Question and Answer Screening for Ovarian Cancer
Q:Why screen for ovarian cancer?
Q: What type of screening is recommended?
A: Ovarian cancer is the leading cause of death of A: Ultrasonography has been found to be a n all gynecologic cancers in the United States (Luxman, appropriate screening tool for ovarian abnormalities. Bergman, Sagi, & Menachem, 1991; Lynch et al., 1991; Sparks and Varner (1991) reviewed data regarding the Trimbos et al., 1991; van Nagall et al., 1991) and has effectiveness of ul trasonography in detecting early stage steadily increased in the past 25 years (Hricak, 1991). ovarian cancer. They concluded that “ultrasonography, This year 20,000 American women will be affected, and especially transvaginal ultrasonography, is reasonably 13,500 will die prematurely from this disease (Creasman accurate in evaluating the size and morphology of the & DiSaia, 1991). By the time the symptoms of ovarian postmenopausal ovary and thus in distinguishing cancer appear, which are bloating, abdominal discom- normal from abnormal,” and that ultrasound is fort, ascites, loss of appetite, indigestion, frequency, significantly more accurate than the pelvic examination nausea, and weight loss (U.S. Department of Health in detecting adnexal masses. They also found that 10% and Human Services, 1990),the disease is usually already of masses less than 10 cm in size could not be detected beyorid stage I or 11. Seventy-five percent of patients by pelvic examination alone (Sparks & Varner, 1991). diagnosed with ovarian cancer have stage I11 or IV Other investigators have also reported on the accuracy disease (Creasman & DiSaia, 1991; Hricak, 1991; Sparks of detecting abnormal ovarian size and morpholocgy & Varner, 1991; Trimbos et al., 1991; van Nagall et al., (cystic, complex, or solid) by ultrasound (Luxman, et 1991). The survival rates of ovarian cancer at these stages al., 1991; van Nagall et al., 1991). Rodriquez, Platt, have not changed in 30 years, and the five-year survival Mederais, Lacarra, and Lob0 (1988) used transvaginal rate remains only 15% to 20% (Sparks & Varner, 1991; ultrasound to evaluate postmenopausal women before Trimbos et al., 1991; van Nagall et al., 1991). gynecologic surgery unrelated to adnexal disease. Of The rate of detection of early stage ovarian cancer the eighty-five women whose ovaries were visualized, by pelvic examination alone is so low that more effective nine were determined to have abnormal ultrasounds; screening strategies are indicated (Sparks & Varner, 1991; all nine were found to have pathology by laparoscopy, van Nagall et al., 1991).Many investigators believe that one of which was adenocarcinoma (Sparks & Varner, if methods can be found to improve early detection, 1991). The largest screening study to date, conducted the mortality from this disease would be greatly reduced in England in 1989, screened 14,597 patients from one (Sparks & Varner, 1991; van Nagall et al., 1991). Recent to three times and identified 338 women with abnormal reports indicate that a 90% survival rate is possible scans. Of the 338 women with abnormal scans, 326 among patients who have stage I disease (van Nagall underwent exploratory laparotomy. Five primary, three et al., 1991). Extensive research is being conducted to borderline, and four malignant ovarian cancers were try to identify effective diagnostic tools to screen for found. Of the primary cancers, all were stage I early ovarian cancer (Creasman & DiSaia, 1991; Sparks (Campbell, Bhan, Royston, Whitehead, and Collins, & Varner, 1991). 1989; Creasman & DiSaia, 1991). Serum C A 125 is a serum marker for ovarian cancer. Q: Is there a genetic predisposition? “CA 125 has been shown to be elevated in 82%of patients A: A specific genetic link in ovarian cancer has not with histologically verified ovarian cancer, in contrast been identified (Creasman & DiSaia, 1991; Lynch et al., to elevations in 1% of controls” (Lynch et al., 1991, 1991).However, it is well documented that women with p. 1465).Serum CA 125 may also be elevated in patients a family history of ovarian cancer have a higher with endometriosis and other benign inflammatory incidence of this disease (Creasman & DiSaia, 1991; disorders of the pelvis. As a result, it has been found Lynch et al., 1991; Sparks & Varner, 1991; van Nagall to lack specificity when used alone as a screening tool et al., 1991) and should be considered a higher risk (Lynch et al., 1991). In addition, some ovarian tumors do not consistently produce elevated CA 125, so that (Lynch et al., 1991). 36
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
a normal CA 125 level may not necessarily predict the absence of ovarian cancer (Sparks & Varner, 1991). It is unknown at this time if screening all women for ovarian cancer is cost effective; however, screening high-risk patients is highly recommended (Creasman, & DiSaia, 1991; Sparks & Varner, 1991). Serum CA 125 in conjunction with ultrasonography is an appropriate screening process, especially in high-risk patients with a positive family history of ovarian cancer (Lynch et al., 1991; Sparks & Varner, 1991). It has been found that CA 125 levels “greater than 35 U/mL in a postmenopausal patient with an adnexal mass is very predictive of an invasive lesion” (Sparks & Varner, 1991, p. 790). “The combination of CA 125 with ultrasonography as a screening method for ovarian cancer (increases) the positive predictive value of abdominal ultrasound from 80%-100%’’(Lynch et al., 1991).
