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VOL. 4 • NO. 4

© DECEMBER 2009 PHOTO: COURTESY OF BOSTON MEDICAL CENTER

Ovarian cancer: Ending the “silent killer” myth

Maria Pinheiro, who survived two bouts with ovarian cancer, struts out front in the 2009 Ovarian Cancer Walk. Pinheiro is wearing teal, the official color of ovarian cancer.

Young survivor shares her story The moment of discovery occurred when Chana Garcia was having an ultrasound performed on her abdomen. She had been complaining for months about discomfort and indigestion and a strange gurgling sound coming from her stomach. But her doctors couldn’t find anything. She thought the problems were the result of a recent trip to Mexico where she admits that she might have had a few too many glasses of wine or roadside tacos or even some of the contaminated water. What was odd, she recalls, is that she was losing weight and feeling bloated at the same time. For two months her gastroenterologist, a specialist in diseases of the digestive tract, could not find the source of her discomfort. The ultrasound eventually marked the start of her diagnosis. It was the technician’s response that got Garcia’s attention. “She kept clicking away over the same spot — as if some-

P H O TO : Courtesy of C hana Garcia

prior approval from her insurance carrier. But when they opted to perform the procedure at no charge, “I knew something was wrong,” she said. Garcia still remembers the technician’s parting words. “Good luck, the tech said. “You’re going to be OK.” At that point, panic set in. As a 33-year-old African American woman, ovarian cancer is not a likely condiChana Garcia (left), who works with Ovarian Cancer tion. But her test results National Alliance, is shown with actress Kelly Washington (right), a spokesperson for L’Oreal Color of Hope, L’Oreal confirmed an exception to the norm. Paris’ campaign for ovarian cancer awareness. Garcia had two large thing looked bizarre,” she said. masses — one the size of a softball When a transvaginal ultrasound — blocking her ovaries. A subsequent — a pelvic ultrasound used to examine blood test for CA125, a protein found in a woman’s reproductive organs — was greater concentration in ovarian cancer recommended, Garcia knew she required Garcia, continued to page 

test — CA125 — that determines the level of a specific type of protein found in ovarian malignancies. But some studies have indicated that this protocol may not result in improved survival rates. The problem is detecting the symptoms and making the right diagnosis. All too often, women are incorrectly diagnosed as having urinary or digestive problems and treated for those sorts of ailments. But a study published in the Journal of the American Medical Association in 2004 reported that four symptoms in particular — bloating with increased abdominal size, urinary problems, pelvic pain and trouble eating — were found more often in those with ovarian cancer. The study further revealed that the symptoms signaled a stark contrast from the norm and were frequent, persistent and severe. So significant was this finding that in June 2007, the American Cancer Society, in concert with the Gynecologic Cancer Foundation and the Society of Gynecologic Pinheiro, continued to page 

The disparity of ovarian cancer While blacks have one of the lowest incidence rates of ovarian cancer, between 2002 and 2006, they had the highest death rates of all minorities. Incidence 15

Incidence Rates

would require six cycles of chemotherapy following her surgery. Pinheiro is now 57 and thankful that she learned those valuable lessons. “Thank God I had that pain,” she said. “It forced me to go [to get treatment] right away.” And that’s the key — early detection. When cases are caught very early — which occurs less than 20 percent of the time — the five-year survival rate exceeds 90 percent. It drops to 31 percent if the cancer spreads to other parts of the body. Unlike cervical cancer, which touts Pap tests for screening and Gardasil for prevention, ovarian cancer offers no comparable solution. “We’re still looking for a test,” said Dr. Colleen Feltmate, a gynecologic oncologist at Brigham and Women’s Hospital, “But it’s like looking for a needle in a haystack.” Although some tests are recommended for those of very high risk, Feltmate warns that they remain imperfect. The protocol consists of a transvaginal ultrasound every six months as well as a blood

