Gilda Radner, who died of ovarian cancer at the age of 42, The American Cancer Society and the Society for Gynecologic Oncologists have issued a consensus opinion outlining the symptoms of ovarian cancer, and more importantly, urging women and their doctors to consider ovarian cancer in the differential diagnosis when these symptoms present.
What are the symptoms? They are vague and all too common – bloating, pelvic or abdominal pain, early satiety, and urinary sympotms such as urgency and frequency. But, when present and persistent for more than 2 weeks and less than 1 year (or in the case of urinary symptoms, persistent after treatment for a UTI), one must consider ovarian cancer in the differential. And consider it early, because this is one cancer that won’t wait around while you exclude everything else.
For almost 2 decades now, this is exactly how I have been practicing. As I’ve said before, I don’t hesistate a second before performing a pelvic ultrasound in women with any of the symptoms listed in the consensus statement. I happen to be pretty good with a vaginal ultrasound probe, and I have an amazing gynecologic radiologist to whom I can refer.
Despite this, in all these years, after performing or referring for thousands of sonograms (and not a few ca125 tests) in what I believe is an optimally aggressive screening approach for ovarian cancer in symptomatic women, I have yet to diagnose a single case of early ovarian cancer. Of the 5 or so cases (it is, after all, not a common cancer), all but one presented to me at stage 3 or more. That early tumor was a borderline cancer, and she would have done well no matter what I had done.
I wish I could say my aggressive management of symptoms has impacted ovarian cancer mortality. It’s certainly reassured a lot of frightened women and found quite a bit of benign disease. But ultimately, I just don’t think it has made a difference in terms of ovarian cancer outcomes.
Maybe it is because my patients with ovarian cancer ignored their symptoms for too long before coming in to see me. If so, then publicizing this consensus statement may make a difference. I certainly hope that it does. And despite my reservations about my practice’s efficacy, I’m not changing what I do, because at this point, there is nothing else I can do. It’s what I have to do, and what my patients deserve.
What we really need is a good early ovarian cancer screening test for asymptomatic women. (No, it’s not the Ca125 test.)
Or better yet, how about a pill to prevent ovarian cancer? Oh, wait a minute – we already have that. It’s called the Birth Control Pill.
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Here’s the Consensus Statement:
Historically ovarian cancer was called the “silent killer” because symptoms were not thought to develop until the chance of cure was poor. However, recent studies have shown this term is untrue and that the following symptoms are much more likely to occur in women with ovarian cancer than women in the general population. These symptoms include:
- Bloating
- Pelvic or abdominal pain
- Difficulty eating or feeling full quickly
- Urinary symptoms (urgency or frequency)
Women with ovarian cancer report that symptoms are persistent and represent a change from normal for their bodies. The frequency and/or number of such symptoms are key factors in the diagnosis of ovarian cancer. Several studies show that even early stage ovarian cancer can produce these symptoms.
Women who have these symptoms almost daily for more than a few weeks should see their doctor, preferably a gynecologist. Prompt medical evaluation may lead to detection at the earliest possible stage of the disease. Early stage diagnosis is associated with an improved prognosis.
Several other symptoms have been commonly reported by women with ovarian cancer. These symptoms include fatigue, indigestion, back pain, pain with intercourse, constipation and menstrual irregularities. However, these other symptoms are not as useful in identifying ovarian cancer because they are also found in equal frequency in women in the general population who do not have ovarian cancer.
Um… I didn’t know this was news. When I was a resident, we always ordered pelvic ultrasounds for women who came in with those complaints. _Especially_ post-menopausal women. And I take OCPs because I have this fantasy that they’ll keep me from getting ovarian ca.. oh, yeah, and because I hate my periods (so I decided not to have them).
MWAK:
Sounds like we practice the same way, as I suspect do most gynecologists…However, I Maybe letting women in on know what we know may help…
I’m not entirely optimistic, as I think you can tell.
I know they’re not trying to do the panic inducing thing, but reading the symptoms to look out for always makes me suddenly wonder if I’m having those symptoms. (Until I get doing something else and realize a couple hours later that I can’t quite remember what symptoms I thought I was having… happily!)
I’m with MWAK on the skipping periods thing! Why didn’t I learn about that when I was 20 or something? What a wonderful thing!
Bardiac:
I’m a bit worried that all this publicity will scare the bejesus out of every woman out ther carrting a bottle of Evian everywhere she goes, thus having urinary frequency…
It already scared my mother…. Never mind that she had pelvic pain for years, had it investigated, and the only found problem caused a fibroid. Never mind that she has had urinary symptoms for as long as I remember, and that her blood pressure medication makes them worth. No satiety symptoms though, just the opposite.
