Listen for the "whispering disease"

Nurse Practitioner, Apr 2000 by Martin, Virginia R

learn the subtle signs and symptoms of ovarian cancer.

Ovarian cancer...it whispers...so listen." So advises the National Ovarian Cancer Coalition a group of 9,000 survivors who want you to know how elusive-and deadly-the disease can be. While ovarian cancer represents only 4% of cancer incidence in women, it's the fourth leading cause of cancer-related deaths in 1999, about 25,500 new cases were diagnosed and about 14,500 women died from the disease.

In its earliest stages, ovarian cancer is curable. So why the high death rate? Early signs and symptoms are so vague that most women ignore them and then, unfortunately, are already in the late stages of the disease when they're diagnosed. That's why it's so important for women to listen to their bodies. Read on to learn the risk factors for ovarian cancer, what you can do to reduce them, and how you can detect the warning signs.

Are you at risk?

The major risk factors for ovarian cancer fall into three categories: hormonal, environmental, and genetic.

On the hormonal level, the risk may be directly related to the number of ovulatory cycles in a woman's life. The postulated theory is that the uninterrupted cell division and regeneration of the ovarian epithelium-without pregnancy-induced rest periods-may invite mutation and malignancy. Therefore, women who've had no pregnancies are at an increased risk. Infertility also may be a risk factor because childless women who've been pregnant show the same risk as women who've never been pregnant. The risk for ovarian cancer peaks in the eighth decade of life.

We know less about links between environmental factors and ovarian cancer. Industrialized countries report the highest incidence; developing countries report the lowest incidence, but we don't low why. Lifestyle factors such as diet and exercise are being studied. Cosmetic use of talc in powders used to dust the perineum, in feminine hygiene sprays, and on sanitary napkins or condoms has been identified as a risk factor.

Nothing alters the magnitude of risk for ovarian cancer more than genetics. Hereditary ovarian cancer syndromes account for 5% to 10% of ovarian cancers. In general, the closer the degree of relative and the younger the relative at diagnosis, the higher the risk.

Research is ongoing in all these areas and continues to provide us with new information.

Reducing your risk

You can do something to reduce the risk of ovarian cancer. Oral contraceptives taken in combination for longer than 5 years may reduce your risk. A tubal ligation or hysterectomy surgery may be protective. And pregnancy and breast-feeding seem to provide some protection. Women who use powder should use only cornstarch-based products.

Pinning down a diagnosis

Contrary to what you may have heard, ovarian cancer does present with signs and symptoms. Unfortunately, they can be so general-lower abdomen discomfort, dyspepsia, and early satiety, for example-that you dismiss them. The most important message I can convey is: Don't ignore any persistent symptoms.

The classic pelvic examination-during which the clinician searches for palpable ovarian masses-is the starting point for a diagnosis of ovarian cancer. In premenopausal women, enlarged ovaries are common and usually are caused by ovarian cysts. The clinician usually follows the mass through several menstrual cycles.

In premenarchal children and adolescents and postmenopausal women, a palpable ovarian mass isn't normal and must be investigated with a CA-125 tumor antigen blood test and a transvaginal ultrasound. Color Doppler imaging studies also may be used to measure blood flow patterns to ovarian vessels. Increased blood flow resistance signals a malignancy.

If these studies document an abnormality, the next step is a computed tomography scan of the abdomen and pelvis, possibly followed by a barium enema or a colonoscopy.

The CA-125 tumor antigen is associated with ovarian cancer. In fact, 80% or more of women with ovarian cancer have an elevated CA-125 level. The problem is that it's also elevated in some benign diseases and other malignancies as well, so it's not specific enough to detect the disease. The CA-125 tumor antigen has a role in indicating early treatment failure, confirmation of relapse, and in decision making during relapse therapy in ovarian cancer.

Treatment goals

Surgery--generally a total abdominal hysterectomy and bilateral salpingo-oopherectomy-is the mainstay of treatment for ovarian cancer. A major goal of surgery is to stage the disease and to improve the patient's response to chemotherapy, which follows surgery.

The earlier the stage of the cancer, the better the chance of a cure. Low-risk patients may need no further therapy after surgery. High-risk patients must receive postoperative chemotherapy. The preferred regimen includes carboplatin and paclitaxel.

About 75% of ovarian cancer patients achieve a complete remission after surgery and chemotherapy. However, most of these patients have a recurrence of their disease within 3 years.