Symptomatology of ovarian cancer

Prognostic Significance of CD109 Expression in Patients with Ovarian Epithelial Cancer

Background

Ovarian epithelial cancer (OEC) is the second-most common gynecologic malignancy. CD109 expression is elevated in human tumor cell lines and carcinomas. A previous study showed that CD109 expression is elevated in human tumor cell lines and CD109 plays a role in cancer progression. Therefore, this study aimed to determine whether CD109 is expressed in OEC and can be useful in predicting the prognosis.

Methods

Immunohistochemical staining for CD109 and reverse transcription-quantitative polymerase chain reaction was performed. Then we compared CD109 expression and chemoresistance, overall survival, and recurrence-free survival of OEC patients. Chemoresistance was evaluated by dividing into good-response group and poor-response group by the time to recurrence after chemotherapy.

Results

CD109 expression was associated with overall survival (p = .020), but not recurrence-free survival (p = .290). CD109 expression was not an independent risk factor for overall survival due to its reliability (hazard ratio, 1.58; p = .160; 95% confidence interval, 0.82 to 3.05), although we found that CD109 positivity was related to chemoresistance. The poor-response group showed higher rates of CD109 expression than the good-response group (93.8% vs 66.7%, p = .047). Also, the CD109 mRNA expression level was 2.88 times higher in the poor-response group as compared to the good-response group (p = .001).

Conclusions

Examining the CD109 expression in patients with OEC may be helpful in predicting survival and chemotherapeutic effect.

Adherence to practice guidelines is associated with reduced referral times for patients with ovarian cancer

BACKGROUND

Patients with ovarian cancer tend to receive the highest quality of care at high-volume cancer centers with gynecological oncologists. However, the care that they receive prior to gynecological oncology consult has not been examined. We investigated the quantity and quality of care given to patients with ovarian cancer before being seen by a gynecological oncologist.

OBJECTIVE

We evaluated the variability, quantity, and quality of diagnostic testing and physician-referral patterns prior to consultation with a gynecological oncologist, in women with suspicious pelvic masses seen on imaging.

STUDY DESIGN

A chart review was performed on patients treated for ovarian cancer at a single institution from 2001 to 2014. We evaluated their workup in 4 categories, drawn from National Comprehensive Care Network guidelines: provider visits, abdominal/pelvic imaging, chest imaging, and tumor markers. Workup was classified as guideline adherent or guideline nonadherent.

RESULTS

We identified 335 cases that met our criteria. In the provider visit category, 83.9% of patients received guideline-adherent workup: 77% in the abdominal/pelvic imaging, 98.2% in the chest imaging, and 95.2% in the tumor marker categories. Each patient's workup was assessed as a compilation of the 4 categories, yielding 65.7% patients as having received an adherent workup and 34.3% of workup as nonadherent to guidelines. The timeframe to see a gynecological oncologist for patients with guideline-adherent workup was significantly shorter than for those whose workup was nonadherant (20 vs 86 days, P < .001). A suspicious pelvic mass was identified by obstetrics-gynecology in only 23.9% of patients; 42.7% of patients did not have tumor marker testing before a gynecological oncologist consult. When an obstetrics-gynecology specialist discovered the suspicious pelvic mass, the remaining workup was more likely to be guideline adherent prior to gynecological oncologist referral than when initial imaging was not ordered by an obstetrics-gynecology specialist (P = .18). Survival was not significantly different (P = .103).

CONCLUSION

With a guideline-adherent workup, including tumor marker testing, gynecological oncologist referral times can be shortened, minimizing cost inefficiencies and delays that can compromise the effectiveness of downstream care for patients with ovarian cancer. Guidelines should be disseminated beyond the obstetrics-gynecology field.

Time to diagnosis of Type I or II invasive epithelial ovarian cancers: a multicentre observational study using patient questionnaire and primary care records

OBJECTIVE

To compare time to diagnosis of the typically slow-growing Type I (low-grade serous, low-grade endometrioid, mucinous, clear cell) and the more aggressive Type II (high-grade serous, high-grade endometrioid, undifferentiated, carcinosarcoma) invasive epithelial ovarian cancer (iEOC).

DESIGN

Multicentre observational study.

SETTING

Ten UK gynaecological oncology centres.

POPULATION

Women diagnosed with primary EOC between 2006 and 2008.

METHODS

Symptom data were collected before diagnosis using patient questionnaire and primary-care records. We estimated patient interval (first symptom to presentation) using questionnaire data and diagnostic interval (presentation to diagnosis) using primary-care records. We considered the impact of first symptom, referral and stage on intervals for Type I and Type II iEOC.

MAIN OUTCOME MEASURES

Patient and diagnostic intervals.

RESULTS

In all, 78% of 60 Type I and 21% of 134 Type II iEOC were early-stage. Intervals were comparable and independent of stage [e.g. median patient interval for Type I: early-stage 0.3 months (interquartile range 0.3-3.0) versus late-stage 0.3 months (interquartile range 0.3-4.5), P = 0.8]. Twenty-seven percent of women with Type I and Type II had diagnostic intervals of at least 9 months. First symptom (questionnaire) was also similar, except for the infrequent abnormal bleeding (Type I 15% versus Type II 4%, P = 0.01). More women with Type I disease (57% versus 41%, P = 0.04) had been referred for suspected gynaecological cancer. Median time from referral to diagnosis was 1.4 months for women with iEOC referred via a 2-week cancer referral to any specialty compared with 2.6 months (interquartile range 2.0-3.7) for women who were referred routinely to gynaecology.

CONCLUSION

Overall, shorter diagnostic delays were seen when a cancer was suspected, even if the primary tumour site was not recognised to be ovarian. Despite differences in carcinogenesis and stage for Type I and Type II iEOC, time to diagnosis and symptoms were similar. Referral patterns were different, implying subtle symptom differences. If symptom-based interventions are to impact on ovarian cancer survival, it is likely to be through reduced volume rather than stage-shift. Further research on histological subtypes is needed.

TWEETABLE ABSTRACT

No difference in time to diagnosis for Type I versus Type II invasive epithelial ovarian cancers.

Wnt/β-catenin pathway as a potential prognostic and predictive marker in patients with advanced ovarian cancer

Background

β-catenin is the key protein in the WNT signalling pathway and it forms adherent junctions together with E-cadherin. In ovarian carcinoma, abnormal expression of β-catenin, E-cadherin and WNT-1 was observed, but their prognostic and predictive role is unclear. The aim of this study was to clarify the prognostic and predictive role of E-cadherin, β-catenin and WNT-1 in advanced epithelial ovarian carcinoma (AEOC).

Methods

The expression of E-cadherin, β-catenin and WNT-1 was determined by immunohistochemistry in AEOC. The correlation between expression of these proteins and progression-free survival (PFS) and overall survival (OS) was evaluated. Statistical analyses included Kaplan-Meier estimation, log-rank test, Spearman correlation and Cox proportional-hazards model.

Results

In ovarian cancer, intense expression of E-cadherin, β-catenin and WNT-1 was found. In multivariate analysis, strong membrane β-catenin expression was an independent unfavourable predictor for PFS (HR 2.19, 95% CI 1.09-4.39; p = 0.028), while in univariate analysis, strong membrane β-catenin expression was a prognostic factor for OS in patients with AOC (p = 0.039). In multivariate analysis, only resistance to first-line chemotherapy was an adverse independent prognostic factor for OS (HR 16.84; 95% CI 5.07-55.98; p < 0.0001). Additionally, strong membranous β-catenin expression was associated with resistance to platinum-based chemotherapy (p = 0.027).

