Fig. 4, the largest motor-use applications (in terms of numbers of motors) within the chemicals and allied products industry are pumps and material processing. However, the application using the most energy is compressed air, followed closely by pumps and material processing. These areas represent the greatest potential sources of efficiency upgrades.
Figure 4. SIC 28: Distribution of Motor Population by Application and Energy Use
Source: Xenergy study, 2001
Getting started
A motor management plan puts plant decision-makers in the driver's seat to make the most cost-effective decisions when motors fail. By considering electric motors as a cost of production in the same way American industry looks at labor costs and material costs, these decision-makers could improve their facilities' overall efficiency and bottom line.
For more information about Motor Decisions Matter, visit www.motorsmatter.org, or contact DOE's Office of Industrial Technologies Clearinghouse at (800) 862-2086. Visit www.chemicalprocessing.com for an expanded version of this article, which includes a motor management case study.
Jones is the industrial program manager for the Consortium for Energy Efficiency, and Mason is an industrial program associate for the consortium. Contact them at (800) 862-2086.


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It's Pumpkin Season at Great Harvest Bread Co. in Plano!!!
Pumpkin Oh's are Back at Great Harvest Bread
Co. in Plano!!!
Our purpose and passion is to provide you and your family with the freshest and most flavorful baked goods you've ever tasted. Come in for a free slice of hot-out-of-the-oven bread or a taste of our legendary sweets. Enjoy yourself and bring your children. We're locally owned and community focused. We also offer you a fun place to hang out. Sign up for our emails to receive the latest news and special offers.
At Great Harvest Bread Co. in Plano you'll find a full range of baked goods from traditional breads to custom rolls and desserts and everything in between. Find out more about our irresistible bakery products! There's always something cooking at Great Harvest whether it's a Hot Cinnamon Roll or just our latest creation of Freshly Baked Breads coming out of the oven. It's worth stopping by just for the aroma and free slice of bread!
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*Dining Options Served until 4 pm M-F*
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Great Harvest Bread Co.
1201 E. Spring Creek Parkway, #100
Plano, TX 75074
(972) 578-5051
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Mouth-watering sweets, sandwiches, cookies, healthy bread and much more! Find out more about who we are and what we do.