New hope for ovarian cancer.

At 44, Joan Derwin was living an active life as a first-grade schoolteacher in New York City. She has always enjoyed wonderful health and has taken meticulous care of herself since she was 26, the year her mother had a mastectomy.

In April of 1990 Derwin was experiencing an overall feeling of malaise. When she began noticing changes in her bowel movements, Derwin's concerns changed to worry. She met with her internist, and a sonogram revealed a large mass that could have been a fibroid tumor. A CAT scan and barium enema (a series of X-rays of the lower bowel) confirmed the mass, although she now knew it wasn't a fibroid.

Derwin was then referred to a gynecologic oncologist, and a battery of tests suggested ovarian cancer. She underwent a full hysterectomy and removal of her appendix and omentum (the membrane supporting the abdomen) on July 25, 1990. The diagnosis - stage 3 ovarian cancer.

After six months of chemotherapy, second-look surgery in April of 1991, and three treatments of intraperitoneal chemotherapy (a dousing of the abdominal cavity to kill stray cells), her cancer is in remission. Follow-up visits every nine months have been advised, but she's more comfortable checking in quarterly. "It's my only assurance, and it's not even a great one," says Derwin.

Derwin knows she's one of the fortunate ones. Current survival rates for stage 3 ovarian cancer - cancer that has spread from the ovaries to lymph nodes or other areas within the abdomen, such as the surface of the liver or the intestines - is 15 to 20 percent. These diagnoses comprise 70 to 80 percent of all cases. Stage 4 diagnoses (about 5 percent of cases) offer little hope for survival.

According to the National Cancer Institute, ovarian cancer is diagnosed in approximately 21,000 women each year in the United States and claims 13,000 lives. Although only one woman in 70 is diagnosed with the disease compared to one in nine with breast cancer, ovarian cancer is more deadly. It is the fourth-leading cause of death among women.

Difficult to detect. The only symptoms of ovarian cancer are abdominal swelling, bloating or discomfort, loss of appetite, a feeling of fullness even after a light meal, gas, indigestion, nausea, fatigue, and weight loss. As the tumor grows, constipation or frequent urination can occur.

The majority of ovarian cancer cases are diagnosed in postmenopausal, Caucasian, middle- to upper-middle-class women. Where there's a family history of the disease, the onset is often earlier in life.

Heredity link. Since Gilda Radner's death from ovarian cancer six years ago, we have learned much about the heredity link of the disease. A nationwide database of women with a family history of ovarian cancer was renamed the Gilda Radner Familial Ovarian Cancer Registry, following her death. The registry was actually developed in 1981 by M. Steven Piver, M.D., chief of the Department of Gynecologic Oncology at Rozwell Park Cancer Institute, in Buffalo, New York. To date more than 1,000 women are in the registry and about 300 new families are added each year.

"Familial ovarian cancer means having two or more first-degree relatives (mother, sister, daughter), or two or more first- and second-degree relatives (grandmothers, aunts) who have the disease," says Piver.

"By analysis of the pedigrees, there's a 50 percent chance that other first-degree relatives (male or female) will inherit the gene," continues Piver. "For the females who have the inherited gene, there's a 40 to 50 percent lifetime risk that they'll develop ovarian cancer."

This compares to a 1.4 percent chance for women with no family history. The risk of developing ovarian cancer with one first-degree and one second-degree relative or two or more second-degree relatives is a little less than 50 percent.

Gilda Radner and her husband, Gene Wilder, (now honorary chair of the Registry), weren't aware that she was at high risk for developing ovarian cancer, believing only that her first cousin had the disease and that her maternal aunt had stomach cancer. Nor did they know that her mother's breast cancer doubled Gilda's risk. By 1990 the Registry had verified that Gilda, her maternal aunt, first cousin, and second cousin all had ovarian cancer.

"The best prevention against ovarian cancer is knowing your family history," says Piver. "It's especially important if your grandmother, mother, or sister died of something you didn't know about."

Other risk factors. Taking birth control pills decreases a woman's risk by half for developing ovarian cancer, a finding similar to nonhereditary ovarian cancer. Having few or no children increases risk.

Some studies indicate that taking infertility drugs may increase the risk for developing ovarian cancer. For women who are infertile (who are already at a higher risk), and who are taking fertility drugs, Piver warns that an ovarian cyst, should one develop, needs to be evaluated very carefully.

Although no procedure used alone is ever conclusive, screening methods for ovarian cancer include the pelvic and abdominal examination, CA125, CAT scan, barium enema, and transvaginal ultrasound (sonogram). Women from ovarian cancer families with a first-degree relative who has the disease should begin genetic counseling in their twenties, and physical surveillance by 25.

Promising technology. In 1987 John van Nagel, M.D., professor and director of gynecologic oncology at the University of Kentucky Medical Center, was the first doctor in the United States to use transvaginal sonography (TVS). Through several clinical trials of pre- and postmenopausal women, his goal has been to screen asymptomatic women who have ovarian cancer.

To date, about 5,000 women have been screened, using TVS, and five ovarian cancers have been detected. Four women were found to have stage 1 ovarian cancer; one had stage 3. All are alive and well following conventional treatment.

"Preliminary results are encouraging, but a national multi-institutional trial to determine the effect of TVS screening on ovarian cancer mortality is needed," says van Nagel. This would require that approximately 100,000 women be screened. "Once we can prove that yearly TVS screening can significantly remove the risk of death from ovarian cancer, women will demand it," adds van Nagel.

A similar study is currently being conducted by the National Cancer Institute. Nationwide, thousands of women are being screened to determine if a trial of tests-the CA125, pelvic exam, and transvaginal ultrasound - will reduce mortality.

Another promising technology to add to the armamentarium is the oncovscient test. Recently FDA approved, it is given after the patient has received about six months of chemotherapy and before second-look surgery. According to Hugh R. K. Barber, M.D., gynecologic oncologist, director of obstetrics and gynecology at Lenox Hill Hospital and professor of clinical obstetrics and gynecology at Cornell University Medical College, a monoclonal antibody against ovarian cancer that is attached to a radioactive substance called indium, is administered intravenously. The antibody searches out and attaches itself to die tumor. The patient is then scanned with a gamma counter, which detects any cancerous sites.

"After administering the oncovscient test, a decision is made to continue the chemotherapy a little longer and then repeat die test, or do second-look surgery," says Barber. "With second-look surgery, about 35 percent of patients will have recurrent cancer within five years, so we must be missing small amounts of tumor," adds Barger. "A patient may require just two or three more treatments to eradicate the tumor. The oncovscient will take much of the guesswork out of second-look surgery."

In the area of chemotherapy, the most exciting advancements are with the anticancer drug Taxol. Many researchers think the greatest advantage of Taxol will be when it is used as the first line of protocol.

It is still too early to know if advancements in drugs and diagnostic technologies are helping patients to live longer than five years. Most ovarian cancers recur within the first 18 months. What is known is that patients are living a longer and better-quality life than would be possible without these advances.

Jeanne Griffin Francavilla is a New York-based freelance writer who writes on women's health and other related topics.