To be fair, her mother (my grandmother) died of some kind of cancer of these organs, but we don’t know what it was, only that it spread to the spinal cord. It was in a former Soviet Union and zillion years ago and my grandfather who mostly dealt with doctors was vague about the details. All I know though, is that my grandmother’s uterus was removed first (although it could be unrelated and because of a fibroid), so it could’ve been uterine cancer. But we don’t know…None of my grandmother’s numerous sisters had it, but both my mother and me are the “only children”.
Hi there,
Just found your blog and I do enjoy it, as I start my OB/GYN residency in a few weeks!
As for this statement, it seemed to me maybe it’s more about giving patients something to “look out for” rather than alter how we practice, since up till now it’s been thought as one of those cancers that you find out about when it’s too late. Though I do wonder what this new awareness will cost and if it will help – I bet there’s a whole lotta women who read this in the Times yesterday and called their docs today! And of course, I too thought I had it for about 5 minutes till I realized maybe it was all the fast food that I ate while we were in the process of moving and not so much a tumor 😉
Diora:
No calls yet, but I think my practice tends to be very well-informed and do come in when they have sx…
Jen: Agree – I think the value here is in informing women what to lookout for…Thanks for reading, and good luck in the residency!
Great post – and that picture of Gilda really got me. Her book ‘It’s Always Something’ definitely contributed to me choosing oncology. Her account of trying to maintain grace and her sense of humor in the face of disease is amazing.
I hope this statement does have an impact, but why does it seem like that would be too easy?
On a lighter note, I made the chamomile squares – instant love.
I hate to sound so naive to the medical world (but I am so whatever), but my mother-in-law has these symptoms. It’s not like carrying bottled water everywhere. She needs to go to the bathroom ALL THE TIME. Really. No waiting when she’s got to go. In fact, she has ALL these symptoms. I’m not a worrier but it does seem to be something everyone on this blog thinks should be checked out. But the thing is, she’s had these symptoms for a while. Maybe a couple of years. So, it’s probably something else like incontinence or a bladder control problem. Still, should I tell her to get it checked out? Her mother died of breast cancer so there is a family history of cancer.
two patients come to mind…
the first had vague complaints like the ones mentioned. internist ordered radiology scan, read as normal. Two months later, patient still had symptoms, referred to me. My scan looked like ovarian cancer. Phone call to marvelous gyn-onc: I think this is one you can really help. Patient was in gyn-onc’s OR in less than a week and ta da! Stage I ovarian ca, cured for 3 years and counting.
the second patient came in for annual exam which was as normal as can be (though pelvic sono is not routine part of my exam, too bad). Three WEEKS later, I saw her in ER with distended abdomen and (you already know the dx) Stage III-C ovarian ca.
sigh…screening test can’t come too soon. Meanwhile I’ll do pelvic sonos on anyone who wants one.
Hmm I have had these symptoms since May 16th and they came on all of a sudden. I have been taking 800mg of motrin round the clock and lortab as needed. I called my obgyn’s office and the nurse blew me off and said call back in a month if I was still having issues. (I had a lap last year that diagnosed adhesions, my ob took them down and no problems since until May 16th) It got worse and I had held out the whole weekend to avoid the ER. I called my pcp and she had me immediately come in. By that point I was in tears and bawling. She thought I had appendictis. Sent me to the ER. Cat scans and tests were normal. No ultrasound done. They said they thought it was adhesions again or a cyst that had ruptured. Fast forward 5 days. No better. Saw my obgyn. Keep taking motrin take lortab as needed go for an US. Scheduled the US for the earliest appt in 2 weeks. Ended up spending the night in the ER that night because it was so bad and I couldn’t stand it anymore. Had the 10k workup all normal. Still a cyst that has ruptured and probably has caused adhesions now. Because I didn’t get the US before it was too late. Did it anyway, normal. Follow up with pcp (she still is between a wierd case of appendicitis or adhesions). ER drs all suggested another lap, made me very upset to think about that again. Pcp agrees. Follow up with OBGYN (they wanted me to follow up with both). OBGYN says nope not a cyst for this long. Could be adhesions. Time to go in for another look. So I am now scheduled for a lap on 7/3 again. But this article (I have been seeing it all over the news) makes me wonder. I don’t think it is that (been on continuous BCP for two years now and I am only 33). But I do have cervical, breast, and ovarian cancer that run in my family so can’t rule it out.
