Ovarian cancer: Recognizing early symptoms can make a difference
Based on these studies, the Gynecologic Cancer Foundation, American Cancer Society, and Society of Gynecologic Oncologists issued a consensus statement regarding symptoms of ovarian cancer in June of 2007. The consensus statement was meant to provide information for both patients and practitioners about the importance of symptom recognition for the early detection of ovarian cancer (Table 3).
Recent studies have shown that these symptoms may not cause women or their physicians to test for ovarian cancer because of their nongynecologic and frequently nonspecific nature. They do, however, appear to cause women to seek medical care, and if the association of specific patterns of symptoms with ovarian cancer could be identified, then the earlier detection of disease may be possible.
When Smith and associates evaluated Medicare claims linked to the California Surveillance, Epidemiology and End Results (SEER) database, they found that ovarian cancer patients were significantly more likely to have provider visits for abdominal swelling and gastrointestinal symptoms in the 6 months prior to diagnosis than the control groups. The study included 1,985 ovarian cancer patients and age-matched breast cancer and non-cancer clinic controls. Their results suggest that there may be a window of opportunity to make an earlier diagnosis of ovarian cancer for women with these symptoms. While we don’t know if diagnosing ovarian cancer 3 to 6 months earlier will improve prognosis, we do know that in women for whom an optimal cytoreduction (no gross residual disease following surgery) can be achieved, cure rates are double that of women who do not have an optimal surgery (30%–40% cure vs. 15%–20%). For those who achieve optimal cytoreduction followed by intraperitoneal chemotherapy, we can now achieve median survival of over 60 months. The most significant factor associated with optimal cytoreduction is volume of disease at the time of presentation. Since ovarian cancer can have very rapid doubling times, 3 to 6 months could represent a significant time interval for improved prognosis associated with early diagnosis.
TABLE 3: A closer look at the Ovarian Cancer Consensus Statement Symptoms
We cannot overemphasize the importance of considering ovarian cancer when evaluating a woman who is complaining of bloating, increased abdominal size, and urinary urgency. New symptoms, symptoms that coexist with other symptoms and occur almost daily, and are more severe than expected warrant close attention.
The first step in evaluating these types of symptoms is to perform a pelvic examination, including a rectovaginal examination. If the findings are abnormal, then transvaginal or pelvic ultrasound is usually the next step. Depending on ultrasound results, abdominal and pelvic CT and/or serum CA125 testing may be indicated. If the pelvic examination is normal, then it may be reasonable to wait an additional 2 to 4 weeks to see if symptoms resolve. If they do not, then ultrasonography of the pelvic organs should be performed.
DR. GOFF is Professor in the Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA.
DR. MUNTZ is Clinical Associate Professor of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA.
REFERENCES
1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin. 2007;57:43-66.
2. Ozols RF, Rubin SC, Thomas GM, et al. Epithelial ovarian cancer. In: Hoskins WJ, Perez CA, Young R, et al, eds. Principles and Practice of Gynecologic Oncology. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:895-987.
3. Goff BA, Muntz HG. Screening and early diagnosis of ovarian cancer. Women’s Health in Primary Care. 2005;8:262-268.
4. Menon U, Jacobs IJ. Ovarian cancer screening in the general population. Curr Opin Obstet Gynecol. 2001;13:61-64.
5. Paley PJ. Ovarian cancer screening: are we making any progress? Curr Opin Oncol. 2001;13:399-402.
6. Van Nagell JR Jr, DePriest PD, Reedy MB, et al. The efficacy of transvaginal sonographic screening in asymptomatic women at risk for ovarian cancer. Gynecol Oncol. 2000;77:350-356.
7. Jacobs I, Davies AP, Bridges J, et al. Prevalence screening for ovarian cancer in postmenopausal women by CA 125 measurement and ultrasonography. BMJ. 1993;306:1030-1034.
8. Liede A, Karlan BY, Baldwin RL, et al. Cancer incidence in a population of Jewish women at risk of ovarian cancer. J Clin Oncol. 2002;20:1570-1577.
