Fact Sheet: What the Gastroenterologist Needs to Know About Ovarian Cancer

Most cases of ovarian cancer are diagnosed in advanced stages when treatment is least effective, making it the deadliest of all gynecologic cancers. While the information in this fact sheet contains important information for all health care providers, it was developed specifically for gastroenterologists to facilitate the identification of ovarian cancer symptoms among female patients. It is hoped that, ultimately, implementation of the best practices recommended in this fact sheet will lead to the early diagnosis of ovarian cancer among women whose symptoms may be misinterpreted and attributed to less serious medical conditions.

This fact sheet was developed with input from a multi-disciplinary work group of gastroenterologists, gynecologic-oncologists, oncology nurses and ovarian cancer survivors.

Ovarian Cancer Facts

  • Ovarian cancer is the deadliest gynecologic cancer and the fifth1 leading cause of cancer death in women in the United States; the incidence of ovarian cancer is highest in White women and in Western industrialized countries.
  • Approximately 70% of ovarian cancer diagnoses are made in late stages2,3 when the chance of survival is significantly compromised.4
  • Prompt recognition of symptoms, followed by an appropriate evaluation, may enable the diagnosis of ovarian cancer to be made in an earlier, more treatable stage.
  • Gastrointestinal complaints are the symptoms most commonly associated with ovarian cancer5,6 and women may present to a gastroenterologist with these symptoms.
  • A multi-disciplinary and collaborative approach between gastroenterologists, gynecologists and gynecologic oncologists provides the highest standard of care for women with suspicious ovarian cancer malignancy.

Ovarian Cancer is not a "Silent Killer"

  • Ovarian cancer was previously called a "silent killer" because it was thought to not cause symptoms until it was at an advanced stage. Research has found that symptoms do exist. Ovarian cancer symptoms can be vague, non-specific, and cause women with these symptoms to seek the attention of a gastroenterologist.
  • Ovarian cancer symptoms are often attributed to less serious conditions such as menopause, stress or functional bowel problems.6,7
  • The following symptoms were identified in the first national Ovarian Cancer Symptoms Consensus Statement which was jointly issued in 2007 by the Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists (SGO), and the American Cancer Society. This Statement affirms that women who experience these symptoms almost daily for more than a few weeks should see their doctor, preferably a gynecologist.
    • Bloating/increased abdominal size
    • Pelvic or abdominal pain
    • Difficulty eating or feeling full quickly
    • Urinary symptoms (urgency or frequency)
  • The Consensus Statement also identifies other symptoms commonly reported by women with ovarian cancer, including fatigue, indigestion, constipation and back pain. These symptoms, while important to consider as a possible presentation of ovarian cancer, have been found to occur in equal frequency in women who do not have ovarian cancer.
  • More than 90% of women with ovarian cancer have symptoms that have been present for at least three months prior to diagnosis.5,7,8
  • Most women who complain of these symptoms will not have ovarian cancer. However, it is important that the gastroenterologist have an appropriate index of suspicion for ovarian cancer in women who present with abdominal, pelvic or urinary complaints that are new and persistent.

Inherited Ovarian Cancer Susceptibility Syndromes

  • Ten percent of all breast and ovarian cancer cases are hereditary; a confirmed genetic diagnosis can greatly impact the patient's treatment plan and long-term medical management.
  • Hereditary breast/ovarian cancer syndrome (HBOC) and hereditary non-polyposis colorectal cancer syndrome (HNPCC), also referred to as Lynch Syndrome, are associated with an increased risk of developing ovarian cancer. If either syndrome is suspected, genetic counseling is recommended. It is important for gastroenterologists and gynecologists to coordinate the care of patients with HNPCC.
  • Red flags for the possible presence of these syndromes include:
  • HBOC syndrome HNPCC Syndrome (Lynch Syndrome)
    Breast cancer prior to age 50 Colorectal cancer prior to age 50
    Ovarian cancer at any age Endometrial cancer prior to age 50
    Both breast and ovarian cancer Two or more HNPCC cancers in an individual or family*
    Bilateral breast cancer at any age  
    Maternal or paternal family members with breast cancer before age 50 or ovarian cancer at any age.  
  • *HNPCC cancers: colorectal, endometrial, gastric, ovarian, ureter/renal pelvis, biliary tract, small bowel, pancreas, brain, sebaceous adenoma

Diagnostic Modalities

  • Transvaginal ultrasound (TVS) provides the best imaging modality currently available for evaluating a suspected ovarian malignancy. The demonstration of an adnexal mass is suspicious for ovarian cancer.
  • Cancer antigen 125 (CA125) is a serum marker for some cancers, including ovarian cancer. Due to inadequate sensitivity and specificity, CA 125 is not used to screen for ovarian cancer in the general population.9 It is often utilized as an adjunct with other screening tests such as additional serum biomarkers and TVS to assess a suspicious malignancy for ovarian cancer. CA125 is also used in ovarian cancer patients to monitor their response to treatment and disease recurrence.
  • The OVA1™ Test is a pre-surgical diagnostic tool which was approved by the Food and Drug Administration in 2009 to help physicians further assess whether an ovarian cancer mass is malignant. The test can be used as an adjunct with other diagnostic and clinical procedures but it should not replace an independent clinical/radiological evaluation. OVA1™ should not be used as a screening test for the general population.10,11,12,13

