Gynecologic Cancer: What Every Woman Should Know
Ovarian Cancer: Symptoms Should Not Be Ignored
Updated on: June 20, 2003
Sheryl Silver
Ovarian cancer accounts for more deaths in the U.S. each year than all other gynecologic cancers combined, over 135,000 in the last 10 years alone. In August of 2000, those statistics became very personal and painful for my family when my sister Johanna lost her life following a determined 3 1/2 year battle against the disease.
When Johanna was first diagnosed, she was stunned. A vigorously healthy, active woman all her adult life, she had no family history of the disease and had been diligent about seeing her gynecologist for annual exams and Pap smears. She hadn't realized she was at risk for this cancer.
She also had no idea that the persistent bloating, constipation and heartburn that preceded her diagnosis were common symptoms of ovarian cancer.
Sadly, my sister's story is not unique. Since her diagnosis, I have met and heard the stories of many ovarian cancer survivors whose stories were nearly identical. Prior to being diagnosed, none had known that the symptoms they experienced were related to ovarian cancer. All were shocked by their diagnoses.
In the article that follows, gynecologic oncologists Richard Barakat and Barbara Goff shed light on the risk factors, symptoms and methods available to detect ovarian cancer. I urge you to take advantage of their knowledge. Although it is too late to save the life of my precious sister, it may not be too late to save your life — or the life of a woman you love.
Myth:
Pap smears screen for all types of gynecologic cancers including ovarian, uterine and cervical cancer.
Fact:
Pap smears test for cancer of the uterine cervix. No other cancer can be reliably detected using a Pap smear. Rarely, Pap smear abnormalities lead to the diagnosis of cancer of the uterus, tubes or ovaries, but Pap smears are not reliable for screening for these cancers.
Ovarian cancer, the most lethal of the gynecologic cancers, will take the lives of an estimated 14,300 women in the U.S. this year. Of the 25,400 American women who will be newly diagnosed with this cancer in 2003, a stunning 70 percent will be diagnosed in the later stages, when the five-year survival rate is only 20 percent.
"The five-year survival rate is over 90 percent and the long-term prognosis is very good for women whose ovarian cancer is detected at Stage I, when the cancer is confined to the ovary," said Richard Barakat, M.D., chief of gynecology service, Department of Surgery at Memorial Sloan-Kettering Cancer Center in New York City. "Unfortunately, only 30 percent of women diagnosed with the disease are detected at that early stage."
Why is this cancer so rarely detected at its earliest — and most survivable — stage?
"The currently available screening tools are still disappointing in their ability to detect early stage ovarian cancer," said Dr. Barakat. "Also contributing to the high percentage of late stage diagnoses is the fact that ovarian cancer symptoms are non-specific.
Many are associated with the gastrointestinal tract — bloating, heart-burn— so many people pass off the symptoms as a bit of gastrointestinal distress."
"Even when women go to their doctors with complaints about symptoms like abdominal bloating and constipation, they often receive vague diagnoses. They’re told their symptoms are due to stress or irritable bowel syndrome or if they’re severely fatigued, they’re diagnosed with depression, even though no one has done a complete work-up that explores ovarian cancer as a possible cause," said Barbara Goff, M.D., professor, Department of Ob/Gyn, Division of Gynecologic Oncology, University of Washington Medical Center, Seattle, Wash. "We’re seeing it less than we used to but unfortunately, ovarian cancer still isn't high on the radar screen for many primary care physicians."
"To be fair to these physicians," added Dr. Goff, "ovarian cancer is fairly rare. Although 1 in 55 women have a lifetime risk for the disease, most physicians will only rarely see patients with ovarian cancer in their practices. What’s more, medical textbooks have traditionally described ovarian cancer as a ‘silent’ disease, which doesn’t exhibit symptoms until it's too late. That, however, is simply not true."
According to Dr. Goff, two recent studies have now confirmed that a high percentage of women diagnosed with ovarian cancer had symptoms as early as Stage I. Dr. Goff conducted one of the studies, researchers at Sloan-Kettering the other.
"In both studies, 89 percent of the women surveyed, including the hundreds that had been diagnosed with early stage cancer, recalled having symptoms," said Dr. Goff.
The results of these studies have now led to the issuance of a Joint Committee Opinion by the American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic Oncologists (SGO), which confirms: "… studies have shown that women with ovarian cancer are symptomatic often several months before the diagnosis, even with early-stage disease."
The ACOG/SGO opinion goes on to state: "Currently, it appears that the best way to detect early ovarian cancer is for both the patient and her clinician to have a high index of suspicion of the diagnosis in the symptomatic woman. This requires education of both as to the symptoms commonly associated with ovarian cancer."
