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Infertility affects one in every 10 couples. About 20 to 25 percent of cases are attributable to ovulatory disturbances.
"Fertility drugs" are potent medicines that infertility specialists use to help couples achieve pregnancy. Many joyful couples are raising "miracle" children thanks to judicious use of these medications.
While thousands of happy mothers rejoice at the good these drugs can do, several recent reports have suggested there is a downside to their use--an increased risk of ovarian cancer among recipients.
It has been recognized for some time that ovarian cancer risk is related to the number of lifetime ovulatory cycles (those cycles in which an egg is released.) Thus women who have had an interruption of these cycles are, in general, at lower risk for ovarian cancer development.
Ovarian cancer risk has been shown to be decreased among women who have had children, breast fed for prolonged intervals, taken birth control pills, or those who have certain ovulatory disorders. All of these interrupt ovulation and allow the ovaries a "rest" from monthly egg release.
Recent reports on ovarian cancer have caused concern among women with infertility, and the physicians who treat them. However, the data are far from definitive and should not be a cause for alarm.
The most commonly prescribed drug for infertility in the United States is clomiphene citrate (Clomid). This drug, and many others used for infertility, works by stimulating the ovary to release one or more eggs during the treatment cycle.
An article in the New England Journal of Medicine last year demonstrated that women who took clomiphene citrate for more than 12 monthly cycles had a higher risk of ovarian tumors than women with infertility who did not take this drug. Treatment for fewer than 12 cycles did not increase risk.
However, since clomiphene citrate is not usually used for more than three to six months, it is unclear what impact this drug has in current practice. Other studies have shown conflicting results regarding the use of fertility drugs and ovarian cancer.
If there is an increased risk for ovarian cancer among women given these medications, it is probably highest among those who are treated for multiple cycles with these medications but do not achieve pregnancy. For women who become pregnant as a result of the therapy, it may be that any increased risk of ovarian cancer is offset by the protective effect of pregnancy.
Further studies of the influence of fertility drugs on ovarian cancer development are in progress. We hope to learn from these investigations whether certain drugs cause a higher risk of ovarian cancer than others, whether achieving pregnancy neutralizes any risks of ovarian cancer posed by the drugs, and if there are other interventions that can lessen the risk of ovarian cancer among patients given these medications.
Since ovarian cancer might not develop for decades following infertility treatment and fertility drugs are a relatively recent medical innovation, research into the link between these agents and ovarian cancer is difficult and requires that infertility patients be followed for long periods of time.
Thus, it may take a number of years to answer all our questions relating to ovarian cancer risk and infertility drugs.
Meanwhile, the recent studies should not dissuade infertile couples from seeking treatment. If fertility drugs are recommended, a frank discussion of the latest research on ovarian cancer risk should be held with the prescribing physician.
Women who have already received fertility drugs or want more information about ovarian cancer risk and current strategies for ovarian cancer screening should contact a gynecologic oncologist (specialist in reproductive tract cancers in women).
-- A.C. "Craig" Evans Jr., MD, PhD, is in the division of gynecologic Oncology at Duke University Medical Center, and has a doctorate in endocrinology.
But brochures on ovarian cancer? Never.
The Information Blackout on America's leading cause of gynecologic cancer death is puzzling, and it is a disgrace.
Ovarian cancer kills more American women every year--a projected 14,500 in 1995--than all other gynecologic cancers combined. Ovarian cancer is the fourth leading cause of cancer death in U.S. women, and has been for some 33 years.
You are a contemporary information-seeking woman who does not have cancer--and you want to reduce your risk of developing it. Or you are dedicated to ending the neglect of ovarian cancer, because you or someone you love has been diagnosed with it.
And so you already know the Information Blackout afflicts most books, magazines, women's organizations and major cancer organizations.
Shame! In 1995, the American Cancer Society, with no sign of shame, mails outdated ovarian-cancer brochures marked 1988.
The taxpayer-funded National Cancer Institute (NCI) turns its back on the millions of well women actively seeking facts to help them stay healthy. Instead, all the NCI's ovarian-cancer materials are pitched at women already diagnosed with the disease...important, but no help to the vast majority of women.
