You’ve made that appointment for your yearly checkup; you are a patient patient as you peruse expired periodicals in the waiting room. You then have to pee into a cup, put on a ridiculous gown that doesn’t close and when the medical practitioner arrives, go though an exam that requires an undignified lithotomy position. (You know, with your feet in stirrups, your legs apart and your tush at the end of the exam table). The least that you should expect from all this is reassurance that you do not have cancer, or in the worst case scenario that the cancer has been found at an early stage and can be successfully treated. There are pap smears and HPV tests, pelvic bimanual examinations which allow the examiner to palpate pelvic abnormalities such as tumors, cysts or fixed, scarred and painful masses, blood tests and, of course, ultrasound. All these plus a carefully obtained medical history are used to rule out cervical and uterine cancer (as well as inflammation, benign cysts, and endometriosis), but the definitive tests for ovarian cancer still eludes gynecologists.
A quick review: Ovarian cancer is the leading cause of gynecologic cancer deaths, not because it is so prevalent but because it is usually found only after it has spread to other organs in the pelvis, abdomen or distant parts of the body. Our lifetime risk of developing this cancer is 1.4% which means that 1 in 71 women will develop ovarian cancer in their lifetime. One in 95 will die from it. Ovarian cancer is a cancer of older age…two thirds of cases occur after the age of 55…and the older we are the greater that risk.
Whenever you give your family medical history you are asked if you have first degree relatives (parents, siblings, and/or children) who have had or died from ovarian or early onset breast cancer. If so, this can triple your risk. And the risk of ovarian cancer is highest for BRCA gene mutation carriers. Testing for this mutation is recommended if you have a significant family history of ovarian cancer, female or MALE breast cancer, or multiple relatives with breast cancer and/or any of these combined with a high incidence of prostate or colon cancer. Mutations in the BRCA1 gene increase lifetime risk of ovarian cancer to 30 to 46% while mutations in BRCA2 are somewhat less of a risk but still high at 12 to 20 %. There are 3 sites for single mutations in these genes that are found in 2% of individuals who are Ashkenazi Jews (from Eastern Europe). So if you are Jewish and your ancestors came from Eastern Europe (this describes me)) and there is a relevant history in your family of these cancers, I would highly suggest you get the 3 site testing for the BRCA mutation.
(An aside… if there is no breast or ovarian cancer history and you are an Ashkenazi Jew, testing is not recommended “just to make sure”. I queried several physicians while visiting Israel a few weeks ago as to whether BRCA testing was routinely carried out in women who were of Ashkenazi Jewish heritage and the answer was a resounding no. But they do perform genetic testing on pregnant women for a wide range of potential diseases that are more prominent in the newborns of the families with this heritage. As our government discusses medical reform I would hope that they look at the system in Israel….where nearly everyone has medical coverage and choice options are available.)
So how can we diagnosis this relatively rare but often deadly cancer? Are there symptoms? Yes, but they are fairly non specific and are often ignored. They include pelvic or abdominal pain, urinary frequency or urgency, increased abdominal size (not just overall weight gain), bloating or difficulty eating or feeling full more than 12 times in a month. Yes this could be indigestion, a persistent urinary infection, overactive bladder or gas….but studies have shown that when women diagnosed with ovarian cancer where asked about a history of these symptoms, many had them. So if you are over 50 and experience these symptoms, see you doctor.
What about routine screening? Why can’t we simply do a pelvic exam, blood test, ultrasound or some combination of all these and find the disease at an early stage? After all, when ovarian cancer is confined to the ovary (stage 1) the 5 year survival is 90%, but falls to 33% when the diagnosis is made at stage III or IV.
