Ovarian Cancer - Making the Diagnosis in Time

Summarized by Robert W. Griffith, MD
August 20, 2004

Introduction

Ovarian cancer is the fifth leading cause of cancer deaths in women in the USA, after lung, breast, colon/rectum, and pancreas. More seriously, 60% of cases die from the disease. This is largely because it's diagnosed too late. Cure rates in the early stages approach 90%, but most women are diagnosed during stage III or IV, when cure rates are very low. What can be done to improve this dismal situation?

Since screening tests such as ultrasound or a blood test for 'cancer antigen 125' have proved disappointing in accuracy, attention has been focused on the symptoms reported by victims. Some hope is raised by a study reported in the Journal of the American Medical Association, which reviewed the most frequent symptoms of the cancer.¹

The most frequent symptoms

In this study, Seattle physicians compared self-reported symptoms from women visiting their primary care physician with those from women who had been operated on for a pelvic tumor. Both groups were invited to select their symptoms from a list of 20 that represented those typically associated with ovarian cancer.

Women who were found at surgery to have a malignant pelvic mass had reported symptoms that were more severe, more frequent, and of more recent onset than those reported by the other women. Women with ovarian cancer typically experienced symptoms 20 to 30 times a month.

However, both groups reported roughly the same set of symptoms - there were no clearly distinguishing complaints. The most common were back pain (45%), fatigue (34%), bloating (27%), constipation (24%), abdominal pain (22%), and urinary symptoms (16%). Bloating, increased abdominal size, and urinary symptoms were reported by 43% of those with cancer, but by only 8% of those attending primary care clinics.

This study demonstrated that how difficult it is for the diagnosis of ovarian cancer to be made based on symptoms alone. And we've already said that the screening tests available are not reliable.

What's to be done?

The study results don't provide doctors with the sort of confidence they can get with the help of blood tests or X-rays for diagnosing other cancers. The author of this review suggests that teasing out the truth from the symptoms listed by a woman requires close cooperation between the physician and the patient.

No hard and fast rules can be set. For example, relying on the 4 symptoms identified in the study - bloating, increased abdominal size, urinary symptoms, and pelvic pain - would still miss a considerable number of cases of ovarian cancer. In the same way, just relying on the severity or frequency of the symptoms would also miss a number of cancer-positive patients.

The early diagnosis of ovarian cancer must, therefore, rely on the clinical judgment of the doctor, based on a full exploration of the patient's symptoms and possible known risk factors (age, family history, breast cancer, menstrual and childbirth history, diet, and the use of estrogen replacement therapy). As we said, this approach reinforces the concept of a good doctor-patient relationship with open communication; if a woman feels that her concerns are not being properly addressed, she should seek another doctor.

Source

• Symptoms of ovarian cancer - where to set the bar? MB. Daly, RF. Ozols, Editorial. JAMA, 2004, vol. 291, pp. 2755--2756

Footnotes
1. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. BA. Goff, LS. , CH. Melancon, HG. Muntz, JAMA, 2004, vol. 291, pp. 2705--2712

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