With a strong family history of ovarian cancer, I cowered for decades in the shadow of the Information Blackout.
Turning Point. The turning point came in 1989, while I was writing an article on ovarian cancer. I asked the NCI Press Office, "What is NCI's current budget for ovarian- cancer research?"
To my astonishment, the public servant in the National Cancer Institute Press Office gave me a deceptive answer, both in writing and by telephone. This outrageous action radicalized me for life.
Fighting the Information Blackout on ovarian cancer has become the adventure of my lifetime. The latest result is OVARIAN PLUS, which taps useful information the cancer establishment has not bothered to bring to the general public.
You will not find this comprehensive, "stay well" approach toward ovarian cancer anywhere else. The mission of OVARIAN PLUS is to press for a significant reduction in the number of women who die from ovarian cancer and other gynecologic cancer, through public education.
The other gynecologic cancers are shrouded in the Information Blackout, too. The secondary aim of OVARIAN PLUS is to spotlight every category of cancers "below the belt," including cancers of the vagina and vulva. Even cervical cancer, generally preventable and killing one- third as many U.S. women as ovarian, can occur in health- conscious women. See "Homicide Trial" on page 2. 21st Century. If you are a typical 21st Century woman, you want to work in partnership with your physicians. Some physicians recognize and welcome this trend. You will see their words and their faces in OVARIAN PLUS.
You choose not to wait passively for the paternalistic system to toss crumbs of information. You reject the Information Blackout. OVARIAN PLUS is for you.
-- Ceil Sinnex
Editor & Publisher
Ceil Sinnex is a journalist since 1967. She lobbied successfully to quadruple the ovarian-cancer research budget at the National Cancer Institute, 1992 to 1995; and published a previous ovarian-cancer newsletter. Sinnex keeps in touch with figures in the ovarian-cancer scene around the world.
M. Steven Piver MD is Founder and Director of the Gilda Radner Familial Ovarian Cancer Registry, and Chief of Gynecologic Oncology at Roswell Park Cancer Institute in Buffalo, N.Y.
A.C. "Craig" Evans MD, PhD earned his medical degree and a PhD with distinction in endocrinology at Medical College of Georgia, and is a Fellow in Gynecologic Oncology at Duke University Medical Center.
Arthur C. Fleischer MD is Chief of Diagnostic Sonography and Professor of Obstetrics and Gynecology at Vanderbilt University Medical Center.
Robert C. Bast Jr., M.D., Chief of Medical Oncology at M.D. Anderson Cancer Center in Houston
"We believe it's the first case in the U.S. that involves homicide and a medical laboratory's fatal misdiagnosis," said E. Michael McCann, Milwaukee County District Attorney.
Milwaukee County Circuit Judge David Hanscher will hear the case against the Chem-Bio Corporation of Oak Creek, Wis. Chem-Bio (which has since sold its medical laboratory) is charged with failure to detect cancer in two Pap smears of each victim.
The Smith family won out-of-court settlements totaling more than $6 million, while the Geary family won more than $3 million.
Before her death March 8, Smith asked District Attorney McCann to initiate the investigation.
This evil little test was the cause of purportedly countless "unnecessary" surgeries, and was often inaccurate, according to the news reports. The 4 million CA-125 tests performed in 1993 burdened America's health care budget, or so NIH claimed.
The talking head on my TV then told the nation that ultrasound tests, commonly performed to diagnose ovarian cancer, were guilty of the same unspeakable crimes. Press Machine Speaks. This carefully-cultured product of the NIH press machine was so startlingly ill-reasoned that I could scarcely believe it was based on the same conference I had just witnessed.
I do not own stock in either the company that manufactures the CA-125 test, or in any of that company's competitors; I don't know about the officials at NIH.
Imperfect lab test are a fact of everyday life. But according to the politically-attractive theory put forward by the NIH, if a test can't be accurate and absolutely predictive the vast majority of the time, then it should not be used at all--not for initial diagnosis of ovarian cancer.