A recent report in The New England Journal reviewed the current status and recommendations for ovarian cancer screening. First they reported on the tumor marker CA-125. This is a protein found at greater concentration in ovarian cancer cells than other cells and is elevated in blood tests of 80% of women with advanced stages of ovarian cancer. But there are some severe limitations to screening with this protein. High levels can be found in 1 to 2 % of normal women. CA-125 is elevated in only 50% of stage I cancers and it can be falsely elevated due to many benign and malignant conditions (endometriosis, fibroids, pelvic inflammatory disease, hepatitis, pregnancy, menstrual bleeding, recent abdominal surgery, breast cancer, pancreatic cancer, colon cancer, lung cancer and endometrial cancer). Currently, because it is so nonspecific, the American Cancer Society as well as the American College of Obstetricians and Gynecologists does not recommend its use as a routine screening test for ovarian cancer. They do feel it’s useful if an ovarian mass is found or if there is a significant family history putting a woman “at risk”. Most insurance companies and Medicare agree and won’t pay for a CA-125 test when it is ordered without a very specific indication!
There are other markers that have been investigated, some based on particular proteins produced by tumor cells or the presence of certain growth factors but to date, they have not been validated in large populations of women in randomized prospective studies. (Translation: Are the women who are given the tests diagnosed earlier than control women who are not tested?)
Ultrasound done with a vaginal probe (transvaginal) has been a mainstay for viewing pelvic tumors. So why not simply perform transvaginal ultrasounds on all women, especially those over 50? Multiple studies have unfortunately demonstrated that this type of imaging has not been as successful as we would wish. The positive predictive value has been reported to range from a mere 1% to 27%; which indicates that many of the women in whom a suspected tumor was found with ultrasound did not have ovarian cancer. And some had unnecessary surgery that resulted in surgical, medical and psychological complications as well as significant financial cost.
The New England Journal of Medicine article reviews several large studies. One included 25,327 women who were at average risk for ovarian cancer and who had annual transvaginal ultrasound. Among women with suspicious findings 364 patients underwent removal of the abnormal ovary but only 29 were indeed cancerous and only 14 (48%) of these were found early at stage I.
And what if women had both tumor marker blood tests and ultrasound? So far an American study has been equally disappointing. It is called the Prostate, Lung, Colon and Ovarian Cancer Screening Trial. Final results won’t be issued until 2014. To date a total of 34,261 healthy women between the ages of 55 and 74 have been randomly assigned to undergo either annual CA-125 testing plus transvaginal ultrasound or to receive “usual care”. Their test results were considered positive if the CA-125 was above 35IU and/or their ultrasound showed an enlarged ovary (it should shrink with age) or a cyst with solid areas. During 4 years of screening, 3388 women had positive results and 1170 or 34% underwent surgery with removal of the one or both ovaries. Only 5.1% of those who had surgery were found to have cancer and 72% of these cancers were stage III or IV. Moreover, 29 cases of ovarian cancer were diagnosed during the study period and were not detected by screening! In statistical terms (and we all have to use these) the positive predictive value of positive screening was only 1.0 to 1.3% during the 4 years of the study.
Bottom line: If you are not at what is deemed “at increased ovarian cancer risk” having a CA-125 blood test or a transvaginal ultrasound to screen for this cancer is not recommended by any of the major gynecologic or cancer societies. These tests may allow you (and your doctor) to feel that you are proactive but neither guarantee that you don’t have an early stage ovarian cancer nor do they reassure you that you won’t receive a future diagnosis of late stage ovarian cancer. If you are at risk because of family history, consider genetic testing. The current recommendation for BRCA positive women is to undergo surgical removal of the ovaries between the ages of 35 and 40 at the completion of child bearing or at the earliest age at which cancer was diagnosed in affected family members. If women who are BRCA positive chose to wait for surgery, the Comprehensive Cancer Network recommends CA-125 and vaginal ultrasound every 6 months although no one is sure that this will increase survival rates. Finally, if you have signs or symptoms of ovarian cancer (pelvic mass, pelvis or abdominal bloating, urinary frequency or urgency, increased abdominal size, bloating, difficulty eating or feeling of fullness) see you doctor… ultrasound and CA-125 may be warranted. When I perform these tests on my symptomatic patients I warn them that they may, however, be falsely positive or negative. Hopefully, in the future, my colleagues and I can do better.