COMMENTARY

Overcome Challenges in Screening for Ovarian Cancer

Peter Kovacs, MD, PhD

Disclosures

November 06, 2013

Frequency and Disposition of Ovarian Abnormalities Followed With Serial Transvaginal Ultrasonography

Pavlik EJ, Ueland FR, Miller RW, et al
Obstet Gynecol. 2013;122:210-217

The Study

The incidence of ovarian cancer is 12.5 per 100,000 females. A woman has a 1 in 70 chance in her life to be diagnosed with an ovarian malignancy. The mean age at diagnosis is 63 years, and about 10% of the cancers are diagnosed in women younger than 45 years old. Survival is affected by the stage of the disease at diagnosis. The overall survival rate was 44.2% between 2003 and 2009. The survival rate, however, is close to 90% when the disease is confined to the ovary but only about 25% when the disease has already given metastasis.[1]

Advanced-stage cancer carries a poor prognosis, and unfortunately the majority of cases are already at stage III-IV at the time of detection. Therefore, researchers have spent the past few decades searching for effective screening tools, but because of the relatively low prevalence of the disease, even those screening tests that are associated with high sensitivity and specificity have a poor positive predictive value.[2]

Assessment of the individual's risk is based on reproductive factors, family background, symptom history, transvaginal ultrasound, and tumor markers. If needed, more expensive imaging studies can be considered as screening tools.

Certain ultrasound findings (increased ovarian volume, presence of septae, papillary projections, and increased flow) may all suggest malignancy. Elevated tumor markers (mainly CA 125) have been associated with epithelial cancers. This study assessed the benefits of serial transvaginal ultrasound in the management of adnexal masses as part of an ovarian cancer screening program.

Summary

The study group included 39,337 women who enrolled in the University of Kentucky Ovarian Cancer Screening Program. This report is based on those women who had an abnormal transvaginal scan during the study period between 1987 and 2012. Researchers enrolled women over the age of 50 years who did not have symptoms indicating ovarian pathology. They also enrolled asymptomatic women over the age of 25 years with a family history of ovarian cancer. The findings on transvaginal ultrasound were considered abnormal when the ovarian volume was enlarged and when cysts, septae, papillary protrusions, or solid areas were found. In cases of abnormal findings, a follow-up scan was arranged in 6 weeks to 6 months.

Surgery was recommended for cases in which the size of the ovary or the complexity of the structure increased during follow-up or if the patient developed clinical symptoms suggesting a possible malignancy.

Almost one fifth of the participants (6807) had an abnormal ultrasound at some point during the study period. About half of these patients had the abnormality picked up on the first scan. In two thirds of these cases, the follow-up scan did not find the abnormality anymore. The majority of the participants (80.9%) never had an abnormal scan.

Most abnormalities were found in premenopausal women, and they were mainly simple cysts or cysts with septae. Complex abnormalities (cysts with solid areas and solid cysts) were more likely to resolve during follow-up, and the time to resolution was significantly less when compared with simple cysts (8 weeks vs 55 weeks).

Among those operated on, 85 true positive malignancies and 472 benign adnexal masses were found (positive predictive value: 15.3%). The positive predictive value did change over time and with serial ultrasounds increased from 8% to 24.7%.

The authors concluded that for low-risk women, serial transvaginal ultrasound surveillance is an option and could reduce the number of surgeries performed for benign lesions that resolve on their own.

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