What Factors Influence Perception of Risk and Screening Behavior

Screening asymptomatic women at average risk of ovarian cancer with available methods transvaginal ultrasound and the CA-125 test has not been shown to be effective and is, therefore, not recommended. Clinical trials currently underway, however, may offer further insight. Such screening procedures, as well as genetic counseling, are recommended for women with a strong family history of cancer indicative of a hereditary genetic mutation, such as BRCA1 or BRCA2. Although the literature demonstrates a positive association between family history and screening behavior, several recent studies have found that women most likely to report high levels of perceived risk and high levels of screening for ovarian cancer were not women at highest risk. In addition, women at high risk for ovarian cancer may not be receiving recommended clinical evaluations. Gaining a comprehensive understanding of the role of risk perception in cancer screening adherence is a priority area for behavioral research in cancer prevention and control. Identifying and elucidating the processes by which women arrive at their perceptions of vulnerability to cancer can shed light on how they make decisions to undergo screening or engage in preventive behaviors. To examine the determinants of perceived risk and its influence on screening behaviors, DCPC is conducting a study of approximately 2000 women at average, elevated, and high risk who will be randomly selected from enrollees in a managed care organization with a racially diverse population. As part of the study, Risk Perception, Worry, and Use of Ovarian Cancer Screening among Women at Average, Elevated, and High Risk of Ovarian Cancer, women will be interviewed by telephone to collect information on family history of cancer, perceived risk, cancer worry, anxiety, personal experiences with cancer in family or friends, and intent to undergo screening or actual screening behavior. A 1-year follow-up telephone interview will be conducted to assess changes in perceived risk or family history of cancer and additional screening activity. The results of this investigation could have important implications for encouraging the appropriate use of screening and for informing educational and communication efforts to maximize screening effectiveness and minimize worry for women at average and elevated risk.

Patterns In The Diagnosis Of Ovarian Cancer

Delays in the diagnosis of ovarian cancer have been attributed to the absence of ovarian cancer symptoms or vague symptoms at an early stage, delays in careseeking among symptomatic women, and physician delays in considering ovarian cancer in the differential diagnosis. Early-stage symptoms may be subtle, seemingly unrelated, and not necessarily gynecological in nature, and a woman may undergo a number of medical tests before ovarian cancer is considered a possible diagnosis. The most common diagnostic pathways from first provider visit to diagnosis of ovarian cancer are not known and are likely to vary by age and risk factors related to the patient, the symptoms reported, the specialty of the physician initially consulted, and myriad other patient, provider, and healthcare setting characteristics. In addition, a substantial proportion of ovarian masses detected during diagnostic workup are benign. Aggressive follow-up of ovarian abnormalities to detect cancer must be balanced with appropriate assessment to reduce the number of women who undergo unnecessary diagnostic surgery. If surgery identifies ovarian cancer, the specialty of the attending surgeon can affect the quality of staging and tumor debulking procedures conducted and, ultimately, the disease-free survival time. To discover if such interventions as physician guidelines, educational materials, or other actions can significantly reduce the time to diagnosis, detect the cancer at earlier stages, or improve surgical evaluation, a great deal more information is needed about the symptoms reported and the current diagnostic process. A specific component in the diagnostic pathway is the management of ovarian masses, and DCPC is currently conducting a study, Clinical Practice in the Follow-Up of Ovarian Masses. This study will search for clinical findings that could be used by clinicians to more effectively differentiate between women with potentially malignant masses who require immediate surgery and women with benign abnormalities. Set in a managed care organization, the goals of the study are to investigate the symptoms or other conditions that lead to a diagnosis of an ovarian mass, the radiological characteristics of masses most likely to be malignant, and the diagnostic pathways commonly followed. Medical records, imaging studies, and surgical reports will be abstracted for a cohort of women aged 40 and older who have an ultrasound-identified ovarian mass. Data will be collected on mass characteristics, medical and family history, symptoms, findings, diagnoses, and related diagnostic tests and treatment. Researchers will assess the prevalence, characteristics, symptoms, and diagnostic management of benign vs. malignant ovarian masses.

