Epithelial Ovarian Cancer

Epithelial ovarian cancer was diagnosed in an estimated 25,580 women last year and accounted for 16,090 deaths according to the American Cancer Society. The mortality rate for ovarian cancer is higher than other common cancers such as breast, uterine and colon cancer. This is partly due to the difficulty in finding ovarian cancer at an early stage and the lack of an effective screening test.

The goal of any screening test or symptom education is to find a cancer at an early stage where treatment and overall survival is improved. With ovarian cancer those women diagnosed with stage 1 or 2 disease (where the cancer is confined to the ovaries, stage 1, or with extension only to other pelvic organs, stage) have an 80-95% 5 year survival rate. Compare this to the 10-30% 5 year survival rate in women in whom the cancer cells have spread within the abdomen or to the lungs; stage 3 and 4 disease.

Population factors associated with ovarian cancer include older age, the incidence peaks in women in their seventies, Caucasian race, not having children, a personal history of breast colon or endometrial cancer and a family history of breast, ovarian or colon cancer. Despite the concern women have if they have a relative affected by ovarian cancer only 10% of all ovarian cancers have a hereditary basis. The majority of these women will have the BRCA-1 or BRCA-2 mutation. Women with a strong family history suggestive of a hereditary cancer syndrome should discuss the pros and cons of genetic testing with their physician. Factors that decrease risks of ovarian cancer include having children, breast-feeding, tubal-ligation and prolonged use of oral contraceptives.

It was thought that ovarian cancer could spread because women with early stage cancer had no significant symptoms. Recent studies have not shown this to be true in all cases. 75% of women with ovarian cancer will report abdominal or gastrointestinal symptoms, half report some type of pain or constitutional symptoms (fatigue, weight loss), and a third report urinary tract symptoms. Part of the problem in diagnosing ovarian cancer is that many women (and men) will have these sorts of complaints at some time in their life. Another study looked at women presenting to their primary physician with complaints that have been associated with ovarian cancer; abdominal pain, pelvic pain, bloating, increasing abdominal size and urinary tract symptoms. They found that the symptoms tended to be less severe, and less frequent when compared to women with ovarian cancer. They would occur a few times a month and were often associated with menses. Conversely women diagnosed with ovarian cancer had recent onset of the symptoms, they occurred 20 or more times a month and would have multiple symptoms at the same time.

Women who note a new onset of abdominal pain, pelvic pain, pressure on their bladder, bloating, abdominal distension, or gastrointestinal symptoms should have an evaluation that includes a consideration of ovarian cancer as the cause of their distress. The evaluation should include a complete history and physical exam including a pelvic exam. A pelvic ultrasound should also be considered.

Screening tests are designed to pick up cancers in an early stage before they produce any symptoms. Good examples of effective screening tests for cancer are mammograms to detect early breast cancer, colonoscopy to detect early colorectal cancers and pap smears to detect precancerous lesions of the cervix. Unfortunately a good screening test does not exist for ovarian cancer.

Levels of the CA-125 protein will be elevated in about 50% of stage 1 ovarian cancers and in 80% of more advanced ovarian cancers. Other conditions both benign and malignant can cause elevations in the CA-125 levels. Many women will ask to be screened for ovarian cancer using the CA-125 test. Because of its low specificity and sensitivity (meaning it may be normal in women with cancer and abnormal in women without cancer) it is not recommended as a screening tool for low risk women. Studies are ongoing looking at other markers and combinations for ovarian cancer but as of now are not available for use in the general population.

Women who are concerned that symptoms they are having may be a sign of ovarian cancer should not panic but share their concerns and undergo an appropriate evaluation by their physician. Unfortunately a good early detection test for this cancer does not exist as of this time but women at particularly high risk should discuss undergoing some sort of surveillance with a physician well versed in the benefits and limitations of screening tests.