Rachel Spieldoch, MD
One of the most frightening gynecologic malignancies for women is ovarian cancer. While it only affects about 1.7% of the general population, once detected it is often lethal. Early detection of ovarian cancer remains an ongoing challenge for healthcare providers. Many women suffer from recurring ovarian cysts or a significant family history of gynecologic cancers. Even in today’s world of technology, it remains very difficult to screen and diagnose ovarian cancer. Ovarian masses are seen frequently in gynecology. While most represent benign disease, it is important not to miss the premalignant and malignant disease processes.
At this time, there is no “gold standard” screening test for ovarian cancer. Furthermore, symptoms associated with ovarian disease can be vague ranging from bloating or loss of appetite to pain and generalized malaise. There are several known risk factors for ovarian cancer. Age is the most important independent risk factor. The incidence and mortality increase sharply after menopause. The average age for an epithelial ovarian cancer is 60 years old. Up to 10% of ovarian cancers are associated with a genetic mutation such as BRCA1, BRCA2 and Lynch syndrome. Having a known genetic mutation can increase a woman’s risk by 10-45%. Without genetic testing, a strong family history is important for assessing risk. Other risk factors include women who have not had children, early onset of periods, and late menopause. Infertility also seems to have an association with increased risk.
Clinical history and physical exam are always instrumental in effective evaluation. Once this has been performed, pelvic ultrasound is most frequently used to evaluate uterine and adnexal structures. If a patient has been found to have a complex mass or concerning finding, 3D-ultrasound and/or MRI may be helpful. Gynecologic expertise in assessing ovarian masses in relation to clinical evaluation and radiologic findings are very important.
Several blood tests may also be helpful in evaluation. A serum CA-125 is the most widespread blood test used for assessing ovarian disease. However, CA-125 is far from a perfect screening test. The CA-125 is also expressed in many benign and normal female conditions, especially in a premenopausal female. There are many false positives with this test. Furthermore, the CA-125 is only elevated in 50% of early epithelial ovarian cancers and is not elevated at all with other types of less common ovarian malignancies. The OVA-1 test is another blood test which evaluates several serum protein markers that are elevated with ovarian cancer. This test is to be used in addition to complete evaluation for a woman with highly concerning lesions. Additionally, this test is very costly and should not be used for routine screening.
Thus, it remains important for the clinician to distinguish between low, intermediate and high risk ovarian masses. Often, serial repeat ultrasounds and CA-125 levels are used for evaluation of an ovarian mass over a given period of time. If there is interval change or other reasons for concern, surgical intervention may be indicated. Even for benign disease, surgical intervention may be indicated due to pain, mass size, interval growth, risks for ovarian torsion and cyst rupture. Please consult with your doctor if you are having new symptoms or radiologic findings suggestive of ovarian or adnexal disease.