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Ovarian Cancer - The Silent Killer?.
Ovarian cancer is the commonest gynaecological cancer in the UK
6,600 new cases of Ovarian Cancer are diagnosed each year. (8 every hour)
4,400 women die from Ovarian Cancer each year. (5 every hour)
Ovarian Cancer Screening takes 30 minutes
Ovarian Cancer accounts for 6% of cancer related deaths in women.
The survival rates from Ovarian Cancer in the UK are the worst in Europe
Most cases of Ovarian Cancer cases present late after it has spread.
Survival is strongly linked to the stage of the cancer when it was diagnosed and treatment started.
What are the risk factors and signs of Ovarian Cancer?
Most cases occur after the menopause with 90% occuring in women over 45 years old.
The risk is doubled in women who have never had any children.
Only a small number occur in women at increased risk because of genetic factors but in some women where is a strong family history of ovarian and other cancers who carry a faulty BRCA1 or BRCA2 gene the lifetime risk of developing ovarian cancer is up to 50%.
Few early cancers present with any symtpms and most are diagnosed at an advanced stage when treatment is less effective. Some women do however have persistent pelvic or abdominal pain, increased abdominal size/persistent bloating or difficulty eating and feeling full quickly but these symptoms are common and often not taken seriously.
In the UK, awareness of the symptoms of ovarian cancer is low with few women realising that persistent stomach pain, increased abdominal size and persistent bloating, difficulty eating or feeling full quickly might be the signs of ovarian cancer. These common symptoms alongside needing to urinate more frequently, a change in bowel habits, back pain and extreme fatigue are often confused for less serious and more common conditions, such as Irritable Bowel Syndrome or the menopause. Whilst it is most likely that these symptoms are not ovarian cancer, it is important that anybody experiencing them on most days discusses any concerns with their GP.
A simple Ovarian Cancer Symptom Diary is a useful way of recording these common symptoms for women to discuss with their GP and Annual Screening based on a transvaginal pelvic ultrasound scan and a blood test to measure a tumour marker (CA125) can be used to provide reassurance for all women over the age of 50 or younger women with a family history of ovarian or breast cancer.
95% of those with early diagnosis and treatment will survive more than 5 years so it is therefore reasonable to expect that since most cases occur in oherwise apparently healthy women with no obvious symptoms, that screening and early detection will allow earlier treatment and potentially better survival.
What is Screening?
Screening is the testing of a person to check that they are not in the early, pre-symptom stages of a disease. Current cancer population screening in the UK includes breast, cervix and bowel cancer screens. In order for a screening test to be made available on the NHS, the test has to be proven to be accurate and safe.
There are ongoing studies to find a general population screening test for ovarian cancer but until their work is completed Ovarian Cancer Screening will not be available on the NHS.
Why is screening for ovarian cancer important?
Early stage ovarian cancer confined to the ovaries (Stage 1) has an extremely good outlook and can be successfully treated. Unfortunately most ovarian cancers are not recognised at an early stage for a number of reasons.
First, the cancer of the ovary usually develops after the menopause; when the ovaries are inactive and abnormal function of the ovary is not therefore easily noticed. Second, the ovaries are located deep inside the pelvis and are difficult to examine. Finally, even when symptoms do occur they are usually vague, non-specific symptoms, which could be due to a host of other causes.
For these reasons, by the time most women with ovarian cancer develop symptoms and their cancer is detected, it has spread outside the ovaries to the pelvis (Stage 2), the abdomen (Stage 3) or more distant sites (Stage 4) and is far more difficult to treat successfully.
This information has long suggested that an effective method of screening to detect early stage ovarian cancer may save the lives of many women who develop the cancer.
What screening tests are available?
Three potential methods of screening for ovarian cancer have been assessed:
1. An internal examination
An internal examination (bimanual examination)can be performed to identify enlarged ovaries.
Although internal examination can detect large ovarian tumours even experienced doctors are not able to reliably detect ovarian cancer at an early stage.
Internal examination is not regarded as an effective method for early detection of ovarian cancer.
2. CA 125 Blood Test
CA 125 is a protein released into the circulation in high levels in most women with ovarian cancer. The CA 125 test is frequently used to diagnose ovarian cancer in women who have symptoms and to monitor women during and after treatment of ovarian cancer. It is important to recognise that many normal tissues produce varying levels of CA 125 in the bloodstream. It can therefore also be raised in normal situations (e.g. pregnancy, menstruation) and benign conditions (e.g. fibroids, endometriosis) as well as ovarian cancer. The CA 125 test is easily and quickly performed on a small blood sample sent to the laboratory.
