For each article assigned below, develop a simple (1 to 2 paragraph) case study of a typical patient experiencing the symptoms of the condition. Use the article provided to deve

Ovarian cancer: Ensuring early diagnosis

www.tnpj.com The Nurse Practitioner • September 2015 47

varian cancer is the most fatal of all gynecologic cancers. There is a widespread misconception that ovarian cancer is a “silent killer,” despite fi ndings

of common warning symptoms.1-6 Unfortunately, the symp- toms that accompany ovarian cancer are typically subtle and associated with other benign conditions (see Symptoms of ovarian cancer).1,5,7,8 Patients and practitioners therefore tend to overlook the vague symptoms or investigate other potential conditions not associated with the ovaries, ulti-

mately leading to late diagnoses.5 In fact, more than 70% of women will be diagnosed in Stage III or IV; less than 30% are diagnosed at Stage I.1-4,6,7 At Stages III and IV, a woman’s chance of surviving 5 years is as low as 20% and 6%, respectively.7 Conversely, women with Stage I ovarian cancer have a 90% chance of surviving 5 years.3,5-9 Diagno- sis at an earlier stage would improve prognosis and greatly increase a woman’s overall chance of survival.3,5 Effective screening programs would help nurse practitioners (NPs)

By Christa L.P. Slatnik, NP, RN, BN and Elsie Duff, NP, BScN, MEd

O

Abstract: Ovarian cancer is the most fatal of all gynecologic malignancies. Despite the lack of

a recommended screening test for ovarian cancer, NPs can identify risk factors, ensure patients

are aware of subtle symptoms, and provide adequate testing and analysis of results.

Keywords: abdominal distension; CA 125; early diagnosis gynecologic malignancy; cancer survival;

BRCA1, BRCA2, and MMR mutations; ovarian cancer; pelvic pain; screening; subtle symptoms; ultrasound Ph ot

o co

ur te

sy is

to ck

©

OVARIAN CANCEREnsuring

early diagnosis

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

48 The Nurse Practitioner • Vol. 40, No. 9 www.tnpj.com

Ovarian cancer: Ensuring early diagnosis

diagnose patients in the earliest stages of ovarian cancer. Unfortunately, a screening test has yet to be established for ovarian cancer. Recent studies have shown that ovarian cancer may actually originate in a premalignant state with lesions in the distal fallopian tube, which would make the prospect of screening tests able to detect ovarian cancer before it develops promising.3

■ Why screening is not recommended

Over twenty-five years ago, the cancer antigen 125 (CA 125) was considered a promising tumor marker for ovar- ian cancer, and it was initially anticipated that this marker would allow for screening among the general public.3 With further use, however, the CA 125 test was found to lack specificity, as this marker can be increased due to ovarian cancer but also a variety of benign causes (en- dometriosis, age, race, menstrual cycle, pregnancy, and hysterectomy) as well as other malignancies (pancreas, breast, colon, and lung cancers).3 The CA 125 test has also been found to lack sensitivity. For example, although increased levels of this marker have been found in up to 90% of women affected by advanced stages of ovarian cancer, values remain normal in up to 50% of patients in earlier stages of cancer.2,7,8 Due to this lack of specificity and sensitivity, using the CA 125 test as a screening tool for ovarian cancer could lead to stressful false-positives and misleading false-negatives. Therefore, a CA 125 test is not recommended.

Transvaginal sonography (TVS) has shown promise in screening for ovarian cancer, as it is highly sensitive to pelvic masses.2 Unfortunately, due to its lack of specifi city, it produces false-positive results that lead to unneces- sary surgical procedures.2,3 If used as a screening tool, the TVS test would require an estimated 5,200 ultrasounds be performed to detect one case of invasive carcinoma.5 Despite the expectation that combining the TVS with the CA 125 would increase the specifi city and help decipher which pelvic masses were malignant, the predictive values were shown to be less than expected (less than 5%) with no notable decrease in mortality from ovarian cancer.3,10,11 Routine screening with the CA 125 and TVS tests com- bined is therefore not recommended due to the increased risk of harm from high rates of false-positive results.5,11

