June 13, 2007
The New York Times

Symptoms Found for Early Check on Ovary Cancer

By DENISE GRADY

Cancer experts have identified a set of health problems that may be symptoms of ovarian cancer, and they are urging women who have the symptoms for more than a few weeks to see their doctors.

The new advice is the first official recognition that ovarian cancer, long believed to give no warning until it was far advanced, does cause symptoms at earlier stages in many women.

The symptoms to watch out for are bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly and feeling a frequent or urgent need to urinate. A woman who has any of those problems nearly every day for more than two or three weeks is advised to see a gynecologist, especially if the symptoms are new and quite different from her usual state of health.

Doctors say they hope that the recommendations will make patients and doctors aware of early symptoms, lead to earlier diagnosis and, perhaps, save lives, or at least prolong survival.

But it is too soon to tell whether the new measures will work or whether they will lead to a flood of diagnostic tests or even unnecessary operations.

Cancer experts say it is worth trying a more aggressive approach to finding ovarian cancer early. The disease is among the deadlier types of cancer, because most cases are diagnosed late, after the cancer has begun to spread.

This year, 22,430 new cases and 15,280 deaths are expected in the United States.

If the cancer is found and surgically removed early, before it spreads outside the ovary, 93 percent of patients are still alive five years later. Only 19 percent of cases are found that early, and 45 percent of all women with the disease survive at least five years after the diagnosis.

By contrast, among women with breast cancer, 89 percent survive five years or more.

The new recommendations, expected to be formally announced on June 25, are being made by the Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists and the American Cancer Society.

More than 12 other groups have endorsed them, including CancerCare; Gilda’s Club, a support network for anyone touched by cancer; and several medical societies.

“The majority of the time this won’t be ovarian cancer, but it’s just something that should be considered,” said Dr. Barbara Goff, the director of gynecologic oncology at the University of Washington in Seattle and an author of several studies that helped identify the relevant symptoms.

In a number of studies by Dr. Goff and other researchers, these symptoms stood out in women with ovarian cancer as compared with other women.

“We don’t want to scare people, but we also want to arm people with the appropriate information,” said Dr. Goff, who is also a spokeswoman for the Gynecologic Cancer Foundation.

She emphasized that relatively new and persistent problems were the most important ones. So, the transient bloating that often accompanies menstrual periods would not qualify, nor would a lifelong history of indigestion.

Dr. Goff also acknowledged that the urinary problems on the list were classic symptoms of bladder infections, which is common in women. But it still makes sense to consult a doctor, she said, because bladder infections should be treated. Urinary trouble that persists despite treatment is a particular cause for concern, she said.

With ovarian cancer, even a few months’ delay in making the diagnosis may make a difference in survival, because the tumors can grow and spread quickly through the abdomen to the intestines, liver, diaphragm and other organs, Dr. Goff said.

“If you let it go for three months, you can wind up with disease everywhere,” she said

Dr. Thomas J. Herzog, director of gynecologic oncology at the Columbia University Medical Center, said the recommendations were important because the medical profession had until now told women that there were no specific early symptoms.

“If women were more pro-active at recognizing these symptoms, we’d be better at making the diagnosis at an earlier stage,” Dr. Herzog said.

“These are nonspecific symptoms that many people have,” he added. “But when the symptoms persist or worsen, you need to see a specialist. By no means do we want this to result in unnecessary surgery. But I would not expect that to occur in the vast majority of cases.”

Although the American Cancer Society agreed to the recommendations, it did so with some reservations, said Debbie Saslow, director of breast and gynecologic cancer at the society.

“We don’t have any consensus about what doctors should do once the women come to them,” Dr. Saslow said. “There was a lot of hope that we’d be able to say, ‘Go to your doctor, and they will give you this standardized work-up.’ But we can’t do that.”

At the same time, Dr. Saslow said, the cancer society recognized that in some cases doctors had disregarded symptoms in women who were later found to have ovarian cancer, telling the women instead that they were just growing old or going through menopause.

“There are so many horror stories of doctors who have told women to ignore these symptoms or have even belittled them on top of that,” Dr. Saslow said.

In a survey of 1,700 women with ovarian cancer, Dr. Goff and other researchers found that 36 percent had initially been given a wrong diagnosis, with conditions like depression or irritable bowel syndrome.

“Twelve percent were told there was nothing wrong with them, and it was all in their heads,” Dr. Goff said.

Dr. Goff and other specialists said women with the listed symptoms should see a gynecologist for a pelvic and rectal examination. (The best way for a doctor to feel the ovaries is through the rectum.) If there is a question of cancer, the next step is probably a test called a transvaginal ultrasound to check the ovaries for abnormal growths, enlargement or telltale pockets of fluid that can signal cancer. The ultrasound costs $150 to $300 and can be performed in a doctor’s office or a radiology center. A $100 blood test should also be conducted for CA125, a substance called a tumor marker that is often elevated in women with ovarian cancer.

Cancer specialists say any woman with suspicious findings on the tests should be referred to a gynecologic oncologist, a surgeon who specializes in cancers of the female reproductive system.

An unresolved question is what exactly should be done if the test results are normal and yet the woman continues to have symptoms, Dr. Saslow said.

“Do you do exploratory surgery, which has side effects, which are sometimes even fatal?” she asked. “What do you do? We don’t have the answer to that.”

Depending on the test results, the woman may just be monitored for a while or advised to undergo a CT scan or an MRI. But if cancer is strongly suspected, she will probably be urged to go straight to surgery. A needle biopsy, commonly used for breast lumps, cannot be safely performed to check for ovarian cancer because it runs a risk of rupturing the tumor and spreading malignant cells in the abdomen. Instead, the surgeon must carefully remove the entire ovary or the abnormal growth on it and examine the rest of the abdomen for cancer.

While the patient is still on the operating table, biopsies are performed on the tissue that was removed, so that if cancer is found, the surgeon can operate more extensively. Experts say such an operation should be carried out just by gynecologic oncologists, who have special training in meticulously removing as much of the cancerous tissue as possible. This procedure, called debulking, lets chemotherapy work better and greatly improves survival.

Dr. Carol L. Brown, a gynecologic oncologist at the Memorial Sloan Kettering Cancer Center in Manhattan, said, “Ideally, we need to develop a screening tool or a test to find ovarian cancer before it has symptoms.”

No such screening test exists, Dr. Brown said, and until one is developed, the list of symptoms may be the best solution.

“This is something that women themselves can do,” she added, “and we can familiarize clinicians with, to help make the diagnosis earlier.”