Clinical Review

Gynecologic Cancer

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Distinctive symptoms flag early ovarian cancer … Where’s the blood test? … Don’t fail to counsel risk-reducing BSO … Serial histologic sectioning is vital


 

This Update reviews recent findings of importance to obstetricians and gynecologists. Late detection of ovarian cancer is still the main reason for the high mortality rate of the most deadly of the gynecologic cancers. Approximately 22,200 women will be newly diagnosed in the United States this year, and there will be 16,210 deaths. Since ovarian cancer is still initially detected in its advanced stages in more than 70% of cases, when cure rates are low, early detection and prevention remain our greatest challenge. The gynecologic oncologist’s opportunity to successfully treat malignancy depends on early detection, and therefore physicians providing primary care for women are our firstline guardians.

“Silent killer” may not be so stealthy

Women ultimately diagnosed with malignant masses had a triad of symptoms, as well as more recent onset and greater severity of symptoms than women with benign masses or no masses. A diagnostic workup employing transvaginal ultrasound and CA-125 should be considered when a woman says she has these symptoms.

Ovarian cancer is not a silent disease. It was believed to be a “silent killer” because it was thought to be asymptomatic until a woman had very advanced disease. However, Goff and colleagues, in a previous study, found that 95% of women with ovarian cancer had had symptoms prior to diagnosis—and that the type of symptoms was not significantly different, whether disease was early stage or late stage.

This new study aimed to identify the frequency, severity, and duration of symptoms typically associated with ovarian cancer, by comparing symptoms reported by different groups of women. Symptoms reported by women presenting to primary care clinics were compared with symptoms reported by a group of 128 women with ovarian masses. Importantly, women were surveyed about their symptoms before undergoing surgery, and before they had a diagnosis of cancer or benign disease.

Main findings:

  • A triad of symptoms—abdominal bloating, an increase in abdominal girth, and urinary symptoms—occurred in 43% of women found to have ovarian cancer, but in only 8% of women who presented to a primary care clinic.
  • The frequency and duration of symptoms in women with ovarian masses were more severe in the women with malignant masses, but were of a similar type regardless of whether the mass was benign or ovarian cancer.
  • Onset of symptoms was more recent in women with ovarian cancer than in the control group.

Listening carefully and evaluating the severity, frequency, and duration of symptoms, especially abdominal bloating, an increase in abdominal girth, urinary symptoms, and abdominal pain, is all-important.

Ovarian cancer should be included in the differential diagnosis when a woman says she has these symptoms.

I found it interesting that symptoms with a more recent onset may be more consistent with ovarian cancer.

In an ideal world, a simple blood test with an absolute cutoff, with perfect sensitivity and specificity, would identify ovarian cancer at its earliest stages. However, until such a test exists, primary care physicians and ObGyns should continue to put weight on the symptoms the patient communicates.

Transvaginal ultrasound and CA-125

Consider performing a diagnostic workup employing transvaginal ultrasound and CA-125 measurement in women presenting with these complaints.

RELATED REFERENCES

  • Goff BA, Mandell L, Muntz HG, Melancon CH. Ovarian cancer diagnosis: results of a national ovarian cancer survey. Cancer. 2000;89:2068–2075.

Whatever happened to the ovarian cancer blood test?

Ransohoff DF. Lessons from controversy: ovarian cancer screening and serum proteomics. J Natl Cancer Inst. 2005;97:315–319.

Science is still seeking the Holy Grail—a blood test for early detection of ovarian cancer.

When Petricoin et al reported in 2002 that a serum proteomic profiling test had nearly 100% sensitivity and specificity, the media trumpeted the phenomenal news. The public’s hopes soared when news articles reported that a company would soon begin offering the test. Patients brought in these reports to their ObGyns and asked for the test.

Plans to introduce a commercial screening test by early 2004 were delayed, however, due to FDA concerns about its reliability. The reasons for claims, plans, and delays were reported in both professional journals and the lay press, but details on the “question about whether the approach of discovery-based serum proteomics can accurately and reliably diagnose ovarian cancer—or any cancer—have not been resolved,” Dr. Ransohoff explains in this thoughtful 2005 essay.

He describes in a simple and straightforward way the requirements of reproducibility, and what these new technologies must demonstrate. He concludes that serum proteomic profiling for the early detection of ovarian cancer has not demonstrated the reproducibility required of a clinical test.

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