My aunt, Pam, was a healthy and active 56 year-old woman when she presented to her physician’s office with abdominal pain and bloating. Her physician drained three liters of fluid from her abdomen (known as ascites) and began treatment for ovarian cancer. Despite aggressive chemotherapy, my aunt passed away four months later. I was in college at the time — a “pre-med” student — which meant that I knew nothing about actual medicine, but that I could describe the chemical structure of glucose. I thought Pam’s course must be unusual and uncharacteristically aggressive. As I’ve progressed in my career I’ve discovered that, unfortunately, Pam’s course is not unusual.
Ovarian cancer is the leading cause of death from gynecologic cancer in the United States and Europe.1 Organizations, such as NRG Oncology, have been tirelessly investigating treatment options. Despite a multitude of clinical trials, however, we have made little progress in decreasing the death rate in the last 40 years.2
Survival depends largely on stage at diagnosis. Those who have disease confined to the ovaries (stage I) have a 5-year survival of 80-95 percent; whereas, those with disease spread outside of the pelvis (stage III or IV disease) only have a 5-year survival of 10-35 percent.2 This has led to an intense focus on screening and early diagnosis.
Several screening modalities have been trialed, most commonly a pelvic ultrasound and a blood test, CA-125. While we all agree that ovarian cancer is a disease that needs improved detection strategies, it occurs only in 1-2 percent of those without a genetic predisposition, making large screening programs futile and potentially harmful to those women who have a false positive screen and subsequently undergo unnecessary surgery.3 Completed trials so far have not shown a benefit to screening women without a genetic predisposition to ovarian cancer.4-6 One ongoing trial in Europe has shown some promise, but final data will not be available until 2015.7 Currently, no organization recommends screening in this population and, in fact, the United States Preventative Services Task Force (USPSTF) recommends against screening in this population.8
You may be thinking, what’s the point?There’s nothing that we can do to affect ovarian cancer outcomes. Don’t lose hope yet. Let’s review some things that we have discovered which may help us.
- We know that women with a BRCA mutation have a lifetime risk of ovarian cancer of 20 percent to 60 percent, depending on the specific mutation, and that we can reduce this risk to nearly zero if we remove the fallopian tubes and ovaries at age 35-45.9
- We also know that screening these women with pelvic ultrasounds and CA-125 levels can safely delay removal of the tubes and ovaries until they reach an appropriate age or complete childbearing.10
- And we now know that ovarian cancer is not a “silent killer” as previously described and that in fact, 95 percent of women diagnosed with ovarian cancer experience symptoms prior to diagnosis. These are most commonly abdominal pain/bloating, urinary urgency/frequency, and decreased appetite/feeling full early.11
So what can we do? We can increase the diagnoses of BRCA mutation carriers and subsequent implementation of screening until fallopian tubes and ovaries can be removed. We can also increase the awareness of ovarian cancer symptoms such that those presenting with these symptoms are evaluated for ovarian cancer earlier than they have been in the past.
What can you do? Talk to your doctor! Tell your doctor if you have a family or personal history of breast, ovarian, or colon cancer and tell your doctor if you’re frequently experiencing the symptoms described above. And of course, we’ll all anxiously await the development of better screening and diagnostic tests to make Pam’s story and others like her the exception instead of the rule.
Brooke Schlappe, MD is a chief resident in the Obstetrics and Gynecology department at the University of Vermont Medical Center. She will graduate in June of this year and start a fellowship in Gynecologic Oncology at Memorial Sloan-Kettering Cancer Center. Her research interests include ovarian cancer screening and early detection, obesity, and quality improvement.
- “SEER Stat Fact Sheets: Ovary Cancer.” Cancer Statistics: Statistical Summaries. National Cancer Institute, n.d. Web. <http://seer.cancer.gov/statfacts/html/ovary.html>.
