VOL: 101, ISSUE: 11, PAGE NO: 28
Julie M. Winning, RGN, is lead Macmillan cancer nurse at the Gynaecological Cancer Centre, Birmingham Women's Hospital NHS Trust, BirminghamOvarian cancer is difficult to diagnose and manage. Meeting the needs of patients with the disease is a challenge in all care settings, from diagnosis to palliation, or more rarely, cure. Raising awareness and understanding of the disease and focusing on the importance of early detection may improve survival outcomes, which have remained relatively unchanged for three decades. WellBeing of Women, the research fundraising arm of the Royal College of Obstetricians and Gynaecologists, is running a campaign called 'Breaking the Silence', with events planned throughout March, to raise awareness about ovarian cancer (www.wellbeing.org.uk).
Ovarian cancer is difficult to diagnose and manage. Meeting the needs of patients with the disease is a challenge in all care settings, from diagnosis to palliation, or more rarely, cure. Raising awareness and understanding of the disease and focusing on the importance of early detection may improve survival outcomes, which have remained relatively unchanged for three decades. WellBeing of Women, the research fundraising arm of the Royal College of Obstetricians and Gynaecologists, is running a campaign called 'Breaking the Silence', with events planned throughout March, to raise awareness about ovarian cancer (www.wellbeing.org.uk).
Ovarian cancer is the most common gynaecological malignancy in England and Wales. It is the fourth most common cancer among women, with about 6,900 new cases diagnosed each year (Cancer Research UK, 2004). It is also the most common cause of cancer death, affecting about one in 70 women, with overall five-year survival rates of 30-40 per cent (Nguyen et al, 1993).
Ovarian tumours are classified according to the cell type of origin (surface epithelium, stroma or germ cells). Most malignant tumours (85-95 per cent) are epithelial in origin, with further subgroupings of histological types of serous, mucinous, endometrioid and clear cell.
Ovarian cancer is predominantly a disease of middle to old age (Fig 1). Seventy-five per cent of cases are diagnosed at International Federation of Gynaecological Oncology (FIGO) Stage III or IV (Nguyen et al, 1993). Vagueness of symptoms, lack of public awareness and a high percentage of late-stage diagnoses are the main factors associated with poor survival outcomes. However, although early detection and successful treatment continue to present health care challenges, there has been a definite, albeit modest, improvement in the overall outcome of treatment for the disease in the past 20 years (Kaye, 1999).
Signs and symptoms
Ovarian cancer is often called a 'silent killer'. Symptoms are often vague and attributed to more common conditions, therefore delaying diagnosis. Most reflect the effect of a tumour filling the pelvis and/or abdomen. Early stage disease will only physically show a mass in the pelvis, often an incidental finding on examination.
However, new evidence suggests that women with malignant masses typically experience symptoms 20 times per month and have significantly more symptoms of higher severity and more recent onset than women with benign masses (Goff et al, 2004). The same study suggests that symptoms that are more severe or frequent than expected and of recent onset warrant further diagnostic investigation because they are more likely to be associated with both benign and malignant ovarian masses. Symptoms may include:
- Abdominal distension and/or bloating;
- Pressure effects upon the bladder/rectum;
- Gastrointestinal symptoms (often of indigestion or mimicking irritable bowel syndrome);
- Abnormal vaginal bleeding (postmenopausal).
Patients often falsely believe that cervical smears help in disease diagnosis.
Risk factors for ovarian cancer
- Nulliparity/low parity - risk is higher in these combined groups of patients. The risk of developing the disease is reduced by 10-16 per cent for each pregnancy (Banks et al, 1997). Breastfeeding may further reduce the risks.
- Genetic predisposition - seven per cent of women diagnosed with ovarian cancer express a family history. With epithelial disease the figure rises to 10 per cent. Other genetic risks include inherited alterations in the genes BRCA 1 (on chromosome 17), BRCA 2 (on chromosome 13) and hereditary non-polyposis colorectal cancer (HNPCC/Lynch type-II variant).