Conclusions

These findings support that WNT/β-catenin pathway and E-cadherin are important factors in advanced epithelial ovarian cancer.

Early clinical detection of ovarian cancer: a review of the evidence

Subjective and objective evidence suggest that a third to half of patients developing ovarian cancer report symptoms at 3 or more months prior to diagnosis. Early ovarian cancer-associated symptoms constitute a constellation of mostly nongynecological complaints, suggesting a visceral disturbance, which do not point immediately to a pelvic origin. Abdominal bloating and pain predominate with recent onset and multiple symptomatic episodes. Gastrointestinal and urinary symptoms and fatigue/malaise may be part of the symptom complex. Women aged 50 years and older with this constellation of symptoms should have medical evaluation and, if symptoms are unexplained or persist, should undergo pelvic imaging (e.g., transvaginal ultrasound) and serum CA125.

Microenvironmental regulation of BRCA1 gene expression by c-Jun and Fra2 in premalignant human ovarian surface epithelial cells

Reduced BRCA1 gene expression is common in the sporadic form of ovarian carcinoma. The spread of this highly lethal cancer often begins when tumor cell clusters are shed into the fluid of the abdominopelvic cavity such that they can float freely before seeding distant sites on the peritoneal walls and organs. Thus, the microenvironment that tumor cells find themselves in changes dramatically during these early shedding and floating stages of transperitoneal metastasis. To mimic this microenvironmental change in vitro, we released premalignant human ovarian surface epithelial cells from the substratum and forced them to cluster in suspension. Under these conditions, steady state levels of BRCA1 mRNA and protein fell significantly and the transcriptional activation state of the BRCA1 promoter was suppressed. Analysis of the promoter indicated that the previously identified "CRE" element located within the "positive regulatory region" (PRR) contributed to this suppression. More specifically, we show that the suppression was mediated, at least in part, by a suspension culture-driven decrease in the levels of two members of the AP1 transcription factor complex, c-Jun and Fra2, that bind to the CRE element. Therefore, a microenvironmental change that is manifested during the initial stages of ovarian carcinoma dissemination may, potentially, help suppress BRCA1 expression in sporadic tumors and thus promote their progression.

Ovarian cancer: screening and early detection

Ultimately, the timely diagnosis of ovarian cancer will rely on clinical judgment and careful analysis of presenting symptoms within the context of a thoughtful dialogue between the patient and her physician. Symptoms most typical of ovarian cancer include bloating, abdominal or pelvic pain, and difficulty eating. In some studies, urinary symptoms are also a common presenting symptom. When these symptoms occur more than 12 times per month and are of recent onset, then ovarian cancer should be considered as a possibility. Although most women who have these symptoms do not have ovarian cancer, it is important that providers include ovarian cancer in their differential diagnosis. Through research from the past decade, we now understand that there are patterns of symptoms associated with ovarian cancer. Importantly, we now know that ovarian cancer is not a “silent disease.” Finally, clinicians must always listen carefully to their patients avoid potentially harmful delays in diagnosis. Until there is a screening test, awareness is best.

Symptoms associated with ovarian cancer

Over the past decade there has been considerable evidence that women with ovarian cancer do have recognizable symptoms before diagnosis. The most common symptoms associated with ovarian cancer are abdominal bloating, increased abdominal size, pelvic pain, abdominal pain, feeling full quickly, and difficulty eating. Some studies also suggest that urinary symptoms are frequently present. When these symptoms occur more than 12 times per month and are of new onset, then ovarian cancer should be considered as a possibility. It is important for women and practitioners to be aware that ovarian cancer is not a "silent disease."

Patient-reported symptoms and survival in ovarian cancer

OBJECTIVE

While the development of an index of clinical symptoms to use for the detection and diagnosis of ovarian cancer is under active investigation, the role of clinical symptoms in survival after the initial diagnosis is poorly understood. The aim of this study was to correlate the type and extent of clinical symptoms with survival outcomes in ovarian cancer.

METHODS

Medical records of 276 cases of primary epithelial ovarian, fallopian tube, and peritoneal cancers were evaluated. Thirty-one symptoms in 5 categories were cataloged. The significance of clinical symptoms in progression-free survival (PFS) and overall survival (OS) was evaluated.

RESULTS

Overall, 93.5% of ovarian cancer patients expressed at least 1 symptom at the time of initial diagnosis. The 3 most common symptoms were abdominal pain (40.6%), increased abdominal size (33.7%), and bloating (21.7%). In survival analysis, weight loss (16.3%), nausea/vomiting (13.4%), and lower extremity edema (6.5%) were significantly associated with both decreased PFS and OS (all, P < 0.05). In multivariate analysis, lower extremity edema remained the strongest significant symptom, associated with increased surgical mortality rate, decreased response rate to adjuvant chemotherapy after primary cytoreductive surgery, and diminished survival outcomes (median PFS, 4.9 vs 15.3 months, P < 0.0001; and median OS, 5.9 vs 49.1 months, P < 0.001). Multiple symptoms were associated with poor survival outcomes (individual number of symptom ≤1 vs 2 vs ≥3; median PFS, 26.8 vs 17.4 vs 11.7 months [P < 0.001]; and median OS, 70 vs 41.6 vs 37.2 months [P < 0.001]).

CONCLUSIONS

Lower extremity edema at initial diagnosis is a strong prognostic indicator of ovarian cancer patient.

Reducing time to diagnosis does not improve outcomes for women with symptomatic ovarian cancer: a report from the Australian Ovarian Cancer Study Group

PURPOSE

To determine if time to diagnosis is associated with stage of disease at diagnosis or survival among women with symptomatic ovarian cancer.

METHODS

A representative sample of Australian women (n = 1,463) with ovarian cancer diagnosed between 2002 and 2005 who participated in a population-based case-control study were interviewed regarding the events leading to their diagnosis and were observed for mortality for 5 years.

RESULTS

Of the 1,318 women (90%) who presented to a medical practitioner with symptoms, 55% presented within 1 month, 70% in less than 2 months, and 92% within 6 months of symptom onset. There were no significant differences in the time from symptom onset to first medical practitioner consultation (P = .19) or symptom onset to diagnosis (P = .64) among women with borderline, early (International Federation of Gynecology and Obstetrics [FIGO] stages I to II) or late (FIGO stages III to IV) disease. There was also no association between time to diagnosis and survival; adjusted hazard ratio for long delay (> 12 months from symptom onset to diagnosis) versus short delay (≤ 1 month) was 0.94 (95% CI, 0.68 to 1.30). Women who had asymptomatic cancers diagnosed incidentally (n = 145) were younger and were more likely to have borderline or stage I disease compared with women who had symptomatic ovarian cancer.

CONCLUSION

The results of this study suggest that, once ovarian cancer is symptomatic, reducing the time to diagnosis would not greatly alter stage of disease at diagnosis or survival.

Selective removal of ovarian cancer cells from human ascites fluid using magnetic nanoparticles

A majority of ovarian cancer metastases result from the shedding of malignant cells from the primary tumor into the abdominal cavity. Free-floating cancer cells in serous effusions of late-stage ovarian cancer patients may spread to internal organs, making effective treatment extremely difficult. Selective removal of ovarian cancer cells from serous fluids may abate metastasis and improve long-term prognoses. We have already shown that superparamagnetic nanoparticles conjugated to an ephrin-A1 mimetic peptide with a high affinity for the EphA2 receptor can be used to capture and remove cultured human ovarian cancer cells from the peritoneal of experimental mice. Here we demonstrate the potential clinical utility of the methodology by in vitro capture and isolation of cancer cells from the ascites fluid of ovarian cancer patients.

