women’s health update
Ovarian Cancer Screening – not there yet Media reports this year have suggested that scientists may be getting close to developing an effective population-based screening tool for ovarian cancer, the disease commonly referred to as the “silent killer”. However a position statement by Australia’s National Breast and Ovarian Cancer Centre (NBOCC) published in this month’s edition of the Australian and New Zealand Journal of Obstetrics and Gynaecology has found that there is currently no evidence to support the use of any tests for either individual or population-based screening for the disease. Christy Parker, Women’s Health Action Policy Analyst, looks at the disease burden of ovarian cancer for women in New Zealand and the work underway to develop an effective screening tool for ovarian cancer. It is almost impossible not to notice that it is currently Breast Cancer Action Month. Pink is everywhere, from the lighting of Auckland’s Sky Tower, to special edition “pink” products lining supermarket shelves, and even pink afternoon tea at the Langham. Increasing public awareness about, and attention to, the disease burden of breast cancer is encouraging. With over 2500 New Zealand women diagnosed with breast cancer each year and 640 women dying from it, breast cancer remains the leading cause of cancer deaths amongst New Zealand women and is a women’s health issue of critical concern1. However there is much less awareness about the reproductive cancer ranked second in terms of cancer deaths amongst females - the much rarer but lethal ovarian cancer. While women can, and do survive ovarian cancer the disease is often referred to as the “silent killer” because often there are few or no symptoms until the disease has progressed to an advanced stage. This makes it the cancer with the highest mortality among cancers affecting women. Because ovarian cancer is often identified too late to save women’s lives there is much interest in how we can detect ovarian cancer in the early stages of the disease when treatment may be more successful.
vol 13 no 4 • October 2009
I n s i d e ●
Alcohol advertising harms women’s health ● Look in g forwa rd wit h Cart wright ● “Big Latch On” Big impac t! the type of ovarian cancer more likely to affect younger women. This type of ovarian cancer accounts for about 5% of cases. Stromal ovarian cancers develop from the cells in the ovary that hold the ovary together and produce hormones, and account for the other 5%6. Risk factors
Ovarian Cancer
According to the latest Ministry of Health statistics, among the 359 deaths from cancers affecting women’s genital organs per year (which includes uterine, cervical and vulval cancers) ovarian cancer is responsible for 190 of these. In comparison, around 80 women die from uterine cancers and 54 from cervical cancer2. Ovarian cancer affects more younger women than many other cancers with around 15% of diagnoses occurring in young women (25 -44 years), 40% in middle age women (45 – 64 years), and the remaining 45% in old age (65 years and above). However older women are more likely to die of the cancer than younger women3. Maori women are at greater risk of getting the disease and thus early detection could have a positive impact on health inequalities4. There are three main types of ovarian cancer. The most common type is called epithelial ovarian cancer, which comes from the cells that lie on the surface of the ovary known as epithelial cells. It comprises about 90% of ovarian cancer cases and is more common in older women5. Germ cell ovarian cancers arise from the ovarian cells that produce eggs and are
We do not currently know why one woman may get ovarian cancer and another not, however there is a growing body of evidence about some risk factors. There is a much higher incidence of ovarian cancer in industrialized countries. One reason for this may be the lower birth rate in industrialized countries as there is a connection between a higher frequency of ovulation and ovarian cancer. Women who have more children and breastfeed have longer periods of time when they do not ovulate and this may reduce their risk7. There is also compelling evidence about the link between ovarian cancer and the use of talcum powder in the genital region. Recent research by the Harvard Medical School has provided further support for a main effect of the use of frequent genital talc exposure on risk of epithelial ovarian cancer8. It also appears that a susceptibility to developing ovarian cancer can be genetically inherited and research on the relationship between genes and cancer is on-going. A family history of ovarian cancer is therefore a known risk factor.
