Screening Necessary for Early Detection of Ovarian Cancer

Diagnosis of ovarian cancer is difficult because symptoms are vague and often associated with more common conditions, and diagnostic tests are limited.

Unfortunately, there is not yet a screening test for ovarian cancer. A screening test detects a disease in people who have no symptoms. For example, a mammogram can detect breast cancer at an early stage, before one can even feel a lump or mass in the breast. The development of an effective screening test for ovarian cancer would be a major step in the fight against the disease.

Without a screening test, diagnosis begins by considering a person's symptoms and risk factors. Recent research has identified six symptoms usually found in women with ovarian cancer:

• Pelvic or abdominal pain, pressure, fullness, or swelling.
• Abdominal bloating.
• Urinary urgency (needing to get to a bathroom immediately).
• Urinary frequency (having to urinate often).
• Feeling full.
• Having difficulty eating.

In addition, the following symptoms have also been associated with ovarian cancer:

• Increased abdominal girth or clothes fitting tighter around your waist.
• Persistent indigestion, gas or nausea.
• Unexplained changes in bowel habits, including diarrhea or constipation.
• Unexplained weight loss or gain.
• Loss of appetite.
• Pain during intercourse.
• A persistent lack of energy.
• Low back pain.
• Bleeding from the vagina.
• Abnormal periods.

The problem with these symptoms is that each is also associated with other, less dangerous conditions. That's one reason why it's also important to consider the risk factors (things that increase your chance of getting a disease) for ovarian cancer. They include:

• Family history of cancer: women with a mother, daughter or sister with ovarian cancer have a higher risk of the disease, especially if she was younger when she developed it. Women with a family history of breast, uterine, colon or rectal cancer may also have a higher risk of ovarian cancer. A strong family history of ovarian cancer means more than one woman in a family has had it. This history may be caused by the women in the family inheriting a genetic mutation. If you have a strong family history of ovarian or breast cancer, you may want to talk to a genetic counselor. For more detailed information about genetic mutations, genetic testing and ovarian cancer, go to Key Point 2.
• Personal history of cancer: Women with a personal history of breast, uterine, colon or rectal cancer have a higher risk of ovarian cancer.
• Age and menopause: Most ovarian cancers develop after menopause; most develop in women over 55.
• Never pregnant: Older women who have never been pregnant have an increased risk of ovarian cancer; women who started menstruating before age 12, had their first child after 30, and/or experienced menopause after 50 may have an increased risk of ovarian cancer.
• Hormone replacement therapy: After menopause, the ovaries produce far less estrogen and progesterone. To lessen the unpleasant symptoms this can create, many women take one or both of these hormones. Some studies suggest that women who take estrogen alone for 10 or more years may have an increased risk of ovarian cancer. But other studies do not find a link between HRT and increased ovarian cancer risk.  A study reported by the National Cancer Institute in October 2006 says women who haven't had a hysterectomy and who used HRT for five or more years face a significantly increased risk of ovarian cancer.
• Ovarian cysts: Ovarian cysts are fairly normal in women before menopause; after menopause, ovarian cysts have a greater risk of being malignant (cancerous), and the risk increases as the cyst gets larger and/or the person gets older.
• Obesity: A study from the American Cancer Society reports the death rate from ovarian cancer is higher in obese women, and increases as the obesity increases. Further research is needed in this area.
• Infertility and fertility drugs: Some studies report that prolonged use of the fertility drug clomiphene citrate, especially without becoming pregnant, may increase the ovarian cancer risk. But infertility itself, even without using fertility drugs, increases the risk of ovarian cancer.  Further research is needed in this area.
• Talcum powder: Some, but not all studies, suggest that talcum powder applied directly to the genital area or on sanitary napkins may increase the risk of ovarian cancer. Further research is needed in this area.

By definition, risk is uncertain. Having a lot of risk factors for a disease does not mean you will get it; having no risk factors does not mean you won't get it. But if you do have some of the symptoms listed above, and some of these risk factors, it may be a good idea to ask your doctor to run some tests. 

Among the possible tests are:

• Physical exam: Your doctor may press on your abdomen to check for tumors or an abnormal buildup of fluid. A fluid sample can be taken to look for ovarian cancer cells.
• Pelvic exam: Your doctor examines your reproductive organs, including the ovaries, for lumps, masses, growths or other changes in their shape or size. However, even skilled diagnosticians find it difficult to detect early ovarian cancers. Though a Pap test is part of a normal pelvic exam, ovarian cells are not collected; the Pap test looks for cervical cancer, not ovarian cancer.
• Ultrasound (sonography): Sound waves are bounced off the ovaries to produce images of it (similar to ultrasound imaging used with pregnant women to produce images of fetuses). The ultrasound device can be inserted into the vagina to produce better images of the ovaries; this is called a transvaginal ultrasound or transvaginal sonography. Ultrasound can find masses or growths, but can't distinguish between a cancerous one and a non-cancerous one.
• Other imaging tests are not used as often for initial diagnosis, but may be used if other tests suggest more tests are needed, or, if cancer has been discovered, to see if it has spread and how far. These imaging tests include:

    ◦    Computerized tomography (popularly known as CT scan or "CAT scan"), a technology that "sees through" bones and other obstructions (like an X-ray) to produces a series of very detailed, cross-sectional images of organs and tissues.
    ◦    MRI (magnetic resonance imaging), another imaging technique that also produces detailed cross-sectional pictures ("slices") of internal organs and body parts.

