Symptoms associated with diagnosis of ovarian cancer: a systematic review

Time to Diagnosis and Treatment for Ovarian Cancer and Associations with Outcomes: A Systematic Review

Background: Ovarian cancer is commonly diagnosed symptomatically at an advanced stage. Better survival for early disease suggests improving diagnostic pathways may increase survival. This study examines literature assessing diagnostic intervals and their association with clinical and psychological outcomes. Methods: Medline, EMBASE, and EmCare databases were searched for studies including quantitative measures of at least one interval, published between January 1, 2000 and August 9, 2022. Interval measures and associations (interval, outcomes, analytic strategy) were synthesized. Risk of bias of association studies was assessed using the Aarhus Checklist and ROBINS-E tool. Results: In total, 65 papers (20 association studies) were included and 26 unique intervals were identified. Interval estimates varied widely and were impacted by summary statistic used (mean or median) and group focused on. Of Aarhus-defined intervals, patient (symptom to presentation, n = 23; range [median]: 7-168 days) and diagnostic (presentation to diagnosis, n = 22; range [median]: 7-270 days) were most common. Nineteen association studies examined survival or stage outcomes with most, including five low risk-of-bias studies, finding no association. Conclusions: Studies reporting intervals for ovarian cancer diagnosis are limited by inconsistent definitions and reporting. Greater utilization of the Aarhus statement to define intervals and appropriate analytic methods is needed to strengthen findings from future studies.

Molecular analysis for ovarian cancer detection in patient-friendly samples

BACKGROUND

High ovarian cancer mortality rates motivate the development of effective and patient-friendly diagnostics. Here, we explored the potential of molecular testing in patient-friendly samples for ovarian cancer detection.

METHODS

Home-collected urine, cervicovaginal self-samples, and clinician-taken cervical scrapes were prospectively collected from 54 patients diagnosed with a highly suspicious ovarian mass (benign n = 25, malignant n = 29). All samples were tested for nine methylation markers, using quantitative methylation-specific PCRs that were verified on ovarian tissue samples, and compared to non-paired patient-friendly samples of 110 age-matched healthy controls. Copy number analysis was performed on a subset of urine samples of ovarian cancer patients by shallow whole-genome sequencing.

RESULTS

Three methylation markers are significantly elevated in full void urine of ovarian cancer patients as compared to healthy controls (C2CD4D, P = 0.008; CDO1, P = 0.022; MAL, P = 0.008), of which two are also discriminatory in cervical scrapes (C2CD4D, P = 0.001; CDO1, P = 0.004). When comparing benign and malignant ovarian masses, GHSR shows significantly elevated methylation levels in the urine sediment of ovarian cancer patients (P = 0.024). Other methylation markers demonstrate comparably high methylation levels in benign and malignant ovarian masses. Cervicovaginal self-samples show no elevated methylation levels in patients with ovarian masses as compared to healthy controls. Copy number changes are identified in 4 out of 23 urine samples of ovarian cancer patients.

CONCLUSIONS

Our study reveals increased methylation levels of ovarian cancer-associated genes and copy number aberrations in the urine of ovarian cancer patients. Our findings support continued research into urine biomarkers for ovarian cancer detection and highlight the importance of including benign ovarian masses in future studies to develop a clinically useful test.

Adenocarcinoma of Mullerian Origin Found Through an Elective Inguinal Hernia Resection: A Case Report

We report an asymptomatic 59-year-old female undergoing an elective umbilical hernia excision who was found to have an ovarian adenocarcinoma within the excised hernia. Patients are rarely diagnosed with cancer after an umbilical hernia excision. An excised hernia is rarely the means for an initial diagnosis of cancer. We describe a case of an ovarian carcinoma incidentally found through an umbilical hernia excision with consequential treatment with neoadjuvant platinum-based chemotherapy followed by debulking surgery with a total hysterectomy with bilateral salpingo-oophorectomy with a transoperative pathology report of a high-grade serous carcinoma located in the left fimbrial frond surrounded by a background of serous tubal intraepithelial carcinomas. This case demonstrates the need to perform histological examinations of all excised hernias, even in asymptomatic patients, as malignancy can be found inside a hernia, and it emphasizes the importance of considering adenocarcinomas of Mullerian origin in the differential diagnosis of a malignancy found in a hernia in an asymptomatic female patient.

Genetic variants associated with post-traumatic stress symptoms in patients with gynecologic cancer

OBJECTIVE

Patients with cancer experience symptoms of post-traumatic stress disorder (PTSD) more commonly than the general population. The objective of this study was to identify single nucleotide polymorphisms (SNPs) associated with increased risk of post-traumatic stress disorder (PTSD) in patients with gynecologic cancer.

METHODS

A prospective cohort study recruited 181 gynecologic cancer survivors receiving care at the University of Minnesota between 2017 and 2020 who completed PTSD DSM-V surveys to self-report their symptoms of PTSD and provided saliva samples. DNA samples were genotyped for 11 SNPs in 9 genes involved in dopaminergic, serotonergic, and opioidergic systems previously associated with risk of PTSD in populations without cancer.

RESULTS

Most participants had either ovarian (42.5%) or endometrial (46.4%) cancer; fewer had cervical (7.7%) or vaginal/vulvar (3.3%) cancer. Two SNPS were identified as statistically significantly associated with higher PTSD scores: rs622337 in HTR2A and rs510769 in OPRM1.

CONCLUSIONS

Genetic variation likely plays a role in development of PTSD. HTR2A is involved in the serotonin pathway, and OPRM1 is involved in the opioid receptor pathway. This information can be used by oncologic providers to identify patients at greater risk of developing PTSD and may facilitate referral to appropriate consultants and resources early in their treatment.

Menopausal status, ultrasound and biomarker tests in combination for the diagnosis of ovarian cancer in symptomatic women

BACKGROUND

Ovarian cancer (OC) has the highest case fatality rate of all gynaecological cancers. Diagnostic delays are caused by non-specific symptoms. Existing systematic reviews have not comprehensively covered tests in current practice, not estimated accuracy separately in pre- and postmenopausal women, or used inappropriate meta-analytic methods.

OBJECTIVES

To establish the accuracy of combinations of menopausal status, ultrasound scan (USS) and biomarkers for the diagnosis of ovarian cancer in pre- and postmenopausal women and compare the accuracy of different test combinations.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), five other databases and three trial registries from 1991 to 2015 and MEDLINE (Ovid) and Embase (Ovid) form June 2015 to June 2019. We also searched conference proceedings from the European Society of Gynaecological Oncology, International Gynecologic Cancer Society, American Society of Clinical Oncology and Society of Gynecologic Oncology, ZETOC and Conference Proceedings Citation Index (Web of Knowledge). We searched reference lists of included studies and published systematic reviews.

SELECTION CRITERIA

We included cross-sectional diagnostic test accuracy studies evaluating single tests or comparing two or more tests, randomised trials comparing two or more tests, and studies validating multivariable models for the diagnosis of OC investigating test combinations, compared with a reference standard of histological confirmation or clinical follow-up in women with a pelvic mass (detected clinically or through USS) suspicious for OC.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed quality using QUADAS-2. We used the bivariate hierarchical model to indirectly compare tests at commonly reported thresholds in pre- and postmenopausal women separately. We indirectly compared tests across all thresholds and estimated sensitivity at fixed specificities of 80% and 90% by fitting hierarchical summary receiver operating characteristic (HSROC) models in pre- and postmenopausal women separately.