"It is imperative for women to educate themselves about the symptoms of ovarian cancer and to seek appropriate medical attention should they experience any of the known symptoms," said Dr. Goff.
"Abdominal bloating, difficulty eating, unexplained weight gain, constipation, heartburn, severe back pain, urinary frequency, and severe fatigue are the most common symptoms.
Ovarian cancer is usually not the cause of such symptoms. We all have bloating or a change in bowel habits from time to time, plus there are other medical conditions that can cause these symptoms. What’s different about the symptoms of ovarian cancer is that they’re new for you and that they persist or even get a little worse."
According to Dr. Goff, "Women must know their own bodies. They must know what’s normal for them and what’s not. And if any abnormal symptom — typical of those associated with ovarian cancer — persists more than three weeks, women should seek medical attention."
Know The Risk Factors
"It’s also important for women to be aware of the risk factors for ovarian cancer," said Dr. Barakat.
"Family history is the biggest risk factor. If you have one or more close relatives with a history of ovarian cancer, your risk is higher than that of the general population. In the U.S., 1 in 55 women have a lifetime risk of being diagnosed with ovarian cancer. For a woman who has one first degree relative with the disease, the lifetime risk is more than doubled and can, in fact, be 35 times higher if the cancer is due to an inherited [gene] mutation."
Age is also a risk factor. "Sixty five percent of women diagnosed with this cancer are over age 50," noted Dr. Barakat.
Infertility, late menopause, and not bearing a child are additional risk factors. "The common theme with ovarian cancer is that whatever decreases the number of ovulations a woman has during her lifetime decreases her risk for ovarian cancer.
That’s why pregnancy, breast-feeding and using oral contraceptives— things which inhibit ovulation—decrease a woman’s risk of ovarian cancer," explained Dr. Barakat. "Conversely, things that increase the number of ovulations, like late menopause, increase a woman's risk."
Even if a woman doesn’t have any known risk factors, she cannot afford to be complacent. According to Dr. Barakat, "Statistics indicate that more than half of women diagnosed with ovarian cancer have no known risk factors. Over 90 percent have no family history of the disease."
What Can Be Done?
What can be done to determine if a woman's symptoms are due to ovarian cancer?
"First, it’s important that you have a complete pelvic/rectal exam. It may be uncomfortable but it can save your life," said Barbara Goff, M.D. "If there are ovarian masses or nodularity in the pelvis, that can frequently be picked up by a pelvic exam. I’ve had many patients who have had expensive tests including colonscopies, for abdominal or pelvic distress, but never had a pelvic exam following the onset of their symptoms."
If the pelvic exam identifies an abnormality, your doctor should order a pelvic ultrasound, said Dr. Goff. "Ultrasound can tell us if an ovary is enlarged or has a mass on it. Ultrasound will also image the fluid called ascites, which is given off by ovarian tumors or metastases," she explained.
What if your pelvic exam is normal but your symptoms persist? "There are certain times when a woman can have ovarian cancer but it can't be felt during a pelvic exam," acknowledged Dr. Goff. "If your symptoms persist, I’d also recommend a transvaginal ultrasound exam."
"If the ultrasound indicates an area of concern, the next step would be for your doctor to order a CA125 blood test," said Richard Barakat. M.D. "Although certain benign conditions like endometriosis can elevate a CA125 above the normal range, when a woman with persistent symptoms has an elevated CA125 and an area of concern on her ultrasound, it’s much more likely that ovarian cancer is the cause. Surgery to confirm the diagnosis would be the next step."
According to Goff, "If the diagnosis is unclear, a laparoscopy, a surgical procedure which can be done on an outpatient basis, could be considered. If there’s a high index of suspicion, a laparotomy, where we make an incision in the belly, may be warranted."
In either case, Dr. Barakat says whenever surgery is being considered, that’s the time to seek the expertise of a gynecologic oncologist. "Women should first see their gynecologists for their screening examinations. Then, if there’s anything that looks suspicious on a pelvic exam, if there’s a complex cystic mass on an ultrasound or an elevated CA125, these should all raise a red flag about ovarian cancer and a woman should be referred immediately to a gynecologic oncologist," he said.
"Studies have shown that when women are operated on by gynecologic oncologists, they have better outcomes."
This article by the Gynecologic Cancer Foundation originally appeared in an advertising supplement to the New York Times on Sunday, June 22, 2003.
GCF gratefully acknowledges Aventis Oncology for its generous support of this educational supplement. The content of this supplement is the work of many individuals and does not reflect commercial interests.
Aventis Pharmaceuticals
www.AventisOncology.com