For article attached below, develop a simple (1 to 2 paragraph) case study of a typical patient experiencing the symptoms of the condition. Use the article provided to develop your diagnostic criteria, differential diagnosis, and treatment plan. Explain why you chose the plan you propose for your patient. include one fact you found surprising about the disease process
NPR0915_Cover_Puneet.indd Ovarian cancer: Ensuring early diagnosis www.tnpj.com The Nurse Practitioner • September 2015 47 varian cancer is the most fatal of all gynecologic cancers. There is a widespread misconception that ovarian cancer is a “silent killer,” despite fi ndings of common warning symptoms.1-6 Unfortunately, the symp- toms that accompany ovarian cancer are typically subtle and associated with other benign conditions (see Symptoms of ovarian cancer).1,5,7,8 Patients and practitioners therefore tend to overlook the vague symptoms or investigate other potential conditions not associated with the ovaries, ulti- mately leading to late diagnoses.5 In fact, more than 70% of women will be diagnosed in Stage III or IV; less than 30% are diagnosed at Stage I.1-4,6,7 At Stages III and IV, a woman’s chance of surviving 5 years is as low as 20% and 6%, respectively.7 Conversely, women with Stage I ovarian cancer have a 90% chance of surviving 5 years.3,5-9 Diagno- sis at an earlier stage would improve prognosis and greatly increase a woman’s overall chance of survival.3,5 Effective screening programs would help nurse practitioners (NPs) By Christa L.P. Slatnik, NP, RN, BN and Elsie Duff, NP, BScN, MEd O Abstract: Ovarian cancer is the most fatal of all gynecologic malignancies. Despite the lack of a recommended screening test for ovarian cancer, NPs can identify risk factors, ensure patients are aware of subtle symptoms, and provide adequate testing and analysis of results. Keywords: abdominal distension; CA 125; early diagnosis gynecologic malignancy; cancer survival; BRCA1, BRCA2, and MMR mutations; ovarian cancer; pelvic pain; screening; subtle symptoms; ultrasound Ph ot o co ur te sy is to ck © OV ARIAN CANCEREnsuring early diagnosis Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. 48 The Nurse Practitioner • Vol. 40, No. 9 www.tnpj.com Ovarian cancer: Ensuring early diagnosis diagnose patients in the earliest stages of ovarian cancer. Unfortunately, a screening test has yet to be established for ovarian cancer. Recent studies have shown that ovarian cancer may actually originate in a premalignant state with lesions in the distal fallopian tube, which would make the prospect of screening tests able to detect ovarian cancer before it develops promising.3 ■ Why screening is not recommended Over twenty-five years ago, the cancer antigen 125 (CA 125) was considered a promising tumor marker for ovar- ian cancer, and it was initially anticipated that this marker would allow for screening among the general public.3 With further use, however, the CA 125 test was found to lack specificity, as this marker can be increased due to ovarian cancer but also a variety of benign causes (en- dometriosis, age, race, menstrual cycle, pregnancy, and hysterectomy) as well as other malignancies (pancreas, breast, colon, and lung cancers).3 The CA 125 test has also been found to lack sensitivity. For example, although increased levels of this marker have been found in up to 90% of women affected by advanced stages of ovarian cancer, values remain normal in up to 50% of patients in earlier stages of cancer.2,7,8 Due to this lack of specificity and sensitivity, using the CA 125 test as a screening tool for ovarian cancer could lead to stressful false-positives and misleading false-negatives. Therefore, a CA 125 test is not recommended. Transvaginal sonography (TVS) has shown promise in screening for ovarian cancer, as it is highly sensitive to pelvic masses.2 Unfortunately, due to its lack of specifi city, it produces false-positive results that lead to unneces- sary surgical procedures.2,3 If used as a screening tool, the TVS test would require an estimated 5,200 ultrasounds be performed to detect one case of invasive carcinoma.5 Despite the expectation that combining the TVS with the CA 125 would increase the specifi city and help decipher which pelvic masses were malignant, the predictive values were shown to be less than expected (less than 5%) with no notable decrease in mortality from ovarian cancer.3,10,11 Routine screening with the CA 125 and TVS tests com- bined is therefore not recommended due to the increased risk of harm from high rates of false-positive results.5,11 Studies have shown that the screening ability of up to 28 other biomarkers demonstrated no improvement over the CA 125.3,10 However, the human epididymis protein 4 (HE4) is a newer serum biomarker that is showing prom- ise as a potential screening tool when combined with the CA 125 and TVS tests.2,3,8 The HE4 biomarker may aid in screening, since it is more sensitive than other markers. Thirty-two percent of women with ovarian cancer and a negative CA 125 have a positive HE4.2 However, although the HE4 biomarker is highly expressed by ovarian cancers, it is a nonspecifi c test with elevations also occurring with changes in the trachea and salivary gland.2 To date, limited research has been conducted to determine the