At least one symptom present in 72% of high-risk, early epithelial ovarian cancer cases

Maurie Markman, MD

In an important retrospective chart review of women confirmed to have early-stage ovarian cancer who participated in a GOG clinical trial, investigators found that the majority (72%) noted symptoms prior to their diagnosis of a malignancy. These data are similar to those previously reported, with the unique aspect of this analysis being the surgically confirmed diagnosis of early-stage disease.

Not surprisingly, the most common symptoms were abdominal pain, fullness or increased abdominal girth. Of interest, symptoms were more common with the presence of larger ovarian masses, recognizing this patient population did not have evidence of widespread intra-abdominal disease.

This report provides additional support for the conclusion that ovarian cancer is not necessarily a “silent disease.” Unfortunately, the nonspecific nature of the symptoms, which may be caused by a wide variety of nonmalignant conditions that together are far more common than ovarian cancer, makes it difficult to suggest any definitive recommendations.

However, it is reasonable to highlight the logical conclusion that an individual woman will best know her own body and if unusual abdominal symptoms develop and particularly if they persist, she should not hesitate to inform her primary care physician or gynecologist and request an evaluation.

Stephanie Wethington, MD, MSc

There has been considerable excellent work done by Barbara Goff and her team at the University of Washington looking at symptoms reported by those with advanced stage ovarian cancer. They have sought to parse out which symptoms, their duration and severity predict the presence of advanced ovarian cancer. However, we do not have robust literature on the symptoms associated with early-stage disease. Here, Chan et al examine the symptoms associated with early-stage disease, a unique question and an area without extensive prior literature on which to draw.

Most notably in this study, we see that even early-stage disease is associated with symptoms for the majority of women. Ovarian cancer is often labeled a “silent killer,” something that does not present with a lot of symptoms, but it is not something that is silent as much as vague. The symptoms are usually vague feelings we do not infrequently notice — a little bit of bloating, abdominal distension, abdominal pain, change in urinary function or appetite. Almost everyone has experienced these symptoms at some point in their life as transient events. What makes them unique in the setting of ovarian cancer is that they are more persistent, more common over a 1-month time course and they do not resolve as quickly on their own. One would have wondered prior to this study whether those women who have early-stage disease have fewer symptoms, because they do not have as advanced cancer. However, what we see here is with early-stage disease, the majority of women have these vague symptoms.

For clinicians, this article emphasizes the importance of being aware of ovarian cancer as a potential diagnosis, and for women, it stresses the need for body awareness. Most women know their bodies and they know when something is off. What we see here is that body awareness and then seeking medical care for changes in your body are very important. While these symptoms are vague and might be experienced infrequently, if they happen more commonly or with greater intensity, it is very important to seek care of a physician. Statistically it is unlikely you have ovarian cancer, but it is one of the things to consider on the list of possible etiologies. And even if it is not ovarian cancer, it is important to seek help when you are having symptoms that are bothersome and new.

This article does not talk about the “other awareness” that is critically important — family history. In addition to women speaking up about what they are feeling, it is important to ask questions to ensure they know about family members who have had cancers — men or women, gynecologic or non-gynecologic. A health care professional will then be able to determine whether referral to a genetic counselor or genetic testing is indicated.

This study design is a retrospective review. The records that the researchers reviewed in this study were records related to a clinical trial designed for patients with early-stage ovarian cancer raising the question as to whether recall bias factored into the results. When you carry a diagnosis, you often think back and say, “I did have that, maybe I did not recognize it, but I did have it.” This may be particularly prominent when it comes to the vague symptoms associated with ovarian cancer. While this study is thought-provoking, it provides a starting point for further research and investigation and is not a definitive answer. It calls for validation in different patient populations and in a prospective design.

Joshua G. Cohen, MD, FACOG, FACS

Patients should advocate for themselves and seek medical care when they have new symptoms such as persistent bloating, abdominal pain, irregular vaginal bleeding, pelvic pressure, urinary frequency or pelvic pain. Medical providers want patients to reach out when they have concerns regarding new physical symptoms, and women should have an open line of communication with their primary care doctor or OB/GYN.

Ovarian cancer is often found when it has already spread throughout the abdomen (late-stage). This study found more than 70% of patients with early-stage ovarian cancer (confined to an ovary or the pelvis) have symptoms which should be reported to a medical provider. By reporting these symptoms to a health care professional, we may be able to find ovarian cancer earlier.

Patients with early-stage ovarian cancer have a better chance at prolonged survival. Physical symptoms are important. Cancer doctors are trying to determine how we can do better in finding ovarian cancer earlier. In addition to reporting new symptoms, patients should know their family history. If there is a history of breast, ovarian and/or pancreatic cancer in the family, genetic testing may be important, as 20% of ovarian cancer is due to genetic predisposition from genes in a family. Doctors can help prevent ovarian cancer, as well as other cancers in these patients, if these patients are appropriately identified.