Doctors on Parade. The NIH Consensus Development Conference on Ovarian Cancer in Bethesda, Md. seemed carefully orchestrated.
Physicians from Europe had been flown in, presumably at the expense of the American taxpayers, to speak for less than a quarter of an hour.
The second day brought more excitement. David S. Alberts MD of the University of Arizona presented preliminary results of his study of the cytogenetics of ovarian cancer cells, including the suggestion that patients with a negative JSB-1 marker had a survival advantage over those with a positive JSB-1 marker.
"The future lies in molecular therapeutics," Robert C. Bast Jr., MD told the conference. Bast painted a refreshing picture of new research avenues, new drugs under consideration, genetic discoveries and hope for the future. Robert F. Ozols MD outlined future directions and emphasized the need for participants in clinical trials. Miserable Failure. Officially-invited panel members, often reading prepared questions, were given priority over members of the general audience in question and answer sessions. If there are dissenters, they were not invited to speak at NIH.
The Consensus Conference was an opportunity to advance the fight against ovarian cancer. Instead, this conference will be only be remembered for its efforts to deny American women the health care they have the right to demand.
-- Lawrence E. Gawell, JD lost his former fiancee to ovarian cancer. He is an attorney in Cleveland, Ohio.
"What does that mean?" I asked.
"You have a form of ovarian cancer."
My gynecologist gave me this news over the telephone, on my 36th birthday, three days after he removed my right ovary, fallopian tube and a tumor which we had thought was an endometrial cyst, given my long history of endometriosis.
I wasn't exactly unprepared for the news that I had low malignant potential ovarian cancer, but I wasn't ready for it, either.
I sat on the bed and stared straight ahead as he described the disease and explained what he thought would happen next: hysterectomy, perhaps chemotherapy. I didn't cry until my husband, Brian, came upstairs and asked if I was okay.
"I can't have cancer," I thought. "I'm too young. I don't have a family history of this. I take really good care of myself."
After shock came self-blame. "I ate too much dairy," I agonized. "Dyed my hair too many times. Maybe I slept with too many men before I got married."
All sorts of thoughts raged in my brain. I had an anxiety attack and canceled my visit with my parents to celebrate my birthday. I went to bed and stayed there all day.
The next day, I started my research. My tips:
-- Ginnie Lupi, M.A., is a mental health advocate and ovarian cancer activist in Albany, N.Y.
NOTE: Any woman facing surgery for a suspected ovarian or
other gynecologic cancer should consult a gynecologic
oncologist, not a gynecologist.
-- The Editor
INFORMATION WINS. An ovarian-cancer information program is mandated in a bill that was signed into law by New York Gov. George E. Pataki July 25..
The bill appropriates $55,000 to the New York State Health Department to develop and distribute ovarian cancer information in print, multimedia or hotline form.
Assemblywoman Melinda Katz and Senator Ronald Stafford sponsored the bill. Ginnie Lupi of Albany led the lobbying effort to get the bill adopted.
BREAST-OVARIAN LINK OVERLOOKED. "Six percent of all ovarian-cancer patients have had a prior breast cancer--and that's a huge percentage," said Jeffrey G. Schneider, M.D., a medical oncologist at Winthrop University Hospital in Mineola, N.Y.
In Schneider's study of 53 breast-cancer patients who subsequently developed primary epithelial ovarian cancer, 83 percent were not diagnosed with ovarian cancer until advanced stages.
"The real tragedy here is that these women failed to benefit in terms of early detection of their ovarian cancer, despite their prior cancer experience," Schneider said.
Schneider said the study identifies a sub-group of breast cancer patients who should be screened for ovarian cancer, including those diagnosed at unusually young ages, and with a good prognosis for breast cancer, measured by such factors as tumor size and lack of axillary lymph node involvement.
Schneider also found that among women taking the drug Tamoxifen, the median interval between breast and ovarian cancer diagnosis was only 1.9 years. The median interval for women not taking Tamoxifen was 9.2 years.