MAIN RESULTS

We included 59 studies (32,059 women, 9545 cases of OC). Two tests evaluated the accuracy of a combination of menopausal status and USS findings (IOTA Logistic Regression Model 2 (LR2) and the Assessment of Different NEoplasias in the adneXa model (ADNEX)); one test evaluated the accuracy of a combination of menopausal status, USS findings and serum biomarker CA125 (Risk of Malignancy Index (RMI)); and one test evaluated the accuracy of a combination of menopausal status and two serum biomarkers (CA125 and HE4) (Risk of Ovarian Malignancy Algorithm (ROMA)). Most studies were at high or unclear risk of bias in participant, reference standard, and flow and timing domains. All studies were in hospital settings. Prevalence was 16% (RMI, ROMA), 22% (LR2) and 27% (ADNEX) in premenopausal women and 38% (RMI), 45% (ROMA), 52% (LR2) and 55% (ADNEX) in postmenopausal women. The prevalence of OC in the studies was considerably higher than would be expected in symptomatic women presenting in community-based settings, or in women referred from the community to hospital with a suspicion of OC. Studies were at high or unclear applicability because presenting features were not reported, or USS was performed by experienced ultrasonographers for RMI, LR2 and ADNEX. The higher sensitivity and lower specificity observed in postmenopausal compared to premenopausal women across all index tests and at all thresholds may reflect highly selected patient cohorts in the included studies. In premenopausal women, ROMA at a threshold of 13.1 (± 2), LR2 at a threshold to achieve a post-test probability of OC of 10% and ADNEX (post-test probability 10%) demonstrated a higher sensitivity (ROMA: 77.4%, 95% CI 72.7% to 81.5%; LR2: 83.3%, 95% CI 74.7% to 89.5%; ADNEX: 95.5%, 95% CI 91.0% to 97.8%) compared to RMI (57.2%, 95% CI 50.3% to 63.8%). The specificity of ROMA and ADNEX were lower in premenopausal women (ROMA: 84.3%, 95% CI 81.2% to 87.0%; ADNEX: 77.8%, 95% CI 67.4% to 85.5%) compared to RMI 92.5% (95% CI 90.3% to 94.2%). The specificity of LR2 was comparable to RMI (90.4%, 95% CI 84.6% to 94.1%). In postmenopausal women, ROMA at a threshold of 27.7 (± 2), LR2 (post-test probability 10%) and ADNEX (post-test probability 10%) demonstrated a higher sensitivity (ROMA: 90.3%, 95% CI 87.5% to 92.6%; LR2: 94.8%, 95% CI 92.3% to 96.6%; ADNEX: 97.6%, 95% CI 95.6% to 98.7%) compared to RMI (78.4%, 95% CI 74.6% to 81.7%). Specificity of ROMA at a threshold of 27.7 (± 2) (81.5, 95% CI 76.5% to 85.5%) was comparable to RMI (85.4%, 95% CI 82.0% to 88.2%), whereas for LR2 (post-test probability 10%) and ADNEX (post-test probability 10%) specificity was lower (LR2: 60.6%, 95% CI 50.5% to 69.9%; ADNEX: 55.0%, 95% CI 42.8% to 66.6%).

AUTHORS' CONCLUSIONS

In specialist healthcare settings in both premenopausal and postmenopausal women, RMI has poor sensitivity. In premenopausal women, ROMA, LR2 and ADNEX offer better sensitivity (fewer missed cancers), but for ROMA and ADNEX this is off-set by a decrease in specificity and increase in false positives. In postmenopausal women, ROMA demonstrates a higher sensitivity and comparable specificity to RMI. ADNEX has the highest sensitivity in postmenopausal women, but reduced specificity. The prevalence of OC in included studies is representative of a highly selected referred population, rather than a population in whom referral is being considered. The comparative accuracy of tests observed here may not be transferable to non-specialist settings. Ultimately health systems need to balance accuracy and resource implications to identify the most suitable test.

Immunoprotecting Effects of Exercise Program against Ovarian Cancer: A Single-Blind, Randomized Controlled Trial

Exercise is known to help the immune function of cancer survivors after cancer cell removal, but there is little information about the effect of exercise on ovarian cancer survivors. We conducted this study to investigate the effects of exercise training on the physical fitness and innate immunity of ovarian cancer survivors (OCS). Twenty-seven OCS between forty-two and sixty-one years of age volunteered for this study. The participants were divided into a control group (COG, n = 15) and an exercise group (EXG, n = 12). The mean (SD) age was 51.07 (5.67) years, and the mean post-operation period was 45.96 (5.88) months. EXG participated in regular exercise training 6 days a week for 12 weeks. Body weight, fat mass, and body mass index of EXE were significantly decreased compared with those of COG. The muscle mass in EXE was increased compared to that of COG. Physical fitness factors showed positive changes in EXG compared to COG. We found that exercise training enhanced lymphocyte and neutrophil counts of leucocytes and total natural killer (NK) and natural killer T (NKT) cell counts of lymphocytes through improved body composition and physical fitness after 12 weeks. Moreover, we found that improved innate immune cells through the exercise program were achieved through an increase in NKG2D+NK receptors and a decrease in KIR2DL3+NK receptors in OCS.

Ovarian tumor frozen section, a multidisciplinary affair

BACKGROUND

Ovarian Cancer (OC) constitute the eighth most common cancers among women worldwide. Surgery remains the cornerstone in the management of OC. Intraoperative frozen section (FS) diagnosis is widely used to decide the surgery course. We aimed to assess the reliability of intraoperative FS diagnosis for treatment planning of patients with suspected OC from a multidisciplinary perspective. The clinical consequences of reclassification and the multidisciplinary management of the therapy plan, is the secondary aim of this study. To our knowledge, this information is sparely investigated.

METHODS

A single-center, retrospective population-based study of patients who underwent surgery for suspected OC between 2018 and 2020. Histopathological outcomes were classified as benign, borderline, or malignant. The FS diagnosis was the diagnostic test, and the final histopathology report was the gold standard. Diagnostic capability for treatment planning was assessed, and modifications made possible by overall clinical knowledge were discussed.

RESULTS

A total of 358 patients were identified, of whom 187 were included in the FS group. Overall accuracy was 89.8%, and 19 patients were reclassified; the malignancy grade of 15 tumors was underestimated. Prevalence, sensitivity, specificity, positive predictive value, and negative predictive value for invasive malignancies on FS were 54.0% (CI 46.6-61.3%), 88.1% (CI 80.2-93.7%), 98.8% (CI 93.7-99.9%), 98.9% (CI 92.7-99.8%), and 87.6% (CI 80.6-92.4%), respectively. Tumors incorrectly graded by FS tended to be of borderline-related.

CONCLUSIONS

The reliability of the FS methodology was an accurate test to help perform appropriate surgery and plan swift oncological treatment. FS is a reliable method to diagnose invasive malignancies and benign pathology. The communication between the pathologist, surgeon, and medical oncologist is highly important for both intraoperative decision-making and postoperative patient care.