Suspicious adnexal masses discovered by ultrasound should be surgically evaluated. It is believed that benign tumors as well as malignancies should be removed at that time because of their malignant potential (Luxman et al., 1991). Luxman states that up to 6% of patients with “simple cysts” by ultrasound may have malignant disease, therefore, a “non-laparotomy approach in postmenopausal women with adnexal masses based on abdominal ultrasonography may not be safe” (Luxman et al., 1991, p. 727).
Mary Arthur Powell, RN, BS, CRNP Director, Student Health Services, Dickinson College, Carlisle, Pennsylvania
References Campbell, S., Bhan, V. Royston, J. P., Whitehead, M. I., & Collins, W. P. (1 989). Transabdominal ultrasound screening for early ovarian cancer. British Medical Journal, 299, 1363-1367. Creasrnan, W. T., & Disaia, P. J. (1991). Screening in ovarian cancer. American Journal of Obstetrics & Gynecology, 165(1), 7-10. Hricak, H. (1991). Carcinoma of the female reproductive organs. Value of cross-sectional imaging. Cancer, 67(Suppl. 4), 1209-1218. Luxman, D, Bergman. A., Sagi, J., & Menachem, R. D. (1991). The postmenopausal adnexal mass: Correlation between ultrasonic and pathologic findings. Obstetrics& Gynecology, 77(5), 726-728. Lynch H. T., Watson, P., Bewira, C., Conway T. A,, Hippee C. R., Kaur, P., Lynch J. F., & Ponder, B. A. (1991). Hereditary ovarian cancer. Heterogeneity in age at diagnosis. Cancer, 67(5), 1460-1466. Rodriquez, M. H.. Platt, L. D., Mederais, A. L., Lacarra, M., & Lobo, R. A. (1988). Use of Transvaginal sonography for evaluation of post menopausal ovarian size and morphology.American Journal
VOLUME 4, NUMBER 1, JANUARY-MARCH, 1992
of Obstetrics and Gynecology, 159, 810-814. Sparks, J. M., & Varner, R. E., (1991). Ovarian cancer screening. Obstetrics & Gynecology, 77(5), 787-792. Trimbos, J. B., Schueler, J. A,, van der Burg, M., Hermans, J., van Lent, M., Heintz, A. P., & Fleuren. G. J. (1991). Watch and wait after careful surgical treatment and staging in well-differentiated early ovarian cancer. Cancer, 67(3). 597-602. US. Department of Health and Human Services. (1990). NIH Publication No. 91 -1561, p. 4. Washington, D.C: Author. US. Department of Health and Human services. (1990). What you need to know about ovarian cancer (NIH Publication No. 91-1561, p. 4). Washington, DC: National Cancer Institute. van Nagall J. R., DePriest, P. D., Puls, L. E., Donaldson, E. S., Gallion, H. H., Pavlik, R. J., Powell, D. E.. & Kryscio, R. J. (1991). Ovarian cancer screening in asymptomatic postmenopausal women by transvaginal sonography. Cancer, 68(3),458-462.