FROM THE CLINICAL EDITOR

Ovarian cancer metastases usually are the result of shedding of malignant cells from the primary tumor into the abdominal cavity. In this paper, a novel nanotechnology-based method is demonstrated for the in vitro capture and isolation of cancer cells from the ascites fluid of ovarian cancer patients.

Prediagnostic symptoms of ovarian carcinoma: a case-control study

OBJECTIVE

Women with ovarian carcinoma experience poor survival because symptoms are vague and diagnosis is unlikely at an early stage. The objective of this study was to identify a set of symptoms that might assist gynecologists and other clinicians in the diagnosis of localized ovarian carcinoma when treatment is most effective.

METHODS

This population-based case-control study included 432 women, aged 19-88 years, with invasive ovarian carcinoma and 491 controls frequency-matched to cases on age, ethnicity, and interview time. Symptoms data were collected using interviewer-administered questionnaires. Odds ratios and 95% confidence intervals for the association of symptoms with ovarian carcinoma by stage and histology were estimated using unconditional multiple polytomous logistic regression models. The predictive ability of symptoms was evaluated by comparing the area under receiver operating curves (ROC).

RESULTS

The following self-reported symptoms were significantly predictive of localized ovarian carcinoma irrespective of histological type: abdominal pain (ROC=0.81), distended and hard abdomen (ROC=0.83), vaginal bleeding not associated with periods (ROC=0.88), and a palpable abdominal mass (ROC=0.88). Urinary symptoms had low predictive ability, and bowel symptoms and fatigue/loss of appetite were predictive only at advanced stages. The best predictive ability was observed for a 4-symptom index that included abdominal pain, distended and hard abdomen, abdominal mass, and abnormal vaginal bleeding (ROC=0.90 sensitivity=74%; specificity=71%).

CONCLUSION

Greater awareness of the symptoms potentially related to ovarian cancer might lead to earlier diagnosis and might improve survival.

The effect of symptom duration in epithelial ovarian cancer on prognostic factors

PURPOSE

To assess the association between duration of symptoms and main prognostic factors of invasive epithelial ovarian cancer (EOC).

METHODS

The data of all histologically confirmed EOC patients diagnosed in Israel during the period 1994-1999 (n = 1,005) were retrieved from discharge summaries and admission records. Of the 371 (36.9%) patients with known presenting symptoms, the durations of 187 (50.4%) were recorded.

RESULTS

The most common presenting symptoms were abdominal pain (65.2%). The percentage of patients with three or more symptoms increased significantly with stage (P = 0.001). No statistically significant association between duration of symptoms and prognostic factors was found.

CONCLUSION

Our findings did not show an association between duration of symptoms and prognostic factors in EOC patients and may indicate that prognosis is not a function of delay in diagnosis.

Symptoms of ovarian cancer in young patients 2 years before diagnosis, a case-control study

Ovarian cancer is usually diagnosed after it has spread and is difficult to cure. Most of attempts to identify early symptoms have lacked control group or have been based on interviews. We examined early symptoms of ovarian cancer in young women and compared with a matched control group. Symptoms recorded in medical files of 100 women aged 15-35 years with ovarian cancer who were referred to Vali-Asr hospital between 1995 and 2005. Symptoms of cases were compared with 100 matched controls during 2 years before diagnosis. More cases (95%) than controls (28%) complained of at least one symptom up to 2 years before diagnosis, most of these symptoms were abdominal. Others included urinary symptoms, infertility and abnormal vaginal bleeding. The most common symptoms among cases were: unusual abdominal or lower back pain 52%, unusual bloating, fullness and pressure in the abdomen 37%, gastro-intestinal problems 36%. In total, 11%, 3% and 12% of controls reported these symptoms respectively, resulting in odds ratios of 8.7, 18.9 and 4.1 respectively for these symptoms. Unusual abdominal or lower back pain, fullness and pressure, gastrointestinal, urinary problems and infertility should make women and physicians more aware of changes associated with ovarian cancer.

Temporal Patterns of Conditions and Symptoms Potentially Associated with Ovarian Cancer

BACKGROUND

The late stage at which ovarian cancer is typically diagnosed and its subsequent high mortality have been attributed to a lack of symptoms in its early stages. This study examined the temporal patterns of prediagnostic ovarian cancer symptoms and conditions among women with and without ovarian cancer.

METHODS

We identified 920 ovarian cancer cases from 1998-2002 claims and encounters from Thomson Healthcare's Medstat MarketScan Commercial Claims and Encounters and Medicare Supplemental Databases. These were matched with 2760 comparison women based on age, geographic region, Medicare eligibility, and health plan type. The rates of ovarian cancer-related symptoms, conditions, and procedures recorded in the claims data were compared between the two groups using chi-square and Student's t tests.

RESULTS

In the 270 to 31 days prior to the case diagnosis dates, cases had nearly five times more recorded abdominal symptoms (36.2% vs. 7.5%), 3.5 times more recorded female genital symptoms (9.8% vs. 2.7%), and 1.5-2 times more recorded gastrointestinal symptoms (7.7% vs. 3.5%), urethra/urinary tract disorders (12.7% vs. 6.4%), and menopausal disorders (12.4% vs. 7.5%) than the comparison women. However, when the data were examined in 30-day increments for these five diagnosed conditions, the rates for cases and comparison women only started to diverge as the cases' diagnosis drew closer-60-90 days prior.

CONCLUSIONS

The presence of ovarian cancer-related symptoms and conditions prior to diagnosis among cases was documented in claims data; however, this increase was most pronounced in the 2-3 months prior to diagnosis. It is likely that physicians will see similar symptoms and conditions for women with and without ovarian cancer during most of the 9 months prior to the cases' diagnosis.

The morphogenic function of E-cadherin-mediated adherens junctions in epithelial ovarian carcinoma formation and progression

E-cadherin expression is unusually regulated in epithelial ovarian carcinoma. It is not expressed in poorly cohesive ovarian surface epithelial (OSE) target cells, but is expressed in cohesive pre-malignant lesions and in highly cohesive, well-differentiated tumors where it is membrane associated, presumably in adherens junctions. E-cadherin expression is subsequently suppressed, or its function is disrupted, in late-stage invasive tumors. Here, we observed that increased E-cadherin expression in ovarian carcinoma cells was associated with increased E-cadherin promoter activity, increased adherens junction formation, decreased beta-catenin signaling-dependent LEF-1 activity, and the generation of cohesive spheroids in basement membrane gel culture. Forced expression of wild-type E-cadherin in immortalized OSE cells initiated adherens junction formation, decreased LEF-1 activity, decreased the mesenchymal migration that is a characteristic of OSE cells that have been maintained in monolayer culture, and induced the formation of cohesive spheroids in basement membrane gels. Conversely, forced expression of a dominant-negative E-cadherin mutant in ovarian carcinoma cells disrupted adherens junctions, increased mesenchymal cell migration, and prevented spheroidal morphogenesis without altering LEF-1 signaling. Therefore, in addition to suppressing late-stage tumor progression, E-cadherin-mediated adherens junctions may also contribute to the initial emergence of a cohesive morphogenic phenotype that is a hallmark of differentiated epithelial ovarian carcinoma.

Symptoms, diagnoses, and time to key diagnostic procedures among older U.S. women with ovarian cancer

OBJECTIVE

To examine the types of symptoms and diagnostic procedures reported in Medicare claims 12 months before diagnosis for women with ovarian cancer by stage, and to assess the association between types of symptoms and time to key diagnostic procedures.