9. Fishman DA, Cohen L, Blank SV, et al. The role of ultrasound evaluation in the detection of early-stage epithelial ovarian cancer. Am J Obstet Gynecol. 2005;192:1214-1221.
10. Skates SJ, Horick N, Yu Y, et al. Preoperative sensitivity and specificity for early-stage ovarian cancer when combining cancer antigen CA-125-II, CA 15-3, CA 72-4, and macrophage colony-stimulating factor using mixtures of multivariate normal distributions. J Clin Oncol. 2004;22:4059-4066.
11. Petricoin EF, Ardekani AM, Hitt BA, et al. Use of proteomic patterns in serum to identify ovarian cancer. Lancet. 2002;3:355-366.
12. Jacobs IJ, Menon U. Progress and challenges in screening for early detection of ovarian cancer. Mol Cell Proteomics. 2004;3:355-366.
13. National Institutes of Health Consensus Development Conference Statement. Ovarian cancer: screening, treatment and follow-up. Gynecol Oncol. 1994;55(3 Pt 2):S4-S14.
14. ACOG Committee Opinion: Routine cancer screening. No. 185. Int J Gynaecol Obstet. 1997;59:157-161.
15. US Preventive Services Task Force. Guide to Clinical Preventive Services, Second Edition. Alexandria, VA: International Medical Publishing, Inc. 1996.
16. US Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement. Ann Intern Med. 2005;143:355-361.
17. Karlan BY. The status of ultrasound and color Doppler imaging for the early detection of ovarian carcinoma. Cancer Invest. 1997;15:265-269.
18. Kramer BS, Gohagan J, Prorok PC, et al. A National Cancer Institute sponsored screening trial for prostatic, lung, colorectal, and ovarian cancers. Cancer. 1993;71(2 suppl):589-593.
19. Lacey JV Jr, Greene MH, Buys SS, et al. Ovarian cancer screening in women with a family history of breast or ovarian cancer. Obstet Gynecol. 2006;108:1176-1184.
20. Menon U, Skates SJ, Lewis S, et al. Prospective study using the risk of ovarian cancer algorithm to screen for ovarian cancer. J Clin Oncol. 2005;23:7919-7926.
21. Finch A, Beiner M, Lubinski J, et al. Salpingo-oophorectomy and the risk of ovarian, fallopian tube, and peritoneal cancers in women with a BRCA1 or BRCA2 mutation. JAMA. 2006;296:185-192.
22. Goff BA, Mandel L, Muntz HG, et al. Ovarian carcinoma diagnosis: results of a national ovarian cancer survey. Cancer. 2000;89:2068-2075.
23. Olson SH, Mingone L, Nakraseive C, et al. Symptoms of ovarian cancer. Obstet Gynecol. 2001;98:212-217.
24. Vine MF, Ness RB, Calingaert B, et al. Types of symptoms prior to diagnosis of invasive or borderline ovarian tumor. Gynecol Oncol. 2001;83:466-471.
25. Yawn BP, Barrette BA, Wollan PC. Ovarian cancer: the neglected diagnosis. Mayo Clin Proc. 2004;79:1277-1282.
26. Goff BA, Mandel LS, Melancon CH, et al. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. 2004;291:2705-2712.
27. Goff BA, Mandel L, Drescher CW, et al. Development of an ovarian cancer symptom index. Cancer. 2007;109:221-227.
28. Smith LH, Morris CR, Yasmeen S, et al. Ovarian cancer: can we make the clinical diagnosis earlier? Cancer. 2005;104:1398-1407.
29. Hoskins WJ. Epithelial ovarian carcinoma: principles of primary surgery. Gynecol Oncol. 1994;55:S91-S96.
30. Armstrong DK, Bundy B, Wenzel L, et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med. 2006;354:34-43.
31. Ball H, Berek JS. The effect of diameter of largest residual disease on survival after primary cytoreductive surgery in patients with suboptimal residual epithelial ovarian carcinoma. Am J Obstet Gynecol. 1994;170:974-979.
Publish date: Mar 1, 2008
By: Barbara A. Goff, MD, Howard G. Muntz, MD