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Q:Why screen for ovarian cancer?
Q: What type of screening is recommended?
A: Ovarian cancer is the leading cause of death of A: Ultrasonography has been found to be a n all gynecologic cancers in the United States (Luxman, appropriate screening tool for ovarian abnormalities. Bergman, Sagi, & Menachem, 1991; Lynch et al., 1991; Sparks and Varner (1991) reviewed data regarding the Trimbos et al., 1991; van Nagall et al., 1991) and has effectiveness of ul trasonography in detecting early stage steadily increased in the past 25 years (Hricak, 1991). ovarian cancer. They concluded that “ultrasonography, This year 20,000 American women will be affected, and especially transvaginal ultrasonography, is reasonably 13,500 will die prematurely from this disease (Creasman accurate in evaluating the size and morphology of the & DiSaia, 1991). By the time the symptoms of ovarian postmenopausal ovary and thus in distinguishing cancer appear, which are bloating, abdominal discom- normal from abnormal,” and that ultrasound is fort, ascites, loss of appetite, indigestion, frequency, significantly more accurate than the pelvic examination nausea, and weight loss (U.S. Department of Health in detecting adnexal masses. They also found that 10% and Human Services, 1990),the disease is usually already of masses less than 10 cm in size could not be detected beyorid stage I or 11. Seventy-five percent of patients by pelvic examination alone (Sparks & Varner, 1991). diagnosed with ovarian cancer have stage I11 or IV Other investigators have also reported on the accuracy disease (Creasman & DiSaia, 1991; Hricak, 1991; Sparks of detecting abnormal ovarian size and morpholocgy & Varner, 1991; Trimbos et al., 1991; van Nagall et al., (cystic, complex, or solid) by ultrasound (Luxman, et 1991). The survival rates of ovarian cancer at these stages al., 1991; van Nagall et al., 1991). Rodriquez, Platt, have not changed in 30 years, and the five-year survival Mederais, Lacarra, and Lob0 (1988) used transvaginal rate remains only 15% to 20% (Sparks & Varner, 1991; ultrasound to evaluate postmenopausal women before Trimbos et al., 1991; van Nagall et al., 1991). gynecologic surgery unrelated to adnexal disease. Of The rate of detection of early stage ovarian cancer the eighty-five women whose ovaries were visualized, by pelvic examination alone is so low that more effective nine were determined to have abnormal ultrasounds; screening strategies are indicated (Sparks & Varner, 1991; all nine were found to have pathology by laparoscopy, van Nagall et al., 1991).Many investigators believe that one of which was adenocarcinoma (Sparks & Varner, if methods can be found to improve early detection, 1991). The largest screening study to date, conducted the mortality from this disease would be greatly reduced in England in 1989, screened 14,597 patients from one (Sparks & Varner, 1991; van Nagall et al., 1991). Recent to three times and identified 338 women with abnormal reports indicate that a 90% survival rate is possible scans. Of the 338 women with abnormal scans, 326 among patients who have stage I disease (van Nagall underwent exploratory laparotomy. Five primary, three et al., 1991). Extensive research is being conducted to borderline, and four malignant ovarian cancers were try to identify effective diagnostic tools to screen for found. Of the primary cancers, all were stage I early ovarian cancer (Creasman & DiSaia, 1991; Sparks (Campbell, Bhan, Royston, Whitehead, and Collins, & Varner, 1991). 1989; Creasman & DiSaia, 1991). Serum C A 125 is a serum marker for ovarian cancer. Q: Is there a genetic predisposition? “CA 125 has been shown to be elevated in 82%of patients A: A specific genetic link in ovarian cancer has not with histologically verified ovarian cancer, in contrast been identified (Creasman & DiSaia, 1991; Lynch et al., to elevations in 1% of controls” (Lynch et al., 1991, 1991).However, it is well documented that women with p. 1465).Serum CA 125 may also be elevated in patients a family history of ovarian cancer have a higher with endometriosis and other benign inflammatory incidence of this disease (Creasman & DiSaia, 1991; disorders of the pelvis. As a result, it has been found Lynch et al., 1991; Sparks & Varner, 1991; van Nagall to lack specificity when used alone as a screening tool et al., 1991) and should be considered a higher risk (Lynch et al., 1991). In addition, some ovarian tumors do not consistently produce elevated CA 125, so that (Lynch et al., 1991). 36
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
a normal CA 125 level may not necessarily predict the absence of ovarian cancer (Sparks & Varner, 1991). It is unknown at this time if screening all women for ovarian cancer is cost effective; however, screening high-risk patients is highly recommended (Creasman, & DiSaia, 1991; Sparks & Varner, 1991). Serum CA 125 in conjunction with ultrasonography is an appropriate screening process, especially in high-risk patients with a positive family history of ovarian cancer (Lynch et al., 1991; Sparks & Varner, 1991). It has been found that CA 125 levels “greater than 35 U/mL in a postmenopausal patient with an adnexal mass is very predictive of an invasive lesion” (Sparks & Varner, 1991, p. 790). “The combination of CA 125 with ultrasonography as a screening method for ovarian cancer (increases) the positive predictive value of abdominal ultrasound from 80%-100%’’(Lynch et al., 1991).