Presented at the annual meeting of the Society for Gynecologic Oncologists, San Francisco, February 1995.
ESTROGEN CONCERN. Long-term use of estrogen replacement therapy (ERT) may increase the risk of "fatal ovarian cancer", according to a prospective mortality study of 240,073 peri- and postmenopausal women.
Carmen Rodriguez of Emory University and colleagues found that risk appeared to increase with duration of use.
Although previous studies have not strongly supported this conclusion, the authors say strong points of their study include the size of the cohort, or population studied; and the prospective design, which began with healthy subjects and followed them forward in time.
The Rodriguez team found the risk of ovarian cancer death increased 40 percent for women who had taken ERT for at least six years, and 70 percent for women who took ERT for at least 11 years.
Among U.S. women without a family history of ovarian cancer, the lifetime risk of developing the disease is 1.4 percent.
"Women should not be frightened by the American Journal of Epidemiology study," said A.C. "Craig" Evans, MD, Phd. OVARIAN PLUS will be happy to mail a copy of Evans' complete assessment to paid subscribers on request.
Rodriguez Carmen et al, "Estrogen Replacement Therapy and Fatal Ovarian Cancer," American Journal of Epidemiology, 9:828-835, 1995.
TALK TO ME! Cindy Melancon of Amarillo, Texas was not satisfied with the isolation she suffered after an ovarian cancer diagnosis. So she started "Conversations! The Newsletter for Women Who are Fighting Ovarian Cancer" in late 1993.
The monthly newsletter lives up to its title, providing encouragement and networking among women isolated by the disease.
Subscribe by writing to P.O. Box 7948, Amarillo, TX 79114-7948. Subscriptions are free but donations are welcomed.
INFORMATION HOUNDS. The first two in a series of information packets are available from OVARIAN PLUS. Packets include medical and popular articles, correspondence with public officials, and other materials.
The publicly-available materials represent an intensive ongoing collection effort. The charge includes copying, first-class mailing and handling in the U.S. (Outside U.S. please add $5.) Each packet contains about 75 pages.
However, a different newsletter recently published the confusing statement that "the greatest risk factor for ovarian cancer is not a family history of the disease (but is) living in an industrialized country." Although living in an industrialized country may be the most common risk factor, it is not the most important.
Also at increased risk for ovarian cancer are women with family history of endometrial, breast or colon cancer; personal history of breast cancer; and women past menopause.
Women with family history of ovarian cancer should consult a gynecologic oncologist. They may be screened with CA-125 blood test, transvaginal sonography, and pelvic exam every six months. Other options are birth control pills or preventive removal of the ovaries (which reduces but does not eliminate risk.)
All women can reduce their risk of ovarian cancer by eating a low-fat diet; and refraining from use of talc powder in the genital area, the common herbicide Atrazine, and hair dye.
Lynch HT et al, "Hereditary Ovarian Cancer Pedigree Studies, Part II," Cancer Genetics & Cytogenetics 52:161- 183 (1991)
Editor: Ceil Sinnex
Published by Ovarian Plus (TM)
Designed by Aries Graphics & Press
Copyright (C) 1995 by Ceil Sinnex
Mission: To achieve and sustain a significant reduction in the number of women who die from ovarian cancer and other gynecologic cancers, through education.
All rights reserved under international and Pan-American copyright conventions.
Information published in OVARIAN PLUS is not to be construed as medical or professional advice. Readers should always consult their physicians for advice and treatment. OVARIAN PLUS does not endorse any research results or treatments reported.
Bylined articles represent the views of the authors, not necessarily those of the publisher.
The title OVARIAN PLUS is a trademark belonging to Ceil Sinnex.
Permissions: Reproduction of OVARIAN PLUS for distribution without prior written permission is prohibited, except: Bona fide subscribers may reprint up to 100 words without further permission, if they mail a copy to OVARIAN PLUS and credit the newsletter thus: "Reprinted from OVARIAN PLUS: Gynecologic Cancer Prevention News"; and make every attempt to add the name of the author of the piece.
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