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Women’s Health Update features women’s health news, policy and scientific findings, to enable health care professionals and community-based workers to be at the forefront in women’s health. Women’s Health Update is published by the Women’s Health Action Trust
2 • Women’s Health Update • vol 13 no 4 • October 2009 continued from page 1 Ovarian Cancer Screening
Because ovarian cancer is often diagnosed at an advanced stage and has a high mortality rate, prevention and early detection of the disease has been identified as key to improving outcomes. The focus is on the development of effective screening to detect the disease early and prevent it from developing to an advanced stage when it is difficult to treat. Screening essentially involves looking for cancer before a person has any symptoms. Screening can be offered to individuals identified as having risk factors for the disease or through organized population based screening programmes where large numbers of people are invited to take part and where everyone is offered the same services, information and support9. Scientists working to develop an effective screening tool for ovarian cancer are looking for a way to detect changes in the ovary that indicate cancer is likely to develop. There are currently several tests that show some potential. Transvaginal ultrasound (TVUS) can detect changes in the ovary that may signify developing malignancy. Used alone it is not a highly sensitive test as it also picks up masses that are benign. Scientists have also identified a glycoprotein CA125 which is present in higher levels in the blood of women with ovarian cancer which could be used as a screening test. However elevated levels are only present in 50% of patients in early stages of the disease, and 90% of women in late stages of the disease, thus if CA125 was used as a screening test it may not pick up ovarian cancer early enough to change the prognosis. There are also a number of other non-cancer related conditions as well as other cancers that may contribute to a raise in CA125 and therefore it may not be specific enough to screen for ovarian cancer. Two major ovarian cancer screening trials are underway looking at the impact of these tests, used either alone or in combination on the detection of ovarian cancer in asymptomatic women - the United States based Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) and the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). The full results of these trials are not expected for several years but show the most promise in the development of ovarian cancer screening10. A genetic screening test able to identify biomarkers of ovarian cancer is also being actively sought. Genetic testing is a rapidly developing technology and holds much promise however to date no results are available on the use of genetic biomarkers for detecting ovarian cancer in a healthy, asymptomatic population11. The World Health Organisation has developed general principles to be used as criteria for screening programmes12. Because well people, most of whom will never develop the disease, are subjected to a medical intervention for the benefit of the few who will develop the disease the screening tool must demonstrate that it offers more benefit than harm, and there must be a strong evidence base to support the introduction of a screening programme. The Australian Population Based Screening Framework provides criteria for the introduction
of a screening programme that includes the nature of the disease and the quality of the test. The disease needs to be an important health problem that has a recognizable early stage where intervention is likely to disrupt the natural progression of the disease. The screening test must be highly sensitive and specific to the disease, be safe and have a low false positive and false negative rate. It must be recognized that although screening can offer significant benefits through the early detection and prevention of highly lethal diseases it is not risk free technology. The risks of screening include the potential to overemphasize the individual risk of getting the disease to a well population in order to encourage participation in a screening programme13. This problem in compounded by the economics of screening programmes which, because they are expensive, need high uptake to justify the use of health dollars. There is also the risk of falsenegative and false- positive results to screening tests, both of which can have devastating health consequences. A woman who receives a falsenegative test result may delay seeking medical care even if she has symptoms and a woman who receives a false positive result can be subjected to unnecessary invasive procedures as well as unnecessary anxiety. In the case of ovarian cancer, it is also possible that finding the cancer earlier may not improve health or help women live longer14. Because of the risks we will need strong evidence of improved outcomes to justify the introduction of ovarian cancer screening. The Australian National Breast and Ovarian Cancer Centre position paper released this month has made it clear that we are not there yet, but watch this space! Be alert to common signs and symptoms
In the meantime it is important to be alert to signs that ovarian cancer may be developing. Most women who are diagnosed with ovarian cancer report symptoms. They are often vague, generalized, and not gynecological in nature so they can be missed, or dismissed as something else. The Australian National Breast Cancer Centre has developed guidelines to assist GPs in the assessment of symptoms that may be ovarian cancer. According to the guidelines nearly 80% of women diagnosed with ovarian cancer will report vague abdominal or gastrointestinal symptoms. Up to 50% of women will also report constitutional and urinary symptoms15. Symptoms to watch out for include abdominal bloating, increased abdominal girth, indigestion, lack of appetite, feeling full after only a small amount of food, weight gain/loss, change in bowel habits, fatigue, urinary frequency/ incontinence, abdominal and/or pelvic pain, and a feeling of pressure in the abdomen. The guideline states that if women experience vague abdominal symptoms for more than one month a further assessment should be undertaken which includes family history, as well as physical and clinical examination. Persistent symptoms such as these do not necessarily indicate ovarian cancer but should be followed up with your doctor. A transvaginal scan and the CA125
blood test may help with diagnosis at this point. There is hope