Ultrasound scanning is the same technique as is used in pregnancy and can be used to visualise the size and texture of the ovaries. In ovarian cancer, the ovaries increase in size and the texture becomes abnormal due to formation of cysts and solid growths. Unfortunately some of these abnormal features also occur in non-cancerous ovarian tumours and other conditions in the pelvis. So, as with CA125, it is important to realise that ultrasound results can be abnormal even when there is no cancer present. Ultrasound scans can be performed either by placing a probe on the abdomen or by inserting a probe into the vagina (which usually produces a clearer picture). The latter is called a trans-vaginal scan. Other features which may be important and can be assessed with ultrasound (Colour and Power Doppler) include the blood flow to the ovaries.
How effective are screening tests?
There is no doubt that screening can detect ovarian cancer early.
A number of large scale studies have been performed to look at the possibility of using either CA 125 or ultrasound to screen for ovarian cancer.
Two of the largest studies of screening for ovarian cancer have been performed in the UK.
The King's College Study investigated the role of ultrasound in over 5,000 women and demonstrated that ultrasound can detect cases of ovarian cancer at an early stage. The Royal London/St Bartholomew's Hospital Study assessed the use of CA 125 in combination with ultrasound in 22,000 women. This study revealed that it was possible to detect many cases of ovarian cancer before symptoms developed.
It is uncertain whether screening actually saves lives from ovarian cancer. Although screening with CA 125 and/or ultrasound can detect ovarian cancer early, it is important to be aware that this does not necessarily mean that screening will save lives. Screening will only be worthwhile if it detects ovarian cancer sufficiently early to make treatment more effective. Large studies like UKCTOCS are in progress at present and until they have reported their findings, it is unclear whether screening can save lives or not.
What are the problems with screening for ovarian cancer?
False positive results are common. The major problem with screening for ovarian cancer is that both the CA125 test and ultrasound scans can be abnormal in women who do not have cancer of the ovary. These sorts of results, known as 'false positives,' are a serious problem as they can cause a great deal of anxiety. Even worse, if the abnormalities persist, it may ultimately be necessary to perform an operation to exclude the possibility of ovarian cancer. If no ovarian cancer is found, then the operation was unnecessary. Such operations can result in serious complications. As ovarian cancer is relatively uncommon it works out that more abnormal screening results are due to false positive findings than are due to cancer.
False negative results can occur. Most women find a normal screening result reassuring. However, it should be recognised that neither the CA 125 nor ultrasound will pick up every case of ovarian cancer. 'False negative' results do occur and a small number of women will be falsely reassured.
What studies are in progress?
UKCTOCS - UK Collaborative Trial of Ovarian Cancer Screening An extremely ambitious study of ovarian cancer screening has been set up in the UK. The study, called UKCTOCS (UK Collaborative Trial of Ovarian Cancer Screening), involves 200,000 women aged 50-74 years from 13 regional centres. UKCTOCS is a randomised trial, which means that women, who agree to take part, are allocated randomly for screening with either CA 125 or ultrasound, or to a control group who are followed up without screening. This randomisation is essential in order to obtain really clear answers about how effective ovarian cancer screening is at saving lives. The study has completed recruitment and will eventually provide information about the number of lives which can be saved by screening, the financial cost of screening, the psychological impact of screening and the problems caused by false positive results. These results should be available in 2012. UKCTOCS is being co-ordinated by the Gynaecology Cancer Research Centre at University College London and is funded jointly be the Medical Research Council, Cancer Research UK and the National Health Service. Details of the trial can be found at www.ukctocs.org.uk.
Preliminary Results Published Lancet March 2009
Cancer screening test results are welcomed - Mar 16 2009 by Madeleine Brindley, Western Mail
REGULAR screening could help detect ovarian cancer before symptoms develop.Early results from the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) trial detected ovarian cancer or borderline tumours in 87 women and missed picking up 13 women who went on to develop the disease within a year of screening.Almost half (48%) of the cancers detected were at an early stage, according to research published in The Lancet Oncology.More than 16,000 women have been screened in Cardiff, one of 13 centres taking part in the research.Nazar Amso, of the department of obstetrics and gynaecology at the School of Medicine, Cardiff University, said: “This is the largest-ever trial of its kind into ovarian cancer.“We are very grateful to all the women in Wales who have taken part so far. The trial has five years to run and there is much to be done before we have firm evidence whether screening can detect ovarian cancer early enough to save lives.”There is currently no NHS screening programme for ovarian cancer, though Cardiff-based Innnermost Secrets offers it.