Symptoms of Women With High-Risk Early-Stage Ovarian Cancer

OBJECTIVE

To assess the presentation, characteristics, and prognostic significance of symptoms in patients with high-risk early-stage epithelial ovarian cancer.

METHODS

A retrospective chart review was performed on all patients enrolled in a phase III clinical trial (GOG 157). All patients had surgically staged, high-risk early-stage epithelial ovarian cancer (stage IA-IB and grade 3, any clear cell, stage IC or II). Chi-square and Kaplan-Meier estimates and Cox proportional hazards models were used for statistical analyses.

RESULTS

Of 419 patients evaluated for symptoms, 301 (72%) presented with one or more symptoms, and 118 (28%) were asymptomatic but had a mass found on examination. Forty percent had only one symptom, and 32% had more than one symptom. Among those with at least one symptom, the most common were abdominal and pelvic pain (31%), and increased girth or fullness (26%). Overall, 23% of patients with tumors 10 cm or smaller, 27% of patients with tumors larger than 10 cm to 15 cm, and 46% of patients with tumors larger than 15 cm had multiple symptoms (P<.001). There was no significant difference in presentation of symptoms based on age, stage, or histologic subtype. Symptoms at diagnosis were not associated with recurrence or survival.

CONCLUSION

More than 70% of patients with high-risk early-stage, epithelial ovarian cancer present with one or more symptoms, with the most common being abdominal or pelvic pain. The proportion of women with symptoms and the number of symptoms increase with enlarging tumor size.

Cancer of the ovary, fallopian tube, and peritoneum: 2021 update

In 2014, FIGO's Committee for Gynecologic Oncology revised the staging of ovarian cancer, incorporating ovarian, fallopian tube, and peritoneal cancer into the same system. Most of these malignancies are high-grade serous carcinomas (HGSC). Stage IC is now divided into three categories: IC1 (surgical spill); IC2 (capsule ruptured before surgery or tumor on ovarian or fallopian tube surface); and IC3 (malignant cells in the ascites or peritoneal washings). The updated staging includes a revision of Stage IIIC based on spread to the retroperitoneal lymph nodes alone without intraperitoneal dissemination. This category is now subdivided into IIIA1(i) (metastasis ≤10 mm in greatest dimension), and IIIA1(ii) (metastasis >10 mm in greatest dimension). Stage IIIA2 is now "microscopic extrapelvic peritoneal involvement with or without positive retroperitoneal lymph node" metastasis. This review summarizes the genetics, surgical management, chemotherapy, and targeted therapies for epithelial cancers, and the treatment of ovarian germ cell and stromal malignancies.

Guideline No. 403: Initial Investigation and Management of Adnexal Masses

OBJECTIVES

To aid primary care physicians, emergency medicine physicians, and gynaecologists in the initial investigation of adnexal masses, defined as lumps that appear near the uterus or in or around ovaries, fallopian tubes, or surrounding connective tissue, and to outline recommendations for identifying women who would benefit from a referral to a gynaecologic oncologist for further management.

INTENDED USERS

Gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists, radiologists, sonographers, nurses, medical learners, residents, and fellows.

TARGET POPULATION

Adult women 18 years of age and older presenting for the evaluation of an adnexal mass.

OPTIONS

Women with adnexal masses should be assessed for personal risk factors, history, and physical findings. Initial evaluation should also include imaging and laboratory testing to triage women for management of their care either by a gynaecologic oncologist or as per SOGC guideline no. 404 on the initial investigation and management of benign ovarian masses.

EVIDENCE

A search of PubMed, Cochrane Wiley, and the Cochrane systematic reviews was conducted in January 2018 for English-language materials involving human subjects published since 2000 using three sets of terms: (i) ovarian cancer, ovarian carcinoma, adnexal disease, ovarian neoplasm, adnexal mass, fallopian tube disease, fallopian tube neoplasm, ovarian cyst, and ovarian tumour; (ii) the above terms in combination with predict neoplasm staging, follow-up, and staging; and (iii) the above two sets of terms in combination with ultrasound, tumour marker, CA 125, CEA, CA19-9, HE4, multivariable-index-assay, risk-of-ovarian-malignancy-algorithm, risk-of-malignancy-index, diagnostic imaging, CT, MRI, and PET. Relevant evidence was selected for inclusion in descending order of quality of evidence as follows: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional articles were identified through cross-referencing the identified reviews. The total number of studies identified was 2350, with 59 being included in this review.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework (Table A1 of Online Appendix A). See Table A2 of Online Appendix A for the interpretation of strong and weak recommendations. The summary of findings is available upon request.

BENEFITS, HARMS, COSTS

Adnexal masses are common, and guidelines on how to triage them and manage the care of patients presenting with adnexal masses will continue to guide the practice of primary care providers and gynaecologists. Ovarian cancer outcomes are improved when initial surgery is performed by a gynaecologic oncologist, likely as a result of complete surgical staging and optimal cytoreduction. Given these superior outcomes, guidelines to assist in the triage of adnexal masses and the referral and management of the care of patients with an adnexal mass are critical.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

A multidisciplinary approach remains the best strategy to improve and strengthen the management of ovarian cancer (Review)

Ovarian cancer represents one of the most aggressive female tumors worldwide. Over the decades, the therapeutic options for the treatment of ovarian cancer have been improved significantly through the advancement of surgical techniques as well as the availability of novel effective drugs able to extend the life expectancy of patients. However, due to its clinical, biological and molecular complexity, ovarian cancer is still considered one of the most difficult tumors to manage. In this context, several studies have highlighted how a multidisciplinary approach to this pathology improves the prognosis and survival of patients with ovarian cancer. On these bases, the aim of the present review is to present recent advantages in the diagnosis, staging and treatment of ovarian cancer highlighting the benefits of a patient‑centered care approach and on the importance of a multidisciplinary team for the management of ovarian cancer.

Sonic Hedgehog signaling pathway in gynecological and genitourinary cancer (Review)

Cancers of the urinary tract, as well as those of the female and male reproductive systems, account for a large percentage of malignancies worldwide. Mortality is frequently affected by late diagnosis or therapeutic difficulties. The Sonic Hedgehog (SHH) pathway is an evolutionary conserved molecular cascade, which is mainly associated with the development of the central nervous system in fetal life. The present review aimed to provide an in‑depth summary of the SHH signaling pathway, including the characterization of its major components, the mechanism of its upstream regulation and non‑canonical activation, as well as its interactions with other cellular pathways. In addition, the three possible mechanisms of the cellular SHH cascade in cancer tissue are discussed. The aim of the present review was to summarize significant findings with regards to the expression of the SHH pathway components in kidney, bladder, ovarian, cervical and prostate cancer. Reports associated with common deficits and de‑regulations of the SHH pathway were summarized, despite the differences in molecular and histological patterns among these malignancies. However, currently, neither are SHH pathway elements included in panels of prognostic/therapeutic molecular patterns in any of the discussed cancers, nor have the drugs targeting SMO or GLIs been approved for therapy. The findings of the present review may support future studies on the treatment of and/or molecular targets for gynecological and genitourinary cancers.

