Madam AK is a 40 years old engineer who came for a gynaecological check-ups due to abnormal menstruation for 3 months duration. Her mother and one of her auntie died of breast cancer many years ago. Examination findings showed Madam AK has a large left ovarian cyst and presence of some water in her abdomen suggestive of possible ovarian cancer. Surprisingly, two months prior this visit, Madam AK has undergone a complete primary health screening which consist of full blood test and Pap test and was told that she was in good health. Does your annual primary health screening exclude all gynaecological cancer?
The burden of ovarian cancer
Each year, nearly a quarter of a million women around the world are diagnosed with ovarian cancer, and the disease is responsible for 140,000 deaths annually. In general population, approximately 1 in 70 women will develop ovarian cancer in her lifetime.
In Malaysia, ovarian cancer is the 5th most common cancer affecting women and the number one cause of gynaecological cancer deaths. It is estimated about 500 new cases of ovarian cancer is being diagnosed in our country every year and approximately 70% of women are diagnosed at Stage 3 or Stage 4 of the disease, with an overall five-year survival rate of only 30%.
Ovarian cancer is proven deadlier than breast cancer as statistics show that just 45% of women with ovarian cancer are likely to survive for five years, compared with 89% of women with breast cancer.
Who is likely to get ovarian cancer?
There are three categories of women with different risk level of developing ovarian cancer.
- Women with moderate risk i.e. risk level near the general population
This category includes women with any of the followings:
- A history of breast cancer diagnosed at the age of 41 or older
- A history of infertility and/or use of assisted reproductive therapies such as in-vitro fertilization
- A history of endometriosis
- A history of hormonal replacement therapies
- Women with higher risk i.e. risk level 3-6 times greater than a general population.
This category of women include the followings:
- First degree relative (mother, sister, daughter) got ovarian cancer
- A personal history of breast cancer prior the age of 40.
- A personal history of breast cancer diagnosed prior the age of 50 and have one close relatives with breast or ovarian cancer at any age
- Have 2 or more close relatives of breast or ovarian cancer prior to age 50
- Women with inherited risk of ovarian cancer i.e. risk level is more than 6 times to develop ovarian cancer
- Presence of a BRCA1or BRCA2 gene mutation
- Presence of a mismatch repair gene mutation associated with a hereditary cancer syndrome known as Hereditary Non-Polyposis Colon Cancer.
Ovarian cancer screening test (pap test is not designed to detect ovarian cancer)
Pap smear test is a test to detect early cervical cancer or pra-cancer. The package of primary health screening promoted by the wellness unit in hospital often does not include full package of screening for uterus and ovarian cancer and this is the big disadvantage for women given uterine and ovarian cancer are among the most common cancer affecting women.
Thus it is recommended that for women above 40 especially of those with high risk and inherited risk, other than Pap test, additional blood test for Ca 125 and trans-vaginal scan of the pelvis should be pursued as measures of ovarian cancer screening.
- CA-125 measurement
CA 125 is a protein produced by more than 90 percent of advanced epithelial ovarian cancers. However, a single measurement of CA 125 has no value in diagnosing early ovarian cancer because there are many other gynaecological condition cause mild and moderately increase CA 125 level. The predictive power of CA 125 as a screening test improves if it is combined with transvaginal ultrasound finding of the ovaries.
- Transvaginal ultrasound of the pelvis
A number of imaging methods have been evaluated for possible use in ovarian cancer screening. Transvaginal ultrasound has consistently proven to be the most promising imaging method for routine screening of ovarian cancer.
In the largest study to date evaluating ultrasound as a screening method for ovarian cancer, 14,469 women, most of whom were at average risk for ovarian cancer, were monitored using annual transvaginal ultrasounds. Promisingly, 11 of 17 cancers detected by transvaginal ultrasound screening were diagnosed at the earliest stage of the disease, known as stage I.
Ovarian Cancer Screening: To do or not to do?
Ovarian cancer screening may possibly increase detection rate of ovarian cancer as well as other detection of other gynaecology condition (e.g. uterine fibroid, endometriosis and ovarian cyst) however up to date, there is no clear evidence to suggest that ovarian cancer screening with currently available methods will result in a decrease in the number of deaths from ovarian cancer. This is because CA 125 level and transvaginal imaging of enlarged ovaries do not correlate well with the stage and different type of the ovarian cancer.
Furthermore, absence of early symptom of ovarian cancer makes the prospect of detecting early and death prevention of ovarian cancer is more challenging.
Since many women routinely doing annual health check to make sure they are free from the diseases, to include a detailed gynae check up which include measurement of Ca 125 and a transvaginal ultrasound of the pelvis (to visualise the ovaries) would definitely give the women peace of mind and certainty of normal status of her reproductive organ and her health in general.
Dr Sharifah Halimah Jaafar M.D, M.Med O&G (UKM) AM (Mal)
Consultant Obstetrician & Gynaecology @ Regency Specialist Hospital
Women’s Health Advocates