June 8, 2004 -- New research sheds light on symptoms of ovarian cancer, often referred to as a "silent killer." A cluster of symptoms -- increased bloating and abdominal size, pressure to urinate, constipation, and abdominal pain -- should not be overlooked, say study authors.

"Women need to be aware of this cluster [of symptoms]," researcher Lynn S. Mandel, PhD, with the department of obstetrics and gynecology at the University of Washington in Seattle. "It doesn't mean they have ovarian cancer. But the symptoms should be investigated to see what it is. It could be a malignancy, or it could be something else - - an ovarian cyst or endometriosis.

Mandel's study, which appears in this week's Journal of the American Medical Association, should also be a wake- up call for doctors, says Ira Horowitz, MD, vice chairman and director of gynecologic oncology at Emory University's Winship Cancer Institute in Atlanta.

"Ovarian cancer is very silent in the early stages ... any symptoms are usually vague, nonspecific, and doctors tend to blow them off," Horowitz tells WebMD. "This study tells us that we need to heed those vague symptoms. They are screaming for our attention. We need to think of ovarian cancer first -- not last."

Indeed, many women see numerous doctors for their symptoms, including gastrointestinal specialists, before ovarian cancer is even suspected. And, unfortunately, the symptoms are most noticeable when cancer is advanced -- not in the early stages, Horowitz tells WebMD. "When the mass [in the ovary] is significant in size, that's when symptoms are more intense. Then it's too late."

It all points to the need for better -- and ongoing -- doctor-patient communication, writes Mary B. Daly, MD, PhD, in an accompanying editorial. "The early diagnosis of ovarian cancer must rely on the elusive practice of [the doctor's] judgment ... and thoughtful dialogue between patient and physician."

"Women know their bodies, and when something changes, they need to make sure the physician is aggressive in evaluating it," Horowitz says.

Frustrating, Deadly Disease

Ovarian cancer has long frustrated doctors and their patients, writes Mandel. Very few cases of ovarian cancer are caught in the early treatable stages -- and chances of surviving late-stage ovarian cancer is poor.

The reason: There has been no clear pattern of symptoms. For many women, the symptoms are so common and vague that they don't realize anything is wrong. In fact, not all women even have symptoms.

Mandel's research group and others have attempted to unravel this mystery. In an earlier study, her group found a pattern of gastrointestinal and abdominal problems, pain, fatigue, and urinary difficulties that seemed fairly predictable.

This new study attempts to pinpoint the pattern more closely. The survey asked about a variety of symptoms that are often dismissed as unimportant: pelvic, abdominal, and back pain; indigestion; bloating and increased abdomen size; urinary and bowel problems, menstrual problems, and problems during intercourse (like pain or bleeding); and fatigue and leg swelling.

Of the 1,709 women in the study -- all patients at two primary care centers -- 128 were diagnosed with either a benign or malignant pelvic tumor. All the women completed surveys asking about a list of symptoms.

Mandel found this pattern among women diagnosed with ovarian cancer:

• They were more likely to be postmenopausal, average age of 55.
• 94% had symptoms during the past year; 67% had recurring symptoms.
• They experienced their symptoms 15 to 30 times per month -- just about every day.
• Symptoms had become severe in the past two or three months.

• Seven times more likely to have increased abdominal size
• Four times more likely to have bloating
• Two-and-a-half times more likely to have increased urgency to urinate
• Twice as likely to have pelvic and abdominal pain

Mandel's questionnaire is being used by Pacific Ovarian Cancer Research Consortium in a much larger study, she says. Those researchers are collecting tissue and blood from women, in addition to symptom information, to look for other patterns and markers for ovarian cancer -- including genetic markers. The questionnaire is available at http://depts.washington.edu/ovarian/questionnaire.html.

Other research groups are investigating blood proteins that may be markers of certain cancers. The marker could provide an accurate means to test for early-stage ovarian cancer, Horowitz tells WebMD.

SOURCES: Goff, B. The Journal of the American Medical Association, June 9, 2004; vol 291: pp 2705-2719. Lynn S. Mandel, PhD, department of obstetrics and gynecology, University of Washington. Ira Horowitz, MD, vice chairman and director of gynecologic oncology, Emory University's Winship Cancer Institute, Atlanta.