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The Not-So Silent Killer

Ovarian cancer, long known as “the silent killer,” has been tricky to diagnose; it’s a rare disease – roughly one out of every 2,500 women develop it – and many patients present with symptoms, such as abdominal and gastrointestinal issues, that can be easily prescribed to a variety of conditions. The biggest risk factors are a family history, as well as hormone therapy, endometriosis, and obesity. Women have a reduced risk of ovarian cancer if they have taken birth control pills or have had a tubal ligation, hysterectomy, or salpingectomy (removal of the Fallopian tubes).

In 2016, for example, there were 21,500 new cases of ovarian cancer diagnosed, and 70 percent of those patients typically had Stage III or IV, where the five-year survival is very low. So, as Barbara Goff, MD, director of the Division of Gynecologic Oncology at the University of Washington, asked at the 14th Annual Susan Patricia Teck Memorial Lecture in mid-October, “in 2017, how do we make the diagnosis of ovarian cancer?”

The American Congress of Obstetricians and Gynecologists and the Society of Gynecologic Oncology both recommend assessing women at risk with a high degree of suspicion and educating all women and practitioners about ovarian cancer symptoms, such as bloating, constipation, and abdominal problems.  Currently, there are no recommended screening tests for ovarian cancer in the general, low-risk population. 

In 1999, however, Goff embarked on a career-long journey to identify, analyze, and improve screening techniques. She began with a nationwide survey. The goals, she explained, were to include a large sample size of women with ovarian cancer, to evaluate their pre-operative symptoms, and to determine potential causes in delayed diagnosis.

“We concluded that a majority of women with ovarian cancer do have symptoms, the majority of women with early stage have symptoms, and delayed diagnosis was common, with both patient-related factors and physician-related factors,” Goff said, adding that for many of the women, their primary care physicians misdiagnosed their symptoms as stress or depression, among other possibilities.

After the study was released, additional studies replicated Goff’s results, though she did receive one piece of criticism: primary care physicians reported that all of the women in their practices presented with symptoms applicable to ovarian cancer; how were they supposed to distinguish between ovarian cancer and something else?

“We decided that we would try and answer that question, so we designed a study to identify frequency, severity, and duration of symptoms that are typical of ovarian cancer,” Goff said.

She and her team found that pelvic and abdominal pain, difficulty eating, bloating, and frequent urination were significantly more common in ovarian cancer patients. They also determined that that the presence of more frequent symptoms and a more recent onset of symptoms correlated with a diagnosis of ovarian cancer.

“After we completed that study, we were kind of excited, and we [decided] to design an ovarian cancer symptom index that could actually be used by primary care physicians in their clinics to direct symptom trigger screening,” Goff said.

New directions in ovarian cancer screening, she added, have included urine markers, circulating tumor DNA, and molecular alterations on Pap smears. Despite her work and that of others, there remains a lack of official screening tests, other than symptom diagnosis, transvaginal ultrasounds, and CA125 blood tests.

“I hate to be a Debbie Downer, but I don’t think we’re going to have a screening test in the next decade,” she said. “So, whatever we can do to prevent this terrible disease, that’s where a big focus should be.”

Opportunistic salpingectomies – those performed during an ongoing pelvic surgical procedure – could decrease high-grade serious tumors by 80 to 90 percent and could be used in the general population, she explained. Other procedures, such as tubal ligations and bilateral salpingo-oopherectomies, as well as additional genetic testing and the use of oral contraceptives, could likewise potentially help prevent ovarian cancer.

“In conclusion, in 2017, there is no effective screening test for ovarian cancer that’s currently available, much to my dismay. It’s disappointing, but early recognition relies on symptom recognition by patients and practitioners,” Goff said. “It’s very important, as OB/GYNs, to educate patients and primary care colleagues that these symptoms exist around cancer, they’re not silent, and there’s some evidence that early recognition helps some women get diagnosed earlier. Prevention studies, including opportunistic salpingectomy, can also significantly reduce the risk of ovarian cancer.”