Spotlight on Ovarian Cancer: The Importance of Routine Examinations

Recently I had a patient who came into the hospital for something completely unrelated ovarian cancer–besides the fact that she carried the diagnosis. I think it was some kind of viral illness. I carry a pager for 30-40 patients at night so it is difficult to remember all of them–and it all kind of blends together when you are working third shift and exhausted.
Anyways, I spent a decent amount of time just talking to this woman. She was older, had a lot of social stressors and I could tell she didn’t really have a good grasp on her diagnosis/prognosis related to her ovarian cancer. From what I had read about her, her cancer was advanced stage and had metastasized to multiple other organs. She had recently finished up a palliative course of chemotherapy. She didn’t seem to know what that meant in my determination.
Towards the end of our conversation she said to me “You know, I just don’t know how this happened–the cancer. I never had any pain or symptoms. I remembered reading in her chart that when her cancer was discovered she had told the provider interviewing her that she hadn’t been to the gynecologist in “a long time”.
Enlarged ovary with papillary serous carcinoma on the surface.
Enlarged ovary with papillary serous carcinoma on the surface.
It dawned on me that this woman didn’t seem to understand the importance of routine health care. Nonetheless I think her social stressors played a huge role in some self neglect. It appeared to me that she was the cornerstone of her family. The person who kept everyone in line and made sure that everyone else was taken care of–leading to some self neglect.
I took the time and explained to her that ovarian cancer was one of those diseases that have really vague symptoms–if any at all. Which made me think– are gynecologists educating their patients on warning signs of such diseases? Ovarian cancer is the #1 cause of death from GYN cancers. Likely due to the non-specific, minimal symptoms and rapid metastasis.
So, as health care providers who should we be talking to about warning signs? I believe everyone has a role in preventative health (not just the gyn) from hospitalists, PCP’s and gynecologists. As a patient’s PCP it is important to follow-up and simply ask if your patient is attending appropriate preventative care and screening appointments. As someone who has only worked in a hospital based setting, I can say that I do not routinely ask patients about their preventative care. This woman made me think, “maybe I should?” How long would it really take me? 5 minutes? Would it change anything? Maybe, maybe not–but it can’t possibly hurt.
imageSo, what can we do?
Know who is most at risk.
Nulliparity, Early menarche, Late menopause. The reason for this has been postulated to be a result of increased frequency of ovarian cell turnover. The more mitotic activity the increased chace something will go wrong. In addition epithelial damage caused by follicular rupture.
Genetics. Can’t run from your DNA unfortunately. General population risk for ovarian CA is approx 1.6%, 4-5% with one first degree relative affected and 7% with 2 first degree relatives affected. Younger age when affected increases the likelihood that . There is a lot of information out there about genetic components–I’m not covering that right now.
Hormone Replacement Therapy (HRT) increases the risk for Ovarian CA.
Protective factors. Multiparity and oral contraceptives.
Ovarian cancer can be diagnosed at any age; but, the most common age range for diagnosis is 53-64. Perhaps starting to give patients in their 30’s-40’s a heads up regarding symptoms. We counsel patients about breast cancer, we screen for cervical cancer– we don’t really talk about ovarian cancer and maybe that is why the 5th most common cause of cancer death in women.
So, if we are going to initiate any counseling to our patients what do we tell them? Ovarian cancer is vague, some individuals do not even experience symptoms–sometimes tumors are found as what we call “incidentalomas”. Common symptoms when experienced can include non-specific bloating, change in bowel/bladder habits, early satiety, indigestion, pelvic pain/pressure. Oddly enough I just read that presentation of patient with DVT is not uncommon– that is how my patient was diagnosed, unfortunately this usually correlates with a poor prognosis and metastatic disease. The increased risk for DVT with malignancy is significant. I read an article once that said if the patient is actively being treated with chemo the risk of DVT is 1 in 200. I hadn’t realized it was that high. Anyways, so my patient had previously presented with a hot swollen leg and ended up having ovarian cancer. Crazy.
The differential diagnosis for these symptoms is huge. Workup can include imaging–start with ultrasound, tumor marker, CA125, stool and urine samples, colonoscopy or endoscopy, STD screening and beta hcg. This is by no means a comprehensive list. But its a start.
I’m not suggesting that as providers we go into a 30 minute diatribe about ovarian cancer with our patients; however, I’m also saying that maybe its worth mentioning as an FYI/things to watch for as we counsel patients at the end of appointments. Perhaps for the patients without symptoms who present with  dvt or paraneoplastic syndromes it is too late. However, maybe for the women who have non-specific symptoms it may cause them to present sooner for evaluation by taking several minutes to remind them about the importance of routine appointments and exams.

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