Ovarian cancer Whispers …

… so listen… Watch for Pelvic or abdominal pain or discomfort; vague but persistent gastrointestinal upsets such as gas, nausea, and indigestion; frequency and / or urgency of urination in the absence of an infection; unexplained weight gain or weight loss; pelvic and / or abdominal swelling, bloating and / or feeling of fullness; ongoing unusual fatigue; or unexplained changes in bowel habits… If symptoms persist for more than 2 weeks, ask your doctor for a combination pelvic / rectal exam, CA-125 blood test, and transvaginal ultrasound. A Pap Test WILL NOT detect ovarian cancer.

Let’s shout, yell, cry, scream, bellow, screech, bawl, holler and roar until everyone knows its name…

Ovarian cancer: its mere mention is shrouded in fear and mystery. Indeed, there is much to fear and far too much mystery.

Draped in a cloak of anonymity, ovarian cancer is often called “the disease that whispers.” Like a murmur in a darkened theatre, ovarian cancer in its infancy is almost undetectable. Undisturbed, the cancer grows and spreads silently within a woman’s pelvic cavity. As a “woman’s cancer,” it often remains veiled from those closest to us, even our physicians - and ourselves. But the earlier this disease can be caught, the better the prognosis.

The bare facts are grim: survival statistics have hardly changed in fifty years. In 2004 more than 2,600 Canadian women will be diagnosed and about 1,500 of these mothers, sisters, daughters, friends, wives and lovers will die. Multiply that by ten for the United States. Ovarian cancer is the deadliest gynecological cancer.

The key to survival is detecting the disease in its early stages. Sadly, that happens in only about 30% of cases. By the time of diagnosis, the majority of tumours have spread within the pelvic cavity or beyond. The signs and symptoms of ovarian cancer are vague, slyly mimicking those of other common stomach, bowel, or even menstrual disorders, and so it can remain undetected for months, even years.

Symptoms
Most ovarian cancer is “silent,” producing few or no preliminary warning signals. When symptoms do occur they are often innocuous and mistakenly attributed to other causes. Although some cases are diagnosed during a routine gynecologic examination, many women are diagnosed only when they are in later stages of the disease.

Advanced ovarian cancer often results in blockage of the intestines, causing severe nausea, vomiting, pain and weight loss.

The following are some of the symptoms of ovarian cancer. If a woman has several clustered together and these symptoms last longer than two or three weeks she should see her family physician.

• sense of pelvic heaviness
• vague lower abdominal discomfort
• vaginal bleeding not associated with menstruation
• unaccounted for weight gain or loss
• abnormal menstrual cycles
• increased abdominal girth
• non-specific gastrointestinal (stomach/bowel) symptoms such as bloating, increased gas, indigestion, lack of appetite, nausea and vomiting, inability to consume usual amount of food
• increased urinary frequency and/or urgency

Risk Factors
There is a much higher incidence of ovarian cancer in industrialized countries, making it almost a disease of well-developed countries (except Japan). Ovarian cancer can occur in any age group, but it is most common in postmenopausal women. More than half of the deaths from ovarian cancer occur in women between fifty-five and seventy-four years of age. About one-quarter of ovarian cancer deaths occur in women between thirty-five and fifty-four years of age.

Few women are genetically predisposed to develop ovarian cancer. In fact, only between 5% and 10% of those diagnosed have a family history of the disease.
Not ovulating - by having children, using birth control pills or having a medical condition that interferes with ovulation - may offer some protection against developing ovarian cancer: but this is hardly a solution.

Ovarian cancer occurs more often when the following risk factors are present:

• History of ovarian cancer in your immediate family
• Age over fifty years
• No children (the greater the number of pregnancies, the lower the risk for developing ovarian cancer)
• Past history of breast cancer
• Race (ovarian cancer occurs 50% more often in white women than African-American women)
• Ashkenazi Jewish descent
• Post-menopausal hormone replacement therapy (very slightly increases the risk for ovarian cancer)
• Infertility drug use (a nearly three-fold increase in risk in those who fail to conceive - however, this is not a consistent finding)
• High fat diet (associated with higher rates of ovarian cancer in industrialized nations, but the link remains unproven)
• Use of talcum powder in the genital area (has been suggested as a risk factor but again this is not a consistent finding)
• Obesity (may play a role if a woman is 20% to 25% over her ideal body weight)

HOW IS OVARIAN CANCER DIAGNOSED?