13.8

12

9.9

10.1

Asian

Black

10.8

11.3

9 6 3 0

American Hispanic Indian

White

Race Mortality 10

9.1

8

Mortality Rates

It was bad enough that Maria Pinheiro combined. Although it accounts for only 3 was waking up throughout the night to visit percent of all cancers found in women, it the bathroom. What was worse, she said, trails only lung, breast, colon and pancrewas feeling bloated all the time. atic cancers in mortality rates. It was more than a feeling. “My stomThe list of luminaries who succumbed ach got so big I had to buy a bigger dress to the disease is long. Gilda Radner of to attend a wedding,” she said. “Everyone Saturday Night Live fame helped bring the thought I was pregnant. I just thought I was disease to the forefront. Ann Dunham, the gaining weight.” mother of President Obama, died at the age Those were of 52, while Coretta not the only red Scott King sought Ovarian cancer is flags that Pinheiro alternative treatment initially ignored. for her advanced the second most She had trouble diagnosis. common cancer of the eating and felt According to full after only a the American Cancer reproductive system, few bites. But it Society, almost 22,000 was the constant new cases of ovarian but the most deadly, pains in her lower cancer are estimated killing more women than for 2009 and 15,000 back and pelvis that drove her to deaths. The incidence all other gynecological the doctor. She in black women is thought they were one of the lowest, but cancers combined. the result of her blacks die at a higher overdoing it while rate than all other repainting a room minorities. in her house. It’s little wonder that Pinheiro ended She was quite mistaken, and learned a up in an emergency room after a night of valuable lesson about the very real sympextreme pain and discomfort. At first, doctoms of what many believe to be a silent tors thought the cause was kidney stones. killer: ovarian cancer is not all that silent. They later learned the real problem after “I was crying and rolling in bed with reviewing the CT scan results — she had the pain,” she remembered. a deadly mass on her left ovary. She was She was 42 years old at the time, and transferred immediately to Boston Medical while the median age for those diagnosed Center and underwent a complete hysterecwith ovarian cancer is 63, she also learned tomy the following day. an equally important lesson: older women She had Stage IC ovarian cancer. As are not the only targets. cancers go, that wasn’t necessarily all bad Ovarian cancer is the second most news. The good news was that the cancommon cancer of the reproductive system, cer was limited to the one stricken ovary. but the most deadly, killing more women But the bad news was that the cancer had than all other gynecological cancers broken from the confines of the ovary and

6.0

6

6.8

7.3

4.9 4 2 0 Asian

Hispanic American Indian

Black

White

Race

Figures are age-adjusted to the 2000 U.S. standard population, per 100,000 women Source: SEER Cancer Statistics Review, 19762006, National Cancer Institute, Bethesda, Md.

Obscure symptoms should not be overlooked

O

varian cancer’s signs are subtle and there is no annual or early marker test available, which makes the disease challenging to detect. According to Ovations for the Cure, a national ovarian cancer foundation, each day 62 women in the United States are diagnosed with ovarian cancer and 43 lose their fight. However, if detected early (Stage I), with proper treatment ovarian cancer is highly survivable with a 94 percent survival rate. Women can be prepared by knowing the risks and symptoms, the tests required for diagnosis and the treatments available.

Risks and risk reduction

According to the American Cancer Society (ACS), most women have one or more risk factors for ovarian cancer. Risk factors can include age (women over 50 are at higher risk), obesity, and family history, among other factors. Although ovarian cancer is not preventable, some strategies may reduce its incidence. According to the ACS, following a healthy diet, giving birth, and using oral contraceptives (birth control pills) can decrease the risk of developing ovarian cancer. In the case of oral contraceptives, women who used birth control pills for five or more years have about a 50 percent lower risk of developing ovarian cancer compared with women who never used the pill. Some women with a strong family history of ovarian cancer may want to consider genetic testing for mutations in BRCA1 and BRCA2 — two genes that normally suppress the growth of tumors. Women who carry the mutation can have a more than 50 percent lifetime risk of ovarian cancer. Testing can help predict a woman’s likelihood of developing the disease, which can allow her to discuss preventive options with her doctor. One such option for women of very high risk who have finished having children is prophylactic, or risk-reducing surgery – removal of the ovaries in order to prevent the occurrence of ovarian cancer. Prophylactic surgery can reduce the risk of cancer by up to 95 percent and is often advised for women with mutated BRCA1 and BRCA2 genes.