overall speci- fi city and sensitivity of the HE4 biomarker, especially with effect on morbidity and mortality.2 The U.S. FDA has in turn limited the HE4 biomarker to be used for monitoring the recurrence of ovarian cancer until further research is completed.2 On the whole, more research is essential in order to establish a highly-specifi c and sensitive screening test that will detect ovarian cancer in the earliest of stages, prefer- ably in a premalignant state. Until such a screening test is identifi ed, NPs must pay special attention to those at risk while ensuring all patients are aware of the vague signs and symptoms to watch for and the importance of following up in a timely manner if any arise. ■ Paying special attention to those at risk Even though ovarian cancer can occur in a woman with no established risk factors, identifying those at a higher risk of developing the disease may help the NP ensure adequate awareness and follow up, and in turn, early diagnosis.2,3,5 A family history of ovarian cancer is a risk factor with 5% to 20% of those affected by ovarian cancer having a familial history of the disease.2,3,7 Genetic risk for ovarian cancer has been primarily associated with mutations of the Symptoms of ovarian cancer1,5,7,8 • Recent unexplained, increased abdominal size • Abdominal distension • Bloating • Back or abdominal pain • Pelvic pressure or pain • Loss of appetite • Feeling full quickly • Diffi culty eating • Changes in bowel habits (constipation or diarrhea) • Urinary symptoms (frequency or urgency) • Unexplained weight gain or loss • Fatigue • Postmenopausal bleeding • Menstrual irregularities • Rectal bleeding • Suspected new diagnosis of IBS (particularly if >50 years old) Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. 50 The Nurse Practitioner • Vol. 40, No. 9 www.tnpj.com Ovarian cancer: Ensuring early diagnosis BRCA1, BRCA2, and MMR genes, which increase the life- time risk of developing ovarian cancer from 1.6% to 40%, 18%, and 10%, respectively.3 If a patient has more than one fi rst-degree relative who was diagnosed with ovarian or breast cancer, particularly if they were diagnosed before the age of 50 years, the NP must consider the potential for a BRCA genetic mutation. If a patient has multiple fi rst-degree family members affected by ovarian, breast, endometrial, and/or colon cancers, the NP must consider an MMR mutation or Lynch syndrome.3 Women with certain ethnic backgrounds, such as Ashkenazi Jewish, French Canadian, Dutch, and Icelandic descent, may also be at increased risk of having a genetic susceptibility to ovarian cancer.5,12 Although research ana- lyzing annual screening with the CA 125 and TVS tests has been unable to show any effect on morbidity and mortal- ity among those with a familial risk of ovarian cancer, the National Institutes of Health Consensus Panel on Ovarian Cancer currently recommends routine screening with these tests for those with an established familial or genetic risk.2,3,5 Researchers in the United Kingdom and United States are currently evaluating the effectiveness of a screening pro- gram, which would test younger women with a familial history of ovarian cancer every 3 to 4 months.3 Until more frequent testing has been shown to be effective at decreasing morbidity and mortality, annual CA 125 and TVS tests on those with a familial risk must be combined with adequate assessment of symptoms throughout the year in order to ensure early detection. In spite of the fact that there is a clear genetic link in many cases, approximately 80% to 90% of ovarian can- cers are sporadic, occurring in women with no apparent genetic history.2,3,5 Therefore, it is essential to identify other risk factors (beyond genetics) that could also place a woman at risk for developing ovarian cancer. Age is a common risk factor, with women over the age of 50 years being most likely to develop ovarian cancer.3,7 Interrupted ovulation appears to be a protective factor, as women who have ovulated for fewer years tend to have a lower risk of developing ovarian cancer.3 Because oral contraceptive use, pregnancy, breastfeeding, late menarche, and early menopause all decrease the overall amount of ovulation in a woman’s lifetime, assessing for those who have not had any of these protective factors may identify a woman at higher risk of developing ovarian cancer.3 NPs should also utilize the awareness of the protective factor of inter- rupted ovulation in order to encourage women to com- mence oral contraceptive use and/or breastfeeding when appropriate. Although screening has yet to be established for those with an elevated risk, a future population-based screening program is likely to include a risk-stratifi cation algorithm that details a woman’s risk of developing ovar- ian cancer combined with the CA 125 and TVS tests.3,7 For example, by combining TVS ovarian morphology with CA 125 levels and menopausal status, a “risk of malignancy index” (RMI) can be established to help decrease rates of false-positives and improve detection of ovarian ma- lignancies.3 Pending further research, known risk factors are a useful means for NPs to assess and identify at-risk women who will need immediate follow-up should any suspicious symptoms arise. ■ Acknowledgment of symptoms to ensure early detection Although a