While screening able detect the disease before it is symptomatic (and thus in an advanced stage) holds the potential to reduce the number of women who die from ovarian cancer, we are not there yet. In the meantime, being alert to potential signs and symptoms so that the disease is picked up early can help to improve outcomes. Further, research into new treatments for and ways to improve management of the disease are also underway and show some promise. For example, PHARMAC is currently considering the potential health benefit offered by Caelyx, a new treatment for advanced epithelial ovarian cancer. See PHARMAC’s website for more information. It is also worth remembering that women can beat ovarian cancer, even when it is detected late. See the Silver Ribbon Foundation for Gynaecological cancer for inspiring stories of women’s experience and survival of ovarian cancer http://www.silverribbon.co.nz/. References
Dolinsky, C. Vachani, C. 2008 ‘Ovarian cancer: the basics’, Abramson Cancer Center of the University of Pennsylvania. Gates, M. et al. 2008 ‘Talc Use, Variants of the GSTM1, GSTT1, and NAT2 Genes, and Risk of Epithelial Ovarian Cancer’, Cancer Epidemiology Biomarkers and Prevention, Vol 17, No 9, pp. 2436 – 2444. Kim, K. Choi, S. Ryu, S. Kim, J. Kang, S. 2008 ‘Major clinical research advances in gynecologic cancer 2008’, Journal Gynecology and Oncology, Vol 19, No 4, pp. 209 – 217. Menon U et al. 2009 ‘Sensitivity and specificity of multimodal and ultrasound screening for ovarian cancer, and stage distribution of detected cancers: results of the prevalence screen of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS), The Lancet Oncology, Vol 10, April, pp. 327- 340. Ministry of Health. 2009 ‘Cancer: new registrations and deaths 2005 revised edition’. National Breast Cancer Centre. 2005 ‘Assessment of symptoms that may be ovarian cancer: a guide for GPs’, Australia, www.ovariancancerprogram.org.au National Breast and Ovarian Cancer Centre. 2009 ‘Population screening and early detection of ovarian cancer in asymptomatic women – NBOCC Position Statement’. Raffle, A. 2001 ‘Information about screening – is it to achieve high uptake or to ensure informed choice?’, Health Expectations, Vol 4. Pp. 92 – 98. Stern, J. 2007 ‘Ovary’, Women’s Cancer Information Center, www.womenscancercenter.com Stewart-Brown, S. Farmer, A. 1997 ‘Screening could seriously damage your health’, British Medical Journal, Editorial, Vol 314, No 533. Vergote, I. Amant, F. Ameye, L. Timmerman, D. 2009 ‘Screening for ovarian carcinoma: not quite there yet’, The Lancet Oncology, Vol 10, April, pp. 308-309. Wilson, J. Jungner, G. 1968 ‘Principles and practice of screening for disease Public Health Paper’, No 34. Geneva: WHO; 1968. 3 4 5 6 7 8 9
648 women died of breast cancer in 2005. Ministry of Health, 2009. Ministry of Health website. Ministry of Health website. Dolinsky and Vachani, 2008. Stern, 2007. Stern, 2007. Gates et al, 2008. National Screening Unit website. 10 Vergote et al, 2009; Menon et al, 2009. 11 Kim et al, 2008; NBOCC, 2009. 12 Wilson et al.,1968. 13 Stewart-Brown & Farmer, 1997. 14 Risks of Ovarian Cancer Screening’, National Cancer Institute, www.cancer.gov 15 NBCC, 2005. 1 2
Women’s Health Update
• vol 13 no 4 • October 2009 • 3
Alcohol advertising harms women’s health Women’s Health Action representatives met recently with the Law Commission to present some gender-based perspectives on the Law Commission’s review of New Zealand’s liquor laws. Following a series of high profile alcohol related crimes last year the Law Commission was asked to undertake a review of the law governing the sale and supply of liquor and to suggest areas for reform, a request that was confirmed by the incoming Government. The Law Commission has undertaken this review and has come to the conclusion that harmful drinking has become a source of serious social problems in New Zealand today. This work has culminated in an issues paper Alcohol in Our Lives which suggests some significant changes to our alcohol laws. Consultation is now underway to get the perspectives of New Zealand’s communities on these suggested reforms before they are presented to parliament. Women’s Health Action is concerned about the impact of harmful drinking on women and their health and wellbeing. While alcohol is not the cause of domestic and sexual violence towards women, it is known to be a contributing factor. We are also concerned about the increase of heavy or binge drinking by women, and specifically young women. The link between alcohol consumption and reproductive harm has also been well established. We believe that alcohol advertising contributes to alcohol’s impact on women. We are concerned with the sexist nature of beer advertising – think Tui
television ads - which reinforces problematic notions of masculinity and the systematic sexualisation and trivialization of women. Given the role alcohol plays in violence towards women, alcohol advertising that contributes to social myths about sexuality, power and control is very problematic. We are also concerned that young women are increasingly being targeted in the marketing of RTD “ready to drink” prepackaged spirit cocktails or “alco-pops”. These drinks come in sweet flavors and are overtly packaged to mimic soft drinks – particularly appealing to new drinkers. Alcohol is also being marketed in non-direct ways which target youth culture events, particularly those attracting young women. At present the alcohol industry is selfregulating meaning that the industry can determine the nature and content of alcohol advertising guided by the Advertising Standards Authority’s Code for Advertising Liquor. All alcohol advertising in New Zealand should adhere to the principles of the Code. Principle 2 of the Code states that liquor advertisements shall observe a high standard of social responsibility. Alcohol should not be marketed in ways that appeal to minors and that leads to confusion with soft drinks. Advertisements should also not depict or imply offensive, aggressive or irresponsible behavior or unduly masculine themes or portray unrealistic outcomes. Advertisements should not be sexually provocative or suggestive or suggest any link between liquor and sexual attraction
or performance. It is clear that these are seen by the industry as toothless ‘guidelines’ and because adherence relies on complaints from the public, they are pretty much ignored. Now is the ideal opportunity to have your say about the approach to, and content of, advertising by the alcohol industry in New Zealand. It is our contention that government regulation of alcohol advertising or an outright ban on advertising will be necessary to address alcohol related harm. For more information on the Law Commission’s consultation and to have your say go to www.lawcom.govt.nz . You can also contact christy@womens-health.org.nz with your thoughts and we will look at incorporating them in our submission. If you wish to complain about alcohol advertising that you think violates the Code check out www.asa.co.nz.
