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rare for symptoms to appear at this stage. When symptoms do occur, they typically overlap with those of other illnesses and may include bloating, abdominal, back or pelvic pain, changes in bowel and bladder habits, weight loss, and fatigue. "These nonspecific symptoms of ovarian cancer are what makes diagnosis so difficult," says Alan Astrow, M.D., chief of medical oncology and hematology at New York Methodist Hospital. "Constipation and bloating, for example, are very common. Most women experiencing these symptoms do not have ovarian cancer." When gastrointestinal symptoms are nonresponsive to medications or cannot be explained by diagnostic screening tests like colonoscopies, it may be time to consider another culprit. "If bloating persists for three or four weeks, women should see their gynecologist or ask their primary care doctor for an ultrasound referral," says Katherine Economos, M.D., director of gynecologic oncology at NYM. "Women need to be their own advocates in such circumstances." IN THE ABSENCE OF SCREENING There are no reliable tests to check for ovarian cancer. Annual pelvic exams can help doctors find abnormalities like ovarian masses. Women with a known genetic mutation may choose to have their ovaries removed once they are finished having children. Transvaginal ultrasound—an imaging test in which a scope is inserted into the vagina to view the uterus, ovaries and fallopian tubes—and CA-125 testing, which evaluates levels of the CA-125 protein in the blood, may also be recommended for women who have a higher-than-average ovarian cancer risk. "Roughly 75 percent of cancers that arise from the ovarian surface produce CA-125 protein," Dr. Economos says. "But CA-125 levels can be elevated for reasons other than cancer—for example, if a woman has just started her period or has uterine fibroids." For this reason, CA-125 testing alone is not a recommended screening tool for healthy women who are not experiencing ovarian cancer symptoms, but doctors find it valuable in conjunction with a transvaginal ultrasound and tissue biopsy to diagnose the disease. A ONE-TWO PUNCH The cornerstone of ovarian cancer treatment is surgery to remove the affected ovary. Depending on the extent of disease and whether the cancer has spread to other parts of the body or returned after seemingly successful treatment, physicians may remove both ovaries, as well as the uterus and fallopian tubes (also known as a total hysterectomy). Most women also have chemotherapy in addition to surgery. The average five-year survival rate for ovarian cancer is 45 percent. However, advances in chemotherapeutic treatments are helping women with advanced stages of ovarian cancer live longer. New therapies, including immunotherapies that involve using antibodies to fight cancerous cells, are also on the horizon. "We have several excellent treatments for ovarian cancer," Dr. Astrow says. "But we would like the percentage of women who are cured to be higher, and investigations are underway to improve treatments and cure rates. There is hope that more reliable screening methods and more universally effective treatments will soon be available." W H A T A B O U T O V A R I A N C Y S T S ? Fluid-filled sacs on the ovaries, ovarian cysts can cause localized pelvic pain and symptoms similar to ovarian cancer, including nausea and changes in bowel habits. But cysts are usually nothing more than byproducts of ovulation—the release of eggs from the ovary. Treatment or care beyond a follow-up transvaginal ultrasound to make sure the cyst has not grown or changed is not usually needed. WRITTEN IN THE GENES In recent years, celebrities like Angelina Jolie have brought attention to BRCA1 and BRCA2 gene mutations and their potential impact on women's health. These mutations, which run in families, affect the production of tumor suppressor proteins that are thought to help prevent cancer. Such mutations significantly raise a woman's risk of breast and ovarian cancers. The average woman has approximately a 1.3 percent risk of developing ovarian cancer during her lifetime, but that percentage can jump to almost 45percent by age 70 in women with a BRCA genemutation. Women who have a personal or family history of breast cancer— especially breast cancer that developed before age 50 or in a male relative—should consider being tested. Women who have a personal or family history of ovarian cancer at any age should also consider testing. People of Ashkenazi Jewish heritage are more likely to carry BRCA1 or BRCA2 gene mutations and may benefit from testing. BRCA1 and BRCA2 gene mutations are not the only genetic abnormalities linked to ovarian cancer. Lynch syndrome, an inherited condition caused by harmful variations in one of several genes that play a role in DNA repair, also raises a woman's ovarian cancer risk. Up to 12 percent of women with Lynch syndrome develop ovarian cancer. In addition to ovarian cancer, Lynch syndrome raises a woman's risk of uterine cancer and greatly increases the likelihood that both men and women will develop colorectal cancer. Genetic testing for Lynch syndrome may be recommended for women with a personal and/or family history of uterine cancer and men and women with a personal and/or family history of colorectal cancer that developed before age 50. "Having a genetic mutation doesn't mean that a woman has or will develop cancer," says Karen David, M.D., chief of the division of genetics at NYM. "But it does mean that she is more susceptible to it. Knowing the family history and having genetic testing done as recommended allows women to make more informed decisions about screening and prevention." P H Y S I C I A N RE F E R R A L / / 718 . 49 9. C A RE 11

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