The not-so-silent killer

Summarized by Robert W. Griffith, MD
December 21, 2000 (Reviewed: February 17, 2003)

Introduction

Popular medical wisdom has it that ovarian cancer is asymptomatic until late in the course of the disease - indeed, it's often called the "silent killer". Survival rates in the early stages range from 70% to 90%, compared with 20% to 30% for women in advanced stages, so that early diagnosis is obviously of vital importance. A study reported in 1985 found that while 75% of women with early stage disease reported symptoms, 90% of women thought the symptoms were not serious - menstrual irregularities, menopausal, or just aging effects. The present study was done to help identify specific early symptoms and the causes of delays in diagnosis.

Method

Subscribers to a newsletter - CONVERSATIONS! The International Newsletter for Those Fighting Ovarian Cancer - were mailed a 2-page survey that asked about the type of symptoms the women had experienced before diagnosis, and the length of time they had had those symptoms. They were also asked to give the date they first saw their physician, and the date they were diagnosed with ovarian carcinoma. There were further questions on the tests done, the health care provided, whether a pelvic exam was done before diagnosis of carcinoma, the stage of their carcinoma according to the international Federation of Gynecology and Obstetrics staging (if known), and whether they received chemotherapy.

Results

1,500 surveys were mailed out, and 1,725 replies were received from 47 states in the USA and 4 Canadian Provinces - women were allowed to copy and distribute the survey to other women with ovarian cancer. The mean age of the respondents was 52 (range 18 - 84). At diagnosis, 71% had Stage III or IV carcinoma, and 95% went on to receive chemotherapy.
95% of those surveyed had noted symptoms before diagnosis:

abdominal bloating	57%
fatigue	47%
abdominal pain	36%
indigestion	31%
urinary frequency	27%
pelvic pain	26%
constipation	25%

with urinary incontinence, back pain, dyspareunia, anorexia, palpable mass, vaginal bleeding, weight loss, nausea, bleeding with intercourse, deep vein thrombosis, and diarrhea reported with lesser frequency. These symptoms could be grouped to give the following frequencies:

• abdominal symptoms : 77%
• gastrointestinal symptoms : 70%
• pain : 58%
• constitutional symptoms : 50%
• urinary symptoms : 34%
• pelvic symptoms : 26%

Only 11% of those with Stage I or II, and 3% of those with Stage III or IV, reported no symptoms before their diagnosis. Women who ignored their symptoms (22% of the collective) were more likely to be diagnosed with advanced disease, to a significant degree.

Women with the most symptoms were significantly younger, and required more time for a diagnosis to be made. About a third of all the women saw 3 or more healthcare providers before the diagnosis was made. Depression, stress, constipation, irritable bowel and gastritis were among the commonest misdiagnoses.

Once women had visited a provider, there were also delays until the diagnosis was made - up to 2 months in 55%, 3-6 months in 19%, 7-12 months in 15%, and more than 12 months in 11%. While there were no differences in the time taken for different types of health providers to reach a diagnosis of ovarian carcinoma, obstetrician-gynecologists were more likely do a pelvic examination, order tests, and find tumors at an early stage (Stages I and II). Not having a pelvic exam at the first visit, or not having a CT scan, ultrasound or CA 125 test ordered, were all significantly associated with delay in diagnosis.

Comment

The findings of this large survey are not revolutionary - they merely confirm what has been suggested by smaller studies. However, they add weight to three main conclusions to be drawn about the so-called silent killer, ovarian carcinoma.

First, there is no single symptom, or group of symptoms, that the patient or her physician must watch for. Rather, there is a spectrum of symptoms involving various body systems.

Second, women should not ignore vague or non-specific symptoms that do not have an obvious alternative explanation. They should visit their physician and, if their symptoms are not readily resolved by treatment, request a full work-up.

Third, healthcare providers must elevate their awareness of ovarian cancer as a not-so-silent killer. Failure to do a pelvic examination, or to order tests such as an ultrasound scan or CA 125 blood level, are associated with a delay in diagnosis, which, in turn, means that the stage of the tumor is more advanced when it's finally diagnosed.

Increased education of both women and primary healthcare providers should go a long way to ensure that the majority of women with ovarian carcinoma are promptly diagnosed and receive treatment at a stage when it is most likely to be successful.

Source

• Ovarian Carcinoma Diagnosis BA. Goff, L. Mandel, HG. Muntz, CH. Melancon, Results of a national ovarian cancer survey. Cancer , 2000, vol. 89, pp. 2068--2075

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