|November 2009 · Vol. 21, No. 11
Goal is for new ovarian-cancer symptom diary to enhance
A national organization is reaching out to women to increase awareness of symptoms and speed diagnosis
More than 70% of ovarian cancers are diagnosed at an advanced stage
The CA-125 level is normal in 50% of women who have stage-I ovarian cancer.
In a move to provide women as well as physicians with detailed information about ovarian cancer—and to speed diagnosis, preferably at an early stage—a national organization recently posted a symptom diary online at www.ovariancancer.org/diary.
The Ovarian Cancer National Alliance (OCNA) reproduced the diary in conjunction with the Gynecologic Cancer Foundation and obtained permission for its use in the United States. The diary was developed in the United Kingdom by Ovarian Cancer Action.
In addition to the diary, OCNA published Interim Practice Guidance (available at the same link), which has been endorsed by prominent gynecologic cancer specialists, including Barbara Goff, MD, of the Seattle Cancer Care Alliance. This step marks the first time ovarian cancer diagnostic protocols have been made available to the public.
The Interim Practice Guidance points out that “the effect of symptom-based intervention on survival of women found to have ovarian cancer is at this time unknown.”1 It also notes that “over 90% of ovarian cancer patients reported symptoms prior to diagnosis, including 80% to 90% of patients with early-stage disease.”1
5 unhappy statistics about the not-so-silent killer
About 22,000 women will be given a diagnosis of ovarian cancer this year in the United States, and approximately 15,000 women will die from the malignancy
It is the eighth most common malignancy in women, excluding non-melanoma skin cancers, but the deadliest cancer of the female reproductive tract
More than 70% of ovarian cancers are diagnosed at an advanced stage
In late-stage disease, the 5-year survival rate is 13% to 50%, compared with 80% to 90% when disease is confined to the ovary
Approximately half of women who have a diagnosis of ovarian cancer are 60 years or older; younger women do better and live longer after diagnosis
SOURCE: American Cancer Society.4
Why go directly to the patient?
Karen Orloff Kaplan, CEO of OCNA, believes that the symptom diary and interim guidance should be shared publicly to help women who have ovarian cancer obtain a diagnosis sooner.
“Giving women the information they need to more effectively listen to their bodies and recognize the symptoms of ovarian cancer can help reduce the number of deaths from this hideous disease.” If people avail themselves of the symptom diary and the Interim Practice Guidance, Kaplan said, “we believe that more lives can be saved.”
Dr. Goff agrees.
“I think this guidance is important because the symptoms of ovarian cancer are very common, and we all have them from time to time,” she said. “This guidance summary provides information for practitioners and women about when symptoms may be concerning for ovarian cancer and what are the possible diagnostic tests that can be done if ovarian cancer is of concern.”
How to evaluate a symptomatic woman
Until recently, ovarian cancer was known as “the silent killer” because it was assumed that symptoms appeared only very late in the course of disease. However, studies revealed that symptoms can appear even in early stages of the malignancy. As a result, early identification of ovarian cancer began to seem like a more achievable goal.
The symptom diary published by OCNA prompts women to document days on which they experience the following symptoms:
Symptoms that occur frequently for at least 1 month warrant further investigation, according to the diary and interim guidance.1
In addition, as Dr. Goff observed in a clinical article on the subject, “Ovarian cancer can mimic many gastrointestinal disorders and should be considered in the differential diagnosis of these disorders.”2
OCNA and the Gynecologic Cancer Foundation are not the only US-based organizations to endorse the use of symptoms as an indication for more thorough evaluation for ovarian cancer. The American Cancer Society and the Society of Gynecologic Oncologists both published consensus statements advocating assessment of early symptoms.2 In addition, the National Comprehensive Cancer Network published guidelines last year that describe early symptoms—without another obvious source of malignancy—as a reason for a complete ovarian cancer work-up.2
Because there is no definitive test for ovarian cancer, experts suggest that assessment of a symptomatic patient include:
a pelvic/rectal examination. Abnormal findings include increased abdominal girth (a result of ascites); a mass in the middle to left upper abdomen, which may indicate the presence of an omental cake; pleural effusion; lymphadenopathy; and an appearance of malnourishment in the face of stable weight (caused by increasing ascites). In a postmenopausal woman, a nodular or fixed pelvic mass is cause for concern, as are ascites and evidence of abdominal or distant metastasis.2 In both premenopausal and postmenopausal women, a family history that includes at least one first-degree relative with breast or ovarian cancer also is suspicious for ovarian cancer.
serum CA-125 measurement
– In symptomatic premenopausal women, this marker is, alone, unreliable. The CA-125 level is normal in 50% of women who have stage-I ovarian cancer. However, a baseline value is useful in subsequent monitoring. A very high CA-125 level (above 200 U/mL) suggests ovarian cancer.
–In postmenopausal women who have a pelvic mass, the CA-125 level is suspicious for ovarian cancer when it exceeds 35 U/mL.
transvaginal ultrasonography. This imaging may not be immediately necessary if the physical examination is normal, according to Dr. Goff.2 “Depending on the clinical situation, we may wait 2 to 4 weeks to see if symptoms resolve or can be explained by another disorder. If they do not, we obtain an ultrasound examination of the pelvis.”2
When to refer the patient
The American College of Obstetricians and Gynecologists recommends that any woman who has a suspicious mass undergo consultation or referral to a gynecologic oncologist.3
“This recommendation is based on consistent evidence from studies showing that surgical treatment by nongynecologic oncologists, and by low-volume providers, contributes to suboptimal surgical management and shorter median survival,” Dr. Goff writes.2
1. Interim guidance for the management of average-risk women with symptoms suggestive of ovarian cancer.
Ovarian Cancer National Alliance. Available at: http://www.ovariancancer.org/diary/. Accessed Oct. 23, 2009.
2. Goff B. Early detection of ovarian cancer: role of symptom recognition. UpToDate.com. Available at: http://www.uptodate.com/patients/content/topic.do?topicKey=~2CQh2tcdXUVdcU2. Accessed Oct. 23, 2009.
3. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 280. December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol. 2002;100:1413–1416.
4. American Cancer Society.
What are the key statistics about ovarian cancer. Available at: http://www.cancer.org/docroot/cri/content/cri_2_4_1x_what_are_the_key_statistics_for_ovarian_cancer_33.asp. Accessed Oct. 23, 2009.
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