Ovarian Cancer And The Search For Early Detection

Edited excerpts from 
A Gynecologist's Second Opinion
by William H. Parker, MD, OBGYN.net Editorial Advisor 

SUSAN'S ABNORMAL SONOGRAM 
Susan is a 58-year-old woman who saw her family physician after a few weeks of mild abdominal pain and bloating. The examination of her abdomen was normal, as was a pelvic and rectal exam. Blood tests for infection, liver and gall bladder problems were also normal. Susan and her doctor were both reassured by all this, and she was given a medication to reduce any spasm in the intestines. When the pain and bloating persisted despite the medication, her doctor ordered some X-rays of her intestines and a sonogram of her gall bladder and pelvis. All of these tests were also normal, with the exception of a 2-inch fluid filled cyst seen in her left ovary. 

Susan came to the office worried that this test indicated ovarian cancer. On examination, I couldn't feel anything abnormal. In addition, there was no tenderness on examination of her uterus, tubes or ovaries and it seemed unlikely that her original complaints of pain and bloating were at all related to a gynecologic problem. But when I reviewed the sonogram, it was clear that a cystic mass was, in fact, present. We performed a CA-125 test which was thankfully normal. At this point, the suspicion of ovarian cancer was extremely low but because a mass was present, I recommended surgery to remove it. We performed a laparoscopy the next week. During surgery, it was immediately clear that the mass was not her ovary, but rather her fallopian tube that was filled with fluid. This probably resulted from a previous infection that had occurred many years before and had never caused any symptoms or problems. In fact, had the sonogram not been performed, no one would have ever known about the "cyst," and she never would have had surgery. We did remove the tube through the laparoscope in order to prevent similar confusion in the future. The pathologist confirmed that this was an old infection that had been cured by the body's defenses long ago. I think Susan's case illustrates that medical tests are not foolproof and sometimes can lead to other unnecessary tests or procedures. 

If cancer is one of the most dreaded word in the English language, then for most women, "ovarian" is the worst adjective to place before "cancer". In all the bad news we sometimes deal with in gynecology, this is the most frightening. Since the death of Gilda Radner, a comedienne who made so many of us laugh, people seem to be much more aware of ovarian cancer. This increase in interest has led to enhanced medical research regarding ovarian cancer. Studies are being done on the cause or causes, the treatment, and importantly, a means of early detection. For the 5% of ovarian cancer patients for whom the cancer may be hereditary, genetic research is evolving to help determine who actually is at risk. While we still feel as if we are groping in the dark with this disease, when I think back to five years ago, I know that we are making strides. The following chapter deals with what we now know about the detection, treatment and prevention of ovarian cancer. If you are anxious and concerned about this disease, I hope that this information allays many of your fears. 

HOW COMMON IS OVARIAN CANCER? 
While extremely frightening, ovarian cancer is a rare disease. Only one out of every 15,000 women at the age of thirty will be found to have the disease. At 40, about the age that Gilda Radner was discovered to have ovarian cancer, only one of every 10,000 women have this disease. At the age of 60, the average age at which women get ovarian cancer, only one of every 1500 women will be found to have it. In your entire lifetime, if you live to be 90 years old, you have a 1 in 70 chance of developing ovarian cancer. While concerning, compare this with the 1 in 3 chance a women has of dying of a heart attack by the time she is 90 - or the fact that you are more likely to die from an auto accident and twice as likely to die from colon cancer than you are from ovarian cancer. This is not to diminish the human toll from this terrible disease. However, all of the interest and media coverage surrounding ovarian cancer has given the impression that the disease is now more common, that there is an epidemic. In fact, the incidence of ovarian cancer is no greater now than it was 25 years ago. 

ARE MOST GROWTHS ON THE OVARY CANCEROUS?
No. In fact, for a premenopausal woman found to have a growth on her ovary, there is over a 90% chance that this growth is benign. Even for a postmenopausal woman, an ovarian growth has a 70% chance of being benign. Therefore, if a growth is found on your ovary, do not panic. It will most likely not be a cancer. Chapter 4 is devoted to the types of benign ovarian cysts most commonly seen. 

IS SONOGRAPHY A GOOD SCREENING TEST FOR OVARIAN CANCER?
Unfortunately, the answer is no. Sonography is a medical test that uses sound waves bounced off the ovaries to form a picture on a screen, much like the technology used for ship's sonar. This technique was felt to be a promising method to detect growth in the ovaries that might be the beginning of a cancer. The hope was that this test would detect ovarian cancer before it had a chance to spread. Unfortunately, the test has a hard time distinguishing ovarian cancer from other cysts on the ovaries which are benign. These benign cysts are much more common than ovarian cancer, and most of them do not need to be treated at all. 

A study that illustrates this problem was conducted in England where an ad was placed in the paper for free ovarian cancer screening. Within a short period of time, 5700 women readily agreed to get this free testing. Of the 5700 women who had a sonogram of their ovaries performed, 361 of them had abnormal appearing ovaries. All 361 of these women then underwent major abdominal surgery. Three of these women were found to have widely spread ovarian cancer that would have been easily detected by a pelvic exam. And only three women with early ovarian cancer were found and cured. This is wonderful for the three women whose lives were saved by the sonogram. However, 355 women had a major surgery that they did not need. They were subjected to the risks of anesthesia, bleeding, need for transfusion, infection, and injury, in addition to the discomfort of surgery and the time needed for recovery. At this point, for the general population the risk that an abnormal screening sonogram may lead to unnecessary surgery seems to outweigh the benefit. 

