Introduction:
Ovarian cancer is the fourth most frequently diagnosed cancer in women with a life-time risk estimated around 1:50. It is also the most common cause of death from gynaecological malignancy. The 5 years survival is around 90% in the first stage, with total survival for all stages estimated around 40%. As there is no established effective screening programme for ovarian cancer yet; 70% of ovarian cancer cases are diagnosed with an advanced stage.[1,3,4]
A prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS) that included more than 200,000 women; revealed an overall 20% mortality reduction in years 7–14, however, further follow-up is needed before firm conclusions can be reached on the efficacy and cost-effectiveness of ovarian cancer screening.[9]
The majority of ovarian cancers are epithelial and sporadic. Familial and genetic mutations account for around 10% of the cases; BRCA1,2 and HNPCC.[11] Women with BRCA1& BRCA2 genetic mutation have around 40%, 10-20% risk of developing ovarian cancer respectively.[11,12] Its recommended to offer risk reduction surgery to remove both ovaries after completion of family to reduce risk of developing ovarian cancer.
Risk factors of ovarian cancer include; Age with a peak incidence above 60 years, nulliparity, infertility (especially with the use of fertility drugs), and Endometriosis.[1,5]
Protective factors include; pregnancy and usage of combined hormonal contraception. Usage of combined pills for more than 10 years reduces the risk of ovarian cancer by 40%.[1,5]
Many years ago, ovarian cancer was thought to be a silent killer. However, most recent evidence revealed that ovarian cancer always gives symptoms, but healthcare professionals should listen carefully.[1,3] Symptoms of ovarian cancer include abdominal pain, bloating, change in bowel habit, urinary symptoms, and pelvic symptoms. Signs of ovarian cancer include abdominal mass/cyst, weight loss, and reduced appetite. Additionally, ovarian cancer can be diagnosed incidentally during routine investigation.[5]
Recognition of risk factors, symptoms and signs besides greater awareness among people and health care professionals are essential and has an important role in diagnosing ovarian cancer in a relatively early stages where the prognosis and survival is better.
Method :
75 ministry of health family medicine trainees and 75 final year medical students from Jordan university of science and technology participated in this study. Participants were given a case scenario about ovarian cancer and were asked to answer three questions.
The clinical Scenario:
A 60 year old, nulliparous lady, with history of 5 previous failed IVF cycles, diabetic on Metformin and diet,but otherwise normally fit and well. Presented to primary care with 3 months history of constant bloating, lower abdominal discomfort and altered bowel habits. Examination was limited due to body habitus, examination revealed raised BMI with no obvious palpable masses.
Q1. Based on risk factors and symptoms she is at risk of?
Q2. What is the next relevant investigation required in primary care setting?
Q3. If pelvic mass is palpable, the next most appropriate action is?
Answers:
Based on the patient’s age, risk factors and symptoms, the clinical scenario is in keeping with ovarian cancer. It is recommended, and crucial for the healthcare professionals to investigate and rule out ovarian cancer. The initial relevant investigations in a primary setting should be focused on testing for Tumour marker (CA125) followed by an urgent pelvic ultrasound for abnormal result. If a pelvic mass is identified during the examination, this should trigger an urgent suspected cancer referral to cancer unit.
One useful tool could be used to assess and triage women presented with ovarian cysts especially for post-menopausal women called Risk of Malignancy Index (RMI) Tables 1& 2.[1]
RMI can be calculated according to this formula. RMI= M (Menopausal status) XCA125X Ultrasound score.
M equal 1 for pre-menopausal women, 3 for post-menopausal women.
CA 125 is a surface antigen on a high molecular weight glycoprotein recognised by a monoclonal antibody (produced using an ovarian cancer cell line). It is most useful as a marker for non-mucinous ovarian epithelial cancer, and indeed is present in up to 80% of cases of advanced ovarian cancer.[4,5]
Ultrasound score will be calculated based on the cyst’s characteristics. Patients can be counselled and referred according to their cancer risk.[1,5]
Clinical scenario was given to participants, answers were collected on a spread sheet and analysed.