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KATHRYN WHITE
Sydney Cancer Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
PENNY BLOMFIELD
Department of Obstetrics and Gynaecology, Royal Hobart Hospital, University of Tasmania, Hobart, TAS, Australia
ABSTRACT
Ovarian cancer is the most common cause of death due to gynaecological cancers in developed countries. The symptoms of ovarian cancer are common female complaints, are non-specic and do not t any easily recognisable pattern. This frequently leads to a delay in diagnosis. Until an effective screening test becomes available for this disease, increasing the education of women and clinicians regarding the symptoms of ovarian cancer must be seen as a priority. Nurses are ideally placed to disseminate information about the symptoms of ovarian cancer to the community and have a responsibility to do so. It is crucial that nurses are aware of the common symptoms and the usual diagnostic pathway in order to provide empathetic, informed nursing care. This paper draws on the results of a narrative systematic review to describe current knowledge of symptoms of ovarian cancer and describes delays women commonly experience in obtaining a diagnosis.
KEYWORDS: ovarian cancer; symptoms; diagnosis; nursing; experience; women
INTRODUCTION
lthough ovarian cancer is relatively uncommon, it remains the foremost cause of death from gynaecological cancer in Australia (National Breast Cancer Centre [NBCC], 2002) and the western world (Chu & Rubin, 2006:307). As a cause of death from cancer in women, it is fth in the world (Salzberg et al., 2005) and was the ninth most commonly diagnosed cancer in women in Australia in 2005 (Australian Institute of Health & Welfare (AIHW) & Australasian Association
of Cancer Registries [AACR], 2008). In Australia in 2005, 1205 women were diagnosed with ovarian cancer and 888 women died from the disease (AIHW & AACR, 2008). This is despite improvements in treatment in the past 30 years (Bhoola & Hoskins, 2006). In Australia, between 1998 and 2004, patients diagnosed with ovarian cancer had an overall survival rate of 39.8% (AIHW, 2008:179; AIHW, Cancer Australia, & AACR, 2008:7). Most women diagnosed with ovarian cancer are symptomatic. Only a small percentage of
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women presenting with early stage disease will have no symptoms. Due to the non-specic and common nature of the complaints caused by ovarian cancer, there are frequently obstacles encountered in obtaining a diagnosis and therefore delays occur. Most women who are diagnosed with the disease are identied only when the disease is widely disseminated (Behtash, Ghayouri, & Fakhrejani, 2008; Bhoola & Hoskins, 2006; Chan & Selman, 2006; Evans, Ziebland, & McPherson, 2007; Fox & Lyon, 2007; Friedman, Skilling, Udaltsova, & Smith, 2005; Kehoe, 2006; National Comprehensive Cancer Network & American Cancer Society [NCCN & ACS], 2004; NBCC, 2005; Olaitan & McCormack, 2007). While diagnostic tools such as abdominal ultrasound, CA125 blood tests (NCCN & ACS, 2004), computed tomography and magnetic resonance imaging (National Breast and Ovarian Cancer Centre [NBOCC], 2008b) might facilitate the diagnosis of clinically suspected ovarian cancer the disease is usually conrmed as a result of histological examination of tissue removed during surgery (Martin & Cherry, 2006; NBOCC, 2008b). At this time, there is no screening test for ovarian cancer recommended for the general public (Australian Cancer Network (ACN) & NBCC, 2004; National Ovarian Cancer Network [NOCN], 2006). The high mortality rate associated with ovarian cancer is attributed to the fact that it is usually diagnosed at a late stage (American College of Obstetricians and Gynecologists [ACOG], 2002; Chu & Rubin, 2006; Kurman, Visvanathan, Roden, Wu, & Shih, 2008). The stage of the disease at diagnosis has a huge impact on the prognosis (Bankhead et al., 2008). An average of 7075% of women with ovarian cancer are diagnosed at a late stage (ACOG, 2002; Gaetano & Lichtman, 2004; NOCN, 2006). These women have an associated 5-year survival rate of 2030%, in contrast to women diagnosed with an early stage disease, who have a 9095% chance of being cured (ACOG, 2002:237). Given the vast difference in prognosis for those women diagnosed with early
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AIM
The aim of this article is twofold. It aims to rstly describe current knowledge regarding symptoms of ovarian cancer and secondly to examine reasons for delays women commonly experience in obtaining a diagnosis.