Studies have shown that the screening ability of up to 28 other biomarkers demonstrated no improvement over the CA 125.3,10 However, the human epididymis protein 4 (HE4) is a newer serum biomarker that is showing prom- ise as a potential screening tool when combined with the CA 125 and TVS tests.2,3,8 The HE4 biomarker may aid in screening, since it is more sensitive than other markers. Thirty-two percent of women with ovarian cancer and a negative CA 125 have a positive HE4.2 However, although the HE4 biomarker is highly expressed by ovarian cancers, it is a nonspecifi c test with elevations also occurring with changes in the trachea and salivary gland.2 To date, limited research has been conducted to determine the overall speci- fi city and sensitivity of the HE4 biomarker, especially with effect on morbidity and mortality.2 The U.S. FDA has in turn limited the HE4 biomarker to be used for monitoring the recurrence of ovarian cancer until further research is completed.2

On the whole, more research is essential in order to establish a highly-specifi c and sensitive screening test that will detect ovarian cancer in the earliest of stages, prefer- ably in a premalignant state. Until such a screening test is identifi ed, NPs must pay special attention to those at risk while ensuring all patients are aware of the vague signs and symptoms to watch for and the importance of following up in a timely manner if any arise.

■ Paying special attention to those at risk

Even though ovarian cancer can occur in a woman with no established risk factors, identifying those at a higher risk of developing the disease may help the NP ensure adequate awareness and follow up, and in turn, early diagnosis.2,3,5 A family history of ovarian cancer is a risk factor with 5% to 20% of those affected by ovarian cancer having a familial history of the disease.2,3,7 Genetic risk for ovarian cancer has been primarily associated with mutations of the

Symptoms of ovarian cancer1,5,7,8

• Recent unexplained, increased abdominal size

• Abdominal distension

• Bloating

• Back or abdominal pain

• Pelvic pressure or pain

• Loss of appetite

• Feeling full quickly

• Diffi culty eating

• Changes in bowel habits (constipation or diarrhea)

• Urinary symptoms (frequency or urgency)

• Unexplained weight gain or loss

• Fatigue

• Postmenopausal bleeding

• Menstrual irregularities

• Rectal bleeding

• Suspected new diagnosis of IBS (particularly

if >50 years old)

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

50 The Nurse Practitioner • Vol. 40, No. 9 www.tnpj.com

Ovarian cancer: Ensuring early diagnosis

BRCA1, BRCA2, and MMR genes, which increase the life- time risk of developing ovarian cancer from 1.6% to 40%, 18%, and 10%, respectively.3 If a patient has more than one fi rst-degree relative who was diagnosed with ovarian or breast cancer, particularly if they were diagnosed before the age of 50 years, the NP must consider the potential for a BRCA genetic mutation. If a patient has multiple fi rst-degree family members affected by ovarian, breast, endometrial, and/or colon cancers, the NP must consider an MMR mutation or Lynch syndrome.3

Women with certain ethnic backgrounds, such as Ashkenazi Jewish, French Canadian, Dutch, and Icelandic descent, may also be at increased risk of having a genetic susceptibility to ovarian cancer.5,12 Although research ana- lyzing annual screening with the CA 125 and TVS tests has been unable to show any effect on morbidity and mortal- ity among those with a familial risk of ovarian cancer, the National Institutes of Health Consensus Panel on Ovarian Cancer currently recommends routine screening with these tests for those with an established familial or genetic risk.2,3,5 Researchers in the United Kingdom and United States are currently evaluating the effectiveness of a screening pro- gram, which would test younger women with a familial history of ovarian cancer every 3 to 4 months.3 Until more frequent testing has been shown to be effective at decreasing morbidity and mortality, annual CA 125 and TVS tests on those with a familial risk must be combined with adequate

assessment of symptoms throughout the year in order to ensure early detection.

In spite of the fact that there is a clear genetic link in many cases, approximately 80% to 90% of ovarian can- cers are sporadic, occurring in women with no apparent genetic history.2,3,5 Therefore, it is essential to identify other risk factors (beyond genetics) that could also place a woman at risk for developing ovarian cancer. Age is a common risk factor, with women over the age of 50 years being most likely to develop ovarian cancer.3,7 Interrupted ovulation appears to be a protective factor, as women who have ovulated for fewer years tend to have a lower risk of developing ovarian cancer.3 Because oral contraceptive use, pregnancy, breastfeeding, late menarche, and early menopause all decrease the overall amount of ovulation in a woman’s lifetime, assessing for those who have not

