Why Don’t We Screen More Women for Ovarian Cancer?

Pictured: Denis Chi

Dennis Chi, Deputy Chief of the Gynecology Service

Update: On February 13, 2018, the US Preventive Services Task Force (USPSTF) issued a report recommending against screening for ovarian cancer in women without signs or symptoms and women who are not known to be at high risk. This recommendation matches MSK’s position on screening. The report was published in the Journal of the American Medical Association.

Original post: Ovarian cancer is the tenth most common cancer found in women, and the fifth most common cause of cancer death. Only about 15 percent of ovarian cancers are detected at the earliest stage, when the cancer is still confined to the ovary and the disease is most likely to be curable.

For other cancers, including cancers of the breast, cervix, prostate, and colon and rectum, widespread screening approaches have been introduced and shown to increase the likelihood that these diseases are detected at an early stage. And a draft recommendation from a government advisory panel in late July 2013 stated that people who are at high risk for lung cancer should receive annual low-dose CT scans.

Yet finding reliable screening methods for early-stage ovarian cancer has been challenging. Memorial Sloan Kettering gynecologic surgeon Dennis Chi explains why.

Dr. Chi is Deputy Chief of the Gynecology Service, Director of the Fellowship Program for the Gynecology Service, and Co-Director of Pelvic Reconstructive Surgery in Memorial Sloan Kettering’s Department of Surgery.

Unreliable Tests

Dr. Chi says one reason that women of average risk are not screened for ovarian cancer is that current tests are not reliable or accurate enough, especially for early-stage disease.

Transvaginal ultrasound, in which an ultrasound probe is inserted into the vagina to allow a radiologist or technician to view the organs in the pelvic region, has been shown in studies to be a promising imaging method for routine screening of ovarian cancer.

Yet many early-stage cancers are not detected by transvaginal ultrasound, and the rate of false positives — abnormalities that upon further investigation are shown not to be cancer — is very high.

Another test that is currently in use is a blood test for the serum marker CA-125. This protein is elevated in 90 percent of advanced ovarian cancers, but only in 50 percent of patients with stage I cancer. “For early-stage disease, it’s essentially no better than a coin flip,” Dr. Chi says.

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Invasive Biopsies

If a woman is found to have an abnormality in a blood test or an ultrasound, performing a biopsy is more invasive than tests done when abnormalities are found on a mammogram or a Pap smear, Dr. Chi notes. “A needle biopsy of the breast or a colposcopy of the cervix can be done as a relatively simple office procedure,” he explains. “For a potential ovarian cancer, a major surgical procedure called a laparoscopy is required.”

Taking a biopsy of the ovary can lead to future infertility and other problems. “In addition,” Dr. Chi explains, “if you biopsy part of the ovary and it does contain cancer, you run the risk of spilling the cancer cells and spreading the cancer. Yet we don’t want to remove the entire ovary when the likelihood is high it does not contain cancer.”

For women who are at high risk of ovarian cancer because of mutations in the BRCA1 or BRCA2 genes or other family history, guidelines established by a team of Memorial Sloan Kettering experts do recommend such screenings, but for women in the general population, whose risk of ovarian cancer is about one in 70, Dr. Chi and others believe the risks greatly outweigh the potential benefits.

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A Focus on Early Detection

There is currently much research focused on ways to better detect ovarian cancer at an early stage. Many centers, including Memorial Sloan Kettering, are looking for biomarkers in the blood that are more accurate than CA-125 at indicating early-stage disease or even precancerous conditions.

Additionally, research in recent years has shed light on the possible origins of ovarian cancer. “Many studies have suggested that ovarian cancers may start in the fallopian tubes rather than the ovaries,” Dr. Chi explains. “If this hypothesis proves to be correct, it may allow us to develop better imaging methods and more-accurate screening tests.”

“One of the reasons it’s so hard to detect ovarian cancer at an early stage is because ovaries are inside your body where small lumps cannot be felt,” Dr. Chi says. Common symptoms of the disease — such as nausea, pelvic pressure, urinary or gastrointestinal symptoms, or pain — can be caused by many conditions that are not ovarian cancer.

“If you’ve had several of these symptoms together for a duration of time greater than a few months, it’s probably a good idea to see your gynecologist,” he concludes. “He or she may recommend an ultrasound or a CA-125 test or possibly a CT scan.”

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Commenting is disabled for this blog post.

Is there any news on research being done with dogs able to sniff out those elevated proteins?

Donna, we recommend you contact the National Cancer Institute to learn about research in the area of canine cancer detection. You can reach their cancer information service at 800-4CANCER or http://www.cancer.gov/aboutnci/cis. Thank you for your comment.

I had a hysterectomy at age 58 for uterine fibroids. I was still menstruating at that time. The surgeon recommended keeping my healthy ovaries. Now, 3 years later , I have several early warning signs of ovarian cancer. My gynecologist has retired, my surgeon doesn't accept my insurance anymore and the 2 doctors I have seen negated my concerns. Can I be evaluated at MSKCC for ovarian cancer?

I had a partial hysterectomy on 8/1/12. I was having pain on my left ovary. I went for an ultrasound and they found an 8 cm cyst on my right ovary. Is it possible that this formed after the surgery? Is it dangerous? Can it lead to ovarian cancer?

