Can Ovarian Cancer Be Found Early?

Ovarian cancer is the deadliest of all pelvic cancers for a woman. Overall, about one in seventy-two women will develop this disease. Of these, over half will have died within five years of diagnosis. If ever a disease cried out for a screening test, this would be it. Unlike the breasts, for example, the ovaries lie deep within the body and are therefore less accessible to physical exam. The bimanual pelvic exam is also uncomfortable and the discomfort causes women to tighten the abdominal muscles, making detection that much more difficult. If you add factors such as obesity and scars from Cesareans, you find the examiner's ability to feel the ovaries decreases exponentially.

Ultrasound has been suggested as a screening technique since the 1980's. In the US, the leading proponent of transvaginal ultrasound for ovarian cancer screening has been Dr. Van Nagell's group at the University of Kentucky.

Some have tried utilizing blood markers such as CA-125. Most recently, the group at MD Anderson found that evaluating changes in the level of CA-125 over time and combining that with transvaginal ultrasound yielded promising results in finding more early ovarian cancers.

Others, however, have not met with similar success. The US Preventive Services Task Force, in fact, recommends not screening for ovarian cancer.

Later this year, The UKCTOCS,the largest randomized trial of screening will publish its results, hopefully shedding more light on this issue.

In the meantime, there are some women at significantly higher risk for ovarian cancer, those whose strong family history or genetic tests place in a high risk group. For this group of women, screening, with all its foibles, should be considered. For more information or to schedule an ultrasound, please call: (718) 925-6277.

Dad's Magic Moment

Everyone knows that the prenatal ultrasound provides the opportunity for mom to bond with her baby to be. Even before she first feels movement, seeing that tiny heart's beating, watching those movements, makes it all real. There is ample literature to describe the maternal bonding experience. But what about dad? Few have studied his reactions to the process - that is until now. Dr. Tova Walsh and colleagues at the University of Michigan interviewed 22 expectant fathers after they viewed a midtrimester ultrasound.

They found that the ultrasound experience was an important moment for men, establishing the reality of the coming child, and reassuring them that all was going well with the pregnancy.

It also caused the men to reflect on their roles in the life of mother and child, making it an important practical and psychological preparation for parenthood. The study noted that the men’s “plans and dreams alike extended beyond the immediate future of infancy and across the child’s lifespan.”

One man told the researchers, “Now that we know that it’s a girl, you know, now I’m thinking about ... walking her down the aisle someday, you know, (I’m) thinking that far ahead ... which is crazy, but I mean, it’s like my brain went from bringing her into the world and taking care of her and making sure she is taken care of (as) to her future and everything ...”

Another had more immediate worries: “I need to make sure I have a steady job because my child eating depends on me. If I don’t work, he don’t eat. And I’d rather my child eat before I do.”

Dads have magic moments too.

Walsh is a Robert Wood Johnson Foundation Health & Society Scholar at the UW School of Medicine and Public Health. Her study, “Moving up the Magic Moment: Fathers’ Experience of Prenatal Ultrasound,” is being published in the winter 2014 edition of the journal "Fathering".

For more information, or to schedule an appointment for an ultrasound, call: (718) 925 - 6277.

Abnormal Bleeding - My Doctor Scheduled An Ultrasound

Abnormal bleeding is one of the most common reasons for a woman to seek medical attention. About ten to thirty percent of reproductive age women will experience some form of menstrual disturbance. There is a whole laundry list of causes, including stress, underlying hormone imbalance, tumors, clotting disorders and even cigarette smoking. While a disturbance in the normal hormone fluctuation may be the most common reason, it is not the only cause. For this reason, an ultrasound is often performed, usually with transvaginal views. The transvaginal approach obviates the need for that overly filled bladder and can often more easily see pathology such as submucus fibroids or endometrial polyps. The thickness of the uterine lining can also be measured as well.

Sometimes, a 3D sonogram is done to note the architecture of the uterine cavity and to further delineate suspected intracavitary pathology. Finally, if either there is the suspicion of focal pathology or to amplify the findings from the sonogram, a saline sonohysterogram can be performed.

