Correspondence

Cancer of the Ovary

N Engl J Med 2005; 352:1268-1269March 24, 2005

Article

To the Editor:

In many women with ovarian cancer, moderate-to-severe pain develops, and many have recurrent bowel obstructions that severely impair the quality of their lives. The otherwise comprehensive review of cancer of the ovary by Cannistra (Dec. 9 issue)1 would have benefited from including reviews of studies of the quality of life of women with ovarian cancer,2 management of their often neuropathic pain,3 nonsurgical options for the treatment of bowel obstruction,4 and medical decision making.5 Similarly, the discussion should have covered the benefits and limitations of parenteral nutrition, hospice referral, and the psychosocial aspects of care.

Ursula Matulonis, M.D.
Janet L. Abrahm, M.D.
Dana–Farber Cancer Institute, Boston, MA 02115
jabrahm@partners.org

5 References

1. 1

   Cannistra SA. Cancer of the ovary. N Engl J Med 2004;351:2519-2529
   Full Text | Web of Science | Medline

2. 2

   Kornblith AB, Thaler HT, Wong G, et al. Quality of life of women with ovarian cancer. Gynecol Oncol 1995;59:231-242
   CrossRef | Web of Science | Medline

3. 3

   Portenoy RK, Kornblith AB, Wong G, et al. Pain in ovarian cancer patients: prevalence, characteristics, and associated symptoms. Cancer 1994;74:907-915
   CrossRef | Web of Science | Medline

4. 4

   Ripamonti C, Twycross R, Baines M, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer 2001;9:223-233
   CrossRef | Web of Science | Medline

5. 5

   Elit L, Charles C, Gold I, et al. Women's perceptions about treatment decision making for ovarian cancer. Gynecol Oncol 2003;88:89-95
   CrossRef | Web of Science | Medline

To the Editor:

Cannistra does not discuss imaging — computed tomography, magnetic resonance imaging, and positron-emission tomography — in the differential diagnosis of ovarian cancer.1 Despite the difficulty of diagnosing ovarian cancer early, the benefit of measuring a combination of tumor markers such as CA-125, carcinoembryonic antigen, and squamous-cell carcinoma–associated antigen might provide an alternative means of finding some early-stage disease of the ovary. Ovarian cancer may mimic gastrointestinal conditions such as Krukenberg's tumor and colorectal adenocarcinoma.2 Furthermore, although the use of laparoscopic surgery in treating ovarian tumors has been increasing in recent years, this article fails to discuss the advantages and disadvantages of such surgery for ovarian tumors and does not recommend follow-up (“second-look”) laparoscopy or laparotomy for early detection of recurrent ovarian cancer.

Ching-Ming Liu, M.D., M.P.H.
Chang Gung Memorial Hospital, Tao-yuan 333, Taiwan
cliu1218.tw@yahoo.com.tw

2 References

1. 1

   Kawahara K, Yoshida Y, Kurokawa T, et al. Evaluation of positron emission tomography with tracer 18-fluorodeoxyglucose in addition to magnetic resonance imaging in the diagnosis of ovarian cancer in selected women after ultrasonography. J Comput Assist Tomogr 2004;28:505-516
   CrossRef | Web of Science | Medline

2. 2

   Yedema CA, Kenemans P, Wobbes T, et al. Use of serum tumor markers in the differential diagnosis between ovarian and colorectal adenocarcinomas. Tumour Biol 1992;13:18-26
   CrossRef | Web of Science | Medline

Author/Editor Response

Drs. Matulonis and Abrahm write about quality-of-life issues, which are, of course, important. Space limitations precluded inclusion of this topic in my review, and the references in their letter provide helpful information for readers.

Dr. Liu asks whether imaging studies with computed tomography, magnetic resonance imaging, and positron-emission tomography play a role in the differential diagnosis of patients with an ovarian mass. In general, it is not necessary to perform these studies preoperatively in cases of suspected epithelial ovarian cancer, and the decision to proceed with surgery for definitive diagnosis is usually based on the clinical examination and findings on transvaginal ultrasonography, as outlined in my review.1 Dr. Liu also mentions that the use of a combination of serum tumor markers might be a more effective screening strategy than the use of CA-125 by itself — a concept that has been proposed by others and is currently under investigation.2

Finally, Dr. Liu raises the possibility that “second-look” laparoscopy or laparotomy might be useful in the detection of persistent disease or early relapse. For patients with advanced epithelial ovarian cancer in whom a clinical complete response occurs after first-line therapy, second-look surgical techniques are known to be more sensitive than clinical examination or radiographic studies in detecting subclinical, persistent disease.1 However, the central issue is whether early institution of second-line chemotherapy for subclinical, asymptomatic disease confers a benefit similar to that of treatment administered at the time of clinical relapse. To date, there is no convincing evidence to support the use of early second-line chemotherapy,3 although in the future it may be reasonable to revisit this issue, after more effective salvage therapy has become available.

Stephen A. Cannistra, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215
scannist@bidmc.harvard.edu

3 References

1. 1

   Cannistra SA. Cancer of the ovary. N Engl J Med 2004;351:2519-2529
   Full Text | Web of Science | Medline

2. 2

   Skates SJ, Horick N, Yu Y, et al. Preoperative sensitivity and specificity for early-stage ovarian cancer when combining cancer antigen CA-125II, CA 15-3, CA 72-4, and macrophage colony-stimulating factor using mixtures of multivariate normal distributions. J Clin Oncol 2004;22:4059-4066
   CrossRef | Web of Science | Medline

3. 3

   Ozols RF, Bundy BN, Greer BE, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. J Clin Oncol 2003;21:3194-3200
   CrossRef | Web of Science | Medline

Citing Articles (4)

Citing Articles

1. 1

   Fang Fang, Curt Balch, Jeanne Schilder, Timothy Breen, Shu Zhang, Changyu Shen, Lang Li, Carol Kulesavage, Anthony J. Snyder, Kenneth P. Nephew, Daniela E. Matei. (2010) A phase 1 and pharmacodynamic study of decitabine in combination with carboplatin in patients with recurrent, platinum-resistant, epithelial ovarian cancer. Cancer 116:17, 4043-4053
   CrossRef

2. 2

   Daniela E. Matei, Kenneth P. Nephew. (2010) Epigenetic therapies for chemoresensitization of epithelial ovarian cancer. Gynecologic Oncology 116:2, 195-201
   CrossRef

3. 3

   Giovanni D. Aletti, Mary M. Gallenberg, William A. Cliby, Aminah Jatoi, Lynn C. Hartmann. (2007) Current Management Strategies for Ovarian Cancer. Mayo Clinic Proceedings 82:6, 751-770
   CrossRef

4. 4

   G. D. Aletti, M. M. Gallenberg, W. A. Cliby, A. Jatoi, L. C. Hartmann. (2007) Current Management Strategies for Ovarian Cancer. Mayo Clinic Proceedings 82:6, 751-770
   CrossRef