Frequency of Symptoms of Ovarian Cancer in Women Presenting to Primary Care Clinics

Abstract & Commentary

It has been recently recognized and increasingly reported that ovarian cancer patients frequently manifest symptoms, predominately related to their gastrointestinal or urinary tracts, a significant period of time ahead of their diagnosis. Goff and colleagues advance this line of investigation further by conducting a prospective study ascertaining the frequency of self-reported ovarian cancer-associated symptoms between 2 cohorts of patients seeking medical care. The case patients were those about to undergo surgery for a known or suspected pelvic or ovarian mass; the controls were women presenting to one of 2 primary care clinics, in which approximately two thirds were being seen for a specific problem.

The voluntary questionnaire instrument administered to both cohorts asked the respondents to score the severity, frequency, and duration of 20 symptoms generally reported by ovarian cancer patients. In both groups, recurring symptoms were common and non-specific. Symptomatology in control patients was related to the purpose of the visit (general check up vs specific complaint), their underlying disease co-morbidities and their menopausal status. Not surprisingly, women with the final diagnosis of ovarian cancer generally reported numerically more symptoms of greater severity but of shorter duration of onset compared to either the clinic controls or patients with benign ovarian tumors. Ovarian cancer patients were also statistically more likely to report increased abdominal size, bloating, urinary urgency, and pelvic pain. The combination of the former 3 symptoms was reported 5 times more often in cancer patients than controls. The frequency and severity of these associated symptoms prompted Goff et al to conclude that the symptom triad was important enough to warrant further clinical investigation when identified (Goff BA, et al. JAMA. 2004;291:2705-2712).

Comment by Robert L. Coleman, MD

One of the more frustrating aspects in the scientific pursuit to identify early stage ovarian cancer is that there is, as yet, no reliable way to accurately allocate individual risk. The prize when such study or modality is discovered would not only be better screening and surveillance but also improved survivorship through earlier stage detection. Currently, clinicians use a variety of radiographic and biologic tests to survey their patients either deemed at increased risk for the disease by history or in response to some symptomatology or physical exam finding that may suggest neoplastic ovarian pathology. Nonetheless, the algorithms developed so far are largely inefficient and imprecise. With respect to symptoms, the imprecision stems from the lack of correlative representation of stage and symptoms experienced and the broad spectrum of these complaints not specifically focused to the ovary or pelvic structures. For instance, many patients will have undergone a series of gastrointestinal diagnostic procedures and interventions before the diagnosis is made or suspected—many times before a pelvic exam is performed.

The current study does affirm previous reports that women with ovarian cancer do have a set of recognizable symptoms. The prevalence is high among women with this disease.1-3 More than 90% of ovarian cancer patients were symptomatic in the 12 months preceding the diagnosis and two thirds of these reported recurring symptoms. The implication from the identification of the symptom cluster among case patients is that their occurrence should alert the clinician to work-up the patient for ovarian cancer. Unfortunately, strictly using the cluster as a decision tool would miss more than half the cancers and subject many women without cancer to unnecessary and expensive testing and procedures. To bridge this gap, one is called once again to practice the art of medicine. Consideration of these findings obviously can’t be done in a vacuum and attest to the importance of appropriate evaluation of key clinical parameters and clues. It also mandates that clinicians hear what their patients are telling them and asking them what they are not. Without more precise diagnostic tools, the detection of early ovarian cancer will rely on this age-old, but arguably diminishing art.

References

1. Vine MF, et al. Gynecol Oncol. 2003;90:75-82.

2. Smith EM, Anderson B. Cancer. 1985;56:2727-2732.

3. Olson SH, et al. Obstet Gynecol. 2001;98:212-217.

Robert L. Coleman, MD, Dept. of Gynecologic Oncology, University of Texas Southwestern Medical Center, Dallas, TX, is Associatte Editor of OB/GYN Clinical Alert.