Ovarian cancer is disastrous. It’s an insidious cancer which typically presents with subtle symptoms but ultimately manifests with severe, widespread disease. For distal disease, ovarian cancer has a 5-year survival rate of only 25%.
I recently sat in a seminar where a clinician shared a case of ovarian cancer. She consulted a 49 year old lady who presented with change in bowel habits. She had a long history of IBS so the initial thought was whether her condition was due to this. She didn’t display any systemic symptoms and was managed with some dietary advice but soon returned with little to no resolution of her symptoms, this time seeing another clinician. The clinician ordered a whole host of test including a FIT test as well as blood tests. She sought to check the patients full blood count, liver and kidney function as well as her ca-125 which is certainly the right thing to do. All of this returned normal.
She then returned to see the original clinician with what she described was “bad constipation” and complained of bloating. She was examined and she had no abdominal pain and was prescribed some movicol. I guess it all make sense if one is thinking about constipation as a cause. Here the clinician presenting the case said “something was off, it all didn’t really fit.” The patient returned three weeks later and this time had abdominal distension while opening her bowels normally. She was examined and found to have considerable ascites but she was well otherwise. She had an ultrasound the next day and was found to have a large, complex lesion on her right ovary…
She had ovarian cancer.
Bloating, change in bowel habits and abdominal discomfort are such generalised symptoms that ovarian cancer, especially in a young patient isn’t always the first thought. However, the presentation highlighted some really useful take away points:
As good as Ca-125 is, it has its weaknesses. Ca-125 due to its nature as a cancer marker shows variable sensitivity, especially in early disease. It is released by overactive ovarian and uterine cells and can be raised in conditions such as fibroids and endometriosis. I guess that’s why we are recommended to use an ultrasound to confirm or deny any suspicions.
Interestingly in other parts of the world, clinicians are also able to order human epididymis protein 4 (HE4) which is released specifically by ovarian epidermal cells. You can read more about why a combination of both ca-125 and HE4 is best for diagnosing early ovarian cancer.
If you can, try and encourage patients to book with the same clinician if they have presented with a non-resolving problem. It allows the clinician to “follow the story” and make better informed decisions.
The sensitivity of ultrasound for ovarian pathology is approximately 89%. Even if a report does not mention a cyst, secondary findings should still prompt a referral such as “adnexal fluid”.
NICE have recently recommended genetic screening for ovarian cancer. Overtime we have established clearer links between breast and ovarian cancer and those with certain genotypes including BRCA1/2 will be illegible for genetic screening.
This was a really good teaching session with lots of points to take away. Ultimately, we’re not here to pick out mistakes in practice but instead to learn about what we lack by way of technology, investigations and practice and how we can better manage our patients.
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