Consensus Statement on Ovarian Cancer Symptoms Needs to Be Used Wisely, Experts Say

WASHINGTON, DC—In June the Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists, and the American Cancer Society released a consensus statement on four symptoms that occur with more frequency in women with ovarian cancer, even those with early-stage disease. The four symptoms are (1) bloating; (2) pelvic or abdominal pain; (3) difficulty eating or feeling full quickly; and (4) urinary symptoms (urgency or frequency). The consensus statement relies in part on research begun in the late 1990s by Barbara A. Goff, MD, Professor and Director of Gynecologic Oncology at the University of Washington Medical Center. The symptoms statement has been endorsed by quite a few cancer organizations, including the Society of Gynecologic Nurse Oncologists; the Gynecologic Oncology Group; the Ovarian Cancer National Alliance; the National Ovarian Cancer Coalition; the National Coalition for Cancer Survivorship; Ovarian Cancer Canada; Gilda's Club Worldwide; and the Ovarian Cancer Research Fund. Many speakers at the Ovarian Cancer National Alliance's Annual Conference here last month hailed the consensus statement for making official what many patients have long believed: that ovarian cancer is not a silent disease. The myth that the disease is silent prevents women from seeking medical attention and perpetuates late diagnosis, say survivors. The high prevalence of symptoms in ovarian cancer patients came glaringly to light when Dr. Goff worked closely with a co-founder of the Alliance, the late Cindy Melancon, to develop and disseminate a symptoms survey in Ms. Melancon's ovarian cancer survivors' newsletter. In 2006, another Alliance co-founder, Pamela Faerber, asked national cancer organizations to develop a consensus statement that would provide consistency in describing symptoms of ovarian cancer so that women could learn and remember them. ‘Another Piece to This’ But since the symptoms in the consensus statement can be caused by other conditions, physicians acknowledge that the key to the consensus statement is to use it wisely in practice. “There is no question that Dr. Goff's work is very important, but there is another piece to this,” Lori Minasian, MD, Chief of the NCI's Community Oncology and Prevention Trials Research Group, told OT. She cited a study in the journal Cancer showing that if a woman with the symptoms in the consensus statement goes to her primary care physician and receives an abdominal examination, that there could be a delay as long as a year to the diagnosis of ovarian cancer. If, on the other hand, a woman with these symptoms receives a pelvic examination, the time to diagnosis is very fast. Thus, said Dr. Minasian, “We need to remind primary care physicians that women over 50 with abdominal symptoms should be considered for a pelvic exam. This is the cohort that is at higher risk of ovarian cancer.” She said the primary care physician could order pelvic imaging or refer the patient to a gynecologist if the symptoms are present. “We've been saying for a long time that ovarian cancer is not the silent killer,” said Beth Karlan, MD, Director of the Division of Gynecologic Oncology, the Women's Cancer Research Institute, and the Gilda Radnor Hereditary Cancer Detection Program at Cedars-Sinai Medical Center in Los Angeles. Noting that Dr. Goff's research showed that 95% of women with ovarian cancer do have symptoms, Dr. Karlan said, “I think the symptom index is a great advance.” Lead to Unnecessary Testing? Asked by OT if the consensus statement might overload physicians with worried women and lead to unnecessary testing, she said, “I think everybody shares that concern; I think this is a first step. We don't want to flood physicians' offices.” But, Dr. Karlan noted of the consensus statement, “I hope it will empower women.” She said a woman with these symptoms who goes to her primary care physician should ask: Could I have ovarian cancer? Should I have a pelvic ultrasound and CA 125 study? Like Dr. Minasian, Dr. Karlan warned against an abdominal evaluation only, which would likely miss ovarian cancer. “I think, clearly, [the symptoms consensus statement] will lead to earlier diagnosis; it may not lead to earlier stage at diagnosis but to earlier Stage III diagnosis,” said Evan R. Myers, MD, MPH, Professor and Chief of the Division of Clinical and Epidemiological Research in the Department of Obstetrics and Gynecology at Duke University Medical Center. “If you think about it, most of those symptoms are gastrointestinal tract symptoms, so [ovarian] tumor cells have probably spread to the GI tract and may be causing ascites.” Therefore, he predicted, more women with Stage III ovarian cancer will come in earlier for medical evaluation if they are aware of the symptoms checklist. African-American women have a lower incidence of ovarian cancer than white women, but their five-year survival rates for this cancer are lower than those for whites. Asked if the new consensus symptoms statement might improve this health-disparities picture, Claudia Baquet, MD, MPH, Professor of Epidemiology and Preventive Medicine and Associate Dean for Policy and Planning at the University of Maryland School of Medicine, said that the issue is the dissemination of the consensus statement in the most underserved communities. For physicians and nurses, said Dr. Baquet, who served as Deputy Assistant Secretary of Health for Minority Health in the Department of Health and Human Services from 1993 to 1994, dissemination of the symptoms statement can be done through continuing medical education courses. Dissemination at Grassroots Level For minority women in the general public, such dissemination must be done at the grassroots level, Dr. Baquet said: through hospitals that serve a high percentage of minority patients; sororities; churches; and senior centers. “This looks pretty simple,” she said of the consensus symptoms statement's language, noting that consumer health information for low-income minorities “has to be literacy-appropriate.” “The best part of the consensus statement is that it's a tool. It needs to be coupled with regular, routine checkups.” In addition, she said, “We need to educate elected officials,” because they play a key role in the dissemination of the ovarian cancer symptoms statement. In fact, the ovarian cancer community is currently waiting for Congressional appropriation of funds to implement Johanna's Law: the Gynecologic Education and Awareness Act, signed legislation that allocates money to publicize the new consensus statement on ovarian cancer symptoms.

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