Depending on the results of these tests, further evaluation and treatment can be discussed. For more information or to schedule an ultrasound, call: (718) 925 - 6277.

My Placenta Is Low-Lying. Now What?

Now that most pregnant women have a midpregnancy ultrasound, they are often alerted to findings of uncertain significance. One of the most common of these involves the placenta. A placenta is low-lying when the lower edge extends to within 2 centimeters of the internal cervical opening or os. This is different from a placenta previa which actually covers the internal os. A group of investigators at the Brigham and Women's Hospital in Boston reported on their experience with the eventual outcome of pregnancies complicated by these low placentas.

Here's the short answer: Most of these situations resolve by the end of the pregnancy.

In total, 1220 of 1240 low-lying placentas (98.4%) that had sonographic follow up resolved to no previa before delivery; 89.9% of placentas cleared the cervix by 32 weeks, and 95.9% cleared by 36 weeks.

A small minority were not so lucky.

Twenty patients (1.6%) had persistent sonographic placenta previa or a low-lying placenta at or near term, including 5 complete previas, 7 marginal previas, 5 low-lying placentas, and 3 vasa previas; all had cesarean deliveries.

So, about 98/100 times all turns out well. In about 2/100 cases, the situation persists. Moreover, a very few unfortunate women were found to have vasa previa, a condition in which fetal blood vessels actually cross that internal os in front of the baby. Think about that for a moment. If the baby descends toward the birth canal and puts pressure on these blood vessels, those vessels can tear, resulting in a fetal hemorrhage, often severe.

So what should be the plan if they do find a low-lying placenta during your ultrasound? The authors suggest a repeat sonogram after 28-30 weeks to confirm resolution, repeating again at 34-36 weeks if the situation remains the same. During those studies, a search for vasa previa can also be conducted.

So if you're told you have a low-lying placenta, you should be optimistic but should follow up. The late Ronald Reagan said it best: "Trust but verify."

For more information or to schedule an ultrasound, please call: (718) 925-6277.

New UK Project To Improve Prenatal Detection of Birth Defects

Presently, most if not all pregnant women undergo at least two sonograms during pregnancy for the purpose of screening for serious birth defects - the first at 11.5 - 14 weeks and the second at about 20 weeks. While some abnormalities are virtually always detected, many still are missed for a variety of reasons. For one thing, mom's with increased weight gain pose a technical imaging problem as the ultrasound frequency necessary for sufficient penetration may not yield the optimal resolution. Another factor is the fetal position - "if the baby has his back to the camera, you don't get a good picture." For these reasons and more, a groups of investigators at Kings College London are trying to see if technology can solve these issues.

Professor Reza Razavi and colleagues at King's College London, as part of King's Health Partners Academic Health Sciences Centre, have been awarded funding under the joint Wellcome Trust and EPSRC Innovative Engineering for Health scheme to develop a fully automated and computer-guided ultrasound system, which will allow midwives to acquire three-dimensional images of a whole baby in a much higher resolution than is currently possible. The team are also aiming to develop computer software that will be able to automatically analyse the images acquired. These techniques should substantially improve detection rates of congenital abnormalities.

Professor Razavi, who is Head of Imaging Sciences at King's College London and Director of Research at King's Health Partners, said: "Identifying birth defects at an early stage is essential both for medical professionals and for the parents themselves. Current ultrasound scans are relatively crude and many serious abnormalities are not detected, leading to these babies becoming very ill soon after birth, and substantial delay before a diagnosis is made and they can be transferred to a specialist centre for appropriate treatment.

"We are developing a radically new approach to fetal screening, largely removing the need for experts to acquire and interpret the images. It will allow the initial screening scans to be done in a few minutes, and provide a consistently higher detection rate for major abnormalities."

I wish them well.

For more information or to schedule an appointment for an ultrasound, call: (718) 925-6277.

