Groups Say Common Symptoms May Indicate Ovarian Cancer

A new consensus statement recommends that women who experience any of several common symptoms for at least several weeks see a physician, preferably a gynecologist, because these might be indicative of ovarian cancer.

Released by the Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists (SGO), and the American Cancer Society, the statement lists four symptoms, 1) bloating, 2) pelvic or abdominal pain, 3) difficulty eating or feeling full quickly, and 4) the sudden urge to urinate or frequent urination, that studies indicate "are much more likely to occur in women with ovarian cancer than women in the general population." Research also indicates, the statement continues, "that even early-stage ovarian cancer can produce these symptoms."

A recent case-control study, published in January in Cancer, found that this "symptom index" - based on retrospective symptom surveys - had a sensitivity of approximately 57 percent for detecting early-stage disease and approximately 80 percent for advanced-stage disease, with slightly better specificity for women under 50 - 90 percent vs. 86.7 percent for women over 50.

"Although proof that earlier recognition of symptoms improves outcomes does not yet exist, there is little to be lost and much to be potentially gained by increasing awareness of ovarian cancer symptoms that might lead to earlier medical evaluation and intervention," SGO President Dr. Andrew Berchuck explained in a statement.

Ovarian cancer patients who report having these symptoms prior to diagnosis often say they experienced long delays in getting doctors to evaluate them "or even think about ovarian cancer as a possibility," says Dr. Ted Trimble from NCI's Division of Cancer Treatment and Diagnosis. "From that perspective, this statement is part of an educational process that is timely and appropriate."

Dr. Robert F. Ozols, senior vice president at Fox Chase Cancer Center, said he would like to see a stronger evidence base, including prospectively collected data, before making such a recommendation. He also had concerns about just what the symptoms really mean.

"The big question, given the natural history of this disease, is do we expect earlier stage diagnosis based on these symptoms?" he asks. Most of the symptoms, he says, "are sort of mass effects, which would suggest late-stage disease."

The consensus statement, notes Dr. Trimble, reflects the frustration that "all too often, when this disease presents, it's already advanced." A number of ongoing studies hold promise for identifying ways to improve the early detection of ovarian cancer, he continues, including the NCI-funded PLCO Screening Trial and the UK Collaborative Clinical Trial of Ovarian Cancer Screening, as well as other NCI-supported research programs.

Early-Stage Pancreatic Cancer Patients Not Offered Surgery

The first comprehensive, nationwide review of treatment of patients with stage I pancreatic cancer who are candidates for surgery has found that nearly 4 in 10 are not offered the option, even though it has a demonstrable survival benefit.

To conduct the study, the research team analyzed data on all patients with pancreatic cancer listed in the American College of Surgeons' National Cancer Data Base between 1995 and 2004. The database captures 76 percent of all pancreatic cancers diagnosed in the United States. They identified 9,559 patients with stage I disease.

Overall, only 28.6 percent of patients with stage I disease underwent surgery, Dr. Mark S. Talamonti and colleagues from Northwestern University's Feinberg School of Medicine reported in a June 14 early online release from the Annals of Surgery. But after excluding patients who did not receive surgery because of factors such as comorbidities, age, or procedure refusal, they found that 38.2 percent of patients were not offered surgery.

Several factors were associated with not being offered surgery, such as being older than 65, African American, on Medicare or Medicaid, and being treated at lower volume or community hospitals.

Also, patients whose tumor was located in the head of the pancreas - a location that requires a surgical procedure commonly called the Whipple procedure - were less likely to be offered surgery. This has historically been considered a challenging surgery with high mortality rates, says study co-author Dr. David Bentrem. But over the past two decades, he continues, the safety of the procedure has improved dramatically.

Remedying the problem of underutilized surgery is a difficult task, admits Dr. Bentrem.

"Some groups have advocated regionalizing care," he adds, arguing that it could be beneficial for more complicated cancer surgeries, such as those for pancreatic and esophageal cancers. "But even for those, if we can get bigger and smaller centers working more closely together, that would help to ensure patients are getting the best care."

Unrelated Cord Blood Matches Bone Marrow Transplants for Children

The first-ever study in children with acute leukemia directly comparing unrelated cord blood transplants with bone marrow transplants has found that cord blood can be just as good, and maybe better under some circumstances. The results were published June 9 in The Lancet.

Researchers used data from the Center for International Blood and Marrow Transplant Research and the National Cord Blood Program of the New York Blood Center, representing 503 children under the age of 16 who received cord blood transplants and 282 children who received bone marrow transplants.

Relapse rates were similar between cord blood and bone marrow recipients, except that patients who received cord blood that was mismatched at two antigens actually had a lower rate of relapse, which is consistent with a more potent graft-versus-leukemia effect.

Cord blood patients also had similar mortality rates to bone marrow patients when the cord blood was matched or the cell dose was high. The rates of 5-year leukemia-free survival were 38 percent with matched bone marrow, 37 percent with mismatched bone marrow, 60 percent with matched cord blood, 36 percent with low-cell-dose cord blood that was mismatched at one antigen, 45 percent after high-cell-dose cord blood mismatched at one antigen, and 33 percent after cord blood mismatched at two antigens.

Recurrent leukemia was the most common cause of death in both the cord blood and bone marrow groups, but it was proportionally lower among two-antigen mismatched cord blood recipients. Other causes of death included graft-versus-host disease, interstitial pneumonitis, infection, and organ failure.

Noting that the retrospective, nonrandomized nature of this study is a weakness, the authors pointed out that a clear association between cell dose, antigen match, and time to marrow recovery and survival can be used to determine the best transplant source for children with malignant disease when donors are limited. "Our findings support the need for even greater investment in cord blood because of the importance of HLA matching and cell dose on survival," they wrote.

Annual Mammography Reduces Mortality in Older Breast Cancer Survivors

Annual mammography screening for breast cancer survivors older than 65 dramatically lowers their risk of death from breast cancer, whether by recurrence or another primary tumor. Results published early online June 4 in the Journal of Clinical Oncology show that each successive annual mammogram reduces a woman's breast cancer mortality risk by about 31 percent; by the fourth year of compounding that reduction, their cumulative risk has been cut by 88 percent.

Dr. Timothy L. Lash of Boston University was the lead author of the cohort study, which identified 1,846 breast cancer patients from 6 Cancer Research Network (CRN) sites chosen to maximize ethnic and geographic diversity. All women were diagnosed with stage I or II breast cancer between 1990 and 1994, and were designated as "survivors" for the purposes of the study 90 days after finishing their initial breast cancer treatment. The 178 women who died within 5 years were closely matched to 634 controls. Protective effects of annual mammography were found to be the strongest among women with stage I disease, those who had received mastectomy, and those older than 79.

In an editorial, Dr. Jeanne Mandelblatt from the Lombardi Comprehensive Cancer Center in Washington, DC, commended "this high-quality observational research" that emerged from CRN, an NCI-funded collaboration between 12 large managed care systems. The large cohort study provides the best data likely to be developed on this question, because a clinical trial that randomized women to "no mammography" would disregard current guidelines, which recommend survivors receive annual surveillance mammograms.