Ovarian Cancer Surgery

Surgery is crucial in Ovarian Cancer treatment and should be performed by specialists. Primary treatment of Ovarian Cancer is largely surgery-based, and studies have shown that optimal surgery can significantly increase survival rates (37 vs 17 months) and complete response to chemotherapy (50% vs 20%). It is also reported that survival is dependent on
the expertise and degree of specialization of the surgeon, with a 25% improvement in 3-year survival among patients whose ovarian tumors are removed by a specialized gynecologist. Nevertheless, often times neither surgery nor staging are optimal, rendering the interpretation of some studies difficult. Chemotherapy is currently given after surgical resection of the tumor has been performed, and replacing surgery with chemotherapy is not recommended. However, several clinical trials based around new treatment strategies are currently underway, and these may well offer an alternative approach to therapy in the future.
Designing clinical trials of new drug combinations for OC is complicated by the great heterogeneity of patients with this disease. In 2004, the 3rd International OCCC made a number of recommendations regarding the extent of surgery for patients taking part in first-line chemotherapy trials. Staging should be performed according to FIGO guidelines. For example, this includes at least lymph node sampling and peritoneal staging in early-stage invasive disease (FIGO I–IIA). Up-front maximal surgical effort at cytoreduction with the goal of no residual disease should be undertaken. Conservative surgery should only be considered in
specific cases like well-differentiated (grade 1) stage IA, young patient with low parity, and ability for close follow-up. The role of cytoreductive surgery (CS) in recurrent ovarian cancer (ROC) has not been clearly defined.

Ovarian Cancer IP Chemotherapy

IP chemotherapy has yielded promising results when used in combination with standard IV therapy in the first-line setting for advanced ovarian cancer. Improvement in overall survival has been documented in prospective randomized controlled trials, with attainment of median OS of 66.9 months, the longest ever reported to date in advanced ovarian cancer patients. IP therapy was associated with increased toxicity and difficulty administering all scheduled doses, due to catheter complications and possibly due to the higher doses of cisplatin used IP. Catheter complications may be reduced if port-a-caths are used preferentially over Tenckhoff catheters, and are placed laparoscopically or under radiologic guidance, though prospective data are needed to definitively address these issues. Strategies to decrease chemotherapy related toxicities include the substitution of cisplatin with carboplatin or the use of cytoprotectants like amifostine. In addition, further evaluation for the use of IP carboplatin is necessary. Currently the GOG is conducting studies evaluating the feasibility of administering IP carboplatin with IV
paclitaxel (GOG 9917) and IP carboplatin with paclitaxel (IV and IP) or IP carboplatin, IP paclitaxel and IV docetaxel (GOG 9916). Due to the possible relationship between recent major abdominal surgery and administration of IP chemotherapy, it has been suggested that delaying IP chemotherapy until the second cycle may be better tolerated. Due to the clear advantage in OS, the use of IP chemotherapy needs to be strongly considered for patients with optimally
debulked ovarian cancer, despite the increased toxicity.

Advanced Ovarian Carcinoma

Advanced (FIGO stage III/IV) ovarian carcinoma is only occasionally curable at first presentation and is almost always incurable at relapse. Current standard first-line therapy involves treatment with a platinum agent (cisplatin or carboplatin) in combination with a taxane (paclitaxel or docetaxel) delivered on a 3-weekly cycle for six cycles. Patients optimally cytoreduced can expect a median progression-free survival of 22 months and a median overall survival of 57 months, whereas patients with residual tumor nodules .1 cm in diameter have correspondingly poorer figures for median progression-free survival and median overall survival of 18 and 36 months, respectively. No randomized trials of other intravenous cytotoxic regimens or schedules have demonstrated better survival data in the first-line setting,
although emerging data for intraperitoneal cisplatin–paclitaxel may change that paradigm. Ongoing or planned international randomized trials will integrate novel biologic agents such as inhibitors of angiogenesis (eg, the monoclonal antibody bevacizimab) or epidermal growth factor receptor tyrosine kinase inhibitors (eg, gefitinib, erlotinib) with conventional cytotoxics. The implication is that we may have reached a plateau in outcomes from conventional cytotoxic therapy in this disease.