Looking forward with Cartwright The recent book questioning the foundations of the Cartwright Inquiry and the findings of the Cartwright report provide an interesting context for Women’s Health Action’s upcoming one day seminar “Cartwright comes of age?”. While there will no doubt be some reflection on the book, the focus of the day is to look at how we progress the recommendations and key focus areas from Cartwright in the context of today’s challenges and opportunities within the health and disability sector. In the morning the Health and Disability Commissioner, the Assistant Privacy Commissioner, Professor Kevin Dew and Sandra Coney will look at broader issues. In the afternoon, the four major outcomes from Cartwright come under scrutiny. We will look at their implementation, examine current status and identify issues and opportunities for action moving forward. These four areas are: The Commissioner, the Code and patient advocacy; Cancer screening programmes; Patient-centred health care; and Ethics Committees. Registrations are limited to 200 and are filling fast so if you are planning to come it will pay to register today or risk missing out. It’s is easily done online at : www.womens-health.org.nz. The full programme can be found at: http://www.womens-health.org.nz/uploads/ Cartwright%20Comes%20of%20Age%20Seminar%20Programme.pdf
“Big Latch On” Big Impact! On Friday the 7th of August 2728 mums and their babies all over the country participated in another record breaking Big Latch On. Isis McKay, WHA Breastfeeding Advocate reports on this year’s event. This year 1306 babies were latched on and breastfeeding simultaneously for the big count down at 10.30am, exceeding last year’s record of 1129. This was not the only record broken this year. The record for the single biggest Big Latch On in one place was broken at Hoyt’s Cinema at Sylvia Park in Auckland. Getting 178 mums and babies breastfeeding simultaneously was no mean feat given the amount of exciting distractions the breastfeeding babies had to contend with. The event, hosted by Women’s Health Action and the Auckland Breastfeeding Network was attended by over 200 mums with their babies and whanau. All participants were treated to a free movie as well as gift packs and spot prizes donated by generous businesses. The Big Latch On is a growing annual event. This year’s total was nearly double that of the first Big Latch On. The event celebrates breastfeeding mums and babies; promotes the benefits of breastfeeding for babies, mums and society at large; and sends a message that breastfeeding in public is acceptable and will be supported. It is a great opportunity to get community recognition to celebrate and support the hard work these breastfeeding mothers are doing. We are delighted with the increasing involvement in and support for the Big Latch On in communities large and small around New Zealand. At the Southern Cross Bar in Wellington, an amazing 64
mums and their babies latched on - the biggest ever Big Latch On held outside of Auckland. There were 55 Mums and babies latched on at St. Stephens Anglican Church Hall in Christchurch and 40 at Chipmunks Café in Timaru. The turnout was especially impressive this year given the challenges of swine flu and the bar has been set very high for next year. All venues and numbers are available at: www.womens-health.org.nz. Thanks and congratulations to everyone who participated! However, it is not just the main centres that are doing an awesome job. Smaller centres also made a huge contribution and held some wonderful Big Latch On events. There were 26 mothers and babies who attended the Big Latch On held at the Levin movie theatre. Mums were treated to a free movie supported by the Cinema management and Horowhenua District Council, and the local midwives donated money for the mums to enjoy refreshments after the movie. Better still, the positive impacts of the Big Latch On have extended past the event itself. Catriona Fisher, the coordinator of the Levin Cinema venue, says that the involvement with the Big Latch On has prompted her to set up a breastfeeding support group who now meet regularly. Catriona says “there are no Lactation Consultants in Levin so we saw this is as a way of supporting and encouraging each other”. This was also Catriona’s first time organising a Big Latch On, “I did not realize the positive impact an event like this could have, I had one mum who had been quite uncomfortable with the idea of breastfeeding her baby in public, she decided to come along to
the Latch On as a “trial run” and I am happy to say that she now feels confident and supported to breastfeed her hungry baby when she is out in public”. The positive ongoing impacts of the Big Latch On have also been reported elsewhere. Rachel Roxburgh, the coordinator of Franz Josef School Library venue said “Meeting other members of our rather spread out communities to have a wee chat about Breastfeeding Support in our remote environment, has allowed some networking to go on between Playgroups. As a Mum 4 Mum supporter, it gave me the confidence and motivation to get the word out that I am available and know that there are other mum’s out there that can give them much needed support, a lot of mothers are rather isolated in these areas and events like this help us as a community to reach out and support one another”. Rachel is another first time Big Latch On coordinator already looking forward to next year! To join the Levin Breastfeeding Support group, contact Catriona Fisher on 06 368 6251 or cat. atkinson@gmail.com. New members are very welcome.
