Finding ovarian cancer early: What to look for
The lack of an effective screening test makes diagnosing ovarian cancer early enough to cure a challenge. Ovarian cancer is the deadliest of all gynecologic cancers and the fifth leading cause of cancer death among women in the United States. Fortunately, a growing body of research has demonstrated that—contrary to popular wisdom—ovarian cancer does produce early symptoms, though they are often subtle and easy to miss.
To help primary-care providers (PCPs) recognize these symptoms sooner, The Clinical Advisor spoke with two nationally recognized experts, Barbara A. Goff, MD, and Alice Spinelli, MSN, ARNP. Dr. Goff, considered one of the foremost researchers of ovarian cancer symptoms, is professor of obstetrics and gynecology and director of the Gynecologic Oncology Division at the University of Washington School of Medicine in Seattle. Ms. Spinelli, a gynecologic oncology nurse practitioner, is on staff at Gynecologic Oncology of Brevard in Melbourne, Fla. She is also past president of the Society of Gynecologic Nurse Oncologists.
Q: Why has ovarian cancer historically been so hard to diagnose?Dr. Goff: Ovaries are located deep in the body, so they're not accessible to direct palpation or visualization. There has been a dearth of knowledge among women and clinicians about this disease and how to diagnose it.
Ms. Spinelli: Presenting symptoms are vague and tend to be GI rather than gynecologic in nature. When these women finally do go to their PCPs, the PCPs often begin by doing a GI workup. Irritable bowel syndrome is the most common misdiagnosis of ovarian cancer. We want PCPs to consider ovarian cancer as a differential diagnosis and to begin with a pelvic exam. Failing to do pelvic exams is a primary reason for delay. So is age. PCPs often assume women younger than 40 can't have ovarian cancer. This is not true.
Q: Are there often early symptoms?Dr. Goff: Our studies have found that more than 90% of women diagnosed with ovarian cancer do experience early symptoms, although they often go unrecognized. I was involved in research that led to creation of a symptom index for use in screening patients most likely to develop ovarian cancer (Cancer. 2007;109:221-227). The most common symptoms include pelvic or abdominal pain, abdominal bloating, urinary urgency, urinary frequency, feeling full after eating just a little bit, and having difficulty eating. Typically, women will experience several of these symptoms, but some will experience just one. In either case, women will have the symptoms relatively frequently over a short period of time (JAMA. 2004;291:2705-2712).
Ms. Spinelli: If the patient is premenopausal, ovarian cancer can be even more challenging to diagnose. A 30-year-old woman with an adnexal mass should be sent to a general gynecologist for further evaluation. But a 70-year-old woman whose abdomen is so bloated she looks pregnant should be referred to a gynecologic oncologist (the clinician most qualified to perform ovarian cancer surgery).
Q: What can PCPs do to make patients more aware of ovarian cancer symptoms?Dr. Goff: Women need to know that some symptoms which seem vague and benign may not be. PCPs have much less time to spend with patients these days. A symptom index might be helpful. PCPs don't need to educate patients per se, but they do need to be aware of which symptoms could be associated with ovarian cancer.
Ms. Spinelli: Symptom cards are available from the Ovarian Cancer National Alliance (see “Where to get more information”). Put them in your waiting room along with pamphlets for birth control pills. A pelvic ultrasound and cancer antigen (CA) 125 testing may also be indicated. Tell patients what you're considering. Don't “protect” women from the possibility of cancer.
Q: Should PCPs perform tests for ovarian cancer?Dr. Goff: I would like to see PCPs use our symptom checklist to decide who should undergo diagnostic testing. But additional research is needed to see how effective the symptom index will be. If ovarian cancer is suspected based on symptoms, the next steps are pelvic exams, followed by transvaginal ultrasound (with or without CA 125 testing). Screening in the general population is not recommended except for women with genetic mutations or family histories that put them at elevated risk.
Ms. Spinelli: There is no screening test for ovarian cancer. The CA 125 is not a good screen because it has poor sensitivity and specificity. Routine screening results in unnecessary testing, expense, and mental anguish. Endometriosis, for example, can falsely elevate CA 125 levels. Conversely, only 50% of patients with early ovarian cancer have an elevated CA 125. The best way to screen is to listen to patients' complaints and consider ovarian cancer in your differential diagnosis.