had any of these protective factors may identify a woman at higher risk of developing ovarian cancer.3 NPs should also utilize the awareness of the protective factor of inter- rupted ovulation in order to encourage women to com- mence oral contraceptive use and/or breastfeeding when appropriate. Although screening has yet to be established for those with an elevated risk, a future population-based screening program is likely to include a risk-stratifi cation algorithm that details a woman’s risk of developing ovar- ian cancer combined with the CA 125 and TVS tests.3,7 For example, by combining TVS ovarian morphology with CA 125 levels and menopausal status, a “risk of malignancy index” (RMI) can be established to help decrease rates of false-positives and improve detection of ovarian ma- lignancies.3 Pending further research, known risk factors are a useful means for NPs to assess and identify at-risk women who will need immediate follow-up should any suspicious symptoms arise.

■ Acknowledgment of symptoms

to ensure early detection

Although a heightened awareness of those at an increased risk of developing ovarian cancer is essential in order to ensure early detection, adequate awareness and assess- ment of all women that present with vague symptoms is also a necessity.1-3,5,11 Ovarian cancer was previously thought to be a “silent disease” without any obvious signs

or symptoms. It is now known that most affected women will present with similar, vague symptoms.1-3,5,11 In one study, 89% of women in Stage 1 or 2 were able to recall symptoms prior to their diagnosis.4 Up to 97% were able to recall symptoms in Stage 3 or 4, with the type of symptoms very simi-

lar in all stages.5 When patients have these characteristic symptoms but do not have any risk factors for the disease, NPs must differentiate between the symptoms that neces- sitate urgent investigation and those that can be managed more conservatively.

Unfortunately, abdominal and gastrointestinal symp- toms commonly present before any actual pelvic or gy- necologic symptoms.4,5 The initial warning symptoms of ovarian cancer, for example, are abdominal distension, abdominal pain, weight loss, and loss of appetite.2,3,5,7,11 Changes in bowel habits, such as constipation or diarrhea, have also been identifi ed as common initial symptoms.1 Given the presenting symptoms, irritable bowel syndrome (IBS) is a common misdiagnosis.5 The major difference in the symptomatology of these two diseases is the higher fre- quency and severity of bloating and urinary tract symptoms

The initial warning symptoms of ovarian

cancer are abdominal distension, abdominal

pain, weight loss, and loss of appetite.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Ovarian cancer: Ensuring early diagnosis

www.tnpj.com The Nurse Practitioner • September 2015 51

in patients with ovarian cancer when compared with those with IBS.5 In addition, IBS does not typically present for the fi rst time in women over the age of 50 years.5 Therefore, it is essential that NPs consider a differential diagnosis of ovarian cancer in women over the age of 50 who present with new symptoms (onset in the last 12 months) suggestive of IBS, especially if these symptoms include bloating and urinary tract issues.5,7

An ovarian cancer symptom index (SI) is a useful tool that draws upon the awareness of the common vague symptoms that a woman may present with (see Symptom index).2,3,11 When used alone, the SI has only been able to detect ovarian cancer with a sensitivity of 60% in early stages and 79.1% in advanced stages.11 When combined with tests for the CA 125 and HE4 markers, specifi city increased to as high as 98.5%.3 Goff and colleagues found that patients and practitioners in a primary care setting were accepting of symptom-based screening.11 They also discovered that symptom-based screening decreased the need for additional, more invasive diagnostic procedures.11 Therefore, it is recommended that NPs consider present- ing symptoms when planning follow-up investigations for their patients.13 More specifi cally, if a patient presents with vague symptoms, particularly if the patient is over the age of 50 years and is experiencing the symptom(s) more than 12 times per month, a physical exam with a bimanual and pelvic- rectal exam would be required. A CA 125 test would also be warranted, with an ultrasound to follow if results are above normal (greater than 35 units/ mL) or if the physical exam and/or symptoms are highly suggestive of a malignancy.7

A risk prediction algorithm is a useful tool that in- corporates both symptoms and risk factors.7 Independent predictors of undiagnosed ovarian cancer were established by analyzing over 1.75 million women between the ages of 30 and 84 years.7 The algorithm has the potential to identify particular individuals in the general population who may be suitable for targeted investigation or refer- ral.7 For example, if a patient presented with abdominal distension as her sole symptom, evidence suggests that she would be 23 times more likely to have undiagnosed ovarian cancer when compared with a patient without abdominal distension. In this case, further investigation (for example, CA 125 and TVS tests) would be warranted to rule out possible ovarian cancer. If the same patient had presented with abdominal distension accompanied by abdominal pain and loss of appetite, her risk of hav- ing ovarian cancer would be cumulatively 23-, 7-, and

5.2-fold higher, respectively, than a woman without these symptoms.7 Urgent investigation with immediate referral would be required in this case.