I was thinking perhaps making the transvaginal ultrasound part of the regular ob/gyn exam for all women. My thinking is that it would be at least some sort of screening that every woman would be able to have. If that indicated an abnormality then proceed to the CA-125 test. The argument for the lung screening study was that there would be too many false positives that would lead to too many biopsies, but the recommendation still advised that high risk individuals should have a low dose cat scan on a yearly basis.
I also think that there are symptoms of ovarian cancer like nausea, pelvic pressure, urinary and gastrointestinal problems. I think that reminding physicians to take these symptoms in women very seriously and not be dismissive. It is important if these symptoms are present to proceed to the next step of the transvaginal ultrasound in a timely manner. I think one of the problems is when the symptoms are not taken seriously.

I meant the argument against lung cancer screening.

This is a long overdue THANK YOU..... 36 years ago my ObGyn , while performing a laparoscopic tubal ligation, observed
something suspicious on my right ovary. He did a biopsy. Results from the hospital lab came back "inconclusive". My Doc sent the slides (or whatever), to his golf buddy, who happened to be the chief of pathology for the University Of California Medical Center In Sacramento, CA., for a second opinion. He reported back to my Doc that he too, read inconclusive findings. Unbeknown to me, He sent my tissue biopsy to Sloan Kettering, NYC.
About 3 monthes later my ObGyn called and wanted me to come in and see him. I said tell me why or I'll probably "kill" myself driving his office. He explained the process my tissue had gone through..... and then he said " the Sloan Kettering pathology team had identified one of the earliest cases of ovarian cancer they had seen at the time. - YEAH!
My Doc removed half an ovary - All evidence of cancer remove! He also advised
that he would do a laparoscopic procedure the following year, he advised Ovarian cancer was usually bi-lateral.
In that year, I did my homework. The night before that procedure, I told Frank Cook, my Doc., that I wanted to sign permission, that if it was found to take EVERYTHING (after all, I had already had a tubal ligation), all reproductive organs and cervix..... because I fully expected to be on synthetic hormones for the rest of my life!!! He laughed. - the surgery was done - the cancer had spread - He got it all!!! The first few months with the shift to synthetic hormones, I was pretty much..... ah, CRAZY! I leveled out and have been in nearly perfect health ever since! Oh, and I'm still on low dose estrogen, very big into healthy nutrition, preventive medicine, and all appropriate screenings.

Why, 36 years later this THANK YOU? - Frank Cook ObGyn /Trauma go to guy, died earlier this summer. He was my Doc for over 25 yrs, more importantly, we were friends for over 40.
His hunch started it, your institution confirmed it - finally, and based on that, his surgical skills gave me a very long life.
What were the odds back then ....., a 1/2% survival rate? thank you, thank you, thank you
Connie ("CJ") Romero (No response necessary)

Dear Ms. Romero, thank you for your comment…it’s good to hear that you are doing well!

Dr. Chi was my "2nd opinion" doc back in 2000. My Dr. Bruce Patsner performed partial excisions and lasered for vulvar cancer (in-situ) on 3 separate occasions. Dr. Chi was correct - he recommended stopping acid treatments on the vulva (thank you!) that Dr. Patsner was still performing on me and just doing the excision. Thank you doc! I'm still here!

I am currently on lynparza capsules 50 mg 8 pills in the morning and 8 pills in the evening. What is your opinion about this chemo drug.

Because every case is different, we are not able to offer opinions on an individual patient’s course of treatment. We recommend you discuss this with your healthcare team. Thank you for your comment.

I am 48 and have been experiencing bloating and feelings of fullness for about a year. After discussing my symptoms with my GYN she ordered abdominal and vaginal sonogram - both negative. She also ordered CA125. My result was 42. Higher normal limit is 36 for CA 125. Should I be alarmed. I am scheduled for another CA 125 in 4 weeks before further investigation is done. I need help, did I make the right decision ?

Dear Lisa, we are sorry to hear about your symptoms. You are doing the right thing by alerting your doctor and undergoing further examination and testing. We encourage you to continue to dialogue about your concerns with your physician, who may refer you to other specialists for additional follow up. Thank you for reaching out to us.

I had a CT scan 8 months after having a ultrasound the ct scan showed a grossly stable cyst andexl mass on my right overy I have cyst on my left overy also I have had ultrasounds an CA 125 test was normal I been to a couple ob/gyns a friend told me to see if I could come to Sloan to be checked her sister went there and was treated thank you

Is open conventional surgery the standard MSKCC approach for postmenopausal women with a newly developed complex ovarian cyst? I've had yearly transvaginal ultrasounds to monitor cysts. This year showed a change and surgery is recommended. Your input will be very much appreciated. Thank you for this service.

HI, we sent your comment to Dr. Chi, who responded, “Not necessarily. Depending on the size and character of the cyst, serum CA125 level, and other findings on scan, ovarian cysts can be followed or removed with minimally invasive surgery. In general, we perform open conventional surgery when the cyst is very large (> 10 cm) and/or there are other findings suspicious for malignancy.” If you’d like to arrange for a consultation at MSK, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment.