The Annual Meeting on Women's Cancer, "Our Patients: Partners in Progress," was the 35th Annual Meeting of the Society of Gynecologic Oncologists and was jointly sponsored by the American College of Surgeons. Held in San Diego (February 7-11, 2004), the meeting focused on the ongoing need to improve methods for the diagnosis and treatment of gynecologic cancers. This report highlights research relating to the assessment of patient symptomatology and emerging diagnostic tools that may impact the therapeutic choices that patients and providers currently face.
Which signs and symptoms warrant further intervention in the diagnosis of ovarian malignancies and in the management of pelvic masses? For many clinicians, appropriately pursuing further workup and interventions on the basis of symptoms alone is often unclear. Ovarian cancer was once widely described as an asymptomatic condition, particularly at early stages of disease. In fact, a survey of thousands of women with ovarian cancer demonstrated that 95% of these women do have such symptoms as gastrointestinal distress and pain. Many symptoms are not specific and are nongynecologic, however, which makes the decision to intervene more complicated. The topic of when to initiate further workup of symptoms is relevant not only to gynecologists and primary care providers but to such specialists as gastroenterologists, for example, who may be required to further address gastrointestinal symptoms.
Dr. Barbara Goff and colleagues from University of Washington, Seattle, presented data from a case control study that evaluated the "frequency, severity and duration of symptoms" associated with ovarian cancer. The authors surveyed approximately 1700 women who visited primary care clinics and 129 women with malignant and benign pelvic masses. Up to 72% of women, including those in the clinic setting, experienced symptoms. However, a specific "constellation of symptoms" (abdominal bloating, increased abdominal size, and urinary urgency) was associated with ovarian cancer in comparison with benign gynecologic masses or other conditions such as irritable bowel syndrome. A higher frequency and intensity of symptoms also distinguished malignant from benign disease. Further validation of these criteria in a larger group of women is needed. Even so, this study alerts patients and providers to a group of particular and persistent symptoms that may be associated with ovarian cancer.
Dr. Heidi Donovan and coauthors from the University of Pittsburgh School of Nursing (Pittsburgh, Pennsylvania) conducted a survey of women with diagnosed ovarian cancer to assess how symptoms are communicated. The results revealed that only 61% of women, including those with active disease, reported symptoms to their providers. The authors suggested that in addition to inadequate patient reporting, healthcare providers may not be adequately discussing and documenting patient symptoms. Unfortunately, the authors did not detail the type of provider or patient most associated with their findings, and they did not evaluate the overall impact on disease status. Despite these limitations, this group illustrated possible gaps in communication and the need for improved levels of dialogue between women and their providers in identifying and managing symptoms of ovarian cancer.
Gynecologists often face clinical dilemmas in making preoperative assessments differentiating between benign and malignant pelvic masses. Indications for screening and referral are important in the potential early detection and in the management of ovarian cancer. These issues are critical to ensuring that women are referred appropriately to specialized care, particularly if the suspicion for ovarian cancer is high. That there is a survival benefit to women in the care of gynecologic oncologists is supported by the published work of Hoskins. Occult tumors may be missed if staging procedures are not performed appropriately. In 2002, the SGO and The American College of Obstetricians and Gynecologists (ACOG) established guidelines to assist clinicians in determining whom to refer.
The SGO/ACOG guidelines include age, CA125, physical findings and imaging, and family history. Dr. Im and colleagues from the Gynecologic Oncology Group Statistical Office in Buffalo, New York, evaluated these criteria for their predictive value. The authors studied 1034 premenopausal and postmenopausal women and found that, in both groups, the negative predictive value of the guidelines was high -- 92%. Interestingly, the positive predictive value of the guidelines, including family history, was low, due in part to the number of premenopausal women with benign masses.
Dr. Molly Brewer from the University of Arizona, Tucson, presented a review of the same database and found that the combination of abnormal ultrasonographic findings, the presence of ascites, and an elevated serum CA125 tumor marker seemed to have some diagnostic value. In addition, she reported that a CA125 level with a "cutoff" of 100 U/mL or greater was appropriate in distinguishing malignant masses from benign. This result is similar to previously published data from a prospective trial that showed that the relative risk of ovarian cancer was approximately 205 with CA124 values of greater than 100 U/mL. Both Im and Brewer demonstrated that the SGO/ACOG referral guidelines were suitable in determining basic criteria for establishing when to refer a woman with a pelvic mass to a specialist. Following such guidelines in combination with sound clinical judgment may improve the preoperative selection of patients who have benign vs malignant pelvic masses.
Currently, there is no routine screening tool for ovarian cancer in the general population. For high-risk women with family histories and documented hereditary gynecologic and breast cancers, risks and benefits of surveillance must be addressed with healthcare providers, including gynecologists, general surgeons, oncologists, and genetics counselors. Kauff and colleagues from Memorial Sloan-Kettering Cancer Center in New York City evaluated quality-of-life indices for women who are at increased risk of ovarian cancer and undergo heightened surveillance and screening. Among the 147 participants studied, there were high rates of abnormal screen results and procedures such as endometrial biopsies. However, no gynecologic cancers were detected. As illustrated by this report, in some cases, screening may increase interventions, but it may not affect overall survival or the disease process and may potentially cause psychological distress. Communication with appropriately trained personnel, such as genetics counselors, regarding the risks, benefits, and alternatives to screening, as well as the possible consequences of interventions, becomes paramount in such situations.
Several presentations, posters, and courses demonstrated the use of genomics and proteomics in the molecular profiling of gynecologic cancers. These emerging technologies are still in the early phases of development and have not yet been evaluated in large-scale studies. Until further validated, novel diagnostic testing should be viewed with caution. OvaCheck (Quest Diagnostics), one of the newest tests, was reported in The New York Times the week of the meeting and was a topic of discussion among participants. This test applies proteomic technology to identify serum markers of early ovarian cancer. Although it is now commercially available, OvaCheck has not been widely tested, and its potential use is restricted to those women who are at high risk for developing the disease. Despite the fact that methodologies such as this do not have a direct impact on current clinical care, the development and progress reported by several groups at the SGO meeting are promising signs that we may use these tools in the near future.
Medscape Ob/Gyn. 2004;9(1) © 2004 Medscape
Cite this: Highlights From the Society of Gynecologic Oncologists' Annual Meeting -- "Our Patients: Partners in Progress" - Medscape - Mar 15, 2004.