When to see a doctor

If you experience persistent symptoms of bloating, pelvic and abdominal pain, trouble eating, feeling full quickly, change in bowel movements, it is recommended that you see

a gynecologist. These symptoms can signal a urinary or digestive problem. But they also might signal ovarian cancer, and should be evaluated further. The gynecologist may suggest seeing a gynecologic oncologist, who specializes in the treatment of cancer of the reproductive system. Preparing for your appointment with the doctor can help answer your questions, ensure the doctor looks for the right things, and can make you feel more in control of your health care decisions. To prepare, visit these sites for helpful information: • Ovations for the Cure at www.ovationsforthecure.org; • The American Cancer Society at www.cancer.org, or call their 24-hour phone line at 1-800-227-2345. The Partnership for Healthcare Excellence (www. partnership forhealth care.org) suggests other helpful things to bring to any doctor’s appointment, including a list of the symptoms you are experiencing, a list of your medications, and a pad of paper and pen to take notes. If ovarian cancer is suspected after discussing the symptoms, the gynecologic oncologist will schedule tests to confirm the diagnosis. Most often imaging tests — CT scans, MRIs and ultrasounds — are ordered, which can confirm the existence of a mass. A blood test — CA125 — checks for the level of a protein that is often elevated in women with ovarian cancer. A CA125 alone cannot diagnose ovarian cancer, since many other conditions, such as uterine fibroids, inflammation of the pancreas, and even pregnancy can cause an elevated

result. However, elevation of the protein in combination with a positive scan or ultrasound and a confirmed mass, can indicate ovarian cancer. The only way to confirm a cancer diagnosis is by conducting a biopsy, which surgically removes a portion of the tissue.

Ask questions

When diagnosed, understanding the stage of the disease, treatment options, knowing risks and complications of treatment are all important factors. Ensure questions are asked and answered. Below is a printable list of some questions suggested by Ovations for the Cure: • What type of ovarian cancer do I have? • Has my cancer spread beyond the ovaries? At what stage does that put me? • What treatment options or medications do you recommend for me? • Will I need surgery and, if so, how extensive should it be? • How long will I need chemotherapy? • What risks or side effects should I expect from different treatment options? • Given the treatment options we discussed, how likely is it that my cancer returns? • What is my expected prognosis? • How will we know whether the cancer has returned? • Will I be able to have children? • Are there any clinical trials or experimental therapies for which I might qualify? • Should I or anyone else in my family be tested for BRCA1 mutation?

Staging

There are four stages of ovarian cancer, and the prognosis is different for each stage. According to the American Cancer Society, each stage is then subdivided into distinct categories. It is extremely important that ovarian cancer be staged properly since treatment depends on the staging. Stage I: The cancer is confined to one or both ovaries. Stage II: The cancer has spread into the pelvis and may involve other organs such as the uterus, bladder or rectum. Stage III: The cancer has spread outside the pelvis to the lining of the abdomen and may involve lymph nodes. Stage IV: The cancer is advanced and has spread to organs such as the liver or lungs. The five-year survival rate for Stage 1 can be up to 94 percent depending on which subgroup the cancer is in, so the diagnosis of ovarian cancer is highly survivable if caught early.

Treatment

According to the National Cancer Institute, three kinds of treatment are used to fight ovarian cancer, sometimes in combination. An oncologist will advise on treatment options. The cornerstone of treatment is surgery in which as much of the cancer is removed as possible. Typically patients have a total hysterectomy, removing the ovaries, Fallopian tubes, uterus and cervix, but not always. Each patient is different, and the treatment can vary. The second method is chemotherapy, which uses drugs to either kill the cancer cells or stop them from dividing. The medicine can be taken orally or intravenously. In some advanced cases of ovarian cancer, chemotherapy is administered directly into the abdominal cavity through a catheter in a procedure called intraperitoneal chemotherapy. Radiation — the use of high energy x-rays — is another way of treating ovarian cancer, but is rarely used these days. After completing treatment, the American Cancer Society advises continued follow-up care as long as it is recommended. Dr. Karen Boudreau of Blue Cross Blue Shield of Massachusetts noted, “ovarian cancer is often silent or has symptoms that can be masked by other diseases making it difficult to detect. So be sure you are aware of the symptoms and risks and talk with your gynecologist if you have concerns. The relationship with your doctor is a partnership — it’s up to you to ensure you are sharing your symptoms and your concerns.”