If, upon initial investigation, a patient was at low risk of currently having ovarian cancer, the results could be used as a baseline assessment, with any future symptoms triggering

a reevaluation.7 Although the stage at which this algorithm tool is able to detect ovarian cancer is not yet known, it ap- pears to have the potential to promote earlier detection and, thus, improve prognosis among affected women.7 On the whole, with a variety of tools available, combining symptom assessment and risk analysis with TVS and CA 125 tests would help the NP determine if a patient’s condition war- rants urgent referral to a specialist.7,13

■ Differentiating malignant

and benign ovarian masses

When a patient presents with ovarian cancer symptoms, the NP must consider that benign ovarian masses may present with similar symptoms as well.5 Fortunately, subtle characteristics can help distinguish benign and malignant masses. Women with an ovarian mass are likely to have frequent symptoms, which occur as many as 15 to 30 times per month when compared with 2 to 3 times per month in

Symptom index

The symptom index may be used along with the CA 125

and HE4 markers when evaluating a patient for suspected

ovarian cancer.

The symptom index is considered positive if the patient

presents with any of the following symptoms occurring

more than 12 times per month over a period of less

than12 months.

• Pelvic pain

• Abdominal pain

• Bloating

• Increased abdominal girth

• Diffi culty eating

• Early satiety

Adapted from Andersen MR, Goff BA, Lowe KA, et al. Use of a Symptom Index, CA125, and HE4 to predict ovarian cancer. Gynecol Oncol. 2010;116(3):378-383.

A risk prediction algorithm is a

useful tool that incorporates both

symptoms and risk factors.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Ovarian cancer: Ensuring early diagnosis

www.tnpj.com The Nurse Practitioner • September 2015 53

those without a mass.4,5 In addition, women with an ac- tual malignant mass tend to have more severe symptoms, which further differentiates those with a malignant versus a benign mass.4,5 The number of coexisting symptoms further distinguishes those with malignant and benign masses; women with a malignant mass present with an average of eight symptoms, whereas those with a benign mass present with an average of four symptoms.5 Bloating, increased abdominal girth, and urinary tract symptoms are the most common coexisting symptoms.5,13 These symptoms have been identifi ed in up to 43% of women with ovarian cancer.5 Finally, women with cancer tend to experience bloating, fullness, and abdominal pressure on a continuous basis, while those with a benign mass commonly experience these symptoms intermittently.5 Even though there is a potential to differentiate benign and malignant masses based on symptomatology, NPs who suspect an ovarian mass should still order a TVS and CA 125 in order to help rule out ovarian cancer while considering an urgent referral if symptoms or RMI sug- gest a malignancy.

If an ovarian mass is identifi ed by TVS, there are cer- tain characteristics of a pelvic mass on TVS that have been shown to increase the chance of malignancy, including the following: a complex multilocular mass, thick septations, presence of papillary excrescences and solid components, increased central vascularity within the mass, and evi- dence of ascites and peritoneal nodu- larities.3,13 If a CA 125 had not already been performed upon detection of a pelvic mass, guidelines suggest that measurement of CA 125 should be considered to help identify the mass as either benign or malignant, so that appropriate referral and management can take place. 13 Although levels of CA 125 alone lack the sensitivity and specifi city required to diagnose ovarian cancer, serial elevating levels of CA 125 have been associ- ated with a higher risk of diagnosing a malignancy.3,9 If the patient is under the age of 30, serum alpha-fetoprotein (AFP), beta-human chorionic gonadotropin, and lactate dehydrogenase (LDH) tests should also be performed to rule out the rare chance of a malignant germ cell tumor.12 If, based on the results from the TVS, lab investigations, and/or physical exam, the pelvic mass is not considered to be a malignancy, a repeat TVS should be performed within 4 to 6 weeks to assess for an increase in size that would be suggestive of a malignant mass.3,13 If ovarian cancer cannot be ruled out, then urgent referral to a gynecologic oncolo- gist is essential in order to ensure immediate and accurate diagnosis, management, and followup.