METHODS

Medicare claims linked to records in the Surveillance, Epidemiology, and End Results (SEER) cancer registries were used to examine diagnosis and procedure codes in 3,250 women aged 65 years and older before a diagnosis of ovarian cancer.

RESULTS

Over 81% of women with ovarian cancer had at least one target sign or symptom before diagnosis. Gastrointestinal symptoms such as nausea and vomiting (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.40-2.98), and constipation, diarrhea, or other digestive disorders (aOR 2.01, 95% CI 1.58-2.56) were associated with later-stage cancer. In contrast, gynecologic symptoms such as abnormal bleeding (aOR 0.44, 95% CI 0.34-0.58) and genital organ pain (aOR 0.66, 95% CI 0.53-0.80) were associated with earlier disease. Among those with at least one symptom, the rate at which women with gynecologic symptoms went to surgery was higher (hazard ratio 5.5, 95% CI 5.1-6.0) than the rate for women with other nongastrointestinal ovarian cancer-related symptoms.

CONCLUSION

Women with ovarian cancer presenting with gastrointestinal symptoms were more likely to have later-stage disease and longer time to key diagnostic tests than those with gynecologic symptoms. Clinicians should be aware of the potential for unresolved gastrointestinal symptoms to be indicators for ovarian cancer.

Feasibility of screening for ovarian cancer using symptoms as selection criteria

OBJECTIVE

Retrospective studies have reported that 95% of women with ovarian cancer have symptoms prior to diagnosis and that women with these symptoms are at an increased risk of ovarian cancer. Failure to recognise these symptoms may result in a delay in referral and diagnosis. We assess the feasibility of screening for ovarian cancer using symptoms as selection criteria.

DESIGN

A randomised controlled trial.

SETTING

General practices in East London.

POPULATION

Three hundred and ninety GPs.

METHODS

GPs were randomised by practice, and those in the study group were given rapid access to ultrasound and CA125 test for women, >45 years, suffering from symptoms that may be caused by ovarian cancer.

MAIN OUTCOME MEASURES

Symptoms leading to referral, ultrasound and CA125 results and ovarian cancer diagnosis.

RESULTS

Seventy nine practices containing 197 GPs were randomised to the study arm. Three hundred and seventeen women were referred, of which 315 were eligible. Women reported the following symptoms: abdominal 87%, gastrointestinal 41% and constitutional 29%. Twenty-three women had abnormal findings on ultrasound: 20 were managed conservatively and 3 surgically. Histology revealed a mucinous cystadenoma, a Brenner tumour and a serous cystadenoma. Incidental findings included endometrial pathology in 13 women and bladder pathology in 2. Ninety five percent of CA125 results were <35 units/ml.

CONCLUSIONS

This pilot study confirms the feasibility of screening for ovarian cancer using symptoms as selection criteria. Specificity was high and patient compliance good. Initial concerns about referral volumes and additional investigations and referrals generated were not confirmed. No ovarian cancers were detected in this pilot study, and this may be due to the size of the cohort.

Ascites and epithelial ovarian cancers: a reappraisal with respect to different aspects

Ascites is a common finding in patients with epithelial ovarian cancer (EOC). Clinico-pathologic correlations with respect to the presence of ascites, positive cytology and prognostic role of ascites, and the impact of ascitic volumes were not previously studied extensively. A total of 372 patients with EOC were retrospectively evaluated with respect to presence and amount of ascites, cytologic findings, and survival. Two groups were compared by using Chi-square, Student's t and Mann-Whitney U, binary logistic regression, Kaplan Meier and Cox-regression analysis tests, where appropriate. Omental metastasis (P < 0.001; OR: 3.21, 95% CI = 1.945-5.297) and mean number of metastatic lymph nodes (P= 0.008; OR: 1.063, 95% CI = 1.016-1.112) were significantly related with presence of ascites. Evaluation of ascitic volume at different thresholds revealed lymphatic-omental metastasis, and also the disease stage to be significantly different among patient groups at lower threshold values and the positive cytology and high-grade diseases at higher threshold values. In conclusion, presence of ascites correlates with both the intraperitoneal and also the retroperitoneal tumor spread. Amount of ascites has different correlations with the clinico-pathologic factors depending on the thresholds chosen. At lower volumes, lymphatic and omental metastasis seems to correlate with the development of ascites. Once ascites develops, tumor grade seems to be important for larger ascites volumes. Neither the presence of ascites or its volume nor the cytologic positivity was an independent predictor of survival.

Ovarian Cancer: Early Symptom Patterns

PURPOSE/OBJECTIVES

To examine early symptom and diagnostic-seeking experiences of women newly diagnosed with ovarian cancer.

DESIGN

Longitudinal descriptive.

SETTING

Homes of families.

SAMPLE

Purposive; 19 families were obtained by referrals.

METHODS

Interviews and questionnaires; descriptive analysis.

MAIN RESEARCH VARIABLES

Early symptoms and delays in diagnosis.

FINDINGS

Families were 88% Caucasian and 12% African American. Almost two-thirds had annual incomes of 25,000 dollars or more. The ages of the patients with cancer ranged from 28-73 years (mean = 56 years). Delay between initial symptoms and diagnosis was mean = 14 weeks. Early symptoms experienced by 95% of women were abdominal bloating, vague abdominal pain and "spots," indigestion problems, fatigue, and urinary problems.

CONCLUSIONS

Women usually experience a cluster of symptoms, unrecognized and discounted, which delays diagnosis.

IMPLICATIONS FOR NURSING

Pelvic assessments should be reformulated to conceptualize early symptoms, risk factors, and family cancer history as a dynamic, interconnected whole to guide and interpret ovarian health.

Presenting symptoms of epithelial ovarian cancer

OBJECTIVES

Epithelial ovarian cancer is a common disease with a high mortality, the latter being frequently attributed to late diagnosis due to failure to recognise symptoms of early disease. This study was designed to determine any differences in symptomatology between patients with early and advanced stage disease.

DESIGN

A retrospective cohort study of 100 patients with stage 1 disease and 100 with stage 3 disease. Ten consecutive patients with stage 1 disease and 10 with stage 3 disease were identified from the database of patients treated each year from 1990 to 1999.

SETTING

A tertiary referral centre for gynecological malignancy.

OUTCOME MEASURES

The nature and duration of symptoms, age at presentation, and the size, histologic type and grade of tumour were determined by chart review, and the findings compared using logistic regression analysis.

RESULTS

Ninety percent of women with early, and 100% with advanced disease reported at least one symptom. With early disease, abdominal pain was reported by 51% and abdominal swelling by 32%, and with advanced disease abdominal swelling by 62% and abdominal pain by 44%. Seventy percent of the early stage and 69% of the advanced stage cohorts reported symptoms of less than 3 months duration. Tumours less than 5 cm diameter were three times more likely to have advanced disease (P = 0.02). Grade 1 tumours were 40 times more likely to be early stage than grade 3 tumours. Serous tumours occurred in 25% of patients with early disease, and 45% with advanced disease (P = 0.01).

CONCLUSION

Patients with early stage ovarian cancer are likely to be younger and to have larger, better differentiated tumours that are more often non-serous histologically. Advanced disease is not invariably due to delayed diagnosis.

Ovarian cancer: Can we make the clinical diagnosis earlier?

BACKGROUND

Patients with ovarian cancer often report having symptoms for months before diagnosis, but such findings are subject to recall bias. The aim of this study was to provide an objective evaluation of symptoms that precede a diagnosis of ovarian cancer.

