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The Catalyst

Screenings are lacking, ineffective for ovarian cancer

By William Creasman, M.D.
Department of Obstetrics & Gynecology

Ovarian cancer is the second most common gynecological cancer yet it kills more women in the United States than all of the other gynecological cancers combined.

The most obvious reason for this disparity is that, in contrast to other gynecological cancers, the majority of patients with ovarian cancer have advanced disease at the time of diagnosis. Ovarian cancer does not have a reliable screening test. Cervical cancer has a PAP smear, and in endometrial cancer, which is mainly a post-menopausal disease, bleeding is an early sign that requires evaluation. Neither of those is available for ovarian cancer.

Screening for ovarian cancer with pelvic ultrasound or tumor markers was extensively studied and, to date, have been found lacking. As a result, no screening is effective.

It is well known that a woman who has had multiple pregnancies has a decreased risk for ovarian cancer. The birth control pill decreases the risk of ovarian cancer. If a woman has taken the pill for 10 years or longer she has more than a 50 percent reduction in ovarian cancer. Removal of both tubes and ovaries also decreases the risk of ovarian cancer.

Removal of the ovaries will decrease ovarian cancer by more than 90 percent. Prophylactic removal of ovaries, particularly in women with BRCA 1 or 2 gene mutations – which can increase ovarian cancer by about 40 percent with BRCA 1 and about 25 percent with BRCA 2 – has proven to be an effective prevention.

A family history of ovarian cancer may indicate ovarian genetic mutation and increase the risk for ovarian cancer. Inherited genetic mutations are associated with approximately 10 percent of women who develop ovarian cancer. BRCA 1 and BRCA 2 gene mutations increase the risk of ovarian as well as breast cancers. Other conditions may also affect an increased risk of ovarian cancer. If a family member has ovarian or breast cancer and it occurred at an early age, there is an increased risk for the development of ovarian cancer.

There is a group of non-specific symptoms that may warrant evaluation. They include bloating, indigestion and pelvic or abdominal pain that occur several times over a month or longer. These findings may suggest ovarian cancer and further evaluation should be done. In many instances these symptoms lead to the GI tract being evaluated with barium enemas, colonoscopy and even upper tract tests.

Many times these tests are all normal and a patient is given a diagnosis of irritable bowel syndrome and treated symptomatically. Several months later the correct diagnosis is made. These patients should have at least a pelvic exam. In a post-menopausal woman, a CA125 may be helpful although an elevated CA125 may be due to other causes.

If the likelihood of ovarian cancer is suggested, the patient should be referred to a gynecologic oncologist. These specially trained gynecologists are best prepared to evaluate and treat patients with ovarian cancer.

Considerable data exist that women with ovarian cancer who are operated on by a gynecologic oncologist have a better survival rate than a physician without that specialty training.

The goal of surgery is to remove all gross disease, which is accomplished more frequently by a gynecologic oncologist than the gynecologist or other surgeons.

After surgery, essentially all patients receive chemotherapy with carboplatinum and paclitaxel being the drugs of choice. This can be given either intraperitoneally or intravenously depending on the result of the surgery. Several courses of chemotherapy are given, and most patients will be put in remission.

Follow-up appointments for a clinical examination, including a pelvic exam, along with tumor markers are done at frequent intervals. Unfortunately recurrences can occur and retreatment can be done in most instances.

During the past 30 years, the mortality rate from ovarian cancer has decreased, particularly in younger women. This improvement has been due to a better understanding of the disease process, the importance of optimal surgery and the development of new drugs, which have been more effective than were present several decades ago. Research is ongoing to improve the survival rate for women who develop ovarian cancer. 

September 5, 2013

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