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Ovarian Cancer Screening

The majority of women with ovarian cancer are diagnosed after the disease has already developed into its more advanced, less treatable form. Yet in the approximately 20 percent of cases where ovarian cancer is diagnosed and treated early, there is a 93 percent survival rate. While this information would seem to suggest the need for improved screening for ovarian cancer, the current methods used to screen for the most common form of the disease produce too many false positive and false negative results to make them advisable for most women.

Nevertheless, screening may benefit those women who have a high risk of developing ovarian cancer due to a family history of breast or ovarian cancer or inherited defects in certain cancer-causing genes. Memorial Sloan-Kettering Cancer Center's newly released ovarian cancer screening guidelines provide some much needed guidance for women trying to determine if and when they should be screened.

"These guidelines represent a significant step forward in that they allow us to better tailor ovarian cancer risk-reduction strategies to a specific woman's individual level of risk," says Noah Kauff, Memorial Sloan-Kettering's Director of Ovarian Cancer Screening and Prevention.

Ovarian Cancer Risk Factor Categories

Traditionally, women at risk for ovarian cancer have been divided into one of two categories: those who are at or near the average risk of ovarian cancer (which is approximately one and one-half percent over a lifetime) and those who are at increased risk due to personal or family-related factors. Until recently, the increased risk group has included both women at slightly increased risk of ovarian cancer as well as women at vastly increased risk. Over the past several years, however, researchers at Memorial Sloan-Kettering and other institutions have been able to better characterize risk factors for ovarian cancer, allowing them to tailor ovarian cancer screening recommendations to an individual woman's actual level of risk.

Category One -- Near the Risk of the General Population

This category includes women whose risk level for developing ovarian cancer is considered near that of the general population. Women in this category have a lifetime risk of ovarian cancer that is less than approximately one in 20 (less than three times the lifetime risk of the average woman). Risk factors for women in this category include:

  • A history of infertility and/or use of assisted reproductive therapies, such as in vitro fertilization (IVF).
  • A history of endometriosis, a condition in which tissue from the lining of the uterus grows outside of the uterus.
  • A history of hormone replacement use for the management of symptoms related to menopause.
  • A personal history of breast cancer diagnosed after age 40 with no family history of breast or ovarian cancer.

Category Two -- Increased Risk

This category includes women whose lifetime risk of ovarian cancer falls between one in 20 and one in ten (approximately three to six times the lifetime risk of the average woman). Risk factors for women in this category include:

  • A first-degree relative (mother, sister, or daughter) diagnosed with ovarian cancer.
  • A personal history of breast cancer prior to age 40.
  • A personal history of breast cancer prior to age 50 and one or more close relatives with breast or ovarian cancer at any age.
  • Two or more close relatives diagnosed with breast cancer before age 50 or with ovarian cancer at any age.
  • Ashkenazi Jewish heritage (individuals of Eastern European Jewish descent) and a personal history of breast cancer prior to age 50.
  • Ashkenazi Jewish heritage and a first- or second-degree relative diagnosed with breast cancer before age 50 or with ovarian cancer at any age.

Category Three -- Inherited Risk

The final category includes women who have what is known as inherited risk due to identifiable genetic mutations. Women in this category have a lifetime risk of ovarian cancer that is greater than one in ten (more than six times the lifetime risk of the average woman). Risk factors in this category include:

  • The presence of a mutation in either the BRCA1 or BRCA2 genes. (BRCA1 and BRCA2 genes are involved in cell growth, division, and repair. Defects in these genes may increase the likelihood that certain cancers, including breast cancer and ovarian cancer, will develop.)
  • The presence of a mutation in the MLH1, MSH2, or MSH6 genes, which are genes associated with Hereditary Non-Polyposis Syndrome (HNPCC)/Lynch Syndrome. (HNPCC/Lynch Syndrome is a hereditary cancer syndrome caused by mutations in genes that are part of the DNA mismatch repair system. Theses mutated genes can lead to cancers of the colon, uterus, ovaries and urinary tract.)
“These guidelines represent a significant step forward in that they allow us to better tailor ovarian cancer risk-reduction strategies to a specific woman's individual level of risk.”
-- Noah D. Kauff, Director of Ovarian Cancer Screening and Prevention

Ovarian Cancer Screening Tests

The two most commonly used tests to screen for ovarian cancer are transvaginal ultrasound and the CA-125 blood test. Transvaginal ultrasound is an imaging test in which a special wand that emits sound waves is inserted into the vagina. The resulting images, known as sonograms, can reveal the presence of tumors in and around the ovaries. However, these screening tests are not without their limitations. Some ovarian tumors are too small for an ultrasound to detect, while other non-cancerous structures may be mistakenly identified as suspicious during ultrasound screening, requiring a patient to undergo further diagnostic testing. The CA-125 blood test measures the level of CA-125 protein in the bloodstream. CA-125 is a protein that some endometrial and ovarian cancer cells release into the bloodstream. Unfortunately, the CA-125 protein is also released by other, normal tissues, creating the potential for false positive test results.

Ovarian Cancer Screening Guidelines by Risk Category

For Women in Category One -- Near the Risk of the General Population

In clinical studies, existing ovarian cancer screening tests such as transvaginal ultrasound and CA-125 have not been shown to accurately and reliably identify early ovarian cancer in enough women to justify their cost and the number of false positive and false negative results they record. (Screening tests that produce false positive results can lead to unnecessary biopsies and surgery. False negative test results may cause women with ovarian cancer to ignore possible symptoms and avoid further screening.) Consequently, Memorial Sloan-Kettering doctors do not recommend that women with average or near average risk receive routine screening with these technologies in the absence of symptoms. Instead, an annual gynecologic examination, which includes a pelvic examination, is recommended. Additionally, if a woman develops symptoms of bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, or urinary symptoms (urgency or frequency) that occur daily and last for more than two to three weeks, she should consult a gynecologist.

For Women in Category Two -- Increased Risk

At present, there is no clear evidence that ovarian cancer screening using the currently available methods will result in an increased survival rate among women in this category.

If a woman in this category is screened for ovarian cancer using either the CA-125 test or transvaginal ultrasound, then our doctors recommend that it be conducted within the framework of a research study so as to evaluate its usefulness, and only after careful consideration of the risks and benefits of screening. Genetic counseling may also help women in this group to better clarify and understand their individual risk of ovarian cancer.

For Women in Category Three -- Inherited Risk

While it is not clear that ovarian cancer screening will result in fewer deaths for women in the inherited risk category, Memorial Sloan-Kettering physicians do recommend that these women undergo screening using a combination of transvaginal ultrasound and CA-125 testing. Women with mutations in BRCA1 or any of the genes associated with HNPCC/Lynch Syndrome should begin screening between the ages of 30 and 35. For women with mutations in BRCA2, ovarian screening should begin between the ages of 35 and 40.

Because of the potential for both false positive and false negative screening results produced by existing screening methods, and because of the substantial risks associated with such results, our doctors recommend that women in this inherited risk category consider having their ovaries and fallopian tubes surgically removed after the conclusion of their childbearing years. This preventive procedure is known as a risk-reducing salpingo-oophorectomy.

"While the majority of women should not participate in ovarian cancer screening or other ovarian cancer risk-reduction strategies, there are a number of options for women at increased risk," Dr. Kauff notes. "These include screening, use of medications that reduce the risk of ovarian cancer, and in select cases, prophylactic surgery. Experts in gynecologic cancer and cancer genetics can help determine if any of these approaches have a role for an individual woman."

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