METHODS

Medicare provider claims linked to records in the California Surveillance, Epidemiology, and End Results data base were utilized to extract diagnosis and procedure codes for 1985 women age 68 years or older who resided in California with ovarian cancer, 6024 elderly women with localized breast cancer, and 10,941 age-matched, Medicare-enrolled women without cancer. Prevalence of rates of symptom-related diagnoses and procedure codes in Medicare claims records were obtained during 3-month periods up to 36 months before diagnosis of ovarian cancer.

RESULTS

From 1 month to 3 months before patients were diagnosed with ovarian cancer, the frequency and adjusted odds ratios (ORs) with 95% confidence intervals (95%CIs) for 4 "target symptom" code groups were: abdominal pain (frequency, 30.6%; OR, 6.0; 95%CI, 5.1-6.9), abdominal swelling (frequency, 16.5%; OR, 30.9; 95%CI, 21.4-44.8), gastrointestinal symptoms (frequency, 8.4%; OR, 2.3; 95%CI, 1.8-3.0), and pelvic pain (frequency, 5.4%; OR, 4.3; 95%CI, 2.8-6.7). The adjusted odds for abdominal swelling codes was elevated 10-12 months before diagnosis (OR, 2.4; 95%CI, 1.2-4.6) for abdominal pain codes 7-9 months before diagnosis (OR, 1.3; 95%CI, 1.1-1.7). Abdominal imaging (frequency, 7.0%; OR, 1.3; 95%CI, 1.0-1.7) and pelvic imaging/CA125 (frequency, 3.7%; OR, 2.4; 95%CI, 1.7-3.4) showed an elevated frequency and adjusted odds 4-6 months before diagnosis. Patients with claims codes for "target symptoms" 4-36 months before diagnosis were more likely to have abdominal imaging (61.1%) or gastrointestinal procedures (30.8%) than pelvic imaging/CA125 (25.3%).

CONCLUSIONS

Patients with ovarian cancer were more likely than patients with breast cancer and women in a cancer-free control group to have target symptom codes (particularly abdominal swelling and pain) > 6 months before diagnosis. The evaluation of women with unexplained "target symptoms" should include pelvic imaging and/or CA125.

Early symptoms of ovarian cancer: a case-control study without recall bias

BACKGROUND

Ovarian cancer is usually diagnosed after it has spread and is difficult to cure. Previous attempts to identify early symptoms have either lacked a control group or have been based on interviews of cases, with possible recall bias.

OBJECTIVE

The purpose of this study was to identify early symptoms of ovarian cancer by reviewing prediagnostic medical records, free of recall bias, and comparing women with and without ovarian cancer.

METHODS

In an integrated health care delivery system, symptoms recorded in medical records of 102 women with ovarian cancer during the two years before diagnosis were compared with those of 102 matched control women.

RESULTS

More cases than controls complained of several symptoms up to one year before diagnosis. Most of these symptoms were abdominal or gastrointestinal in nature and were more prevalent in the advanced stage cases. Other symptom sites included pelvic, urinary, back, and systemic. Because case-control differences were not large and prevalence is low, positive predictive values were generally quite low.

CONCLUSION

Previous reports of early symptoms of ovarian cancer were confirmed in a study with a control group and free of recall bias. It is not clear that these symptoms occurred while the disease was still localized. Because hundreds of women would have to be investigated to detect one case of ovarian cancer, the clinical utility of these symptoms is uncertain. Nevertheless, health care providers should keep ovarian cancer in mind, when women present with symptoms such as abdominal pain and bloating.

An ovarian cancer diagnosis-seeking process: unraveling the diagnostic delay problem

PURPOSE/OBJECTIVES

To propose a conceptualization that identifies when diagnostic delays occur and suggests a delay-reduction strategy for the diagnosis of ovarian cancer.

DATA SOURCES

Findings and extrapolations from published national and international research studies, research reviews, books, Internet sources, and a family-functioning research project.

DATA SYNTHESIS

Three phases of diagnosis seeking were identified. Self-care was characterized by self-diagnosis, self-interpretation of symptoms, and self-management. Primary provider care was characterized by misdiagnosis and ineffective symptom management. Specialist care was characterized by specialized examinations, tests, and definitive diagnoses. Diagnostic delays were associated with extended periods of self-care and the misinterpretation of symptoms in primary care.

CONCLUSIONS

Periods of opportunity for early diagnosis occurred in the early symptom stages, when self- and primary care were dominant.

IMPLICATIONS FOR NURSING

Women must be taught to self-monitor for early ovarian cancer symptoms. Primary care providers should be urged to attend frequent state-of-the-science updates that regard early symptoms as manifestations of ovarian cancer.

Efficient screening for ovarian cancers using a combination of tumor markers CA602 and CA546

A new efficient screening for ovarian cancer based on a combination of two tumor markers, CA602 and CA546, is reported. These two tumor markers can be detected by a combination immunoenzymometric assay of these two antigens. This combination assay was initially performed in 1189 patients with clinically detected ovarian tumors (final pathological diagnosis: 645 cases of benign disease and 544 cases of malignant disease), and benign disease included 122 patients with endometriosis and 523 normal healthy women. The combination of CA602 and CA546 increased the detection rate of ovarian cancer from 77.8 to 85.8% compared with CA602 alone, demonstrating that the combination assay was effective at detecting ovarian cancers. The combination assay of CA602 and CA546 was then applied to 21,374 random subjects to screen for asymptomatic ovarian cancer. Ovarian cancer was detected in nine patients (detection rate: 0.04%), of which four cases were stage I disease. A retrospective analysis of these four patients revealed that a screening based on only a single assay would have been negative and further reiterates the effectiveness of this combination assay in detecting potential disease.

Snail, Slug, and Smad-interacting protein 1 as novel parameters of disease aggressiveness in metastatic ovarian and breast carcinoma

BACKGROUND

It was demonstrated previously that the Snail family of transcription factors and Smad-interacting protein 1 (Sip1) regulate E-cadherin and matrix metalloproteinase 2 (MMP-2) expression, cellular morphology, and invasion in carcinoma. For the current study, the authors analyzed the relation between the expression of Snail, Slug, and Sip1; the expression of MMP-2 and E-cadherin; and clinical parameters in patients with metastatic ovarian and breast carcinoma.

METHODS

One hundred one fresh-frozen, malignant effusions from patients who were diagnosed with gynecologic carcinomas (78 ovarian carcinomas and 23 breast carcinomas) were studied for mRNA expression of Snail, Slug, Sip1, MMP-2, and E-cadherin using reverse transcriptase-polymerase chain reaction analysis. Snail mRNA and E-cadherin protein expression levels also were studied in ovarian carcinoma effusions using in situ hybridization and immunocytochemistry. The results were analyzed for possible correlation with clinicopathologic parameters in both tumor types.

RESULTS

E-cadherin mRNA expression was lower in breast carcinoma (P = 0.001), whereas Snail expression was higher (P = 0.003). The Snail/E-cadherin ratio (P < 0.001) and the Sip1/E-cadherin ratio (P = 0.002) were higher in breast carcinomas. Sip1 mRNA expression (P < 0.001) and Slug mRNA expression (P < 0.001) were correlated with the expression of MMP-2 in ovarian carcinomas. The Sip1/E-cadherin ratio was higher in primary ovarian carcinomas at the time of diagnosis compared with postchemotherapy ovarian carcinoma effusions (P = 0.003), higher in Stage IV tumors compared with Stage III tumors (P = 0.049), and higher in pleural effusions compared with peritoneal effusions (P = 0.044). In a univariate survival analysis of patients with ovarian carcinoma, a high Sip1/E-cadherin ratio predicted poor overall survival (P = 0.018). High E-cadherin mRNA expression predicted better disease-free survival (P = 0.023), with a similar trend for a low Slug/E-cadherin ratio (P = 0.07). High Snail mRNA expression predicted shorter effusion-free survival (P = 0.008), disease-free survival (P = 0.03), and overall survival (P = 0.008) in patients with breast carcinoma.