METHOD
Systematic review is used as a methodology to identify, evaluate and interpret all available research relevant to a particular topic area or
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Search strategy
In response to the research aims outlined earlier, a search strategy was developed using keyword search terms related to the area of focus; this included terms such as ovarian neoplasms, ovarian cancer, experience, pre-operative period, symptoms and diagnosis. This was combined with an expanded methodological search strategy. The search strategies were run in electronic databases including AMED, CINAHL, EBM Reviews, Medline, Premedline, Proquest, Proquest Dissertation and Theses Full Text and PsychINFO. Additional electronic strategies were utilised for expanding the search depth, such as articles which cite this work and more articles like this. Reference lists of all
articles were reviewed manually to identify additional papers. The search strategy was limited to the time period 19932008. Due to limitations in access to translation, only papers written or translated into English were included. Opinion, editorial or commentary, and any papers not presenting the results of research were also excluded. Literature and systematic reviews were included. A total of 87 papers were examined for this review. Entire papers were obtained, rather than abstracts alone. Editorials, commentaries and unpublished theses identied from the search were subsequently excluded. All eligible papers were included and thus data was extracted from the remaining 56 papers. Of these, 29 were of quantitative design, 11 were literature reviews, one was a systematic review, one used a combination of quantitative and qualitative methods and nine were evidence-based guidelines. Five qualitative studies were also included. This paper will present the data analysis on one aspect of the review presentation, diagnosis and symptom presentations. Data was extracted by the lead author and conrmed by the second author. This data was pooled in six key themes. Discussion of data analysis was ongoing throughout this period. The review of the research will be presented in the six key themes identied from the analysis of the reviewed papers.
RESULTS
A silent disease?
Ovarian cancer has traditionally been referred to as a silent disease, as it was suggested that women do not experience symptoms until the cancer has metastasized widely (Bankhead et al., 2008:10081009; Chan & Selman, 2006; Goff, Mandel, Melancon, & Muntz, 2004; Goff, Mandel, Muntz, & Melancon, 2000; Smith et al., 2005:1398). This may or may not be the case. There is evidence that few women (between 510%) are asymptomatic (Bankhead, Kehoe, & Austoker, 2005; Behtash et al., 2008; Chan, Ng, Lee, Ngan, & Wong, 2003; Fitch, Gray,
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DePetrillo, Franssen, & Howell, 1999; Goff et al., 2000; Lataifeh, Marsden, Robertson, Gebski, & Hacker, 2005; Olson et al., 2001; Partridge & Barnes, 1999; Paulsen, Kaern, Kjaerheim, Trope, & Tretli, 2005) and that most women who have ovarian cancer will describe having symptoms prior to their diagnosis for variable periods of time (Bankhead et al., 2008; Behtash et al., 2008; Ferrell, Smith, Cullinane, & Melancon, 2003; Goff et al., 2004; Lataifeh et al., 2005; Partridge & Barnes, 1999; Paulsen et al., 2005; Webb et al., 2004). Studies comparing women presenting with early and late stage disease do not show major differences in the presence or absence or duration of symptoms. It is suggested that the earlier detection of ovarian cancer would increase the survival rate of women affected with the disease (Goff et al., 2004, 2007; NOCN, 2006; Teneriello & Park, 1995). However, the natural history of ovarian cancer is poorly understood and although women experiencing symptoms often feel let down by the difculties they encounter in establishing a diagnosis, there is no solid evidence to suggest their outcomes would be substantially improved by a more prompt diagnosis. The relationship between the development of symptoms and the extent of ovarian cancers is not well addressed.
Vague symptoms
Ovarian cancer is often a problematic disease to diagnose (Evans et al., 2007; Partridge & Barnes, 1999). This is because the symptoms are frequently not initially recognised by women, and/ or their physicians, as representing a serious illness (Reynolds & Moller, 2006). The symptoms of ovarian cancer are typically vague and non-specic (Cannistra, 2004; Chan & Selman, 2006; Goff et al., 2007; Reynolds & Moller, 2006; Rufford, Jacobs, & Menon, 2007). They may mimic symptoms of other conditions (Fitch, Deane, Howell, & Gray, 2002; NBOCC, 2008c; NOCN, 2006) or be attributed to normal bodily changes due to such things as stress, aging or menopause (Bankhead et al., 2008; Evans et al., 2007; Ferrell et al., 2003; Fitch et al., 2002). The
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and 30 episodes of each symptom per month (Goff et al., 2004). Several authors have attempted to differentiate between symptoms of early and late stage disease (Attanucci et al., 2004; Lataifeh et al., 2005; Ryerson et al., 2007; Webb et al., 2004; Wikborn, Pettersson, Silfversward, & Moberg, 1993). A number of studies reported that gynaecological symptoms (eg abnormal bleeding and pelvic pain) were more common with early stage disease (Ryerson et al., 2007; Webb et al., 2004). Another study reported that abdominal pain was experienced by 51% women with early stage ovarian cancer, versus 44% of women with late stage ovarian cancer (Lataifeh et al., 2005). In contrast, advanced disease was associated with greater abdominal swelling (62%) than early stage disease (32%) (Lataifeh et al., 2005). Similarly, advanced ovarian cancer has been associated with more gastrointestinal symptoms than early stage (Attanucci et al., 2004; Ryerson et al., 2007; Webb et al., 2004), contradicting another study, which found they were more common in early stage patients (Wikborn et al., 1993). Several guides have been published which outline the symptoms that women with ovarian cancer commonly experience. (Outlined below in Table 1).
