Symptoms and diagnosis of borderline, early and advanced epithelial ovarian cancer
Introduction
In the USA, ovarian cancer is the fifth most common cancer in women with 25,400 new cases and 14,300 deaths each year [1]. The situation in other developed countries is similar [2]. Although the age-standardized incidence is not increasing [1], [3], the general ageing of developed populations will lead to greater numbers of new cases and deaths from ovarian cancer each year. Overall, 5-year survival rates are around 40–50% [1], [4]; however, this dismal statistic is largely a consequence of the fact that the majority of ovarian cancers are not diagnosed until they have spread beyond the ovaries. Women with stage I tumors (restricted to the ovary) have 5-year survival rates of up to 70–80% compared with rates of only 5–10% for women with stage III or IV disease (spread beyond the pelvis) [5]. This suggests that earlier detection of ovarian cancer could greatly improve the outlook for women diagnosed with this disease.
Early diagnosis of ovarian cancer is complicated by the fact that there is currently no effective screening mechanism for the disease. While a small proportion of ovarian cancers are diagnosed incidentally when a woman visits a physician for some other reason, most cases are diagnosed only after the woman recognizes that she has a health problem and makes the decision to seek medical attention. Thus, in order for early diagnosis to occur, a woman has to be able to correctly distinguish symptoms that require medical evaluation from those with less serious consequences. In turn, the physician she consults has to be able to recognize when a diagnosis of ovarian cancer should be excluded and promptly order appropriate diagnostic tests or referral to an appropriate specialist. The diagnostic process for ovarian cancer is, however, hindered by the fact that the reported symptoms are largely non-specific.
We have analyzed the symptoms reported by more than 800 women newly diagnosed with borderline or invasive epithelial ovarian cancer to document the most common symptoms at presentation for different stages of disease. We also investigated whether sociodemographic and/or behavioral characteristics of a woman influence whether her tumor is diagnosed at an early or advanced stage and evaluated the association between delay (in seeking medical attention and/or diagnosis following presentation) and stage of disease at diagnosis. In addition, we have systematically reviewed the existing literature regarding presenting symptoms of ovarian cancer to aid interpretation of our data.
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Methods
Subjects were women who took part in a case–control study of ovarian cancer conducted in the three most populous Australian states in 1990–1993. This study was approved by Human Research Ethics Committees at the Queensland Institute of Medical Research and all participating hospitals. The methods of this study have been described previously [6]. Briefly, women aged 18–79 years, newly diagnosed with histologically confirmed epithelial ovarian cancer in Queensland between 1990 and 1993 and in New
Results
Of the 811 women, 146 (18%) had borderline ovarian tumors, 218 (27%) had early stage (stage I–II) disease and 447 (55%) had advanced disease (stage III–IV). There were 429 (53%) serous tumors, 164 (20%) endometrioid and clear cell tumors (including 101 endometrioid, 55 clear cell and 8 mixed) and 121 (15%) mucinous tumors. The remaining 97 tumors (12%) were undifferentiated or of mixed histology. The majority of the serous cancers (71%) were diagnosed at an advanced stage with few early stage
Discussion
Ovarian cancer has been described as a “silent killer” [18] because it is often not diagnosed until it has spread well beyond the ovaries and, by this time, the prospects for survival are poor. In this large representative series of women with invasive and borderline epithelial ovarian tumors, only 7% of women with early stage cancer did not present with any symptoms before diagnosis of their cancer. This figure increased to 16% for women with borderline disease but fell to less than 4% for
Conclusions
The development of ovarian cancer is commonly associated with abdominal symptoms although only a minority of women report an abdominal mass. Generalized abdominal swelling and/or abdominal pain or pressure are the two most common presenting symptoms. Older women may also report less specific gastrointestinal symptoms or general malaise while urinary symptoms may indicate early invasive cancer in particular. Women who experience persistent or recurrent unexplained abdominal pain and/or swelling
Acknowledgements
Funding for this study was provided by the Australian National Health and Medical Research Council and the Queensland Cancer Fund. We gratefully acknowledge the contribution of the members of the Survey of Women's Health Study Group [6] and, particularly, that of the women who agreed to take part in the study.
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