Irregular Cycles May Be More Than An Annoyance

It's been a theory that infrequent ovulation may have some beneficial effect at lessening the risk for ovarian cancer. Women who take oral contraceptives, for example, have a lower incidence. This protective effect of irregular cycles may not always hold true. At the recent American Association for Cancer Research (AACR) meeting, Barbara Cohn, Director of Child Health and Development Studies at the Public Health Institute in Berkeley, CA presented some evidence that irregular cycles may actually be a risk factor for later development of ovarian cancer.

Background. Early detection of ovarian cancer has proved elusive, resulting in poor survival. This is the first prospective study to link a common reproductive condition to risk. Polycystic ovarian syndrome (PCOS) is an endocrine disorder, characterized by irregular menstrual cycles with long-term health consequences. Although some women with PCOS are infertile, the majority achieve pregnancy. It has been suggested that women with less frequent ovulation are protected, however, previous reports are inconsistent. Here we examine whether irregular cycling is associated with subsequent ovarian cancer death in a large prospective pregnancy cohort, The Child Health and Development Studies.

Methods. Subjects were 14,403 pregnant women recruited from the Kaiser Permanente Health Plan in 1959-1967 and followed for over 50 years. Menstrual irregularity, cycles >35 days or anovulation, was a proxy for PCOS, identified from medical record and self-report, at a median age of 26 years in 13% of women. Linkage to California Vital Statistics and National Death Index records identified 64 ovarian cancer deaths diagnosed at a median age of 69 years.

Results. Contrary to expectations, women with irregular cycles had a two-fold greater risk of ovarian cancer (Hazard Ratio=2.4; 95% Confidence Interval=1.3,4.5), independent of age, race, parity, and weight. This association was specific to cancer of the ovary - no association was observed for breast or uterine cancer - and it increased over the follow-up period (p=0.08 for time-dependence).

Conclusions. This is the first large prospective study of irregular cycles as an early marker of ovarian cancer. If confirmed, women with irregular cycles could be targeted for screening. This finding offers a strategy to search for antecedent ovarian cancer biomarkers, creating the opportunity for new early detection strategies.

It's not clear what exactly is going on here. Could later cancer be a side effect of abnormal hormone fluctuations? Could this be a receptor issue in the ovary iteslf? Or could the underlying cause of the hormone pathophysiology be the culprit? It's far too soon to know the answer but further research is clearly needed.

At this point, the best advice is to discuss your concerns with your gynecologist. For more information or to schedule an appointment for a pelvic ultrasound, please call: (718) 925-6277.

Maternal Weight And Stillbirth

This past week in the Journal of the American Medical Association, a statistical analysis of 38 studies of moms' weight either prior to pregnancy or in early pregnancy showed a relationship between maternal BMI and risk of stillbirth. The loss of a wanted pregnancy at any gestational age is tragic but the worst has to be a fetal death in the few weeks prior to birth. The nursery has been set up. The birth announcements prepared. Often, the room is packed with gifts from the baby shower. All this adds to the immense suffering of the loss of a child.

So how is maternal weight linked to stillbirth? The authors suggest the possibility that the increased amount of adipose tissue may exert metabolic effects which affect placental function. We already know the effect of weight, fat, and type 2 diabetes, for example. A similar altered biology may be at work here as well. Another possibility is that heavier women become less sensitive to fetal movement and are thus less apt to pick up on the signals of decreasing fetal movement. The lack of this alarm mechanism may miss that narrow window for life-saving intervention.

So what should a woman considering having a baby do in light of this information? The best, obviously, is to get as close to ideal body weight as possible prior to conception. When this is not possible, early prenatal care would be essential, with a special emphasis to nutritional counseling. As pregnancy enters the "home stretch," certain tests of fetal well-being can be considered - monitoring or non-stress tests, serial ultrasounds for fetal growth, and biophysical profiles. Additionally, fetal kick counts can be done at home which require no sophisticated equipment.

Moms to be should voice any concerns with their Obstetricians. For more information, or to schedule an appointment for an ultrasound, you can call my office at: (718) 925 - 6277.