CONCLUSIONS

Transcription factors that regulate E-cadherin were expressed differentially in metastatic ovarian and breast carcinoma. Snail may predict a poor outcome in patients who have breast carcinoma metastatic to effusions. E-cadherin expression generally was conserved in effusions from patients with ovarian carcinoma, but the subset of patients with postulated Sip1-induced repression of this adhesion molecule had a significantly worse outcome. This finding was in agreement with the stronger suppression of E-cadherin by Snail and Sip1 in breast carcinoma effusions, a clinical condition associated with extremely poor survival.

Quantitative analysis of integrin expression in effusions using flow cytometric immunophenotyping

We have previously shown that flow cytometric (FCM) immunophenotyping is a useful adjunct to morphology, in the diagnosis of serous effusions. The objective of the present study was to evaluate the possible application of FCM to quantitative analysis of adhesion molecule expression in this clinical setting. Fresh frozen cells from 67 effusions underwent quantitative analysis of alphaV, alpha6, beta1, and beta3 integrin subunit expression, using FCM. Specimens were diagnosed as carcinoma (n = 48), reactive (n = 12), or malignant mesothelioma (MM; n = 7) using morphology and, in selected cases, immunocytochemistry prior to FCM analysis. Antibodies against established epithelial, lymphoid, and mesothelial cell epitopes (Ber-EP4, anti-epithelial membrane antigen; (EMA), anti-CD45, anti-CD14, and anti-CD15) completed the panel. Results (percentage of cells expressing the antigen) were analyzed for relationship with the morphologic diagnosis. Frequent expression of the alphaV, alpha6, and beta1 subunits was seen in all diagnostic groups, with significantly higher expression of the alpha6 subunit in MM (P = 0.029, Kruskal-Wallis H test). The beta3 integrin subunit was not detected in any of the specimens. Ber-EP4 and CD15 expression was significantly higher in carcinomas compared with reactive effusions and MM (P < 0.001 and P = 0.001, Kruskal-Wallis H test), and EMA expression was higher in carcinomas and MM, compared with reactive specimens (P < 0.001, Kruskal-Wallis H test). In conclusion, FCM is an efficient tool for quantitative analysis of adhesion molecules in effusions. The high alpha6 integrin subunit expression in MM suggests involvement of this receptor in tumor attachment to laminin. The frequent expression of the alphaV and beta1 subunits support attachment to fibronectin and vitronectin as the major ECM ligands in body cavities.

Health seeking related to ovarian cancer

Critical review of general health-seeking models showed a need for expansion to include the early and atypical symptom period associated with ovarian cancer and the role of self and primary care in the diagnostic process. Data from family functioning research showed that in the self-care phase, the initial gastrointestinal symptoms were unrecognized as serious, given common sense labels, and self-managed. When primary care provider care was sought, misdiagnoses occurred three fourth of the time. Diagnostic delays occurred in these 2 phases of care. An expansion of a model of health seeking links personal and family risks and adds early symptom data may be obtained through monthly self-monitoring by women using a symptom checklist. Organization of risks and symptom information assists in interpretation of disparate streams of data and gives a recommended outcome: high personal risk level + high family risk level + high early and persistent symptoms presence = high need for a prompt gynecological evaluation. The restructured health-seeking process requires women be taught how to monitor their ovarian health. Nurses and primary care providers need frequent continuing education updates and the health media need current and accurate information about this malignancy.

Symptoms and referral of women with epithelial ovarian tumors

OBJECTIVE

To study referral to hospital units and the clinical characteristics of women with epithelial ovarian tumors in a prospective, population-based study.

METHODS

Clinical information on all women diagnosed with epithelial invasive (n=486) and borderline ovarian tumors (n=137) in Norway during 2002 was derived from notifications to the Cancer Registry of Norway and medical, surgical and histopathological records.

RESULTS

Sixty-one percent of women with invasive ovarian tumors were initially referred to gynecology units. The 38% of women referred to surgical and medical units were more likely to have symptoms as 'bowel irregularity', 'pain outside the abdominal cavity', 'persisting fatigue' and 'respiratory difficulties'. These women were older, had lower performance status and had a delay in treatment of 20 and 24 days respectively compared to 11 at gynecology units.

CONCLUSION

Greater awareness of the symptoms of ovarian cancer might lead to earlier diagnosis and treatment and thus possibly improve survival.

Ovarian cancer: the neglected diagnosis

OBJECTIVE

To investigate presenting signs and symptoms of ovarian cancer and stage of tumor in a community cohort of women with the diagnosis of ovarian cancer.

PATIENTS AND METHODS

We reviewed retrospectively the medical records of all women who sought primary and specialty care in Olmsted County, Minnesota, between January 1, 1985, and December 31, 1997, to evaluate presenting symptoms, time from first symptom to diagnosis of ovarian cancer, and stage of tumor at diagnosis.

RESULTS

Of 107 women with a diagnosis of ovarian cancer, the most commonly documented presenting symptom was crampy abdominal pain. Urinary symptoms and abdominal pain were the most commonly documented presenting symptom in patients with stage I and II ovarian cancers, whereas abdominal pain and increased abdominal girth were the most commonly documented symptoms in patients with stage III and IV cancer. Approximately 15% of tumors (n = 15) were found during routine evaluations or during a procedure for another problem. Less than 25% of presenting symptoms (n = 24 women) related directly to the pelvis or were more traditional gynecologic symptoms. Delays in women seeking medical care, health care system issues, competing medical conditions, physicians' failure to follow up, and women not returning for follow-up were associated with longer time to diagnosis.

CONCLUSION

Both stage I and II cancer are associated with symptoms, but few symptoms are directly related to the reproductive pelvic organs or unique to ovarian cancer. A longer interval from first sign or symptom to diagnosis of ovarian cancer is associated with both patient and health care system factors.

Proteomics and ovarian cancer: implications for diagnosis and treatment: a critical review of the recent literature

PURPOSE OF REVIEW

Epithelial ovarian cancer is the leading cause of death from gynecologic malignancies amongst American women. Emerging proteomic technologies have promise for early diagnosis and in advancing treatment directions. Application of these technologies has produced new biomarkers, diagnostic approaches, and understanding of disease biology.

RECENT FINDINGS

Mass spectral blood and tissue analysis has yielded new putative biomarkers that require further validation and assessment of diagnostic specificity and sensitivity. Protein signature patterns derived from mass spectrometry datastreams have been modeled and are moving into validation. Tissue-based protein analysis has led to identification of tumor and stromal protein and signal activation events in ovarian cancer. Clinical trials are now ascertaining tissue samples prior to and during therapy with molecularly targeted agents to evaluate modulation of targeted signaling pathways. Finally, proteomic analysis of tissues and metastases will outline biochemical events underlying the metastatic phenotype of ovarian cancer.

SUMMARY

Proteomic approaches are experimental technologies applied to ovarian and other cancers. Proper validation and use of findings may advance our understanding of biochemical events that have complicated successful detection and intervention. This knowledge is the first step in fulfilling the promise of personalized molecular medicine.

Differences in symptoms between patients with benign and malignant ovarian neoplasms

OBJECTIVE

The purpose of this study was to determine the symptoms that are experienced by patients who receive a diagnosis of early ovarian cancer and to compare those symptoms with the symptoms that are experienced by patients with late ovarian cancer, borderline ovarian cancer, and benign ovarian neoplasms.