• Blood tests for CA-125: a higher than normal level of the protein CA-125 (cancer antigen-125) may be a sign of ovarian cancer, though it can also indicate several other conditions. Further, it's possible to have ovarian cancer without a high level CA-125. That's why it's not a completely reliable test for ovarian cancer, and is most appropriate for use on women at high risk, rather than on all women. Research suggests that serial CA-125 testing (a series of CA-125 tests repeated over a period of time) does give more accurate results. The Food and Drug Administration (FDA) has approved the test only to monitor a woman's response to ovarian cancer treatment and to detect its return after treatment.

If the results of these tests suggest that further testing is necessary, the doctor may do a biopsy. A biopsy is a minor surgical procedure in which the doctor removes a small sample of tissue or fluid; the sample is sent to the lab where it is checked for cancer cells.

Genetic Testing to Determine Cancer Risk  

Genetic testing can tell you if you are at increased risk of developing certain types of cancer. However the decision to have genetic testing needs to be well-informed. Genetic testing will not tell you if you have cancer or even if you are going to get it.

One of the major risk factors for ovarian cancer is inheriting a mutated (changed) version of either of two genes also associated with breast cancer, BRCA1 (breast cancer gene 1) and BRCA2 (breast cancer gene 2). They can be inherited from either parent. Although any woman can inherit them, women of Ashkenazi Jewish descent are known to at particularly high risk. Another genetic risk factor is an inherited syndrome called HNPCC (hereditary nonpolyposis colorectal cancer). If you have this syndrome, your risk of getting several kinds of cancer, including ovarian, is increased.

Genetic testing can reveal whether you have these inherited risk factors. But, as with all risk factors, having them does not mean you will get the disease. The reverse is also true; you can still get the disease even if you don't have them.

This raises the complicated issue of the value of genetic testing. The test is simple for the patient, requiring only an ordinary blood sample. But the lab work is complex, lengthy, and therefore expensive, and may not be covered by health insurance. Further, the results may not be ready for a few weeks. Finally, the results aren't definitive; they don't say if you will or won't get the disease; they say only if you have or don't have the hereditary gene mutations that increase your risk of getting the disease.

But the real issue is what do you do with the results? Obviously, learning that you don't have inherited risk factors is a relief. But what happens if you do have them? How will this information affect other members of your family? Who will want to know this information, and who won't?

The National Cancer Institute points out advantages and disadvantages to having a genetic test. On the positive side, the test may help you:

• Make medical and lifestyle choices.
• Clarify your cancer risk.
• Decide whether or not to have risk-reducing surgery. Sometimes, women at very high risk of breast or ovarian cancer have healthy breasts or ovaries removed to reduce that risk. Obviously, this is a serious step that requires a lot of thought and discussion with your doctor. It is controversial because:

    ◦    It only reduces the risk; it doesn't completely eliminate it.
    ◦    Removing both ovaries may be unnecessary and causes premature menopause (in premenopausal women).

• Give other family members useful information (if you choose to share your results).
• May explain why you or other family members have developed cancer.

The disadvantages include:

• There's no guarantee the results will stay private.
• You may find it harder to cope with your cancer risk if your results are positive.
• You may think you have no chance of getting ovarian cancer if the results are negative.

To sum up, you are a potential candidate for genetic testing for ovarian cancer if you:

• Already have the disease and have relatives (especially daughters) who want to know if there is an inherited risk factor in the family. If the result is positive (you do have an inherited risk factor), family members can also be tested.
• Have a close relative with a known mutation in BRCA 1 or BRCA 2.
• Have close relatives across more than one generation with early-onset (before age 50) breast and/or ovarian cancer.
• Have an individual family member in whom both breast and ovarian cancer was diagnosed.
• Have had cancer in both breasts, especially if one or both cancers were discovered before age 50.
• Are of Ashkenazi Jewish heritage with breast cancer before age 50 or ovarian cancer at any age.
• Have a male family member with breast cancer.
• Have other associated cancers or conditions.