Referral to the Gynecologic Oncologist±

  • The National Institutes of Health, the American College of Obstetricians and Gynecologists (ACOG) and the SGO recommend that any woman who has an adnexal mass that is suspicious for ovarian cancer receive initial surgical evaluation and management by a gynecologic oncologist, who is trained to appropriately stage and debulk ovarian cancer. Studies have found this to result in a survival advantage.
  • The following table was developed by ACOG and SGO to prompt referral to the gynecologic oncologist.
  • ACOG/SGO Referral Guidelines for a Newly Diagnosed Pelvic Mass
    Refer to the gynecologic oncologist if one or more of the following indicators are present
    Premenopausal (< 50 years):
    • CA125 level greater than 200 units/ml
    • Ascites
    • Evidence of abdominal or distant metastasis (by exam or imaging study)
    • Family history of breast or ovarian cancer (in a first-degree relative)
    Postmenopausal (≥ 50 years):
    • Elevated CA125 (> 35 units/ml)
    • Ascites
    • Nodular or fixed pelvic mass
    • Evidence of abdominal or distant metastasis (by exam or imaging study)
    • Family history of breast or ovarian cancer (in a first-degree relative)

± "A gynecologic oncologist is a specialist in obstetrics and gynecology who by virtue of education and training is prepared to provide consultation on and comprehensive management of patients with gynecologic cancer and whose present activity includes the practice of gynecologic oncology in an institutional setting wherein all the effective forms of cancer therapy are available. Comprehensive management should include those diagnostic and therapeutic procedures necessary for the total care of the patient with gynecologic cancer or complications resulting therefrom." – Definition from the American Board of Obstetrics and Gynecology.

References

1U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999 -2006 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2010. Available at: http://www.cdc.gov/cancer/ovarian/statistics/

2Quaye L, Gayther SA, Ramus SJ, Di Cioccio RA, McGuire V, Hogdall E, et al. The effects of common genetic variants in oncogenes on ovarian cancer survival. Clinical Cancer Research. 2008;14:5833-9.

3Goff BA, Mandel LS, Drescher CW, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2007;109(2):221-7.

4Colombo N, Van Gorp T, Parma G, Amant F, Gatta G, Sessa C, et al. Ovarian cancer. Critical Review in Oncology/Hematology. 2006;60:159-79.

5Goff BA, Mandel LS, Melancon CH, Muntz HG. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. 2004;291:2705-12.

6Goff BA, Mandel L, Muntz HG, Melanco CH. Ovarian carcinoma diagnosis. Cancer. 2000;89:2068-75.

7Vine MF, Ness RB, Calingaert B, Schildkraut JM, Berchuck A. Types and duration of symptoms prior to diagnosis of invasive or borderline ovarian tumor. Gynecologic Oncology. 2001;83:466-71.

8Hamilton W, Peters T, Bankhead C, Sharp D. Risk of ovarian cancer in women with symptoms in primary care: population based case-control study. BMJ. 2009;339:b2998doi:10.1136/bmj.b2998.

9Helzlsouer KJ, Bush TL, Alberg AJ, Bass KM, Zacur H, Comstock GW. Prospective study of serum CA-125 levels as markers of ovarian cancer. JAMA. 1993;269:1123-6.

10HemOnctoday: Clinical news in oncology and hematology. FDA clears test that guides surgical decision-making in ovarian cancer. September 14, 2009. Available at: http://www.hemonctoday.com/article.aspx?rid=43660

11Society of Gynecologic Oncologists. Society of Gynecologic Oncologists' Statement Regarding OVA1. September, 2009. Available at: http://www.sgo.org/content.aspx?id=836

12HemOncToday: Clinal news in oncology and hematology. Presurgical ovarian cancer blood test available, covered by Medicare. March 18, 2010. Available at: http://www.hemonctoday.com/article.aspx?rid=62187

13Medical News Today. U.S. Food and Drug Administration clears Vermillion's OVA1™ test to determine likelihood of ovarian cancer in women with pelvic mass. September 12, 2009. Available at: http://www.medicalnewstoday.com/articles/163761.php

  • This ovarian cancer fact sheet was made possible by the New York State Department of Health with funding from the Centers for Disease Control and Prevention (Cooperative Agreement # 1U58DP000783). The information contained herein does not necessarily reflect the position of the Centers for Disease Control and Prevention.