Targeting eukaryotic elongation factor-2 kinase suppresses the growth and peritoneal metastasis of ovarian cancer

Ovarian cancer (OC) is the deadliest gynecological cancer and is currently incurable with standard treatment regimens. Early invasion, intraperitoneal metastasis, and an aggressive course are the hallmarks of OC. The major reason for poor prognosis is a lack of molecular targets and highly effective targeted therapies. Therefore, identification of novel molecular targets and therapeutic strategies is urgently needed to improve OC survival. Herein we report that eukaryotic elongation factor-2 kinase (EF2K) is highly upregulated in primary and drug-resistant OC cells and its expresssion associated with progression free survival TCGA database) and promotes cell proliferation, survival, and invasion. Downregulation of EF2K reduced expression of integrin β1 and cyclin D1 and the activity of the Src, phosphoinositide 3-kinase/AKT, and nuclear factor-κB signaling pathways. Also, in vivo, therapeutic targeting of EF2K by using single-lipid nanoparticles containing siRNA led to substantial inhibition of ovarian tumor growth and peritoneal metastasis in nude mouse models. Furthermore, EF2K inhibition led to robust apoptosis and markedly reduced intratumoral proliferation in vivo in ovarian tumor xenografts and intraperitoneal metastatic models. Collectively, our data suggest for the first time that EF2K plays an important role in OC growth, metastasis, and progression and may serve as a novel therapeutic target in OCs.

Isolated lymph node recurrence in epithelial ovarian cancer: Recurrence with better prognosis?

INTRODUCTION

The aim of this study was to compare overall survival (OS) between women with isolated lymph node recurrence (ILNR) and those with isolated peritoneal localization of recurrence (ICR), in patients managed for epithelial ovarian cancer.

METHODS

Data from 1508 patients with ovarian cancer were collected retrospectively from1 January 2000 to 31 December 2016, from the FRANCOGYN database, pooling data from 11 centres specialized in ovary treatment. Median overall survival was determined using the Kaplan-Meier method. Univariate and multivariate analyses were performed to define prognostic factors of overall survival. Patients included had a first recurrence defined as ILNR or ICR during their follow up.

RESULTS

79 patients (5.2 %) presented with ILNR, and 247 (16.4 %) patients had isolated carcinomatosis recurrence. Complete lymphadenectomy was performed more frequently in the ILNR group vs. the ICR group (67.1 % vs. 53.4 %, p = 0.004) and the number of pelvic lymph nodes involved was higher (2.4 vs. 1.1, p = 0.008). The number of involved pelvic LN was an independent predictor of ILNR (OR = 1.231, 95 % CI [1.074-1.412], p = 0.0024). The 3-year and 5-year OS rates in the ILNR group were 85.2 % and 53.7 % respectively, compared to 68.1 % and 46.8 % in patients with ICR. There was no significant difference in terms of OS after initial diagnosis (p = 0.18). 3- year and 5-year OS rates after diagnosis of recurrence were 62.6 % and 15.6 % in the ILNR group, and 44 % and 15.7 % in patients with ICR (p = 0.21).

CONCLUSION

ILNR does not seem to be associated with a better prognosis in terms of OS.

Evaluation of adnexal tumours in the International Ovarian Tumor Analysis system in reference to histopathological results

Aim of the study

To retrospectively evaluate how the International Ovarian Tumor Analysis (IOTA) simple rules used in ultrasound examinations estimate the probability of malignant and benign tumour occurrence in the studied population.

Material and methods

The study was performed on a group of 425 patients with ovarian tumours operated in the Clinic of Surgical and Oncological Gynecology at the Medical University of Lodz in the years 2014-2015. Adnexal tumours were rated according to IOTA simple rules, classifying them as probably malignant, probably benign, or unclassified. The results of the study were compared with final histopathological results. The statistical analysis was performed using STATISTICA 13 PL with Medical Pack.

Results

We analysed data on n = 43 (11%) patients with malignant, n = 346 (86%) patients with benign, and n = 12 (3%) patients with borderline tumours, respectively. Malignant tumour patients were significantly older (mean age 61.0 ±11.6 vs. 43.6 ±16.2 years, p< 0.001), had higher BMI (mean 27.3 ±7.0 vs. 25.2 ±5.2, p< 0.05), more pregnancies (median 2 vs. 1, p = 0.001), and higher cancer antigen 125 (CA 125) concentrations (median 251.5 vs. 18.5, p< 0.001) than patients with a benign tumour. Also, they more often suffered from diabetes mellitus (19% vs. 8%, p = 0.02) and arterial hypertension (60% vs. 42%, p< 0.01) than benign tumour patients.

Conclusions

In our study, IOTA performance in predicting or ruling out a malignant tumour was highly satisfactory and similar to that of CA 125. Both the methods may be complementary and used to assess the risk of malignant vs. benign ovarian neoplasm, although the context of other clinical variables may also be important.

The Abnormal Ovary: Evolving Concepts in Diagnosis and Management

Ovarian lesions are common and require a consistent approach to diagnosis and management for best patient outcomes. In the past 20 years, there has been an evolution in the approach to abnormal ovarian lesions, with increasing emphasis on reducing surgery for benign disease, standardizing terminology, assessing risk of malignancy through use of evidence-based scoring systems, and triaging suspicious abnormalities to dedicated oncology centers. This article provides an evidence-based review of how these changes in diagnosis and management of ultrasound-detected abnormal ovarian lesions have occurred. Current recommended practices are summarized. The current literature on transvaginal screening for ovarian cancer also is reviewed and summarized.

Variation in the initial assessment and investigation for ovarian cancer in symptomatic women: a systematic review of international guidelines

Background

Women with ovarian cancer can present with a variety of symptoms and signs, and an increasing range of tests are available for their investigation. A number of international guidelines provide advice for the initial assessment of possible ovarian cancer in symptomatic women. We systematically identified and reviewed the consistency and quality of these documents.

Methods

MEDLINE, Embase, guideline-specific databases and professional organisation websites were searched in March 2018 for relevant clinical guidelines, consensus statements and clinical pathways, produced by professional or governmental bodies. Two reviewers independently extracted data and appraised documents using the Appraisal for Guidelines and Research Evaluation 2 (AGREEII) tool.

Results

Eighteen documents from 11 countries in six languages met selection criteria. Methodological quality varied with two guidance documents achieving an AGREEII score ≥ 50% in all six domains and 10 documents scoring ≥50% for “Rigour of development” (range: 7–96%). All guidance documents provided advice on possible symptoms of ovarian cancer, although the number of symptoms included in documents ranged from four to 14 with only one symptom (bloating/abdominal distension/increased abdominal size) appearing in all documents. Fourteen documents provided advice on physical examinations but varied in both the examinations they recommended and the physical signs they included. Fifteen documents provided recommendations on initial investigations. Transabdominal/transvaginal ultrasound and the serum biomarker CA125 were the most widely advocated initial tests. Five distinct testing strategies were identified based on the number of tests and the order of testing advocated: ‘single test’, ‘dual testing’, ‘sequential testing’, ‘multiple testing options’ and ‘no testing’.

Conclusions

Recommendations on the initial assessment and investigation for ovarian cancer in symptomatic women vary considerably between international guidance documents. This variation could contribute to differences in the way symptomatic women are assessed and investigated between countries. Greater research is needed to evaluate the assessment and testing approaches advocated by different guidelines and their impact on ovarian cancer detection.