Ovarian Cancer Chemotherapy

The current standard regimen for advanced ovarian cancer is paclitaxel (Taxol) and the platinum compound carboplatin. Alternatives are docetaxel (Taxotere) with carboplatin or paclitaxel with cisplatin, another platinum compound. Recent clinical trials found no difference in survival between patients receiving carboplatin with either docetaxel or paclitaxel, but the docetaxel/ carboplatin group had a greater incidence of myelosuppression. Those receiving paclitaxel/carboplatin had more neuropathy. Newer drugs being combined with carboplatin and paclitaxel are topotecan, liposomal doxorubicin, and gemcitabine.
The Gynecologic Oncology Group (GOG), a research group funded by the National Cancer Institute, is currently conducting a clinical trial for high-risk early-stage disease comparing three cycles of paclitaxel/carboplatin followed by surveillance versus paclitaxel alone weekly for 24 weeks. The GOG is also proposing a clinical trial on the use of carboplatin and paclitaxel combined
with bevacizumab to treat advanced ovarian cancer.

Categories of Ovarian Cancer

Three major categories of ovarian cancer have been identified: Epithelial cancers, arising from the cells lining or covering the ovaries, account for 90% of ovarian malignancies. Epithelial cancers are further classified as serous (most common), endometrioid, clear cell, mucinous, and poorly differentiated. Germ cell cancers start in cells destined to become ova. Stromal cell cancers start in the connective tissue cells that hold the ovaries together and produce female hormones.

Symptoms of Ovarian Cancer

Contrary to what you may have heard, ovarian cancer does present with signs and symptoms. Unfortunately, they can be so general—lower abdomen discomfort, dyspepsia, and early satiety, for example—that you dismiss them. The most important message I can convey is: Don't ignore any persistent symptoms. The classic pelvic examination—during which the clinician searches for palpable ovarian masses—is the starting point for a diagnosis of ovarian cancer. In premenopausal women, enlarged ovaries are common and usually are caused by ovarian cysts. The clinician usually follows the mass through several menstrual cycles.
In premenarchal children and adolescents and postmenopausal women, a palpable ovarian mass isn't normal and must be investigated with a CA-125 tumor antigen blood test and a transvaginal ultrasound. Color Doppler imaging studies also may be used to measure blood flow patterns to ovarian vessels. Increased blood flow resistance signals a mahgnancy. If these studies document an abnormality, the next step is a computed tomography scan of the abdomen and pelvis, possibly followed by a barium enema or a colonoscopy.
The CA-125 tumor antigen is associated with ovarian cancer. In fact, 80% or more of women with ovarian cancer have an elevated CA-125 level. The problem is that it's also elevated in some benign diseases and other malignancies as well, so it's not specific enough to detect the disease. The CA-125 tumor antigen has a role in indicating early treatment failure, confirmation of relapse, and in decision making during relapse therapy in ovarian cancer.

Ovarian Cancer and Tea

If you need one more reason to begin a habit of drinking tea, the results of a new Swedish study might just push you over the edge and into the tea aisle of your grocery or health food store. Susanna C. Larsson, MSc, and colleagues reported in the Archives of Internal Medicine that middle-aged women who drink two or more cups of green or black tea every day may reduce their risk for invasive epithelial ovarian cancer by almost half.

The Karolinska Institute researchers studied 61,057 women ages 40 to 76 who completed a diet questionnaire and were then tracked for an average of 15.1 years. Women who consumed two or more cups of tea per day lowered their risk for ovarian cancer by 46%, with each additional cup lowering the risk by another 18%. The study found that even enjoying a spot of tea only occasionally offered some benefit: Those who drank less than one cup daily still reduced their risk somewhat when compared with women who rarely or never drank tea.

Tea contains antioxidant polyphenols, substances thought to block cell damage that can lead to cancer. Jeffrey Blumberg, PhD, a professor in Tufts' Friedman School of Nutrition Science and Policy, notes that the antioxidant capacity per cup is similar between green and black tea. You can think of tea as another serving of plant food, providing phytochemicals similar to those in fruits and vegetables, Blumberg says.

The results in the Swedish study may not be entirely due to tea, however, Julie Buring, DSc, of Harvard's Brigham and Women's Hospital cautioned in an Associated Press report. She noted the study also found that women who drank tea tended to be in better health, thanks to lifestyle habits. Indeed, the study's authors acknowledged that "the women who were regular tea drinkers were also those who ate more fruits and vegetables, were slimmer, and generally more health-conscious."