- Oral contraceptive use - evidence suggests a significant reduction in risk associated with use of the combined oral contraceptive pill (COCP). Exposure to the COCP gives up to a 36 per cent reduction, and up to 70 per cent with extended use after six years. Women with a higher risk who use the COCP may reduce that risk by up to 60 per cent (Narod et al, 1998).
- Infertility - research on a link between infertility treatment and increased risk of ovarian cancer has been inconclusive. The likelihood is that any link is more an association with nulliparity or low parity than with ovulation and ovarian oncogenesis.
Screening for ovarian cancer
Screening currently comprises bi-manual clinical examination, history taking, transvaginal ultrasonography +/- doppler velocities, and monitoring of serum Ca-125 levels. These do not represent gold-standard screening methods, but a routine carried out in the absence of more clinically effective tools.
Routine screening, or screening for women thought to be at higher risk of ovarian cancer, is not currently recommended. The government will introduce screening as and when research shows it to be appropriate and cost-effective (Department of Health, 2000a). However, women who may be at higher risk should be offered referral to a cancer genetics clinic and a prophylactic oophorectomy if they wish. Two national ovarian cancer screening trials are under way.
The UK Familial Ovarian Cancer Screening Study (UKFOCSS) aims to recruit 5,000 women by the middle of 2005. Recruitment stands at about 30 per cent. Eligibility criteria are a family history of ovarian cancer confirmed by histopathology report or death certification, or a documented mutation of an ovarian cancer-causing gene. Individuals wishing to participate must be a first-degree relative of an affected member of a 'high-risk' family.
The UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) intends to recruit about 200,000 women. It aims to determine the efficacy of screening in a general population to detect early disease. Recruitment is by invitation of women aged 50-74, chosen randomly from health authority registers. Women who accept the invitation are then surveyed to check they meet the eligibility criteria.
Exclusions to the trial include:
- Bilateral oophorectomy;
- Currently active non-malignancy;
- Ovarian malignancy in the past;
- High risk of ovarian cancer due to familial disposition;
- Participation in other ovarian cancer screening trials.
Recruitment stands at about 80 per cent response to invitation with about 25 per cent entering into the trial (details of both trials are available at www.ncrn.org.uk).
Surgery and chemotherapy are the current standard treatments for ovarian cancer. Surgery is often the primary intervention. The aim of surgical intervention is to achieve an accurate diagnosis and assessment of disease extent and to eradicate or palliate disease either alone or as part of a multidisciplinary approach.
Evidence suggests the volume of disease remaining after primary surgery is related to patient survival. Various maximum residual disease criteria ranging from 0.5-2cm have been established (Davies, 2004). For advanced disease, the major independent prognostic factors seem to be the stage the disease has reached, and the residual tumour mass after surgery.
Epithelial ovarian cancer is a solid tumour whose chemosensitivity often provides the basis of good palliation and prolongation of life. Ovarian cancer is therefore moving towards being regarded as a chronic rather than an acutely life-threatening condition.
Data from the largest-ever international trial of chemotherapy treatments for ovarian cancer, ICON3 (International Collaborative Ovarian Neoplasm), suggested that treating women initially with standard chemotherapy drugs is as effective as adding the drug paclitaxel to those treatments, and causes fewer side-effects (Medical Research Council, 2002). A later study (ICON4) looking at the effect of a combination of paclitaxel and platinum chemotherapy versus conventional platinum-based chemotherapy drugs in women with relapsed ovarian cancer were more optimistic and indicated an increased survival rate of seven per cent.
The National Institute for Clinical Excellence currently recommends that paclitaxel in combination with a platinum-based compound, or platinum-based therapy alone (cisplatin or carboplatin) are offered as alternatives for first-line chemotherapy (usually following surgery) (NICE, 2003). (Additional NICE recommendations on treating recurrent ovarian cancer can be found at www.nice.org.uk).
The contribution of nursing
Nurses are key to the delivery of a comprehensive service for those affected by cancer. They are in an ideal position to spend time with people, providing them with balanced information and advice about ovarian cancer and other illnesses.
This shifts the emphasis of the nursing role from one of carer to advocate and health adviser, and raises awareness among those yet to be diagnosed.
- This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net