Role of cancer-associated fibroblasts in tumor structure, composition and the microenvironment in ovarian cancer

Ovarian cancer (OVAC) remains the most lethal gynecological malignancy; it is ranked fifth among the most common types of cancer that affect women worldwide. Several aspects of the disease, including molecular pathogenesis, epidemiology, histological subtypes, poor prognosis at early stages due to the absence of specific signs and symptoms, and curative treatments in the advanced stages are all responsible for the poor survival rate, which is evaluated to be at 5 years once the cancer is diagnosed and treatment begins. A better understanding of the pathogenesis of ovarian cancer is therefore crucial, even though unexplored pathways, in order to improve the prognosis of patients with OVAC and to develop novel therapeutic approaches. Accordingly, the tumor microenvironment, defined as the combination of proteins produced by all tumor cells and by non-cancerous cells or the stroma, and composed of several cells, including those from the immune, inflammatory and adipose systems, as well as the mesenchymal stem, endothelial and fibroblasts cells, has recently attracted attention. Of particular interest are fibroblasts, which can be activated into cancer-associated fibroblast (CAFs) to become a potent supporter of carcinogenesis, promoting the initiation of epithelial tumor formation, tumor growth, angiogenesis and metastasis, as well as therapeutic resistance and immunosuppression. Thus, the targeting of CAFs for early diagnosis and effective therapy warrants our attention. In this review, we discuss the mechanisms through which CAFs may affect the structure, composition and microenvironment of the ovarian tumor. We also aim to highlight important aspects of OVAC pathobiology involving CAFs, in an attempt to provide insight into novel diagnostic windows and provide new therapeutic perspectives.

Cancer Pain Assessment and Classification

More than half of patients affected by cancer experience pain of moderate-to-severe intensity, often in multiple sites, and of different etiologies and underlying mechanisms. The heterogeneity of pain mechanisms is expressed with the fluctuating nature of cancer pain intensity and clinical characteristics. Traditional ways of classifying pain in the cancer population include distinguishing pain etiology, clinical characteristics related to pain and the patient, pathophysiology, and the use of already validated classification systems. Concepts like breakthrough, nociceptive, neuropathic, and mixed pain are very important in the assessment of pain in this population of patients. When dealing with patients affected by cancer pain it is also very important to be familiar to the characteristics of specific pain syndromes that are usually encountered. In this article we review methods presently applied for classifying cancer pain highlighting the importance of an accurate clinical evaluation in providing adequate analgesia to patients.

Women's Knowledge on Ovarian Cancer Symptoms and Risk Factors in Nigeria: An Institutional-based Study

Ovarian cancer is the 2nd most common and the deadliest gynecological malignancy in Nigeria; yet very little is known about women’s knowledge about the disease in our environment. We evaluated the levels of awareness of ovarian cancer risk factors and symptoms among the Nigerian women, and also determined the factors that predict it. A cross-sectional descriptive study was conducted among 400 women attending out-patient clinics at Lagos University Teaching Hospital, Lagos, Nigeria. Using a structured questionnaire, we assessed their knowledge of ovarian cancer risk factors and symptoms and the factors that influence it. Data were analyzed using SPSS version 20.0. Sixty-three percent of the participants were found to be aware of the disease, whereas only 19.5% and 14.0% demonstrated good knowledge of its symptoms and risk factors, respectively. High level of education and previous conversation with a doctor on ovarian cancer were the only factors that significantly predicted good knowledge of symptoms and risk factors (p < 0.05). The knowledge of ovarian cancer is extremely poor among women in Lagos, Nigeria. Education of the girl child and health education of women about the disease by healthcare providers is important. This will significantly enhance women’s knowledge and encourage early presentation and detection of the disease.

Global epidemiology, risk factors, and histological types of ovarian cancers in Trinidad

Background

Ovarian cancer is the seventh most common cancer in women in the world and Trinidad and Tobago is ranked 18^th in the world with respect to the rate of occurrence. About 68% cases are diagnosed at a late stage, resulting in low survival rates. Since there is very scanty literature available on the epidemiology of ovarian cancer in the Caribbean region, this study was undertaken to assess the most common risk factors, presenting symptoms and common histological varieties in Trinidad.

Methods

A hospital-based, cross-sectional study was designed, and all the 23 diagnosed ovarian cancer cases registered during 2015-2017 were considered. Information on sociodemographics, presenting symptoms, and histological type of cancers were collected after getting the ethical approval. Of the total 23 cases, 17 cases were included in this study after ensuring completeness of data as detailed analysis of patient data was done using Microsoft Excel.

Results

The common risk factors identified were previous pregnancies, previous surgeries, and irregularities in the menstrual cycle. The commonest histological variety was granulosa tumors and the most common associated symptoms were irregular menses and abdominal pain in premenstrual women, and abdominal distention in postmenopausal women.

Conclusions

It would greatly enhance the detection rate if screening and testing for the CA-125 gene were a mandatory practice, for any patient found with more than three risk factors. The public health authorities should identify the modifiable risk factors and implement cancer reduction and health promotion activities to reduce the mortality related to ovarian cancers.

Cancer of the ovary, fallopian tube, and peritoneum

The Gynecologic Oncology Committee of FIGO in 2014 revised the staging of ovarian cancer, incorporating ovarian, fallopian tube, and peritoneal cancer into the same system. Most of these malignancies are high-grade serous carcinomas (HGSC). Stage IC is now divided into three categories: IC1 (surgical spill); IC2 (capsule ruptured before surgery or tumor on ovarian or fallopian tube surface); and IC3 (malignant cells in the ascites or peritoneal washings). The updated staging includes a revision of Stage IIIC based on spread to the retroperitoneal lymph nodes alone without intraperitoneal dissemination. This category is now subdivided into IIIA1(i) (metastasis ≤10 mm in greatest dimension), and IIIA1(ii) (metastasis >10 mm in greatest dimension). Stage IIIA2 is now "microscopic extrapelvic peritoneal involvement with or without positive retroperitoneal lymph node" metastasis. This review summarizes the genetics, surgical management, chemotherapy, and targeted therapies for epithelial cancers, and the treatment of ovarian germ cell and stromal malignancies.

The Imperative for a Triumph-Over-Tragedy Story in Women's Accounts of Undergoing Chemotherapy for Ovarian Cancer

We aimed to examine how women construct their experiences of chemotherapy treatment for ovarian cancer. Through semistructured interviews, we explored the accounts of 18 Australian women about their experiences within a broader cultural imperative-or discourse-to "think positively." By applying a critical realist lens to the analysis, we identified two discursive themes that shaped women's accounts. The "feeling different and managing support" theme highlights the identity challenges women faced because of the lack of formal support for ovarian cancer. Conversely, the theme "women's reconstructions of difficult experiences" illustrates the imperative for women to present a positive story as a way of restoring their position of a lucky and stoic survivor. Such speaking served to mask some of the underlying difficulties that were part of these women's experiences. Health care professionals need to consider looking for the hidden stories of vulnerability that lie beneath the triumphant ones.

