“Symptom-triggered testing”—prompted by symptoms such as pain, abdominal bloating/swelling, and feeling full soon after starting to eat—detected early-stage aggressive ovarian cancer in one of four individuals affected, according to an analysis from the ROCkeTS trial published by Kwong et al in the International Journal of Gynecological Cancer. Complete surgical removal of the cancerous tissue was also possible in 60% of those diagnosed in this way.
The findings challenge the assumption that symptoms always signal advanced disease in women with ovarian cancer, concluded researchers. While most women diagnosed with early-stage disease (stage I or II) survive for more than 5 years (93%), only 13% of those diagnosed with advanced disease (stages III or IV) do so.
Mounting evidence suggests that symptoms precede diagnosis by between 3 months and 3 years, but symptoms are often vague, making early detection difficult, explained the researchers. But symptoms such as pain, abdominal swelling and/or bloating, and feeling full soon after starting to eat are associated with ovarian cancer, and warrant urgent investigation, or “symptom-triggered testing.”
Symptom-Triggered Testing: Background and Efficacy Evaluation
The United Kingdom adopted symptom-triggered testing for ovarian cancer in 2011. Women, especially those over the age of 50 years with these symptoms, are tested for levels of the protein CA125 in their blood and given an ultrasound scan. Abnormal results prompt a fast-track referral to a gynecologist within 2 weeks. But how effective this protocol is for picking up early-stage disease in women with high grade serous ovarian cancer—the most common, aggressive, and lethal form of the disease—was not clear, explained researchers.
To find out, they analyzed data for 1,741 women taking part in the Refining Ovarian Cancer Test accuracy Scores (ROCkeTS) study, which involved 24 UK-based hospitals. The women had all been fast-tracked for treatment under the symptom-triggered testing protocol.
Results
In all, 119 (7%) of these women were diagnosed with high-grade serous ovarian cancer. Their average age was 63 years (range = 32–89 years); 90% were postmenopausal. In most of these women (n = 112; 94%), cancer did not hugely interfere with their daily lives, as they were classified with a performance status of 0 or 1.
One in four (n = 30; 25%) had early-stage—stage I or II—disease. Visible cancerous tissue was completely removed in 73 (61%) and almost completely removed in 18 (15%); disease was only deemed to be inoperable in 9 (8%).
The extent of cancer was low in 43 of the 119 (36%), meaning that it was localized in the pelvis; moderate in 34 (29%), meaning that it had spread to the lower abdomen; and high in 32 (27%), meaning that it had spread up to any of the liver, pancreas, diaphragm, or spleen. Information on disease extent was not available for 10 women (8.5%).
Surgery to remove as much of the tumor as possible, which is associated with longer survival, was carried out in more than three in four (n = 93; 78%) women, with almost two-thirds (n = 78; 65%) having surgery ahead of chemotherapy. Thirty-six (30%) women were given neoadjuvant chemotherapy; 5 (4%) did not have surgery; and information on this was not available for 17 (14%).
“Our figures demonstrate that in a real-world setting, symptom-based testing can potentially lead to diagnosis of high-grade serous ovarian cancer with low disease spread and results in a high proportion of complete [surgical removal of the cancer],” wrote the researchers.
The findings also showed that complete surgical removal of cancerous tissue is possible even in patients with more advanced disease, providing that women with suspicious symptoms are expedited for investigation and treatment, they added.
“These findings challenge the assumption that the disease should always be considered to be in its advanced stages in women once they develop symptoms,” they highlighted.
“More importantly, our findings emphasize the importance of increasing an awareness of ovarian cancer symptoms to facilitate earlier diagnosis via referral through the fast-track pathway to improve patient outcomes.”
Disclosure: For full disclosures of the study authors, visit ijgc.bmj.com.