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TABLE 1: SUMMARY OF CURRENT AUSTRALIAN GUIDES TO THE SYMPTOMS OF OVARIAN CANCER, FOR HEALTH PROFESSIONALS
AND THE PUBLIC
Most common symptoms Abdominal bloating; increased abdominal girth; indigestion, lack of appetite; change in bowel habits; constipation; urinary frequency or incontinence; fatigue; abdominal and/or pelvic pain Abdominal, gastrointestinal, constitutional, urinary, pelvic Abdominal bloating/feeling full, appetite loss, unexplained weight gain, constipation, heartburn, back pain, frequent urination, abdominal/pelvic pain, fatigue Abdominal bloating, abdominal or back pain, appetite loss or feeling full quickly, changes in toilet habits, unexplained weight loss or gain, indigestion or heartburn, fatigue Swollen abdomen, abdominal pain/pressure/discomfort, diarrhoea/constipation, frequency/urgency, unusual vaginal bleeding, early satiety or bloating, indigestion/feeling sick, weight gain/loss, lower back pain, unexplained fatigue, loss of appetite, atulence, dyspareunia Abdominal bloating/feeling full, appetite loss, unexplained weight loss, constipation, heartburn, back pain, frequent urination, abdominal/pelvic pain, fatigue
NBOCC (2008a)
NBOCC (2008b:3)
NBOCC (2009:1)
Abbreviations: ACN Australian Cancer Network; NBCC National Breast Cancer Centre; NBOCC National Breast and Ovarian Cancer Centre.
varied widely between 2 or 3 weeks (Chan et al., 2003) to over 12 months (Goff et al., 2000, 2004; Paulsen et al., 2005). In one study, almost 50% of women waited more than a month before seeking a diagnosis (Thulesius, Lindgren, Olsson, & Hakansson, 2004). In Australia, women sought medical advice for their symptoms after a median of 4 weeks (Webb et al., 2004). A diagnosis of ovarian cancer was an incidental nding for some women (Schaefer, Ladd, Lammers, & Echenberg, 1999; Webb et al., 2004; Yawn et al., 2001). For asymptomatic women the diagnosis is often made at the time of undergoing investigations or treatment for unrelated issues (Vine et al., 2003) such as having a pap smear. Lack of symptoms was more strongly associated with early stage disease: 11% for women with early stage versus 3% for late stage (Goff et al., 2000). In addition, it has been found that women who ignored or rationalised their symptoms were signicantly more likely to be diagnosed with late stage ovarian cancer (Goff et al., 2000).
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in Australia, the median time for diagnosis after seeking medical advice was reported to be 2 weeks (Webb et al., 2004).
Ovarian cancer is the most common cause of death due to gynaecological cancers in women. Although it is not as common as some other cancers, it is associated with signicant morbidity and high mortality rates. Nurses have a responsibility to ensure that their professional practice is based upon current research ndings (ANMC, 2006). Accurate knowledge of the symptoms of ovarian cancer will facilitate their understanding of the diagnosis of the disease thus enabling nurses to provide symptom information and education to members of the community. Nurses can have a signicant impact on community and patient education and on symptom recognition and management (Gaetano & Lichtman, 2004:330). The promotion of community awareness of associated symptoms could facilitate the timely diagnosis of ovarian cancer and thus potentially contribute to reducing the morbidity and mortality of the disease. Until an accurate and reliable screening test is available, the most effective way to diagnose ovarian cancer is for both the woman and her
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doctor to suspect possible ovarian cancer if the woman presents with symptoms (ACOG, 2002; Behtash et al., 2008; Vine et al., 2003). Although the symptoms of ovarian cancer are common and nonspecic, when they are persistent, severe and frequent, prompt investigation should be initiated. Women thus need to be informed and educated about the cluster of ovarian cancer symptoms to enable them to be their own health care advocates (Koldjeski et al., 2005). By having a thorough understanding of the issues associated with the diagnosis of ovarian cancer, nurses will be in a better position to provide informed, optimal health care, to women and their families. This article has described some of the difculties women experience in obtaining a denitive diagnosis and points to how nurses can use their knowledge of the diagnostic process to help women and families cope with the diagnosis and subsequent treatment of ovarian cancer.
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Received 04 May 2009 Accepted 26 October 2009
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Organised into sections on understanding the experience and impact of family violence, systemic and government responses to family violence, and therapeutic responses to family violence, this comprehensive double issue of Journal of Family Studies addresses pressing public health priorities of interpersonal family violence, in 16 innovative research articles across several immigrant cultures.
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