UKCTOCS is using two screening methods – a blood test for the protein CA125 and an ultrasound scan.If a volunteer’s blood test suggested risk of ovarian cancer, the woman was recalled for more screening and follow-up – 97 had their ovaries removed and 42 had ovarian cancer.Women in the ultrasound group who had persistent abnormalities were referred to specialists – 845 had surgery to remove the ovaries and 45 women had ovarian cancer.Dr Usha Menon, one of the trial’s principal investigators, said: “The early results suggest that both types of screening can be used on a large scale and successfully identify ovarian cancers.“However, we must wait until 2015 before we can conclude whether or not wider screening could lead to a fall in deaths.”
UKCFOCCS- UK Familial Ovarian Cancer Screening Study
This national study has been launched to assess and refine screening amongst women with a strong family history of ovarian cancer. A strong family history involves two or more close relatives with ovarian cancer or one relative with ovarian cancer and a relative with breast cancer that occurred at a young age (under 50 years). Women who think they fall into this category should ask their GP for advice and may be referred to a specialist genetics centre for the family history to be confirmed. Most regional genetics centres will know how to enrol eligible women into the familial screening study that involves a CA 125 test every four months and an annual ultrasound scan.
What should you do about ovarian cancer screening?
Many women are concerned about their risk of developing ovarian cancer, particularly if they have a relative or friend who has developed the cancer. It is understandable that many women with this first-hand experience of ovarian cancer wish to be screened. There is no absolutely right or wrong advice about screening but it is important to be aware of the limitations and disadvantages of current screening techniques that have been outlined above. Broad guidelines are provided below but the decision made by an individual woman will understandably be heavily influenced by her experience of ovarian cancer.
1. Women, less than 50 years old with no family history
The risk of ovarian cancer to women less than 50 years of age is small and the risk of a false positive screening is high. Screening is not recommended for this group of women.
2. Women, more than 50 years old with no family history
There is at present no evidence that screening is of value to women in this age group however early detection of Ovarian Cancer in women who have early disease may allow earlier treatment and improve survival.
3. Women with a weak family history
Many women in this group will have one close relative who has developed ovarian cancer and will be understandably anxious about their own risk. The risk to women in this group is slightly but not greatly increased and the value of screening is uncertain. Some centres do offer advice and counselling to women with a weak family history.
4. Women with a strong family history
Women with a strong family history as outlined above may be at a substantially increased risk of ovarian cancer. This group of women should have access to expert advice about prevention as well as screening through referral to a specialist centre . It should be emphasised that screening for women at high risk of ovarian cancer is of unproven benefit and many women at high risk decide to have their ovaries removed surgically to prevent the disease developing. This option is usually discussed after a consultation with aspecialist who can accurately assess a woman's risk.
Can I get screening for Ovarian Cancer on the NHS? NO
Currently there are two large UK trials UK looking at Ovarian Cancer Screening (UKCTOCS for women over 50 years old and UKFOCCS for those with a strong family history). It will be some years before they are completed, probbaly around 2012, and until then routine Ovarian Cancer Screening will not be available on the NHS.
How do I arrange screening for ovarian cancer?
Women over 50 with no family history of ovarian cancer or those under 50 with an affected family member can book a consultation with Dr Tony Griffiths, a Consultant Gyanecologist with a special interest in Gynae Ultrasound and a British Society for Gyanecological Ultrasound Trainer. At the clinic they would have a CA125 Blood Test and Transvaginal Ultrasound as a screening test for ovarian pathology including ovarian cancer. If a benign condition is identified, the options for further investiagtions or treatment will be discussed after the scan. If there is an increased risk of ovarian cancer they have the option of referral back to their GP for subsequent NHS management or directly on a private basis to a Gynaecological Oncologist.
How much does it cost?
Where can I get more information about ovarian cancer?
Further information about Ovarian Cancer is available from Cancer Research UK.