Noticeboard ●
Ngati Whatua o Orakei Breastfeeding Support Clinic
Wednesdays, Thursdays and Fridays 8am – 2pm For more information contact Waimirirangi or Chantal on 09 578 0967
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AUCKLAND PARENT & CHILD SHOW 30th Oct - 1 Nov Look for the WHA Stand
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‘Cartwright Comes of Age?’ Seminar
One Day Seminar in Auckland 6th November This seminar marks the 21st anniversary of the release of the Cartwright Report and aims to provide a forum for critical and consumer perspectives on the major themes and recommendations from the Cartwright Inquiry.
Making Pregnancy Safer
Wednesday 18 November 2009 9.00am to 5.00pm A PMMRC workshop on improving outcomes for New Zealand mothers and babies. For more information email pmmrc@moh.govt.nz
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“Managing Menopause Seminar”
Tuesday 3rd November - 6pm – 9pm A three hour workshop that provides: • An understanding of menopause • A discussion of the range of women’s experiences at menopause • In-depth information on how to manage the transition with simple lifestyle changes, nutrition and traditional therapies. $25.00 Includes Menopause Info Pack and Finger food and refreshments – Bookings essential call 09 520 5295 or download registration form from www.womens-health. org.nz
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To register go to www.womens-health.org.nz or contact us on 09 520 5295 for more information
Refugee Health & Wellbeing Conference – “Looking back and moving forward”
18 - 20 November 2009 AUT University, New Zealand and Refugee Council of New Zealand for more information email Linda Mckay on Linda@no9productions.co.nz
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World Day for Prevention of Child Abuse
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The New Zealand Bioethics Conference “Ethics After Harm”
29-31 January 2010 Salmond College, Dunedin Go to http://www.otago.ac.nz/nzbioethicsconference/ for more information
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18 – 21 May 2010 Hobart, Tasmania Addressing ‘Women’s economic health and wellbeing’, ‘Women’s Mental Health and Wellbeing’, ‘Preventing Violence Against Women’, ‘Women’s Sexual and Reproductive Health’, ‘Improving Women’s Access to Publically Funded and Financially Accessible Health Services’. See: www. awhn.org.au
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19th November 2009
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THE GIRLS DAY OUT 20-22 Nov Look for the WHA and MAMA Stand
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International Day for the Elimination of Violence against women 25th of November 2009
6th Australian Women’s Health Conference
Attn: Midwives - Office Space to Lease!
MAMA Inc. is looking for people to share their rooms in Morningside, Auckland. Join their group of midwives, acupuncturists, massage therapists, psychotherapist and other natural therapists. Space available ranges from an entire suite of offices to sharing a space for a half day. Plenty of free parking and easy access to building all hours – For more information Phone 09 815 8108, 027 474 4652
Women’s Health Update is produced by Women’s Health Action Trust • Edited by Jo Fitzpatrick To receive copies of Women’s Health Update, make suggestions about future contents or send items for publication please contact: Women’s Health Action Trust • PO Box 9947, Newmarket, Auckland, NZ 2nd Floor, 27 Gillies Avenue • Ph (09) 520 5295 • Fax (09) 520 5731 • email: info@womens-health.org.nz Internet address: http://www.womens-health.org.nz • Women’s Health Update is published with the assistance of the Ministry of Health
Women's Health Action Trust celebrating 20 years 1989-2009