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Ovarian cancer: Improving the odds for today and tomorrow

In the last few years, we physicians have witnessed tremendous growth in what is known about ovarian cancer, but there is so much more to know. All of these studies are welcome additions that help in our ability to treat this disease. Sadly, there remains a lack of overall knowledge about ovarian cancer. When I speak to community groups about ovarian cancer, there is not the widespread knowledge about ovarian cancer that you find with breast or other types of cancer. And that’s a dangerous thing because ovarian cancer is the fifth leading cause of cancer death among women in the United States.

This year, about 23,000 women will be diagnosed with ovarian cancer. Women who are diagnosed with early cancer have a very good prognosis for survival. Women with localized disease (that has not spread) are three times more likely to survive five years than women with cancer that has spread. However, only a quarter of women are diagnosed with early stage ovarian cancer. My personal goal is to increase awareness so more women can come into our Ovarian Cancer Detection Program at Yale with earlier, more treatable cancers.

Subtle signs
There are no obvious early warning signals with ovarian cancer. Rather, early on, this disease has no symptoms or very subtle signs. Signs to look for might include a change in bowel habits, such as gas, indigestion or swelling, sometimes nausea or feeling full, increased urination or unexplained weight gain or loss. What should raise a red flag for women is the persistence of these symptoms. Conditions other than cancer can cause these symptoms. Your first step must be to talk to your doctor. If he or she does not take your symptoms seriously, then it may be time to switch doctors.

Who’s at risk?
It’s also helpful to know who is at higher risk of developing ovarian cancer. In Connecticut, we have the oldest tumor registry in the country. A comparison of data from the state’s seven largest hospitals in the 1970s yielded the first clues about these risks, including being Caucasian and having a first-degree relative with ovarian cancer. A first-degree relative is a mother, sister or daughter. In our study, the risks for ovarian cancer if you had a first-degree relative with the disease were 18 fold over the control population. Additional studies have since shown the actual risk to be smaller—three and one-half times the control risk—but still very significant for women with first-degree relatives.

And of course age is a significant factor. The average age at diagnosis is 63. But that should not lull younger women into a false sense of security if they are having symptoms. Having had breast cancer doubles the risk of developing ovarian cancer. Fertility drugs may also increase the risk, although the evidence is not clear. Evidence has been inconclusive about the link between ovarian cancer and talcum powder use for personal hygiene.

Protective events
Events in a woman’s life that inhibit the release of eggs from the ovaries appear protective against developing ovarian cancer. These include having many children, breastfeeding and taking oral contraceptives. In Connecticut, a woman who has never had children has a risk five times greater than that of a woman who had five or more children.

Using CA125
In the past, CA125 has been the best method available to monitor women with ovarian cancer for recurrence. But there are definite problems in using it to diagnose ovarian cancer in women, particularly in those who have not undergone menopause. Any irritation to or inflammation of the lining of the abdominal cavity (the peritoneum) can increase the CA125 reading. Endometriosis can elevate levels of CA125 as can fibroid tumors of the uterus, or the combination of the two. A woman should never have a CA125 test during her period, as menses are associated with elevation of CA125.

Looking to ultrasound
As this latest presentation by the Kentucky researchers points out, ultrasound makes sense for diagnosing this type of cancer. This is particularly true for younger women who have a higher occurrence of noncancerous cysts, which can cause symptoms similar to those of ovarian cancer. About 15 percent of premenopausal women have "simple" cysts at one time or another, which we follow, but which tend to go away on their own. These are distinguished from "complex" cysts, which look like lumps on the inside of a balloon and require further investigation.

Future directions
We should be able to make a real impact in the fight against ovarian cancer in the near future by:

• educating women and physicians about ovarian cancer;
• identifying and following women at increased risk of ovarian cancer;
• developing new and more specific tools to aid in that diagnosis, and;
• coming up with better treatments for ovarian cancer.

In the meantime, it is critically important to detect and treat this disease as early as possible.

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Dr. Schwartz is a gynecological oncologist affiliated with Yale-New Haven Hospital and director of the Yale High Risk Ovarian Cancer Clinic.