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Ovarian cancer Questions & Answers 1. Does the Pap test screen for ovarian cancer? No. The Pap test (also called a Pap smear) is used to test for cervical cancers and infections and does not screen for ovarian cancer. There is currently no standard way to screen for ovarian cancer aside from possible detection during an annual pelvic exam by your doctor. For patients who have specific Joseph R. Betancourt, M.D. symptoms or are of very high risk, docDirector of the Disparities Solutions Center, Massachusetts tors can order a transvaginal ultrasound General Hospital that provides an image of the ovaries as well as a CA-125, a test that detects a protein in the blood that is often higher in many women with ovarian cancer. The ultrasound and CA-125, however, are not recommended for screening women without known strong risk factors for ovarian cancer. 2. Can a woman get ovarian cancer if she has no family history of the disease? Although most women who get ovarian cancer have no risk other than age, all women should be familiar with the factors that increase its incidence. A woman who has a first degree relative (mother, sister, or daughter) with ovarian cancer has a higher risk. Also, up to 10 percent of the cases are genetic and run in families with a higher rate of breast, ovarian, colon and uterine cancer. 3. Do birth control pills cause ovarian cancer? Actually, it’s the opposite. Research has consistently shown that birth control pills (oral contraceptives) reduce the risk of ovarian cancer in women. One large study found that the longer women used the pill, the lower their risk of developing ovarian cancer. Yet birth control pills are not recommended by the American Cancer Society as a way to prevent ovarian cancer. Some research suggests that contraceptives may slightly increase a woman’s risk for breast or cervical cancer, or blood clots, especially in smokers. Speak with your doctor to learn which options are best for you. 4. Does obesity increase the risk of ovarian cancer? The connection between obesity and ovarian cancer is not clear, but recent research has shown some interesting results. Premenopausal women with a body mass index over 30 (considered obese) had a higher risk of ovarian cancer than obese postmenopausal women. Furthermore, according to the American Cancer Society, the death rate from ovarian cancer is higher in obese women. 5. Can a father’s family history of ovarian cancer increase the risk in his daughters? Yes. Some ovarian cancers are caused by mutation in genes that are passed down from both parents. Therefore, inheritance of the defective gene from your father can increase your risk of breast, colon and ovarian cancer. 6. Can ovarian cancer be found early? It is possible, but only 19 percent of ovarian cancers are detected at an early stage largely due to confusion of symptoms with gastrointestinal or urinary problems. When ovarian cancers are found early the five year survival rate exceeds 90 percent. The disease is hard to diagnose since there is no basic screening test aside from the annual pelvic exam. But even the most skilled clinician cannot always feel early ovarian tumors, especially if they are very small. 7. Is there a link between breast cancer and ovarian cancer? Yes. Both cancers can be caused by a mutation in BRCA1 and BRCA2 — two genes that normally prevent uncontrolled cell growth. Therefore, women who have had breast cancer have an increased risk of developing ovarian cancer, especially if breast cancer was diagnosed before the age of 50. Marina C. Cervantes of the Disparities Solutions Center participated in the preparation of these responses.

Risk factors

• Age — incidence increases with age • Reproductive history — not having children or infertility • Inherited gene mutations for ovarian, breast, uterine and colon cancers • Personal history of breast cancer • Family history — higher risk if mother or sister has ovarian cancer • Hormone replacement therapy • Race — more common in whites • Obesity

A closer look The two ovaries — about the size and shape of an olive — sit on either side of the uterus. They produce eggs for reproduction and the female hormones estrogen and progesterone. The majority of ovarian cancers start in the outer surface, or epithelium of the ovary. The remaining cancers develop within the ovary either from the cells that produce eggs or the cells that produce hormones.

Signs and symptoms The following symptoms are more likely to occur in women with ovarian cancer than women in the general population. If they are persistent, severe, occur almost daily for more than two to three weeks and represent a change from normal, they should be checked out by a gynecologist. • Bloating • Frequent or urgent urination • Pelvic or abdominal pain • Difficulty eating or feeling full quickly Other symptoms may occur, but are found in the same frequency as women in the general population who do not have ovarian cancer. • Nausea • Indigestion or upset stomach • Constipation • Diarrhea

