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Pictures Of Ovarian Cancer

She crowned herself "the Queen of Neurosis," but this time, it was not simply an overactive imagination that made her fear for her health. It was symptoms of the ovarian cancer that eventually claimed her life.

Gilda Radner, one of the original Not Ready for Prime Time Players of television's "Saturday Night Live," claimed in her book It's Always Something that she could get neurotic over any health problem. "I hated to be sick and I had an imagination that could turn a stomachache into the plague."

So, she wrote, when a complete physical examination in January 1986 failed to explain the overwhelming fatigue and general malaise she was feeling, she agreed with the doctor that her symptoms might just be from depression; she had, after all, been going through a rough period in both her personal and professional life. It wasn't until October 10 months and several symptoms, diagnoses, and failed therapies later--that cancer of the ovaries was confined.

Delay in diagnosing ovarian cancer is not unusual. Early detection is difficult because disease confined to the ovary sel- dom produces symptoms. And when symptoms do surface, they are often vague and easily mistaken for other, often minor, ailments.

Radner's cancer was not discovered until it had spread to her bowel and liver. She suffered from fatigue, low-grade fever, pelvic cramping, abdominal bloating, gas, and aches and pains in her upper thighs and legs. Loss of appetite and a feeling of fullness, indigestion, nausea, weight loss, and, less often, vaginal bleeding and low back pain are other symptoms.

As the tumor grows, it may press on the bowel and bladder, causing constipation and frequent urination. Malignant cells can break away from the tumor and spread directly to other organs in the abdomen, such as the stomach, colon and diaphragm (muscle separating the chest cavity from the abdomen), causing a fluid buildup that results in swelling and discomfort. The cells can also enter the bloodstream or lymph system and spread to other parts of the body.

Radner wrote that her complaints had been variously attributed to Epstein-Barr virus infection, depression, stress, and anxiety. She had undergone blood tests, a barium enema, and ultrasound (pelvic sonogram). According to Radner, the sonogram, done in the summer of 1986, showed "congestion" and the "ovanes weren't exactly in the place they were supposed to be, but that wasn't serious." There was no sign of tumor or obstruction.

Aspirin to Acupuncture

Attempting to combat her ills through both mainstream and holistic medicine, Radner tried remedies that ran the gamut from aspirin, anti-inflammatories and antidepressants to health foods, vitamins, acupuncture, and colonics (unconventional type enemas).

"Suddenly, I began to wonder how to please so many people," she wrote. "Do I take the magnesium citrate? What about the coffee enema? Do I do both? Do I do the abdominal massage or the colonic? Do I tell the doctors about each other?"

Then, late in October, an abnormal liver function test prompted more exams. A CAT scan and analysis of fluid from the abdomen confirmed ovarian cancer.

Diagnosed at age 40, Radner was younger than most women with the disease. The chance of developing ovarian cancer increases with age; most cases are found in women 55 to 75 years old. As was true with Radner, however, women with a family history of the disease generally are diagnosed at a younger age.

In 1991, an estimated 20,700 American women were diagnosed with ovarian cancer. It is most common in women living in Europe and North America; Asian women have a relatively low incidence. Although Chinese and Japanese women living in the United States have higher rates of ovarian cancer than their counterparts in Asia, the disease is still less common among this group than among the native white population in the United States. Rates among black women in all parts of the world are low.

Certain factors are associated with an increased risk of getting ovarian cancer.

Although the lifetime risk for most women is 1 in 70, it doubles for women who have never been pregnant and women who have had breast cancer.

Women with close relatives who have had ovarian cancer are also at greater risk, reaching perhaps a 1 out of 2 chance in women who have at least two first-degree relatives (mother, sister or daughter) with the disease. This compares with slightly higher than a 1 in 10 chance in women without a family history. Radner wrote that her mother had breast cancer and a cousin had both breast and ovarian cancer. Later, it was learned that other of her relatives had ovarian cancer as well.

The Familial Ovarian Cancer Registry, established in 1981 at Roswell Park Cancer Institute in Buffalo, N.Y., included 2,144 cases of ovarian cancer in 899 families as of April 1992. Despite the familial nature of some cases, familial ovarian cancer is estimated to account for only 5 to 10 percent of the total cases.

Evidence suggests that hormones may influence development of the disease. The risk of ovarian cancer is reduced in women who have had multiple pregnancies and in those who used birth control pills. The Cancer and Steroid Hormone Study by the national Centers for Disease Control and the National Institute of Child Health and Human Services found that use of oral contraceptives for even a few months reduced the risk of ovarian cancer by 40 percent in women 20 to 54 years old.

The study, published in the March 12, 1987, New England Journal of Medicine, found that the longer a woman used birth control pills, the lower her risk of ovarian cancer, and that the protective effect persisted long after stopping the pill. Based on these data, since 1989, the labeling for oral contraceptives has included decreased incidence of ovarian cancer among the non-contraceptive health benefits of the pill.

Search for a Screening Test

According to the registry, more than 90 percent of women diagnosed with ovarian cancer while it's still confined to the ovary are alive five years after diagnosis. Among women whose cancer has spread beyond the ovary by the time it' s diagnosed, only 25 percent survive five years. However, unlike cervical or breast cancer (which may be detected early by a Pap test or mammogram, respectively), ovarian cancer has no reliable screening test.