The Use of Human Epididymis 4 and Cancer Antigen 125 Tumor Markers in the Benign or Malignant Differential Diagnosis of Pelvic or Adnexal Masses

BACKGROUND

Ovarian cancer is one of the highest mortality cancers in gynaecology. Discrimination of benign masses from malignant ones may sometimes become a challenge for the clinician since there is not a reliable tumour marker, thus some unnecessary, highly morbid operations can be performed.

AIMS

To explore the efficacy of human epididymis 4 (HE 4) and cancer antigen 125 (CA 125) markers in differentiating malignant and benign pelvic masses of ovarian origin and to identify the cut-off points for those markers.

STUDY DESIGN

Prospective study.

METHODS

Fifty-one patients who were diagnosed and planned to undergo surgery for ovarian mass between June 2008 and December 2008 were enrolled into this study. Preoperative venous blood samples were taken and frozen for marker investigation and final diagnoses were concluded by histopathological examination. After recruitment of all cases CA 125 and HE 4 levels were evaluated.

RESULTS

The statistical analysis did not indicate any statistically significant difference between the CA 125 levels of the patients with malignant and benign adnexal masses (p=0.105). The HE 4 levels of the patients with malignant adnexal masses were higher at a statistically significant level compared to the patients with benign adnexal masses (p=0.002). For HE 4 tumour marker and at the cut-off point of >25 pM, sensitivity was 1, specificity 0.40, positive cut-off value 0.19, negative cut-off value 1, accuracy 0.47 and positive likelihood ratio 1.65.

CONCLUSION

Human epididymis 4 is a better diagnostic tool than CA 125 in benign-malignant discrimination of adnexal masses. The cut-off value of 25 pmol/L for human epididymis 4 will contribute to providing proper guidance to patients with adnexal masses and applying the proper treatment method.

Role of tumor microenvironment in ovarian cancer pathobiology

Ovarian cancer is the fifth most common cancer affecting the female population and at present, stands as the most lethal gynecologic malignancy. Poor prognosis and low five-year survival rate are attributed to nonspecific symptoms and below par diagnostic criteria at early phases along with a lack of effective treatment at advanced stages. It is thus of utmost importance to understand ovarian carcinoma through several lenses including its molecular pathogenesis, epidemiology, histological subtypes, hereditary factors, diagnostic approaches and methods of treatment. Above all, it is crucial to dissect the role that the unique peritoneal tumor microenvironment plays in ovarian cancer progression and metastasis. This review seeks to highlight several important aspects of ovarian cancer pathobiology as a means to provide the necessary background to approach ovarian malignancies in the future.

The role of transvaginal ultrasound in screening for ovarian cancer

Ovarian cancer is a low-prevalence postmenopausal cancer with a high mortality rate and is the fifth most lethal cancer in women. The most common serous subtype with TP53 mutations spreads rapidly throughout the peritoneal cavity (stage III/IV) when 5-year survival is 10%. If diagnosed while confined to the ovary (stage I), the survival rate exceeds 90%. This is the rationale for screening. Annual transvaginal ultrasound (TVU) scans used as a primary screening modality or as a second-line test following primary screening with serum CA125 (multimodal) have been investigated in several trials. Only two large randomized controlled trials have provided mortality data. The US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial studied over 78 000 women (randomized to screening with either TVU or CA125, or control) over 6 years with 14 years follow-up and found no mortality benefit from screening and increased morbidity in the screened arm. The UK Collaborative Trial of Ovarian Cancer Screening studied over 202 000 women randomized to TVU, multimodal or control in a 1 : 1 : 2 ratio over 7-11 years with 11 years follow-up. CA125 was interpreted by the Risk of Ovarian Cancer algorithm which identifies a rise in the level rather than a fixed cut-off. There was a late reduction in mortality after 7 years in the screened arm (23% in the multimodal arm and 21% in the TVU arm), but the overall reduction was not significant. Further follow-up may reveal whether TVU has a primary or secondary role in ovarian cancer screening.

Symptom Signatures and Diagnostic Timeliness in Cancer Patients: A Review of Current Evidence

Early diagnosis is an important aspect of contemporary cancer prevention and control strategies, as the majority of patients are diagnosed following symptomatic presentation. The nature of presenting symptoms can critically influence the length of the diagnostic intervals from symptom onset to presentation (the patient interval), and from first presentation to specialist referral (the primary care interval). Understanding which symptoms are associated with longer diagnostic intervals to help the targeting of early diagnosis initiatives is an area of emerging research. In this Review, we consider the methodological challenges in studying the presenting symptoms and intervals to diagnosis of cancer patients, and summarize current evidence on presenting symptoms associated with a range of common and rarer cancer sites. We propose a taxonomy of cancer sites considering their symptom signature and the predictive value of common presenting symptoms. Finally, we consider evidence on associations between symptomatic presentations and intervals to diagnosis before discussing implications for the design, implementation, and evaluation of public health or health system interventions to achieve the earlier detection of cancer.

Peptide YY producing strumal carcinoid tumor of the ovary in a postmenopausal woman: a rare cause of chronic constipation

Strumal carcinoid tumor of the ovary is a rare subtype of ovarian carcinoid tumors; it is characterized by an intimate mixture of thyroid and carcinoid tissues. We present a case of a 64-year-old woman who presented with the chief complaint of persistent, severe constipation for over 5 years; she was later found to have an ovarian strumal carcinoid tumor. Computed tomography showed a well-defined solid mass measuring 6.4 cm at the right adnexa. The patient underwent right salpingo-oophorectomy and was histopathologically diagnosed as having a strumal carcinoid tumor. Immunohistochemical examination showed immunoreactivity for peptide YY (PYY), which exerts an inhibitory effect on the peristaltic actions of the distal intestine. After surgery, the patient's constipation resolved rapidly, suggesting a correlation between PYY producing ovarian carcinoid tumor and constipation. This is the first case report of PYY producing primary strumal carcinoid tumor of the ovary associated with persistent, severe constipation from Korea.

Data-Independent Acquisition and Parallel Reaction Monitoring Mass Spectrometry Identification of Serum Biomarkers for Ovarian Cancer

A data-independent acquisition (DIA)/parallel reaction monitoring (PRM) workflow was implemented to identify improved ovarian cancer biomarkers. Data-independent acquisition on ovarian cancer versus control sera and literature searches identified 50 biomarkers and indicated that apolipoprotein A-IV (ApoA-IV) is the most significantly differentially regulated protein. Parallel reaction monitoring with Targeted Ovarian Cancer Proteome Assay validated differential ApoA-IV expression and quantified 9 other biomarkers. Random Forest (RF) analyses achieved 92.3% classification accuracy and confirmed ApoA-IV as the leading biomarker. Indeed, all samples were classified correctly with an [ApoA-IV] breakpoint. The next best biomarkers were C-reactive protein, transferrin, and transthyretin. The Targeted Ovarian Cancer Proteome Assay suggests that ApoA-IV is a more reliable biomarker than had been determined by immunological assays and it is a better biomarker than ApoA-I, which is in the OVA1 test for ovarian cancer. This research provides a PRM/RF approach together with 4 promising biomarkers to speed the development of a clinical assay for ovarian cancer.