Still, Larsson and her team concluded that the dose-response relationship for tea consumption with ovarian cancer risk makes a strong case for the preventive properties of tea.

Treating Ovarian Cancer With Ginger

Researchers at the University of Michigan Comprehensive Cancer Center, Ann Arbor, are currently investigating ginger as a treatment for ovarian cancer. Ginger is already known to be effective at controlling inflammation, and inflammation contributes to the development of ovarian cancer cells. The researcher’s suspect that by halting the inflammatory reaction, ginger could also stop cancer cells from growing. Laboratory studies have shown that ginger caused ovarian cancer cells to die. The way in which the cells died suggests the use of ginger may eliminate the problem of the cells becoming resistant to standard treatments.

Using a standardized research grade ginger powder dissolved in solution, the researchers applied ginger to ovarian cancer cell cultures. The ginger caused two types of cell death—apoptosis and autophagy, in which cells digest themselves— in all the ovarian cancer cell lines tested. "In multiple ovarian cancer cell lines, we found that ginger induced cell death at a similar or better rate than the platinum based chemotherapy drugs typically used to treat ovarian cancer," says Jennifer Rhode, MD, a gynecologic oncology fellow at the University of Michigan Medical School. While the study results are still very preliminary, the researchers, who presented their finding at the poster session at the American Association for Cancer Research annual meeting, plan to test whether they can obtain similar results in animal studies. The advantage of using ginger to treat ovarian cancer is that it could be administered in capsule form with virtually no side effects.

Stages of Ovarian Cancer

Stage 1: Tumor limited to the ovaries

IA , limited to one ovary, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsule intact

IB , limited to both ovaries, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsules intact

IC , limited to one or both ovaries, tumor on ovarian surface, capsule ruptured, ascites or peritoneal washings containing malignant cells

Stage 2: Tumor involving one or both ovaries with pelvic extension

IIA , extension or metastasis to the uterus or tubes, no malignant cells in ascites or peritoneal washings

IIB , extension to other pelvic tissues, no malignant cells in ascites or peritoneal washings

IIC , pelvic extension, ascites fluid or peritoneal washings containing malignant cells

Stage 3: Tumor involving one or both ovaries, peritoneal implants outside the pelvis or regional lymph node metastasis

IIIA , gross tumor limited to the true pelvis, negative nodes, microscopic peritoneal metastasis beyond the pelvis

IIIB , macroscopic peritoneal metastasis 2 cm or less in greatest dimension beyond the pelvis

IIIC , abdominal implants greater than 2 cm in greatest dimension or positive regional nodes

Stage 4: Tumor involving one or both ovaries, metastasis greater than 2 cm in greatest dimension beyond the pelvis. If pleural effusion is present, cytologic test results must be positive.

Parenchymal liver metastases equals stage 5.

Warning Signs of Ovarian Cancer

The major risk factors for ovarian cancer fall into three categories: hormonal, environmental, and genetic.

On the hormonal level, the risk may be directly related to the number of ovulatory cycles in a woman's life. The postulated theory is that the uninterrupted cell division and regeneration of the ovarian epithelium-without pregnancy-induced rest periods-may invite mutation and malignancy.

Therefore, women who've had no pregnancies are at an increased risk. Infertility also may be a risk factor because childless women who've been pregnant show the same risk as women who've never been pregnant. The risk for ovarian cancer peaks in the eighth decade of life.

We know less about links between environmental factors and ovarian cancer. Industrialized countries report the highest incidence; developing countries report the lowest incidence, but we don't low why. Lifestyle factors such as diet and exercise are being studied. Cosmetic use of talc in powders used to dust the perineum, in feminine hygiene sprays, and on sanitary napkins or condoms has been identified as a risk factor.

Nothing alters the magnitude of risk for ovarian cancer more than genetics. Hereditary ovarian cancer syndromes account for 5% to 10% of ovarian cancers. In general, the closer the degree of relative and the younger the relative at diagnosis, the higher the risk.

Research is ongoing in all these areas and continues to provide us with new information.

	Older then 40
	Postmenopausal
	White
	Celibate
	Nulliparous (having no children)
	Infertility problems
	Family history of ovarian, breast, colorectal, or endometrial cancer Inconclusive risk factors include a high fat diet, childhood diseases such as rubella and mumps, and exposure to such ovarian carcinogens as asbestos and talc.