Mrs. J.L., who works as a lunch
lady in a Massachusetts school, is one of 23,000 American women who will
get a dreaded diagnosis this year: ovarian cancer.
It’s the deadliest female malignancy.
week Mrs. J.L. (her initials are used to protect her privacy) was in an
operating room at Massachusetts General Hospital while surgeons huddled
over her abdomen, searching with their eyes and their fingers for
Surgeon Linda Duska says Mrs. J.L.’s cancer was widespread by the time doctors diagnosed it.
we first looked at her she had tiny spots, two or three millimeters of
cancer, all through her entire abdomen,” Duska says. “And there were
also bigger spots of cancer on her bladder, on her colon, behind her
Unfortunately, this is typical. Eight out of 10 women
with ovarian cancer have a widespread disease, called Stage III or IV.
Their chances of cure are low.
The Silent Killer
years, ovarian cancer was called a “silent” killer — causing no symptoms
until it was too late to be cured. There’s no good screening test for
ovarian cancer, like a Pap smear for cervical cancer or colonoscopy for
But in recent years, data from Dr. Barbara Goff
at the University of Washington and other researchers have challenged
the notion that early stages of ovarian cancer give no warning.
Interviewing women after their diagnosis and comparing them with similar
women without ovarian cancer, the researchers found the cancer patients
often had suffered symptoms. But they weren’t recognized as signaling
possible ovarian cancer.
That’s because the symptoms are common and unspecific — and they can point to a wide variety of underlying causes.
The Warning Symptoms
most prominent warning symptoms for ovarian cancer Goff and her
colleagues found are: bloating, pelvic or abdominal pain; difficulty
eating or feeling full quickly; and a frequent or urgent need to
The key indicator, they say, is if such symptoms — alone
or together — come out of the blue and persist, occurring almost daily
for more than two or three weeks.
This summer, the Gynecologic
Cancer Foundation and 19 other groups concerned with women’s health put
out a consensus statement urging women and their doctors to pay serious
attention to these early symptoms of what might be ovarian cancer.
Duska says the symptoms are often ignored or misinterpreted — while the cancer grows.
all have stories of months and months of (women) being worked up …
colonoscopy and all sorts of other tests, before somebody figured out
what was going on,” she says.
A Late Diagnosis
Bennett, a 54-year-old New Hampshire woman, says this was her story. She
was finally diagnosed with ovarian cancer at 9:30 a.m. on July 15, 2005
— the time and date are seared into her memory.
“It started very
slowly, where I would just have these twinge of cramps, which I didn’t
think too much about,” Bennett says. “But I had just had my annual
checkup with my gynecologist, so I called. And they really didn’t think
it was anything.”
That was in April 2005. After that, the symptoms
piled up while Bennett’s doctors scratched their heads — even after an
ultrasound test showed a mass the size of an orange on her left ovary.
Her gynecologist thought it was a benign cyst.
It took four months
before her ovarian cancer was recognized for what it was — and the
diagnosis came only after she started hemorrhaging badly.
Bennett says she hears this story from many women she has met since.
have this whole group of friends now who have ovarian cancer,” she says
as she waits to discuss a new chemotherapy regimen with her doctors.
“They all tell me the same thing — that they had no idea. Not a clue!
Every one of them was diagnosed late.”
Duska says women who think they’re having signs of possible ovarian cancer need to be as persistent as their symptoms.
really need to push their physicians … to get to the next step,” Duska
says. “A lot of them have told me, ‘I’ve had to go back to my doctor
multiple times and say something is really wrong with me and you need to
figure it out.’”
The American Cancer Society agrees. It signed on to the new guidelines — but with reservations.
Concerns About New Guidelines
Debbie Saslow, who heads breast and gynecological cancer programs for
the cancer society, says the group is worried that many women with
common symptoms — most of which will not turn out to be ovarian cancer —
might be unduly alarmed by the new consensus statement. There’s
anecdotal evidence that this may be happening.
we had feared, there have been women who have seen media coverage of
this statement and have run to their doctors because they feel bloated
or they feel some pain,” Saslow says.
She adds that some women
have “been very insistent about getting tests, such as CA-125, that are
inaccurate.” CA-125 is a blood test that can indicate ovarian cancer.
But it’s often a false alarm.
Ultrasounds can help rule out
ovarian cancer. But, as Beth Bennett’s experience shows, they can be
misleading too. The only sure diagnosis is by exploratory surgery called
a laparoscopy. The American Cancer Society is concerned about
unnecessary laparoscopies, but Saslow says, on balance, this concern was
outweighed by the hope that more women will get life-saving early
“The alternative,” Saslow says, “is to not say anything
and to continue having women who then later get ovarian cancer say,
‘Why didn’t anyone tell me about these symptoms?’ or ‘I did tell my
doctor and he or she told me not to worry about that.’”