- Kosary CL. Cancer of the Ovary. In: SEER Survival Monograph: Cancer Survival Among Adults: US SEER Program, 1998-2001. Available at http://seer.cancer.gov/publications/survival/surv_ovary.pdf
- Schorge, John O., Susan C. Modesitt, Robert L. Coleman, David E. Cohn, Noah D. Kauff, Linda R. Duska, and Thomas J. Herzog. “SGO White Paper on Ovarian Cancer: Etiology, Screening and Surveillance.” Gynecologic Oncology 119(2010): 7-17. Print.
- Van Nagell Jr, John R., Paul D. DePriest, Frederick R. Ueland, Christopher P. DeSimone, Amy L. Cooper, J. Matt McDonald, Edward J. Pavlik, and Richard J. Kryscio. “Ovarian Cancer Screening with Annual Transvaginal Sonography: Findings of 25,000 Women Screened.” American Cancer Society 109.9 (2007): 1887-1896. Print.
- Buys, Saundra S., Edward Partridge, Amanda Black, Christine C. Johnson, Lois Lamerato, and Christine D. Berg. “Effect of Screening on Ovarian Cancer Mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial.” Journal of the American Medical Association 305.22 (2011): 2295-2303. Print.
- Skates, Steven J., Usha Menon, Nicola MacDonald, Adam N. Rosenthal, David H. Oram, Robert C. Knapp, and Ian J. Jacobs. “Calculation of the Risk of Ovarian Cancer from Serial CA-125 Values for Preclinical Detection in Postmenopausal Women.” Journal of Clinical Oncology 21.10s (2003): 206s-210s. Print.
- Menon, Usha, Aleksandra Gentry-Maharaj, Rachel Hallett, Andy Ryan, Matthew Burnell, Aarti Sharma, Sara Lewis, Susan Davies, Susan Philpott, Alberto Lopes, Keith Godfrey, David Oram, Jonathan Herod, Karin Williamson, Mourad W. Seif, Ian Scott, Tim Mould, Robert Woolas, John Murdoch, Stephen Dobbs, Nazar N. Amso, Simon Leeson, Steven J. Skates, Mahesh Parmar, and Ian Jacobs. “Sensitivity and Specificity of Multimodal and Ultrasound Screening for Ovarian Cancer, and Stage Distribution of Detected Cancers: Results of the Prevalence Screen of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).” The Lancet 10(2009): 327-340. Print.
- “Screening for Ovarian Cancer: Recommendation Statement.” U.S. Preventivec Services Task Force, Nov. 2012. Web. 2 Mar. 2014. <http://www.uspreventiveservicestaskforce.org/3rduspstf/ovariancan/ovcanrs.htm>.
- Kauff, Noah D., Jaya M. Satagopan, Mark E. Robson, Lauren Scheuer, Martee Hensley, Clifford A. Hudis, Nathan A. Ellis, Jeff Boyd, Patrick I. Borgen, Richard R. Barakat, Larry Norton, and Kenneth Offit. “Risk-Reducing Salpingo-oophorectomy in Women with a BRCA1 or BRCA2 Mutation.” The New England Journal of Medicine 346.21 (2002): 1609-1615. Print.
- Rosenthal, Adam N., Lindsay Fraser, Ranjit Manchanda, Philip Badman, Susan Philpott, Jessica Mozersky, Richard Hadwin, Fay H. Cafferty, Elizabeth Benjamin, Naveena Singh, D. Gareth Evans, Diana M. Eccles, Steven J. Skates, James Mackay, Usha Menon, and Ian J. Jacobs. “Results of Annual Screening in Phase I of the United Kingdom Familial Ovarian Cancer Screening Study Highlight the Need for Strict Adherence to Screening Schedule.” Journal of Clinical Oncology 31.1 (2013): 49-57. Print.
- Goff, Barbara, Lynn S. Mandel, Charles W. Drescher, Nicole Urban, Shirley Gough, Kristi M. Schurman, Joshua Patras, Barry S. Mahony, and M. Robyn Andersen. “Development of an Ovarian Cancer Symptom Index: Possibilities for Earlier Detection.” Cancer 109.2 (2007): 221-227. Print.