However, if you are considering genetic testing for ovarian cancer, the National Cancer Institute suggests you ask appropriate professionals (doctors, nurses, genetic counselors) the following questions (you may want several opinions), and think seriously about the answers:

• What are the chances that an inherited gene alteration is involved in the cancer in me or my family?
• What are my chances of having an inherited altered gene?
• Besides having altered genes, what are my other risk factors for breast and ovarian cancer?
• Are all genetic tests the same? How much does the test cost?
• How long will it take to get my results?
• What would a positive result mean for me?
• What would a negative result mean for me?
• How might a positive test result affect my health, life and disability insurance options?
• How might a positive test result affect my employment?
• Do I want to ask my insurance company to pay for my test?
• Where will my test results be placed/recorded? Who will have access to them?
• Would knowing this information cause me to make changes in my medical care?
• What type of cancer screening is recommended if I don't get tested?

There are other questions only you and your family can answer, like:

• What effect will the test results have on me and my relationship with my family members if I have an inherited altered gene? If I don't have an altered gene?
• Should I share my test results with my spouse or partner? Parents? Children? Friends? Others? How will they react to the news, which may also affect them?
• Are my children ready to learn new information that may one day affect their own health?

Take Steps to Treat Ovarian Cancer

Ovarian cancer is a very bad disease and the symptoms are elusive. However when these symptoms are present, persistent and progressive don't ignore them. Be vigilant because your life may be at risk.

If you have a diagnosis of ovarian cancer, the first step in planning treatment for your doctor to grade and stage the disease.

The grade denotes how aggressive the cancer is; that is, how fast it is likely to grow and spread in the future. The stage denotes how large the cancer is and how much it has already spread. One or more tests may be needed to determine the stage. Most are "imaging" tests; that is, tests that create pictures of areas inside the body to show if cancer is there, like:

• Computerized tomography (popularly known as CT scan or "CAT scan"), a technology that "sees through" bones and other obstructions (like an X-ray) to produce a series of very detailed, cross-sectional images of organs and tissues.
• MRI (magnetic resonance imaging), another imaging technique that also produces detailed cross-sectional pictures ("slices") of internal organs and body parts.

A lymph node biopsy (examining tissue removed from the lymph nodes) will show if cancer has spread to the lymph nodes.

The National Cancer Institute defines the stages of ovarian cancer as:

• Stage I: Cancer cells are found in one or both ovaries. Cancer cells may be found on the surface of the ovaries or in fluid collected from the abdomen.
• Stage II: Cancer cells have spread from one or both ovaries to other tissues in the pelvis. Cancer cells are found on the fallopian tubes, the uterus or other tissues in the pelvis. Cancer cells may be found in fluid collected from the abdomen.


• Stage III: Cancer cells have spread to tissues outside the pelvis or to the regional lymph nodes. Cancer cells may be found on the outside of the liver.


• Stage IV: Cancer cells have spread to tissues outside the abdomen and pelvis. Cancer cells may be found inside the liver, in the lungs or in other organs.

Treatment for ovarian cancer can include surgery, chemotherapy (treatment with drugs), radiation or a combination of these.

Generally, surgery is the first stage of treatment. The surgery, called a laparotomy, usually consists of removing both ovaries and both fallopian tubes, the uterus (removal of the uterus is called a hysterectomy), the omentum (a fold of fatty abdominal tissue that covers the intestines), nearby lymph nodes and possibly tissue samples from the pelvis and abdomen to see if the cancer has spread.

Sometimes, if the cancer is in a very early stage, it may be possible to remove only one ovary and fallopian tube, thereby preserving the ability to have children. On the other hand, if the cancer has spread, the surgeon tries to remove as much as possible in a procedure called "debulking" surgery.

Most women with ovarian cancer have chemotherapy after surgery (though in some cases it precedes surgery). Usually several drugs are given, and they can be given in a variety of ways:

• Intravenous injection (IV): A small tube is inserted into a vein.
• Intraperitoneal therapy (IP): A small tube is inserted into the abdomen.
• Orally: By mouth.

Because the drugs used generally kill not only cancer cells but also other healthy cells (such as blood cells, cells in the digestive tract and cells in the hair), chemotherapy can have side effects (like weakness, nausea, and hair loss), depending on which drugs are used. Most side effects can be controlled with medicine during treatment, and disappear when the treatment is complete.

Radiation therapy (also called radiotherapy) uses high-energy X-rays to kill cancer cells. It too can have a variety of side effects, which can be controlled with medicine and disappear after the treatment.

Keep in mind, however, that the psychological side effects of the disease and its treatment (especially if the treatment causes infertility) must also be dealt with, through counseling, therapy and emotional support.

Complementary medicine is a term that refers to treatment methods used in addition to the standard approaches described above. These include acupuncture, massage therapy, herbal products, vitamins or special diets, and meditation. These methods may be very helpful, but you must talk to your doctor about them. For example, something as seemingly simple as an herbal tea could affect the way your other treatments work, and may even be harmful. 

You may also want to talk to your doctor about taking part in a clinical trial. Clinical trials are research studies that investigate new treatment methods. They're an important option for women with all stages of ovarian cancer.

This article reprinted with permission from Second Opinion, a public television health program hosted by Dr. Peter Salgo and produced by WXXI (Rochester, N.Y.),  West 175 and the University of Rochester Medical Center.

By Second Opinion