Suspicious adnexal masses discovered by ultrasound should be surgically evaluated. It is believed that benign tumors as well as malignancies should be removed at that time because of their malignant potential (Luxman et al., 1991). Luxman states that up to 6% of patients with “simple cysts” by ultrasound may have malignant disease, therefore, a “non-laparotomy approach in postmenopausal women with adnexal masses based on abdominal ultrasonography may not be safe” (Luxman et al., 1991, p. 727).
Mary Arthur Powell, RN, BS, CRNP Director, Student Health Services, Dickinson College, Carlisle, Pennsylvania
References Campbell, S., Bhan, V. Royston, J. P., Whitehead, M. I., & Collins, W. P. (1 989). Transabdominal ultrasound screening for early ovarian cancer. British Medical Journal, 299, 1363-1367. Creasrnan, W. T., & Disaia, P. J. (1991). Screening in ovarian cancer. American Journal of Obstetrics & Gynecology, 165(1), 7-10. Hricak, H. (1991). Carcinoma of the female reproductive organs. Value of cross-sectional imaging. Cancer, 67(Suppl. 4), 1209-1218. Luxman, D, Bergman. A., Sagi, J., & Menachem, R. D. (1991). The postmenopausal adnexal mass: Correlation between ultrasonic and pathologic findings. Obstetrics& Gynecology, 77(5), 726-728. Lynch H. T., Watson, P., Bewira, C., Conway T. A,, Hippee C. R., Kaur, P., Lynch J. F., & Ponder, B. A. (1991). Hereditary ovarian cancer. Heterogeneity in age at diagnosis. Cancer, 67(5), 1460-1466. Rodriquez, M. H.. Platt, L. D., Mederais, A. L., Lacarra, M., & Lobo, R. A. (1988). Use of Transvaginal sonography for evaluation of post menopausal ovarian size and morphology.American Journal
VOLUME 4, NUMBER 1, JANUARY-MARCH, 1992
of Obstetrics and Gynecology, 159, 810-814. Sparks, J. M., & Varner, R. E., (1991). Ovarian cancer screening. Obstetrics & Gynecology, 77(5), 787-792. Trimbos, J. B., Schueler, J. A,, van der Burg, M., Hermans, J., van Lent, M., Heintz, A. P., & Fleuren. G. J. (1991). Watch and wait after careful surgical treatment and staging in well-differentiated early ovarian cancer. Cancer, 67(3). 597-602. US. Department of Health and Human Services. (1990). NIH Publication No. 91 -1561, p. 4. Washington, D.C: Author. US. Department of Health and Human services. (1990). What you need to know about ovarian cancer (NIH Publication No. 91-1561, p. 4). Washington, DC: National Cancer Institute. van Nagall J. R., DePriest, P. D., Puls, L. E., Donaldson, E. S., Gallion, H. H., Pavlik, R. J., Powell, D. E.. & Kryscio, R. J. (1991). Ovarian cancer screening in asymptomatic postmenopausal women by transvaginal sonography. Cancer, 68(3),458-462.
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