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Ovarian cancer: an elusive disease.

Ovarian cancer is the fifth most common cause of cancer deaths among women in the U.S., according to the American Cancer Society. The main reason for this is the fact the disease is so hard to detect--it is typically symptom-free in its early stages, and also has no proven screening test. These factors mean that most women with ovarian cancer are diagnosed at an advanced stage, when the prognosis is poor. However, a 2015 study upended the notion that women diagnosed with advanced ovarian cancer always face poor long-term survival--and another recent study, from Mount Sinai, identifies the treatment approach that may best suit older women with advanced disease. Ovarian cancer screening also has been in the news recently, with data suggesting that screening may significantly reduce the number of deaths from the disease.

Hard to detect Ovarian cancer is one of the hardest cancers to detect for a combination of reasons. "The cancer has to be fairly advanced for doctors to feel any abnormality during a physical examination," says Monica Prasad-Hayes, MD, assistant professor of obstetrics, gynecology and reproductive science at Mount Sinai. "By the time a cancer enlarges the ovary to the extent its size is considered abnormal, the cancer will likely have spread. Another factor that can delay diagnosis is that ovarian cancer symptoms--which include bloating, pelvic pain, low back pain, increased urinary frequency, constipation, and lethargy--are nonspecific, and can easily be mistaken for signs of a less serious problem."

Effective treatment vital Better ovarian cancer survival for older women depends on an effective treatment regimen. This is the focus of a recent study (Obstetrics & Gynecology, January) led by Jenny Lin, MD, associate professor of medicine at Mount Sinai. Dr. Lin and her colleagues examined trends in treatment and overall survival for 7,938 women age 65 and older, with stage III and IV ovarian cancer. Overall, 2.9 percent of the women received no treatment, and 15.4 and 24.8 percent respectively underwent debulking surgery to remove as much as possible of the tumor, or chemotherapy alone, while 41.8 percent underwent surgery and chemotherapy in an optimal time frame (called optimal treatment). In addition, 15.1 percent of women underwent surgery and chemotherapy, but either the timing was not optimal or they did not complete their chemotherapy.

The longest survival time--39 months--was seen in women with optimal treatment. However, the data also showed a decrease in the number of women who received optimal treatment over the last decade. "It isn't entirely clear why there has been a decrease," Dr. Lin says. "It is possible doctors are being more selective when it comes to recommending optimal treatment--you have to be well enough for surgery and chemotherapy."

The study also found that survival was similar for those who underwent surgery only versus no treatment, but better overall survival (14.4 months) was seen for those who received chemotherapy only. "In the U.S., surgery is typically performed prior to chemotherapy," says Dr. Lin. "These data suggest that we maybe need to offer chemotherapy first to women who aren't in good enough health for surgery."

Survival boost? A study published in the September 2015 issue of Obstetrics & Gynecology offers hope for women with advanced disease, suggesting that the 10-year survival rate is higher than previously thought, even in women with factors that have previously been associated with a poor prognosis, such as older age. Researchers analyzed data on 11,541 women who had been diagnosed with ovarian cancer of these women, 3,582 (31 percent) survived for 10 or more years after their diagnosis. The survivors included 954 women who had a poor prognosis because they were older at the time their cancer was detected, and/or had higher-grade tumors, which grow faster and are more likely to spread.

It isn't clear what impacted survival in the study--further investigations will aim to clarify this--but Dr. Prasad-Hayes points to treatment advances as a possible factor. "Surgical techniques are better, and we have better drugs and more effective methods of administering them," she explains. "A combination of intravenous and intraperitoneal chemotherapy, which is given via the abdomen, has been shown to improve survival." It is important to note, however, that side effects such as abdominal pain, nausea, and vomiting are often more severe with intraperitoneal chemotherapy than with intravenous chemotherapy alone. Because it can be so toxic, women must have normal kidney function and be in good overall health to have intraperitoneal chemotherapy.

What about screening? Another recent study (The Lancet, Dec. 17,2015) suggests that ovarian cancer screening may be more effective than previously thought. Researchers tracked 200,000 women across 14 years: ovarian cancers were diagnosed in 630 who had no screening, 314 of those screened by ultrasound only, and 338 of those undergoing blood tests (which check levels of an ovarian cancer marker called CA-125) and ultrasound. Compared with the group that had no screening, from years 0-14 mortality was reduced by 15 percent among those screened by ultrasound and blood tests, and by 11 percent for those screened by ultrasound only. When women who were found to have undiagnosed ovarian cancer on joining the trial were excluded, the average mortality reduction became 20 percent overall, and 28 percent in years seven to 14.

Presently, the U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for ovarian cancer. It reached this decision after a review of studies showed that screening with ultrasound and blood tests doesn't reduce the number of deaths from the disease. Transvaginal sonograms are sensitive for the detection of ovarian cancer, but many of the tumors are already advanced when they are detected.

As for the CA-125 test, levels of this marker can be elevated for other reasons, including many benign gynecologic conditions. However, Dr. Prasad-Hayes thinks these new data are important. "It took seven years before a significant impact was seen, but even so, these findings may change how we monitor patients in the future," she observes. For now, keep in mind that the USPSTF guideline doesn't apply if you are at high risk for ovarian cancer--if you fall into this category, talk to your physician about whether you should be screened.

Guarding against ovarian cancer Dr. Prasad-Hayes says it is vital to know your risk factors for ovarian cancer, and to recognize symptoms that might indicate you have the disease. Factors that increase risk include certain gene mutations, a personal history of breast cancer or a family history of ovarian cancer, being over age 45, and obesity. Early warning signs for the disease include bloating, pelvic or abdominal pain, feeling full quickly when you eat, low back pain, increased urination, and changes in bowel habits. "These symptoms are vague enough to be mistaken for signs of a less serious gastric problem, but what does mark them out is that they tend to become more frequent if ovarian cancer is the cause," Dr. Prasad-Hayes says. "If you experience a combination of these symptoms on a daily basis over the course of a month, you should see your doctor."


* Speak to your doctor about screening if you are high-risk for ovarian cancer--for example, if you have a family or personal history of ovarian and/or breast cancers, or a genetic mutation such as BRCA-1 or BRCA-2.

* Be on the alert for any new and unexplained increase in abdominal girth, abdominal bloating, pelvic pressure or pain, and/or changes in bowel or bladder function lasting at least a month.

There are ways to mitigate some of the risk factors for ovarian cancer.




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Title Annotation:CANCER
Publication:Focus on Healthy Aging
Date:Apr 1, 2016
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