■ Awareness essential to ensure early detection

Increased awareness of the symptoms of ovarian cancer is essential among both NPs and members of the general public to ensure further gynecologic assessment and, thus, earlier diagnosis.7 If patients are unaware of the symptoms to watch for, they are less likely to return for assessment if symptoms arise. In turn, if NPs are not familiar with the symptoms and associated tests to help rule out ovar- ian cancer, a missed or inappropriate diagnosis is more likely. In fact, an estimated 10% of ovarian cancer deaths may be avoidable through increased awareness alone.7 A variety of agencies offer pamphlets, videos, and presenta- tions that aid in increasing this essential awareness. Fact sheets and brochures created by Ovarian Cancer Canada, the National Ovarian Cancer Coalition, the CDC, and the Ovarian Cancer National Alliance, for example, indicate the common symptoms of ovarian cancer and identify the investigations that should be performed if any of these symptoms arise.12,14-17 The “Survivors Teaching Students” programs are an example of presentations that are of- fered by both the Ovarian Cancer National Alliance and Ovarian Cancer Canada.18,19 These presentations utilize the faces and voices of ovarian cancer survivors in order to inform medical students, nursing and NP students, and pharmacy students about the risks and symptoms to

watch for as well as steps to take when patients present with these symptoms.18,19

Ovarian Cancer Canada also offers “Knowledge is Power” presentations to the general public with hopes that increasing the awareness of the signs and symptoms of ovarian cancer will in turn lead to earlier presentation for assessment and ultimately an earlier diagnosis.20 Not only do these pamphlets and presentations encourage women to see a primary care practitioner if they experi- ence new and consistent symptoms, but they may be in a better position to advocate for themselves and ensure that healthcare professionals perform the appropriate investi- gations. NPs should access and utilize the resources that already exist and ensure education sessions are provided to the general public in their area as well as their colleagues and future NPs.

Although NPs tend to seek out opportunities to edu- cate and advocate for their patients, time constraints can

Increased awareness of the symptoms of

ovarian cancer is essential among both NPs

and members of the general public.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

54 The Nurse Practitioner • Vol. 40, No. 9 www.tnpj.com

Ovarian cancer: Ensuring early diagnosis

limit the NP’s ability to provide education and increase awareness regarding ovarian cancer. Despite the fact that existing pamphlets specifi cally regarding ovarian cancer can be given to patients, a patient may fi nd this informa- tion overwhelming if they are provided with a variety of pamphlets with other diseases; they may also consider it irrelevant. As a result, a one-page take-home teaching sheet, listing the signs and symptoms of a variety of ill- nesses, may not only be more practical for the patient but may also reduce the demands on practitioners who would otherwise have to provide this information. The teaching sheet identifi es symptoms that require assessment by a healthcare provider as well as the screening tests and di- agnostic investigations that are or are not available. With these resources, women can have the knowledge required to advocate for their own healthcare, including prompt as- sessments and investigations, ultimately maximizing their chance of early diagnosis, and in turn, survival.

■ Implications for practice

Knowledge and awareness of the risk factors and the vague, yet common symptoms of ovarian cancer can help ensure this disease is detected in earlier stages. It is essential that NPs provide education to ensure that women understand the signs and symptoms that warrant assessment by a healthcare provider. Prompt assessment ensures earlier investigation into the possible causes of such symptoms and may lead to early diagnosis and improved prognosis. Understanding the subtle differences in presentation of a benign versus malig- nant disease, combined with the heightened attentiveness of those at higher risk of ovarian cancer, can help the NP ensure that all appropriate women are sent for a CA 125 blood test and an urgent TVS. Awareness of how to decipher a concerning result as well as an understanding of the limi- tations of the diagnostic tools available is also essential in order to prevent the harm that exists with false-positive and -negative results. When a concerning result does present, it is essential for the NP to make an urgent referral to a gyne- cologic oncologist in order to ensure effi cient and adequate diagnosis, management, and follow up. As a whole, although a reliable screening test has yet to be established for ovarian cancer, by identifying those at risk for ovarian cancer while ensuring a heightened awareness of the vague symptoms of early disease, NPs provide the highest opportunity to ensure early detection, improve survival, and ultimately break the silence of ovarian cancer.