Taking Responsibility

Patient-related diagnostic delay has been established as an analytical category in cancer research. This category has come under critique because it postulates linear cause-and-effect explanations of delayed care-seeking. These explanations are based on a one-dimensional idea of causality that neglects the processual character and the contextual situatedness of bodily experiences and care-seeking decisions. Using a notion of causality that is both process-oriented and context-sensitive, this article aims to understand ovarian cancer patients’ stories on delayed healthcare seeking. It uses data from a qualitative interview study that investigated ovarian cancer patients’ illness and healthcare-seeking experiences. We suggest that the interviewees’ retrospective perspective generated a multilayered notion of diagnostic delay that differs from the definition of patient-related delay commonly used in the literature. Our analysis shows how interviewees negotiate current social discourses on health and (social) responsibility, and thereby situate themselves and their healthcare seeking within a broader socio-economic and political context.

The translational blocking of α5 and α6 integrin subunits affects migration and invasion, and increases sensitivity to carboplatin of SKOV-3 ovarian cancer cell line

Epithelial ovarian cancer is the most lethal gynecologic malignancy. Integrins, overexpressed in cancer, are involved in various processes that favor the development of the disease. This study focused on determining the degree of involvement of α5, α6 and β3 integrin subunits in the establishment/development of epithelial ovarian cancer (EOC), such as proliferation, migration, invasion, and response to carboplatin. The translation of the α5, α6 and β3 integrins was blocked using morpholines, generating morphant cells for these proteins, which were corroborated by immunofluorescence assays. WST-1 proliferation assay showed that silencing of α5, α6, and β3 integrins does not affect the survival of morphants. Wound healing and transwell chamber assays showed that blocking α5 and α6 integrins decrease, in lesser and greater level respectively, the migratory and the invasive capacity of SKOV-3 cells. Finally, blocking α5 and α6 integrins partially sensitized the cells response to carboplatin, while blocking integrin β3 generated resistance to this drug. Statistical analyses were performed with the GraphPad Prism 5.0 software employing one way and two-way ANOVA tests; data are shown as average±SD. Results suggest that α5 and α6 integrins could become good candidates for chemotherapy targets in EOC.

Estimating the Prevalence of Ovarian Cancer Symptoms in Women Aged 50 Years or Older: Problems and Possibilities

Diagnostic testing is recommended in women with "ovarian cancer symptoms." However, these symptoms are nonspecific. The ongoing Diagnosing Ovarian Cancer Early (DOVE) Study in Montreal, Quebec, Canada, provides diagnostic testing to women aged 50 years or older with symptoms lasting for more than 2 weeks and less than 1 year. The prevalence of ovarian cancer in DOVE is 10 times that of large screening trials, prompting us to estimate the prevalence of these symptoms in this population. We sent a questionnaire to 3,000 randomly sampled women in 2014-2015. Overall, 833 women responded; 81.5% reported at least 1 symptom, and 59.7% reported at least 1 symptom within the duration window specified in DOVE. We explored whether such high prevalence resulted from low survey response by applying inverse probability weighting to correct the estimates. Older women and those from deprived areas were less likely to respond, but only age was associated with symptom reporting. Prevalence was similar in early and late responders. Inverse probability weighting had a minimal impact on estimates, suggesting little evidence of nonresponse bias. This is the first study investigating symptoms that have proven to identify a subset of women with a high prevalence of ovarian cancer. However, the high frequency of symptoms warrants further refinements before symptom-triggered diagnostic testing can be implemented.

The double-edged sword of ovarian cancer information for women at increased risk who have previously taken part in screening

BACKGROUND

Women at increased risk who decide not to have, or to delay, risk-reducing salpingo-oophorectomy have to rely on early diagnosis through symptom awareness and presenting to primary care as soon as possible in the absence of screening. However, little is known about the acceptability to women of this strategy. We aimed to gain an in-depth understanding of women's perceptions and previous experiences of ovarian cancer symptom management, and the influences on ovarian cancer awareness and anticipated symptom presentation.

METHOD

Qualitative interviews were conducted with eight women at increased risk of ovarian cancer who had previously taken part in ovarian cancer screening and analysed using interpretative phenomenological analysis (IPA).

RESULTS

Familial experience of ovarian cancer and perceived personal risk shaped women's perceptions and behavioural responses to disease threat. Ovarian cancer information was perceived to be a double-edged sword, regarded as either useful for increasing knowledge and confidence in discussing symptom concerns with health professionals or to be avoided due to fears about cancer.

CONCLUSION

Women may be cautious about searching for information independently and in the absence of routine ovarian screening.

PRACTICE IMPLICATIONS

Thought needs to be given to how best to create and disseminate credible ovarian cancer symptom information materials.

A Systematic Review of Symptoms for the Diagnosis of Ovarian Cancer

CONTEXT

Ovarian cancer is common and has significant morbidity and mortality, partly because it is often diagnosed at a late stage. This study sought to determine the accuracy of individual symptoms and combinations of symptoms for the diagnosis of ovarian cancer.

EVIDENCE ACQUISITION

MEDLINE was searched, identifying 2,492 abstracts, reviewing 71 articles in full, and ultimately identifying 17 studies published between 2001 and 2014 that met the inclusion criteria. Data were abstracted by two researchers, and quality was assessed using the QUADAS-2 criteria adapted to the study question. Bivariate random effects meta-analysis was used where possible, and heterogeneity and threshold effects were explored using receiver operating characteristic curves. Data were analyzed in 2015.

EVIDENCE SYNTHESIS

Most studies were at high risk of bias, primarily because of case-control design or differential verification bias. The highest positive likelihood ratios (LRs+) were found for presence of abdominal mass (LR+, 30.0); abdominal distension or increased girth (LR+, 16.0); abdominal or pelvic pain (LR+, 10.4); abdominal or pelvic bloating (LR+, 9.3); loss of appetite (LR+, 9.2); and a family history of ovarian cancer (LR+, 7.5). No symptoms were helpful at ruling out ovarian cancer when absent. The Ovarian Cancer Symptom Index was validated in five studies and (after excluding one outlier with different inclusion criteria) was 63% sensitive and 95% specific (LR+, 12.6; LR-, 0.39). Two other symptom scores had not been validated prospectively.

CONCLUSIONS

Several individual signs and symptoms significantly increase the likelihood of ovarian cancer when present. More work is needed to validate decision rules and develop new decision support tools integrating risk factors, symptoms, and possibly biomarkers to identify women at increased ovarian cancer risk.

The Association Between Body Mass Index and Presenting Symptoms in African American Women with Ovarian Cancer

BACKGROUND

Ovarian cancer, the most lethal gynecologic malignancy, typically comes to clinical attention due to nonspecific gastrointestinal or pelvic symptoms. African Americans with ovarian cancer have a greater mortality burden than whites and are also much more likely to be obese. The objective of this study is to explore whether the presentation and duration of symptoms differ by body mass index (BMI) in African Americans with ovarian cancer.

METHODS

We conducted a case-only analysis using data from a multicenter population-based study of invasive epithelial ovarian cancer in African American women. Information on risk factors and symptoms leading to diagnosis was obtained in a telephone interview. Frequency and duration of symptoms by BMI categories were compared using logistic regression and linear regression analyses.