Benign Conditions
Around 300,000 American women - and perhaps 30,000 Canadian women - are hospitalized each year for ovarian growths and lesions, and even more are diagnosed with some ovarian condition during a routine checkup. Most are non-cancerous, including benign ovarian cysts, abscesses and infection, fibroids, endometriosis, ectopic pregnancies (when an embryo becomes lodged in a fallopian tube and must be removed surgically), or other non-malignant conditions. Blood tests are used to rule out ectopic pregnancies. Cysts or growths are of greater concern in children or post-menopausal women than women in their reproductive years, since most growths are menstrual-related.

Annual Gynecological Checkup
Every woman should have a regular annual examination with her family physician that includes a bimanual rectovaginal pelvis exam. This means the physician inserts a finger in the vagina and another into the rectum. This allows the physician to judge the size of the ovaries and the shape of the uterus as well as feeling for masses or growths. Sadly, early ovarian cancer rarely produces changes that can be detected during this exam. A pap smear is also done to check for cervical cancer - it does not detect ovarian cancer. If a woman is in a high-risk group for ovarian cancer, a couple of other tests may be ordered, such as a transvaginal ultrasound and CA125 blood test.

Transvaginal Ultrasound
Ultrasound is used to assess tumours or growths discovered during a rectovaginal exam. A probe is placed inside the vagina that emits sound waves - ultrasounds - that bounce off tissues, organs and masses within the pelvis cavity. These echoes are converted to pictures. A probe may also be placed on top of the abdomen - this is a transabdominal ultrasound - but the transvaginal probe provides better pictures of the ovaries. Healthy tissues, fluid-filled cysts and solid tumours produce different sound waves, but this test cannot determine whether a mass is benign or malignant.

Studies indicate that in premenopausal women who have a normal protein CA125 blood test, small cysts that are fluid-filled are usually non-cancerous. These women may be given oral contraceptives and watched for a few months to see of the cyst dissolves. Postmenopausal women, too, are watched to see if the cyst goes away. However, if a cyst is “complex,” meaning it shows a mass or some other abnormality - it is most often removed surgically.

CA125 Blood Test
This test measures the level of a specific protein that is secreted by cells and in more than 80% of cases is elevated when ovarian cancer is present. In general, a normal value lies below 35 m/mL (microns per milliliter) but age and menstrual status can vary that normal value. A number of conditions can affect CA125 levels, including pelvic inflammatory disease, liver disease, fibroids, non-cancerous ovarian cysts and even pregnancy. For example, in one study of premenopausal women, normal levels increased as high as 62 m/mL during menstruation and fell below 32 only around the time of ovulation. In postmenopausal women the normal value is usually well below 35 m/mL. If your physician suspects ovarian cancer may be present, this is usually one test that is performed. If you are diagnosed with ovarian cancer this blood test will be repeated at three-, six-, or twelve-month intervals to check the value.

Other Imaging Techniques Used to Help Identify Ovarian Cancer
Other body imaging techniques to help identify the presence of ovarian cancer include a computed tomography (CT or CAT) scan, magnetic resonance imaging (MRI) and abdominal X-rays. CT scans help determine if the cancer has spread to the lymph nodes, abdominal organs, abdominal fluid or the liver. An MRI creates cross-sectional images of the pelvis and abdominal organs, which are arranged into three-dimensional images. These tests cannot diagnose ovarian cancer but after a diagnosis they can be a useful tool.

Laparotomy surgery is generally needed to diagnose ovarian cancer. An incision, under general anesthesia, is made from the pubic bone to the navel. Any cysts or other suspicious tissues are removed and biopsied - tested for cancer. With this surgery the entire lower abdomen can be carefully explored and assessed. As well, the fluid in the abdomen is also tested for cancer cells. If there is cancer, the surgeon states it according to where it has spread and, of course, removes as much of the cancerous tissue - ovaries, uterus, etc. - as possible.

Looking Forward
We must increase the profile of ovarian cancer among women and family physicians to allow for earlier detection. We also need to significantly boost research and educational funds to establish more sophisticated screening tools — and to uncover the causes of this deadly cancer. The key to finding an early screening tool cannot be overemphasized. This is a disease that whispers but ends roaring in the pain it causes a woman and her family.

Diane Sims Roth is the author of An Ovarian Cancer Companion (General Store Publishing, 2003), on which this article was based. The book, endorsed by the National Ovarian Cancer Association, is available for purchase at: www.gsph.com or 1-800-465-6072.

 

 

For more information, contact the National Ovarian Cancer Association (NOCA). NOCA is dedicated to overcoming ovarian cancer, providing leadership by supporting women living with the disease, and their families; raising awareness in the general public and among health care professionals; and funding research into early detection, improved treatments and, ultimately, a cure.

Contact them at: 1-877-413-7970; www.ovariancanada.org for more information for patients, caregivers, physicians, family and friends.

 

March 2004