STUDY DESIGN

This study used a retrospective case-control design. Cases of invasive and borderline ovarian cancer (n=147 patients) were compared with 76 patients with benign ovarian neoplasms.

RESULTS

Patients with early ovarian cancer were significantly more likely to have symptoms of mass effect (urinary frequency, constipation, palpable mass, pelvic pressure) compared with patients with benign ovarian neoplasms (67% vs 15%; P <.001), late stage disease (67% vs 40%; P =.008), and borderline cancer (67% vs 33%; P =.007).

CONCLUSION

Mass effect symptoms were the only symptoms that differentiated patients with early-stage ovarian cancer from all other groups of patients. However, one third of the patients with early ovarian cancer did not report any of these symptoms.

Effusion cytology in ovarian cancer: new molecular methods as aids to diagnosis and prognosis

Carcinoma of the ovary is the leading cause of death from gynecologic cancer in western countries. Ovarian carcinoma is commonly associated with the accumulation of fluid that contains malignant cells in the peritoneal and pleural cavities. This article details the current knowledge regarding the diagnostic and biologic characteristics of ovarian carcinoma cells in effusions, and the genotypic and phenotypic differences between solid primary tumors and metastatic lesions. Finally, we present a new approach, by which the analysis of fresh frozen viable cells allows us to study in vivo the links between expression and activity of extracellular mediators, membrane receptors, intracellular signaling, and transcription factors, and their potential therapeutic and prognostic significance.

Symptoms, coping strategies, and timing of presentations in patients with newly diagnosed ovarian cancer

OBJECTIVE

The purpose was to explore whether health education on symptoms of ovarian cancer would aid in early detection, by examining the relationship between symptoms, coping strategies, and timing of presentation in patients with newly diagnosed ovarian cancer.

METHODS

Eighty women were included. A questionnaire consisting of a series of open questions was designed to collect information on the sequence of events from the onset of symptoms to the diagnosis of ovarian cancer. The Coping Response Inventory (CRI) was used to assess the coping strategies.

RESULTS

A majority (90.0%) of women with ovarian cancer did have symptoms before the diagnosis. Abdominal pain or discomfort, abdominal distension, a palpable abdominal mass, menstrual, bowel, or urinary symptoms were the commonly reported symptoms. Eight (10.0%) patients were totally asymptomatic prior to the cancer diagnosis. The presence of bowel symptoms was significantly associated with late stage disease. Most of the patients sought medical advice within 2 weeks from the onset of symptoms. There was no association between the presence of any particular symptom(s) and the timing of presentation. There was also no correlation between the coping strategies and stage of disease and timing of presentation. On average, patients with early stage disease saw one more doctor compared to patients with late stage disease before the affirmative diagnosis of ovarian cancer.

CONCLUSION

Most patients presented early after the onset of symptoms. Health education in this regard may not be useful for early diagnosis of ovarian cancer.

Characterization of prediagnostic symptoms among primary epithelial ovarian cancer cases and controls

OBJECTIVE

The goal of this study was to characterize types, frequency, combinations, and relative onset of symptoms among ovarian cancer cases and controls.

METHODS

Participants were from an ongoing, population-based, case-control study of primary epithelial ovarian cancer in a 48-country region of North Carolina. Incident cases (N = 267), aged 20-74, were identified by area hospitals on a rapid case ascertainment basis between April 1999 and March 2001. Population-based controls, with at least one intact ovary, frequency matched on age and race, were identified using random-digit dialing (N = 287) and Health Care Financing Administration (HCFA) phone lists (N = 30). Trained nurse-interviewers, using a standardized questionnaire, asked participants about specific symptoms experienced for at least 2 weeks in the year prior to diagnosis (cases)/interview (controls).

RESULTS

More than 90% of cases reported at least one symptom and symptoms were most often the reason for the doctor visit leading to diagnosis (74%), followed by routine examination (12%). Among invasive cases, symptoms with onsets longer before diagnosis (median 5-7 months) included gas/nausea/indigestion; urinary frequency/urgency; bowel irregularity; abnormal menstrual/vaginal bleeding or discharge; pain during intercourse; and ongoing fatigue. Symptoms with onsets closer to diagnosis (median of 2-4 months) included distended/hard abdomen; bloating/feeling of fullness; unexplained weight gain/loss; pelvic/abdominal discomfort; chest pain/respiratory difficulties; and "other" symptoms. Controls reported fewer symptoms than cases (median 1 vs 5 or 6). Control symptoms were of longer duration and much less likely to occur in combination.

CONCLUSION

Earlier diagnosis of ovarian cancer may be possible if women and physicians recognize the importance of combinations of seemingly unrelated symptoms, especially those identified as occurring longer before diagnosis.

Effect of delays in primary care referral on survival of women with epithelial ovarian cancer: retrospective audit

OBJECTIVE

To examine referral pathways from primary care for patients with epithelial ovarian cancer and to identify factors related to survival at 18 months.

DESIGN

Retrospective review of patient notes.

SETTING

General practices and receiving hospitals within Mersey region.

SUBJECTS

135 patients with epithelial ovarian cancer identified from an audit in the Mersey area between 1992 and 1994.

MAIN OUTCOME MEASURES

Delays between onset of symptoms and treatment attributable to patient, general practitioner, and hospital.

RESULTS

105 (78%) women first presented to their general practitioner within four weeks of the onset of symptoms. 99 (73%) women were referred to hospital by their general practitioners within four weeks of presentation, and 95 (70%) were seen in hospital within two weeks of referral. Multivariate analysis with survival as the dependent variable identified age (odds ratio 0.96, 95% confidence interval 0.93 to 0.99) cancer stage III or more (0.15, 0.05 to 0.43), and non-specific symptoms (0.36, 0.14 to 0.89) as significant variables.

CONCLUSION

Most patients attended their general practitioner within four weeks and were referred within two weeks. No evidence was found that delays in referral or diagnosis adversely affected survival at 18 months. Stage of disease at surgery was the most important adverse factor. An effective screening programme is the most likely method to improve survival.

Types and duration of symptoms prior to diagnosis of invasive or borderline ovarian tumor

OBJECTIVE

The objective was to describe and compare types and duration of symptoms among women with invasive versus borderline ovarian tumors.

METHODS

Cases were women, ages 20-69 years, diagnosed with invasive (616) and borderline (151) epithelial ovarian tumors from 1994 to 1998. Symptoms were obtained using a standardized in-person interview. Differences in types and duration of symptoms, time to diagnosis after consulting a physician, and primary reason for diagnosis by invasive/borderline status and histologic type were determined using bivariate and regression analyses controlling for age.

RESULTS

Borderline and invasive cases reported similar types of symptoms. However, borderline cases were twice as likely to report not having had symptoms as invasive cases (16 vs 8%, P = 0.005). Prediagnostic symptom duration was longer among borderline versus invasive cases (median: 6 vs 4 months, P < 0.001). The median time from first consultation with a physician to diagnosis (1 month) did not differ by invasive/borderline status. Borderline cases were twice as likely to be diagnosed through routine examination as invasive cases (28 vs 16%, P = 0.001). Invasive cases were more likely to be diagnosed because of symptoms (62 vs 48%, P = 0.002).

CONCLUSIONS

Because most (90%) women with ovarian tumors have symptoms and median symptom duration is 4 months, greater awareness of symptoms by women and physicians is needed for the earlier detection of ovarian tumors. The lesser likelihood of being detected by routine examination and the shorter symptom duration for invasive versus borderline cases underscores the need for effective screening and preventive strategies.

Ovarian cancer screening: are we making any progress?

