By Debra Ravasia, MD
Ovarian cancer has long been dubbed the “silent killer” based on a belief that it does not produce symptoms until it is far advanced. However that concept is changing, as new research reveals subtle symptoms which occur more commonly in early ovarian cancer than in the general population.
The symptoms to watch for are bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly and a frequent or urgent need to urinate. These are, of course, very common symptoms for many medical conditions. However if they are new and persistent, they are more concerning.
The American Cancer Society, Gynecologic Cancer Foundation and Society of Gynecologic Oncologists have just released consensus guidelines that women with a new onset of these symptoms, that occur on most days for more than a few weeks should visit their gynecologist for an evaluation. They state that ovarian cancer should be thought of and ruled out when those symptoms occur.
The guidelines stop short of stating what the physician evaluation should consist of, but many gynecologists would take a careful history and do a thorough exam including a pelvic exam. They may consider a transvaginal ultrasound of the ovaries and possibly a blood test called CA-125. They will likely also be considering many other diagnosis as well, since the majority of women with these symptoms do not actually have ovarian cancer.
Screening for ovarian cancer among healthy women has always been a problem. The ideal screening test is inexpensive, catches the disease in a very early state, is sensitive enough to detect the disease most of the time, and does not have a lot of false positives. The PAP test for detection of precancerous lesions of the cervix that lead to cervical cancer is an example of an ideal screen.
The PAP test, however, does not detect ovarian cancer. The other part of the pelvic exam, in which the size and shape of the uterus and ovaries are palpated or “felt,” can only detect about 1.2 % of ovarian lesions, even when performed by the most experienced of gynecologists. The CA-125 blood test tends to be negative until ovarian cancer is fairly advanced and has many false positives. Benign tumors of the uterus, endometriosis, liver disease and many other conditions can cause it to be falsely elevated. The transvaginal ultrasound is fairly sensitive for ovarian cancer. However, the cost of using this test to screen every woman over 40, or even over 50, would be in the billions of dollars. This test is fairly sensitive, but 5 out of 6 suspicious lesions detected on transvaginal ultrasound turn out to be benign when surgery is performed.
Short of surgery, there is not an easy way to biopsy an ovary suspected of ovarian cancer. That’s because these cancers often contain liquid areas which, if punctured by a biopsy needle and spilled into the abdomen, can cause the cancer to spread.
Each year more than 22,000 new cases of ovarian cancer are diagnosed and more than 15,000 women die of ovarian cancer. When ovarian cancer is diagnosed at an advanced state, about 35% of women will still be alive 5 years later. When it is diagnosed early, more than 93% of women are still alive 5 years later. Unfortunately less than 1 in 5 ovarian cancers are being diagnosed in this early stage.
The purpose of the new guidelines is not to scare women, but to provide them with tools that will help them decide when to visit their gynecologist and also to provide physicians information about which symptoms to work up for ovarian cancer. In the research that led to these guidelines, 125 of women who reported these symptoms to their physicians were told it as “all in their head” and thus had their diagnosis delayed.
The committees who developed these consensus guidelines are hopeful that this more aggressive approach to the symptoms of early ovarian cancer will lead to earlier diagnosis of this disease and help save women’s lives.