RESULTS

Of the 326 women, ∼60% was obese (BMI ≥30), with 30.8% having a BMI ≥35 kg/m(2). Ninety-four percent of women reported ≥1 symptom during the year before diagnosis. We observed differences in frequency of symptoms by BMI categories, with most being reported more frequently by the heaviest women. The reported duration of symptoms was longer in women with higher BMI, with statistically significant trend tests for 6 of the 10 symptoms evaluated.

CONCLUSION

BMI appears to impact ovarian cancer symptomatology. Women with higher BMI report having symptoms for a longer period of time before diagnosis of ovarian cancer. Healthcare providers should be vigilant and consider ovarian cancer in the differential diagnosis for obese women presenting with abdominal and pelvic symptoms.

Designing an Educational Website to Improve Quality of Supportive Oncology Care for Women with Ovarian Cancer: An Expert Usability Review and Analysis

A broad-based research team developed a Health Insurance Portability and Accountability Act (HIPAA)-compliant educational website for women with ovarian cancer to improve the quality of supportive oncology care. Prior to a randomized clinical trial of the website, initial usability testing was implemented to evaluate the website. The initial review found that 165/247 checklist items had sufficient information to allow for evaluation with the website achieving an overall score of 63%. By category, lowest scores were for the Home Page, Task Orientation, Page Layout & Visual Design, and Help, Feedback & Error Tolerance. Major issues thought to potentially impede actual usage were prioritized in redevelopment and the second usability review, conducted by the same expert, saw an improvement in scores. Incorporating usability concepts from the start of development, fulfilling the positive expectations of end-users and identifying technical and personal factors that optimize use may greatly enhance usage of health websites.

Outcomes following implementation of symptom triggered diagnostic testing for ovarian cancer

OBJECTIVES

UK is the first country to implement symptom triggered testing for suspected ovarian cancer (OC) following guidance from National Institute of Clinical Excellence in 2011. We evaluated its impact on cancer outcomes and implications on clinical practice.

STUDY DESIGN

This is a cohort study and we analysed data for all new urgent referrals for suspected OC from two large teaching hospitals using a prospectively collected electronic referral database, supplemented with clinical data from electronic records. We evaluated outcomes prior to (2011) and after (2013) implementation of guidance to evaluate stage shift, referrals workload and surgical procedures generated.

RESULTS

Secondary care received 2185 new referrals from primary care for women with suspected gynaecological cancer in post guideline cohort. Of these, 217 women were referred for suspected OC. 90% of primary care referrals were not compliant with guidance. Following implementation of guidance, more women with OC were diagnosed through urgent referral (rapid access clinics): Almost double, 21 of the total 67 (31.34%) OCs in 2013 (post guidance) in comparison to only 11 of 69 OCs (15.94%) were diagnosed in 2011 (pre guidance) through urgent referrals, p=0.03. The predictive value of detecting cancer through rapid access clinics increased, from 4.5% to 9.6%, p=0.04; however, no stage shift was noted. Over 25% of patients underwent surgeries for non-malignant conditions in the post-guideline cohort. No increase was seen in workload of cancer clinics.

CONCLUSION

Implementation of Symptom-triggered testing is challenging in clinical practice. Such testing results in more patients with OC accessing expedited care pathways leading to streamlined routes of diagnosis and care. However, current implementation does not lead to stage shift in diagnosis and may not achieve significant mortality benefit.

Population-based genetic risk prediction and stratification for ovarian cancer: views from women at high risk

There is an opportunity to improve outcomes for ovarian cancer (OC) through advances in risk stratification, early detection and diagnosis. A population-based OC genetic risk prediction and stratification program is being developed. A previous focus group study with individuals from the general population showed support for the proposed program. This qualitative interview study explores the attitudes of women at high risk of OC. Eight women participated in one-on-one, in-depth, semi-structured interviews to explore: experiences of learning of OC risk, risk perceptions, OC knowledge and awareness, and opinions on risk stratification approach. There was evidence of strong support for the proposed program. Benefits were seen as providing reassurance to women at low risk, and reducing worry in women at high risk through appropriate clinical management. Stratification into ‘low’ and ‘high’ risk groups was well-received. Participants were more hesitant about stratification to the ‘intermediate’ risk group. The data suggest formats to effectively communicate OC risk estimates will require careful thought. Interactions with GPs were highlighted as a barrier to OC risk assessment and diagnosis. These results are encouraging for the possible introduction and uptake of a risk prediction and stratification program for OC in the general population.

Ovarian Tissue Characterization in Ultrasound

Ovarian cancer is the most common cause of death among gynecological malignancies. We discuss different types of clinical and nonclinical features that are used to study and analyze the differences between benign and malignant ovarian tumors. Computer-aided diagnostic (CAD) systems of high accuracy are being developed as an initial test for ovarian tumor classification instead of biopsy, which is the current gold standard diagnostic test. We also discuss different aspects of developing a reliable CAD system for the automated classification of ovarian cancer into benign and malignant types. A brief description of the commonly used classifiers in ultrasound-based CAD systems is also given.

Early clinical detection of ovarian cancer: a review of the evidence

Subjective and objective evidence suggest that a third to half of patients developing ovarian cancer report symptoms at 3 or more months prior to diagnosis. Early ovarian cancer-associated symptoms constitute a constellation of mostly nongynecological complaints, suggesting a visceral disturbance, which do not point immediately to a pelvic origin. Abdominal bloating and pain predominate with recent onset and multiple symptomatic episodes. Gastrointestinal and urinary symptoms and fatigue/malaise may be part of the symptom complex. Women aged 50 years and older with this constellation of symptoms should have medical evaluation and, if symptoms are unexplained or persist, should undergo pelvic imaging (e.g., transvaginal ultrasound) and serum CA125.

Genetic variants in matrix metalloproteinase genes as disposition factors for ovarian cancer risk, survival, and clinical outcome

Ovarian cancer is one of the leading female cancers in the United States. Challenges remain in early diagnosis of this deadly disease. Matrix metalloproteinases (MMPs) family genes are paradoxically involved in cancer promotion and suppression. We hypothesize that genetic variants in MMP genes are associated with ovarian cancer development, so they could be potential markers for ovarian cancer diagnosis and prognosis. In this study of 417 ovarian cancer cases and 417 healthy controls, we genotyped a comprehensive panel of 266 single nucleotide polymorphisms (SNPs) in 23 MMP genes and analysed their associations with ovarian cancer risk, overall survival and treatment response in ovarian cancer cases who received platinum-based chemotherapy with surgery. In the analysis on 339 Caucasian cases and 349 Caucasian controls, 4 SNPs were significantly associated with cancer risk. The most significant association was observed for rs2292730 (OR = 2.03, 95% CI = 1.39-2.96, P = 0.0002). Classification and regression tree analysis identified four terminal nodes with differential risk of ovarian cancer. Thirty-four SNPs were significantly associated with overall survival and four of which showed significant association with response to chemotherapy. Unfavourable genotype analysis of top SNPs on overall risk of death showed significant gene-dosage effect, survival tree analysis differentiated patients into distinct risk groups based on their genetic profiles with median survival times (MSTs) ranging from 17.7 to 151.7 months. In conclusion, our results suggest that genetic variants in MMP pathway genes may modulate the risk and clinical outcomes of ovarian cancer, both individually and jointly.