Boston surgeon, has seen no sign that women are overreacting. But she
acknowledges that it could be years before we know if the guidelines
will make ovarian cancer as curable as breast cancer usually is now.
cancer is a rare disease, but it is often deadly because it is
difficult to diagnose. Usually, by the time it is detected it has
New guidelines suggest possible warning signs for
detecting ovarian cancer. Here are some things to consider when
attempting to diagnose the disease:
What do the new guidelines say are possible warning signs of ovarian cancer?
symptoms include bloating, pelvic or abdominal pain, difficulty eating
or feeling full quickly, and an urgent or frequent need to urinate.
any of these symptoms arise suddenly — alone or in combination — and if
they occur every day or almost daily for more than two or three weeks,
the guidelines advise seeing either a primary care doctor or
gynecologist to investigate the cause.
Are there tests doctors can use to tell if these symptoms do signal ovarian cancer?
Unfortunately, there’s no specific test for ovarian cancer, such as the
Pap smear for cervical cancer. And, most of the time, the symptoms will
not be due to ovarian cancer, which is a rare disease.
should first closely question patients with these symptoms and try to
determine if there’s another, more likely explanation — for instance,
infection or diet. They should do a careful pelvic exam. But if the
symptoms persist without other apparent cause, physicians should not
delay in assessing the possibility of ovarian cancer. This can involve
ultrasound exams, a blood test called CA-125, and, ultimately,
exploratory surgery through a minimally invasive approach called
What is the CA-125 test and how good is it in diagnosing ovarian cancer or ruling it out?
is a protein in the blood which can be associated with ovarian cancer.
But the test for CA-125 is notoriously unreliable, since a high level of
the protein can be present without having ovarian cancer — and a
negative test result doesn’t necessarily mean ovarian cancer is absent.
years ago the National Preventive Services Task Force recommended
against using CA-125 or ultrasound tests to screen women for ovarian
cancer. Some doctors use CA-125 in women at high risk for ovarian
cancer, due to genetic markers or family history. If levels of CA-125
rise over several successive tests, this can be a signal to explore
Why are the new guidelines controversial?
are two main reasons. First, some doctors fear the guidelines will
alarm many women who suffer from the listed symptoms, sending them down
the road of costly and unnecessary diagnostic tests — including surgery —
for things that will turn out not to be ovarian cancer. Patient
advocates argue this can be minimized if women and their doctors pay
close attention only to symptoms that are new, regular and persistent
for at least several weeks.
Second, experts differ on whether
finding ovarian cancer earlier will really lead to higher cure rates.
It’s possible that by the time symptoms are present, the cancer may
already have spread. On the other hand, the total tumor mass may be
smaller and thus present a better prospect for cure through surgery and
chemotherapy. Only large prospective studies that follow women for
several years after diagnosis will answer the question.
How early does ovarian cancer need to be detected to be curable?
earlier the stage (from Stage I to Stage IV) the greater the chance of
cure. About 80 percent of Stage III patients — with cancer outside the
ovaries and Fallopian tubes, but still confined to the abdomen — will
achieve remissions. This means they will have no visible traces of
cancer following treatment. But cancer will recur in 80 percent of those
patients who have been in remission.
Among women whose cancer is
found when it is still Stage I — confined to the ovary and Fallopian
tubes — 93 percent are still alive five years later. However, only
one-in-five ovarian cancer patients is diagnosed that early.
aren’t sure how long an ovarian cancer has been growing in a woman’s
body when she has any given stage of cancer. (By comparison, breast
cancer is thought to take years to get to the detectable stage.) It’s
likely that there are different kinds of ovarian cancer, some more
aggressive and fast-growing than others.
What are the current treatment options for ovarian cancer?
is almost always the first step. Often the ovaries and Fallopian tubes
are removed with nearby lymph nodes through a “Band-Aid incision” when
the diagnosis is made. At that time, surgeons assess the extent of
disease and involvement of other organs, which will determine the stage
of cancer — and the scope of further surgery. Doctors usually prescribe
chemotherapy of various kinds, since ovarian cancer is assumed to have
seeded itself within the abdomen and, perhaps, beyond by the time is has
been diagnosed. Chemotherapy is given intravenously, by mouth, and
sometimes directly into the abdominal cavity, depending on the type.