Q: Which patients should be tested?Dr. Goff: Because ovarian cancer is relatively rare and there are so many false positives, current recommendations are that only those with an elevated risk based on personal or family history should be screened for the disease. However, if patients complain of symptoms in the checklist, do a pelvic and a rectovaginal exam. If there are any abnormalities, go directly to ultrasound. If the pelvic exam is normal, consider waiting. Even with a normal exam, you might consider transvaginal ultrasound.
Q: Which women are at increased risk for ovarian cancer?Dr. Goff: A history of premenopausal breast cancer or a family history of premenopausal breast cancer, fallopian tube cancer, male breast cancer, primary peritoneal cancer, and colon cancer all put a person at increased risk.
Ms. Spinelli: Anyone with a known BRCA genetic mutation in the family is at increased risk. This increases their lifetime risk 27%-44%. Another known genetic link is hereditary nonpolyposis colorectal cancer or Lynch syndrome. Roughly 3% of people with colon cancer carry this gene, which increases the chances of developing ovarian cancer by about 13%.
Q: Is there anything PCPs can do to help women reduce their ovarian cancer risk?Dr. Goff: Birth control pills reduce the risk of ovarian cancer, even in women who are at increased risk. Women who have children seem to be at reduced risk. Tubal ligation reduces the risk. Eating well, exercising regularly, and maintaining a normal weight are important in preventing all cancers.
Ms. Spinelli: Birth control pills can decrease risk by as much as 50% and protect women for up to 10 years after they stop taking them.
Q: Under what circumstances should PCPs recommend genetic testing for ovarian cancer?Dr. Goff: Obtain a family history on every patient and if it indicates she may be at risk, schedule an appointment with a genetic counselor. The genetic counselor can assess her risk and recommend testing.
Ms. Spinelli: No one should be tested without being counseled as well.
Q: How is a diagnosis of ovarian cancer confirmed?Dr. Goff: Through surgery. Ultrasound can only tell whether or not a mass is present. You need a tissue diagnosis. Although needle biopsies are sometimes performed, ovarian cancer is most often diagnosed by laparoscopy or laparotomy.
Q: To what extent, if any, should PCPs be involved in the ongoing care of patients with ovarian cancer?Dr. Goff: PCPs are important in referring women to the right specialists. Survival rates are better when women are treated by gynecologic oncologists. Beyond that, it is important for patients to have an ongoing relationship with their PCP to ensure their BP is being maintained, their flu shots are up to date, and their underlying health concerns are monitored.
Ms. Spinelli: Communicate. If we see someone and we're doing her surgery and her chemotherapy, we do not burden the patient with all the responsibility for communication.
Q: What's the outlook for women diagnosed with ovarian cancer today?Dr. Goff: It is good for women diagnosed early; 70%-80% will survive five or more years. For patients with advanced disease who have optimal cytoreduction (no residual cancer after surgery), the survival rates are between 30% and 35%. For those who don't, the cure rates are between 15% and 20%.
Q: What are the latest treatments?Dr. Goff: There are two phases of treatment. The first is surgery, in which ovarian cancer is diagnosed and the disease is cytoreduced. The second phase is chemotherapy. Intraperitoneal chemotherapy is used if the cancer has been optimally cytoreduced. Otherwise, chemotherapy is given IV.
Ms. Spinelli: Fully 85% of women with ovarian cancer are diagnosed in advanced stages (III or IV). Intraperitoneal chemotherapy (for women able to have all gross tumor removed at the time of surgery) in combination with IV chemotherapy has been shown to increase survival by 16 months.
Q: What's on the horizon in terms of new treatments?Dr. Goff: Targeted therapies that attack specific cancer growth factors rather than all fast-dividing cells. The targeted therapies tend to be less toxic than conventional chemotherapy.
Ms. Spinelli: One of the most exciting new technologies is proteomics, which looks at protein patterns in the blood. An early study of 100 women with ovarian cancer was nearly 100% accurate in detecting ovarian cancer, even very early disease.
This technology is being fast-tracked, and a useful screening tool will hopefully be available within five years. When ovarian cancer is detected at stage I, it is 95% curable.