Given the burden of suffering associated with the development of ovarian cancer and the clear survival gradient related to the stage of disease at diagnosis, there is much enthusiasm for the development of effective screening strategies aimed at early detection. To date, no evidence exists to justify mass population screening; however, emphasis on subpopulation screening, identification of novel serologic markers, and multimodality screening designs have provided hope that these refinements may eventually translate into a reduction in ovarian cancer mortality.

Ovarian cancer strategies for nurse practitioners

PURPOSE

To review and outline practical strategies for the effective detection and prevention of ovarian cancer.

DATA SOURCES

Selected scientific literature, government consensus findings, and the author's experience.

CONCLUSIONS

Ovarian cancer is the fourth most common cause of cancer death in American women, ranking behind lung, breast, and colorectal cancer. Seventy-five percent of ovarian cancers are currently diagnosed at an advanced stage.

IMPLICATIONS FOR PRACTICE

No cost-effective screening methods are currently available. The battle to beat ovarian cancer is based on four strategies: identification of risk factors, appropriate screening methods, early detection, and prevention.

E-cadherin and alpha-, beta-, and gamma-catenin protein expression is up-regulated in ovarian carcinoma cells in serous effusions

The aims of this study were firstly, to investigate the expression of E-cadherin complex proteins in ovarian carcinoma cells in serous effusions and in primary and metastatic lesions; and secondly to study the value of these four proteins and calretinin, a mesothelial marker, in the differential diagnosis of ovarian carcinoma cells from reactive mesothelial cells in effusions. Sixty-seven malignant effusions and 97 corresponding primary (n=36) and metastatic (n=61) lesions were immunohistochemically stained for E-cadherin and alpha-, beta-, and gamma-catenin. Staining extent and intensity were scored. Effusion specimens were additionally analysed for calretinin immunoreactivity. Membrane immunoreactivity for E-cadherin and alpha-, beta-, and gamma-catenin was detected on carcinoma cells in the majority of the effusions, but rarely on reactive mesothelial cells (p<0.001 for all markers). Calretinin immunoreactivity was confined to mesothelial cells (p<0.001). An association was seen between E-cadherin and alpha-catenin expression, in both effusions and solid tumours, and for beta-catenin in solid tumours (range p<0. 001 to p=0.014). Up-regulation of all four cadherin complex proteins was seen in carcinoma cells in effusions, when compared with corresponding primary tumours (range p<0.001 to p=0.028). As with effusions, metastatic lesions showed up-regulation of alpha-, beta-, and gamma-catenin when compared with primary carcinomas (p=0.002-0. 015). Carcinoma cells in effusions showed in addition elevated levels of E-cadherin when compared with metastatic lesions (p<0.001). Staining results in effusions showed no association with effusion site, tumour type or histological grade. Immunoblotting on 29 malignant effusions confirmed the presence of all four proteins in the majority of samples and co-precipitation of E-cadherin and beta-catenin was seen in ten specimens examined. E-cadherin complex proteins are widely expressed in ovarian carcinoma cells. Together with calretinin, they form a powerful battery of markers for the cytological diagnosis of carcinoma cells in effusions. The up-regulation of E-cadherin complex proteins in serous effusions and metastatic lesions may mark an early metastatic phenotype and possibly mediates survival of tumour cells at these sites through the inhibition of apoptosis.

Ovarian carcinoma diagnosis

BACKGROUND

Ovarian carcinoma often is called the "silent killer" because the disease usually is not detected until an advanced stage. The authors' goal was to evaluate preoperative symptoms and factors that may contribute to delayed diagnosis for women with ovarian carcinoma.

METHODS

A two-page survey was distributed to 1500 women who subscribe to CONVERSATIONS!, a newsletter about ovarian carcinoma. Because the survey could be copied and given to other patients, 1725 surveys were returned from women in 46 states and 4 Canadian provinces.

RESULTS

The median age of the surveyed women was 52 years, and 70% had Stage III or IV disease (International Federation of Gynecology and Obstetrics). When asked about symptoms before the diagnosis of ovarian carcinoma, 95% reported symptoms, which were categorized as abdominal (77%), gastrointestinal (70%), pain (58%), constitutional (50%), urinary (34%), and pelvic (26%). Only 11% of women with Stage I/II and 3% with Stage III/IV reported no symptoms before their diagnosis. Women who ignored their symptoms were significantly more likely to be diagnosed with advanced disease compared with those who did not (P = 0.002). The time required for a health care provider to make the diagnosis was reported as less than 3 months by 55%, but greater than 6 months by 26% and greater than 1 year by 11%. Factors significantly associated with delay in diagnosis were omission of a pelvic exam at first visit; having a multitude of symptoms; being diagnosed initially with no problem, depression, stress, irritable bowel, or gastritis; not initially receiving an ultrasound, computed tomography, or CA 125 test; and younger age. The type of health care provider seen initially, insurance, and specific symptoms did not correlate with delayed diagnosis.

CONCLUSIONS

This large national survey confirms that the majority of women with ovarian carcinoma are symptomatic and frequently have delays in diagnosis.

Current strategies for prevention, detection, and treatment of ovarian cancer

OBJECTIVE

To review the prevalence, etiology, risk factors, diagnosis, and treatment of ovarian cancer.

DATA SOURCES

English-language journal articles retrieved from a MEDLINE search from 1990 to the present, and selected references retrieved from the bibliographies of those articles.

STUDY SELECTION

Clinical trials and pertinent review articles that discussed the detection, prevention, and clinical management of ovarian cancer.

DATA SYNTHESIS

Although relatively uncommon, ovarian cancer is the leading cause of mortality from gynecologic cancer. Because most ovarian cancers are not detected until the disease has metastasized beyond the ovary, the 5-year survival rate for all cases is only 50%. Pharmacists can educate women about strategies that can reduce ovarian cancer risk, especially the use of oral contraceptives. To aid in earlier detection, pharmacists also should be aware of the nonspecific symptoms that can be associated with the disease, and refer women with suggestive symptoms to their physicians for further evaluation. Treatment usually consists of hysterectomy with debulking surgery to remove as much tumor as possible, followed by chemotherapy, for which the current gold standard is cisplatin and paclitaxel.

CONCLUSION

Pharmacist-provided education can help women reduce their risk of ovarian cancer. As integral members of the health care team, pharmacists also can optimize the efficacy and tolerability of chemotherapeutic regimens; assist with palliative care for nausea, vomiting, and pain; and serve as a resource for patient information and support.

Diagnosis and treatment delay in gynecological malignancies. Does it affect outcome?

Delay of diagnosis and treatment of malignant tumors is perceived as unfavorably affecting outcome. However, tumor behavior may be determined early in the histogenesis process and the outcome may be more a function of the biologic properties of the tumor than of our ability to make an early diagnosis. The objective of the present review is to evaluate data concerning the effect of diagnosis and treatment delay on outcome in gynecological malignancies. A medline search including the terms diagnosis delay, treatment delay, outcome, vulvar carcinoma, cervical carcinoma, endometrial carcinoma and ovarian carcinoma was conducted and all pertinent articles in the English language were included. Relatively few investigations deal with the effect of diagnosis and treatment delay on prognostic factors and on outcome in invasive gynecological malignancies. The reviewed data do not seem to indicate an unequivocal deleterious effect of a delay of several weeks or even several months in patients with some gynecological malignancies. Intentional delay of diagnosis or treatment of gynecologic malignancies is unjustified; however, the data presented should encourage a closer scrutiny and possibly a revision of the concept of "early" diagnosis and of the notion that delay of any duration has a definite, unfavorable effect on outcome.