In addition, it has been calculated that if all 43 million American woman over the age of 50 had a pelvic sonogram every year, we might expect 2.5 million women to have an abnormality found. Thirty-seven thousand of these women would be found to have ovarian cancer that would otherwise have not been detected so early. But, 2,463,000 women would have had unnecessary surgery. Of those women, 2,500 might be expected to die from the procedure, and 112,500 would have a serious complication. In addition, the cost of the sonograms would be $11.8 billion per year. The cost of the unnecessary surgeries would be about $ 37.5 billion per year. So for all these reasons, a sonogram is not recommended as a routine screening test for ovarian cancer.

SHOULD YOU GET GENETIC TESTING FOR OVARIAN CANCER? 
Some women with a strong family history for ovarian cancer have been found to have a mutation in a gene called BRCA, which stands for BReast CAncer gene. In addition to inheriting a higher risk of getting breast cancer, women with this mutation have a higher risk of developing ovarian cancer. In the general population this mutation occurs in about 1 out of 1,000 women. However, in women of eastern European Jewish descent the mutated gene occurs in 20 out of 1,000 women. Women who have a BRCA mutation have a 25-50% chance of developing ovarian cancer in their lifetimes, compared to the 1% risk for women who do not have the mutation. Interestingly, women who have this gene mutation and develop ovarian cancer develop a less aggressive cancer and survive longer than women who do not have this mutation. As is true for the non-genetic form of ovarian cancer, taking birth control pills substantially reduces the risk of inherited ovarian cancer. 

Testing for this gene is now available for women who suspect they are at high risk because of a family history of ovarian cancer. Deciding whether to be tested is often a difficult decision. There are a number of reasons you might consider getting the test. If it is negative, then neither you nor your daughters need to be concerned about an increased risk of this disease. This often lifts an enormous burden of worry. If the test is positive, then you will have some decisions to consider. With an increased risk of ovarian cancer (and an increased risk of breast cancer), the available options to decrease this risk are drastic; removal of your ovaries and/or breasts (mastectomy). Removal of your ovaries will eliminate your risk of ovarian cancer but does involve a surgical procedure. 

Removal of ovaries can now be performed with laparoscopic surgery as an outpatient, but general anesthesia is necessary and, as is true with all surgery, includes some risk. In addition, removal of the ovaries will not prevent a very rare form of inherited cancer that affects the inside lining of your abdomen called the peritoneum. In that this gene mutation also increases your risk of breast cancer you will need to address the issue of removal of your breasts, mastectomy, for preventative reasons. Your age, childbearing issues, your feelings about the possibility of cancer, and your feelings about surgery and removal of feminine parts of your body are all important issues. These are extremely difficult decisions and are best made with the counseling and advice of a trained genetic counselor. It is important to see the genetic counselor before you get tested, so that these issues can be discussed in advance of the results. Ask your doctor to recommend someone to you or call a nearby medical center for a referral.

The following questions and answers can be found in our book

ABOUT FIBROIDS

What Causes Fibroids? 
Do Birth Control Pills Cause Fibroids? 
What Are the Different Types of Fibroids? 
Can Fibroids Cause Bleeding Problems? 
Can Fibroids Cause Pain or Pressure? 
Can Fibroids Cause Sudden Pain? 
Can Fibroids Cause Urinary Problems? 
Can Fibroids Cause Infertility? 
Can Fibroids Cause Miscarriage? 
Can Fibroids Cause Problems During Pregnancy? 
Do Fibroids Mean A Cesarean Section? 
Do Growing Fibroids Mean Cancer? 
What If You Have Large Fibroids? 
Can My Fibroids Just Be Watched? 

TREATMENT OPTIONS FOR FIBROIDS

What Are the Treatment Options for Fibroids? 
Can You Take Medication for Fibroids? 
Are There Any New Medicines for Fibroids? 
What Are the Side Effects of Lupron and Synarel? 
When Should Lupron or Synarel Be Used? 
What About Danacrine? 
Can Progesterone Be Used To Treat Fibroids? 
Are Holistic Remedies Effective for Treating Fibroids? 
Do You Need Surgery for Fibroids? 
What If You Have Uncontrollable Bleeding? 
What If You Are at Risk for Kidney Damage? 
What If There Is Concern That The Fibroids Might Be Cancer? 

TYPES OF SURGERY FOR FIBROIDS 

What Is a Myomectomy? 
What is an Abdominal Myomectomy? 
What is a Laparoscopic Myomectomy? 
Can Lasers Be used for Myomectomy? 
Can Myomectomy Lead to Scar Tissue ? 
What is a Vaginal Myomectomy? 
What is Myoma Coagulation (Myolysis)? 
What is Resectoscope Myomectomy? 
What is Endometrial Ablation? 
Do I Need a Hysterectomy for Fibroids? 

ADENOMYOSIS

What is Adenomyosis? 
What Are the Symptoms of Adenomyosis? 
How Is the Diagnosis of Adenomyosis Made? 
What Is the Treatment for Adenomyosis?