• Menstrual irregularities • Pain during intercourse • Fatigue • Back pain

Healing the racial divide in health care

Dr. Joseph Betancourt wrote the book on health care disparities. Now he’s trying to erase them. When Joseph Betancourt was in medical school, he often saw children acting as interpreters for family members who did not speak English. Originally from Puerto Rico, and as the only Spanish-speaking medical student on his team, he had to interpret for hospitalized patients. Years later, Joseph Betancourt, MD, MPH, co-authored a landmark study by the Institute of Medicine that found striking inequities in health and health care for racial and ethnic minorities across the US. When Massachusetts General Hospital president Peter Slavin, MD created the Disparities Solutions Center at MGH, he chose Dr. Betancourt to lead it. “It is time to move from diagnosing the problem to treating it,” said Dr. Slavin. The MGH Center is the first hospital-based Disparities Solutions Center in the country to move disparities beyond research into policy and practice. It has $3 million in support from MGH and Partners HealthCare. The Disparities Solutions Center will: • advise MGH in its efforts to identify and address racial and ethnic disparities in care; • develop and evaluate customized solutions to

eliminate disparities in the health care community in Boston and beyond; • educate, train and expand the number of leaders working to end disparities nationwide. Perhaps most important, the center will transfer what it learns to hospitals and health centers, community groups, insurers, medical schools, educators, government officials, and of course, physicians and nurses across the country. One of the Center’s first efforts is the new Diabetes Management Program at the MGH Chelsea Health Care Center, where more than 50 percent of patients are Latino. Latinos are more likely than whites to die from diabetes complications including kidney failure, blindness, heart disease, and amputations. MGH Chelsea health professionals will help patients control their diabetes, get regular screenings, and prevent complications through telephone outreach, individual coaching, and group education sessions in English — and Spanish. Translating talk into action is what Dr. Betancourt has been doing all his life. More information at Boston Public Health Commission at www.bphc.org

A charitable non-profit organization

The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex and risk factors, and make timely visits to your primary care physician.