"The traditional routine pelvic examination, now relied on as the only screening measure available, is largely ineffective for early detection," says Grant Bagley, M.D., an obstetrician/gynecologist in the Food and Drug Administration's Office of Health Affairs. "Often you can't feel a normal-sized ovary. And even if you can, it's hard to tell if it's enlarged because ovaries vary in size from person to person and day to day. Ovarian cancers start very small, and by the time they' re large enough to feel, the cancer is most likely already advanced." The problem with ovarian cancer, he says, is that "you have to detect very small changes, and these are hard to detect on a pelvic exam because it's a very indirect examination."

Researchers are looking for tumor markers--substances that may appear in abnormal amounts in the blood or urine-- that may prove useful in developing a screening test.

One marker that has received much attention recently is CA 125, a substance in the blood that is elevated in patients with advanced ovarian tumors. Doctors now measure CA 125 levels in patients treated for advanced disease to determine if the tumor has shrunk or if disease has recurred. Its value in monitoring treatment prompted scientists tn study its potential for early detection.

Transvaginal ultrasound is also being studied as a screening tool. With ultrasound, high-frequency sound waves are projected into the body, and the echoes produced are converted by computer into a picture. Unlike abdominal ultrasound, in which the sound wave-emitting device is placed on the outside of the belly, transvaginal ultrasound uses a probe placed in the vagina that can reach within millimeters of the ovaries, producing more detailed images.

"There is uncertainty as to the value of these tools as screening tests and their ultimate impact on mortality ," says John Gohagan, Ph.D., chief of the National Cancer Institute' s Early Detection Branch in the Division of Cancer Prevention and Control. NCI is conducting a clinical trial including 74,000 women aged 60 to 74 tn clarify the issue. The trial is designed to assess the value of CA 125 and transvaginal ultrasound for early detection of ovarian cancer and to measure their impact on mortality.

Women in the trial are randomly assigned to either a screening group or a control group nf 37,000 women each. The screening group will have periodic pelvic examinations along with CA 125 and transvaginal ultrasound tests. The control group will have routine medical care.

Diagnostic Procedures

If a woman or her doctor suspects ovarian cancer, diagnosis begins with a medical history of the patient, review of her symptoms, and complete physical examination, including a pelvic exam, in which the physician feels the vagina, ovaries, fal1opian tubes, bladder, and rectum to check for any growths. A Pap test may also be done because, even though it cannot reliably detect ovarian cancer, it may detect cancer cells that have migrated to the uterine cervix from the ovaries.

Blood and urine tests may also be done, as well other procedures, depending on the woman's symptoms and results of her physical exam. These procedures include:

* abdominal or transvaginal ultrasound- helps distinguish fluid-filled cysts from a solid tumor.

* CAT scan- produces x-ray images of cross-sections of body tissues.

* lower GI series (barium enema)highlights the bowel on x-ray to detect abnormal areas that may be caused by ovarian cancer

* intravenous pyelogram (IVP)--produces x-ray pictures of the kidneys, bladder and ureters (tubes carrying urine from the kidneys to the bladder). Often, ovarian cysts or tumors can cause pressure on these organs, which may show up on an IVP.

The only sure way to diagnose ovarian cancer, however, is through microscopic examination by a pathologist of abnormallooking fluid or tissue. While fluid can sometimes be obtained by needle aspiration or other techniques, more commonly a laparatomy or laparoscopy is done.

Laparotomy is an exploratory operatioon in which the surgeon examines the abdomen thoroughly and removes fluid or tissue for examination. In laparascopy, a flexible, lighted tube is passed through a small incision in the abdomen, allowing the surgeon to examine the area and extract tissue for a biopsy.

If cancer is suspected, the surgeon usually removes the entire affected ovary to avoid cutting through the outer layer, which might cause the tumor to spread.

The tissue is sent to the pathologist for immediate evaluation, and if cancer is confirmed, the surgeon nearly always removes the second ovary, the uterus, and the fallopian tubes. Samples are taken of nearby lymph nodes, the diaphragm, the omentum (a fold of membranous lining in the abdominal cavity), and fluid from the abdomen to see whether the cancer has spread. If no fluid is found, several "washings" are taken; a saline solution is put into the abdomen and then removed to be examined for cancer cells. If there are suspicious lesions, tissue samples are also taken from the liver, small intestine, and large intestine.

The Ovaries-How They Work

The ovaries are located in the pelvis, one on each side of the uterus. About the size and shape of almonds, they are made up of several different cell types. Some carry out the functions of the organ, while others provide physical support. The ovaries have two main functions:

* ovulation (the release of an egg each month)

* production of estrogen and progesterone, hormones that regulate the menstrual cycle and pregnancy and control the development of female physical traits, such as the breasts, pelvic structure, fat distribution, and body hair.

From birth, the ovaries contain the cells that eventually become ova (eggs). Each month, beginning with puberty and until menopause, hormones produced by the pituitary gland in the brain stimulate ovulation (release of an egg), which alternates each month between the two ovaries. (Not all women ovulate every month).

The egg travels through the fallopian tube to the uterus. If it is fertilized, it may grow and develop in the womb. If not, hormone changes cause shedding of the uterine lining, and menstruation begins about two weeks later.

COPYRIGHT 1992 U.S. Government Printing Office
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