Genetic Considerations

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Only 10% of ovarian cancer cases are believed to be genetic in etiology. Susceptibility to ovarian cancer coexists with breast cancer susceptibility when BRCA1/2 mutations are present. Breast/ovarian cancer can be transmitted through families as an autosomal dominant trait from

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either the mother's or the father's side of the family. The likelihood that ovarian cancer is inherited increases if two or more relatives are affected with ovarian cancer or several relatives are affected with breast and/or ovarian cancer. Genetic risk is also increased if breast and ovarian cancer occur in the same person, there is Ashkenasi Jewish heritage, or there are family members who carry the BRCA1/2 or HNPCC gene mutations.

The incidence of ovarian cancer is highest in postmeopausal women, with 50% of the cases occuring in women who are greater than 63 years of age. In rare instances, the disease can occur in childhood and during pregnancy. In the general population, ovarian cancer occurs in 1 in 70 women; the risk is increased to 5% if one first-degree relative has the disease. Ethnicity and race have no known effects on the risk for ovarian cancer.

HISTORY. Elicit a detailed family history of all cancer-related illnesses, paying particular attention to the history of female relatives. The patient's descriptions of the signs and symptoms vary with the tumor's size and location; symptoms usually do not occur until after tumor metastasis. The symptoms patients most commonly report are back pain, fatigue, bloating, constipation, abodomi-nal pain and urinary urgency. Most patients with ovarian cancer have at least two of these symptoms. Other symptoms include urinary frequency, abdominal distension, pelvic pressure, vaginal bleeding, leg pain, and weight loss. Pelvic discomfort and acute pelvic pain may occur, and if infection, tumor rupture, or torsion has resulted, the pain may resemble that of acute appendicitis.

PHYSICAL EXAMINATION. The patient often appears thin and chronically ill. Her abdomen may be grossly distended, but her extremities are thin and even wasted. When you palpate the abdominal organs, you may be able to feel masses. During the vaginal examination, you may be able to palpate an ovary in postmenopausal women that feels like the size of an ovary in pre-menopausal women. An ovarian tumor may feel hard like a rock or pebble, may feel rubbery, or may have a cystlike quality. Palpation of an irregular, nodular ("handful of knuckles"), insensitive bilateral mass in the pelvis strongly suggests the presence of an ovarian tumor.

PSYCHOSOCIAL. If the patient is a young woman who needs to undergo surgery and loses her childbearing ability, determine the meaning of children to her and her partner. Consider the patient's developmental level, financial resources, job responsibilities, home care responsibilities, and the degree of independence of any children. If the patient is a child, determine whether or not her parents have told her she has cancer. If the prognosis of the patient's cancer is poor, determine the patient's degree of understanding of the gravity of the prognosis. Determine the effect of the patient's religion and spirituality on the course of the disease.

Diagnostic Highlights

General Comments: None of the tumor markers is specific enough to be considered for routine screening, but they are helpful in differential diagnosis of pelvic masses and to follow-up treated cases.

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