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Pinheiro

directly into the abdomen for those with advanced cases. The surgery — called Cancer Center, for her treatment. Within continued from page  Oncologists, formed a consensus statement debulking — involves the removal of the two weeks of her diagnosis she underwent agreeing that the four symptoms signaled uterus, Fallopian tubes, ovaries as well as cells, was extremely high. surgery — a complete hysterectomy and ovarian cancer — and finally confirmed abdominal fat (omentum) and any other Instead of a normal reading of less lymph node removal. what Pinheiro learned the hard way: ovarsigns of disease. than 35, her results were over 1000, acThe surgery confirmed what she ian cancer is not a “silent killer.” “The idea is to get it down to no viscording to Garcia. Experts maintain that already knew — she had Stage IIIC ovarian “Any symptom [of ovarian cancer] ible tumor,” Feltmate explained. “Less than a reading greater than 65 in combination cancer. Eventually, she started on six rounds that persists for more than a couple of one centimeter is ideal. It’s predictive of a with a pelvic mass reveals cancer in about of intravenous and intraperitoneal chemoweeks deserves investigation and should better response.” 90 percent of the cases. therapy, the injection of medication directly not be ignored,” said Feltmate. She offered Chemotherapy typically follows She finally got the word after adinto the abdomen through a catheter. an example. “Any one whose abdominal surgery. ditional tests — she had Stage IIIC ovarian Garcia’s struggle is not quite through. size increases with no reason should have it Even after all that, recurrence remains cancer, which meant that the disease had Four months after the first round of treatchecked,” she warned. a possibility. “Cells may have escaped spread to both ovaries and had infiltrated ments, the gurgling sounds — which she The exact cause of ovarian cancer is within the abdomen,” she indicated. “Cells lymph nodes. now recognizes as fluid buildup — reunknown, but certain factors increase its can pop back up that were in hiding.” “At first,” Garcia, a New Yorkturned and her worst fears were realized. PHOTO: Courtesy of DANA-FARBER CANCER INSTITUTE risk. And that is what based author, would later write, “I was in The doctors found residual cancer. Heredity is one. happened to Pinheiro. disbelief, then shock. After speaking with She then underwent an additional Families that have a Two years after her my surgeon about plans to undergo a full seven cycles of chemotherapy that was genetic predisposition for initial surgery, the cancer hysterectomy and learning that this would designed to cut off the blood supply of the certain cancers — breast, struck again. This time it make it impossible for me to have children cancerous cells. uterine and colorectal was more extensive — of my own, an overwhelming sadness Garcia says that it’s been easier for — also have a higher tumors were found near set in. Its one thing to choose not to have her the second time around and is still goincidence of ovarian her kidney and colon. children; it’s another to have the choice ing strong. She continues to write and blog cancer. Women who Despite her experience taken from you.” and has told her story in the September inherit these mutations the first time around, For Garcia, the diagnosis was even issue of Black Enterprise. “We think we’re have a 10 to 44 percent Pinheiro sadly admits more depressing. “To make matters [black women] exempt,” she warned. “It’s lifetime risk of developthat she didn’t recognize worse,” she wrote, “my boyfriend and important to be your own advocate.” ing ovarian cancer rather the symptoms the second I had been discussing starting a family. To say her life has changed is an than the 1 to 2 percent in time. “I never thought it Like most women, I envisioned the baby understatement. As she wrote in Black the general population. could happen again,” she I would carry in my belly and the family Enterprise, “Hearing my doctor utter three Some cases of confessed. we would have together. That’s when my mundane words, “Everything looks good,” ovarian cancer run in She was on vacasadness turned to anger.” is like winning a victory lap — the result Colleen M. Feltmate, M.D. families — even without Gynecologic Oncologist tion in Florida at the time Garcia was dazed but undeterred. “I of enduring dozens of inch-long needles a genetic connection. A Brigham and Women’s Hospital and instead of making can do this,” she said. “I can kick this.” that have ruined my veins, the impending woman’s risk is ina doctor’s appointment, She was on a mission to survive. nausea, and the countless days I was too creased if her mother, sister or daughter has she blamed her pain on her brother’s She found out everything she could about sick to get out of bed…” been diagnosed with ovarian cancer. The “uncomfortable” car. She finally sought the disease, but what she learned was not And she has good advice for those risk increases with the number of relatives medical help and the diagnosis was not good. “It does not have a favorable outwho think they are immune. “Of equal affected. good — cancerous cells were left behind come,” she said. “It’s depressing.” importance,” she wrote, “is a patient’s perReproductive history is also a factor. after the first treatment. Fortunately for Garcia, she comes sonal vigilance; paying attention to your One theory — the “incessant ovulation” She had surgery again to remove the from a family of survivors — her mother body, making sure you keep regular checktheory — suggests that the ovaries may kidney and part of the colon — and more overcame breast cancer and her sister ups, asking your doctor questions, seeking suffer tissue damage from the monthly rounds of chemotherapy. Fortunately for Hodgkin disease, a type of lymphoma. a second or third opinion, and speaking release of eggs, thus contributing to the Pinheiro, doctors were able to catch both Garcia chose Memorial Sloan-Ketup when you suspect something is wrong. growth of abnormal cells. Therefore, wom- cancers while they were still treatable. It’s tering Cancer Center, a National Cancer Personal vigilance is the most important en who started their period early, entered been 13 years since her last surgery and so Institute-designated Comprehensive lesson I learned from this experience.” menopause late, or who never had children, far she has remained cancer free. may be of increased risk. Pinheiro leads a busy life. She is an participates in the support group at Boston “When women tell me they have a Thanks to earlier diagnosis and interpreter and travels throughout the area Medical Center. severe back pain [and there is no medical improved treatments, there are more wherever a Portuguese-speaking person reAnd she is quick to tell others about reason for it], I tell them to see the doctor,” survivors. Studies have shown that treatquires her assistance. More important, she the lessons she learned along the way. she said. ment by gynecologic oncologists who are specially trained in both gynecology and cancer has improved outcomes largely Circle the days of the week you experience the following symptoms. If you have any of these symptoms almost due to more aggressive and skilled interdaily for two to three weeks and they are severe and out of the ordinary, see a gynecologist right away. vention. Yet a cure for all cases remains elusive. The cornerstone of treatment is surgery. According to Feltmate, surgery * confirms the diagnosis, helps stage the disease and initiates intraperitoneal chemotherapy, which provides the medicine continued from page 

Garcia

Symptoms Diary: Persistence Matters!

Want more information? It’s a phone call away. American Cancer Society 800-247-2345 www.cancer.org National Cancer Institute 800-4-CANCER (422-6237) www.cancer.gov Gynecologic Cancer Foundation 800-444-4441 www.thegcf.org Ovarian Cancer National Alliance 866-399-6262 www.ovariancancer.org

* Women may also experience nausea, indigestion, constipation, diarrhea, backache, fatigue, menstrual changes, pain during intercourse.

National Ovarian Cancer Coalition 888-OVARIAN (888-682-7426) www.ovarian.org  BE Healthy • http://behealthy.baystatebanner.com

Reprinted with permission from Ovarian Cancer Action. www.ovarian.org.uk

Comments on Be Healthy? Contact health editor Karen Miller at [email protected].