Can you tell at a lap if it is early stage ovarian cancer. Or do you have to wait till it gets big enough. This isn’t enough to make me RUN to the ob’s office. But it does put that seed in my head now. Especially since with adhesions before it would come and go with where I was at in the cycle and now it is always there.
These symptoms are so common and can be so many things, I don’t know how a dr could get to a diagnosis of ovarian cancer just from this. Wouldn’t most do a pelvic exam, run an US, maybe some bloodwork and try an OCP???
Off Paper Words:
Sounds like you need to keep trying to get mom to the doc. Given the time course of her symptoms, it sounds as though ovarin cancer is far down on the diagnostic tree,but there are many other conditions that could be causing her symptoms, most of which are benign and completely treatable…Let me know how things go.
Rural Ob-Gyn:
Great save on case #1. It’s hearing about those kinds of outcomes that keep me going. Again, time is of the essence when it comes to pelvic symptoms. An ultrasound is quick and easy, often we can do it right there in the office. (Sometimes I think the bimanual exam needs to be replaced with a vaginal probe exam…) But as you saw, a normal ultrasound sometimes is falsely reassuring – Gilda had a normal sono as well early in the course of her disease.
Of course, we haven’t begun to touch on the costs of this approach, the false positives and how to deal with it, etc, etc. Long term, we have GOT to find a better way to diagnose orvarian cancer. God knows how much we are spending with this hunt and peck approach….
PE Mommy:
Oh dear, sounds like you have been trhrough a lot. Yes, a laparoscopy will diagnose ovarian cancer if it is there, but given the extent of your work up to date, I would put that diagnosis at the far far bottom of the list.
Do email me after your surgery and tell me how things went.
Onc RN:
I read that book during my residency, and it was all I could do to keep myself from trying to jump from my chair into the pages of the book to save her….
My mother recently got dx’ed with early stage ovarian cancer… Her gyn actually told her that there was no way she had cancer after the US showed a rather large cyst.
I have to wonder what would have happened if I didn’t maker her go get the CA-125.. her levels were 8X the norm which prompted her to get an appt with a gyn oncologist. Not sure what her gyn was thinking, based on the size, her age and the fact she’s post-menopausal should have raised concern.
How do you know when to stop worrying about Ovarian Cancer? I have so many strange symptoms… something is not right. I have been through so many tests and everything is coming up normal… transvaginal ultrasound last year showed nothing… planning to have another… anyway, I can't get the symptoms out of my head or the statistics or Gilda! When do we stop worrying and just go on with life? Is ovarian cancer a common cancer? What about risk factors.. I never took birth control, had my first baby at 36, my first period at ~10?? sounds risky to me.. when do I stop worrying??
Bill and Stef-
Not sure why it is you have focused on ovarian cancer to worry about – one could say what you have said about almost any disease, calamity or accident. How do New Yorkers get through the day without worrying about another 9/11? How do mothers stop worrying about their kids when they send them off to school alone in the morning? How do women whose mothers or sisters had breast cancer stop waiting for the next shoe to drop?
I guess the answer is to have a healthy lifestyle, make smart choices, act with wisdom and dignity and then let it go and go on with your life. You may want to raise these questions with your doc or someone who knows you, or seek counseling if these worries are interefering with your ability to enjoy life.
Peace,
Hi everyone, I’m in some need of advice. I am 34yrs. old and was diagnosed 2years ago with Pelvic Congestion Syndrome due to terrible right side pain I was having every ovulation. It would only last during my ovulation and then subside till the next month. Two years ago I had the ultra sound and laparoscopy which helped him come to his diagnoses.
For a month straight I have had constant pain on my right side (which is the side it’s always been) I’ve also become extremely bloated, gassey, I’m having episodes of indegestion, also had brown blood when wiping 2 days apart (the right side pain was there before and much worse couple days after the brown blood). Theses are all very new things for me. They ruled out my appendix and took blood work that came back normal (except my AST levels were at 48)and said it was probably a ruptured cyst. I’m not sure if I should ask for more testings or not. I have a lot of faith in my family doctor and gyn. I hate to be a bug and get paranoid over nothing.
Deena R-
I hope you understand that I cannot give medical advice on this blog. I will say that if you have concerns, call your doctor and discuss it with him/her. That’s what we are here for.
I think more sensitization/awareness needs to be done on ovarian cancer so that its detection is made earlier.School of Medicine Kenyatta University