REFERENCES

1. Fields MM, Chevlen E. Ovarian cancer screening: a look at the evidence. Clin J Oncol Nurs. 2006;10(1):77-81.

2. Andersen MR, Goff BA, Lowe KA, et al. Use of a Symptom Index, CA125, and HE4 to predict ovarian cancer. Gynecol Oncol. 2010;116(3):378-383.

3. Gentry-Maharaj A, Menon U. Screening for ovarian cancer in the general population. Best Pract Res Clin Obstet Gynaecol. 2012;26(2):243-256.

4. Goff BA, Mandel LS, Drescher CW, et al. Development of an Ovarian Cancer Symptom Index: possibilities for earlier detection. Cancer. 2007;109(2):221-227.

5. Goff BA, Mandel LS, Melancon CH, Muntz HG. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. 2004; 291(22):2705-2712.

6. Hamilton W, Peters TJ, Bankhead C, Sharp D. Risk of ovarian cancer in women with symptoms in primary care: population based case-control study. BMJ. 2009;339:b2998.

7. Hippisley-Cox J, Coupland C. Identifying women with suspected ovarian cancer in primary care: derivation and validation of algorithm. BMJ. 2011;344:d8009.

8. Bandiera E, Romani C, Specchia C, et al. Serum human epididymis protein 4 and Risk for Ovarian Malignancy Algorithm as new diagnostic and prognostic tools for epithelial ovarian cancer management. Cancer Epidemiol Biomarkers Prev. 2011;20(12):2496-2506.

9. Menon U, Gentry-Maharaj A, Hallett R, et al. Sensitivity and specifi city 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). Lancet Oncol. 2009;10(4):327-340.

10. Buys SS, Partridge E, Black A, et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening randomized controlled trial. JAMA. 2011;305(22):2295-2303.

11. Goff BA, Lowe KA, Kane JC, Robertson MD, Gaul MA, Andersen MR. Symptom triggered screening for ovarian cancer: a pilot study of feasibility and acceptability. Gynecol Oncol. 2012;124(2):230-235.

12. Ovarian Cancer Canada (OCC). Think Ovarian! Facts for health professionals. www.ovariancanada.org/OCC-PDFs/OCC_HealthPro FactSheet2011_EN.

13. Le T, Giede C, Salem S, et al. Initial evaluation and referral guidelines for management of pelvic/ovarian masses. J Obstet Gynaecol Can. 2009_31 (7):668-680.

14. Ovarian Cancer Canada. Ovarian Cancer—Overlooked and Under- diagnosed. 2012. passthrough.fw-notify.net/download/528978/http://www. ovariancanada.org/OCC-PDFs/OCC_GeneralDiseaseInfoBro.

15. National Ovarian Cancer Coalition (NOCC). What Everyone Should Know About Ovarian Cancer. 2012. http://passthrough.fw-notify.net/ download/283017/www.ovarian.org/assets/pdf/NOCC_Everyone ShouldKnow.pdf.

16. Centers for Disease Control and Prevention. Ovarian cancer. Inside knowledge: get the facts about gynecologic cancer. www.cdc.gov/cancer/ ovarian/pdf/Ovarian_FS_0308.pdf.

17. Ovarian Cancer National Alliance. Ovarian Cancer: What All Women Need to Know. www.ovariancancer.org/wp-content/uploads/2011/06/2012.01_ needtoknow_color.pdf.

18. Ovarian Cancer National Alliance. Survivors Teaching Students: Saving Women’s Lives. May 2012. www.ovariancancer.org/wp-content/ uploads/2012/07/sts-handbook.pdf.

19. Ovarian Cancer Canada. Survivors Teaching Students. www.ovariancanada. org/OCC-PDFs/OCC_STSBrochureEN.

20. Ovarian Cancer Canada. Knowledge. www.ovariancanada.org/ KnowledgeAwareness/Knowledge.

21. Centers for Disease Control and Prevention. Inside knowledge: get the facts about gynecologic cancer. www.cdc.gov/cancer/knowledge/pdf/CDC_GYN_ Comprehensive_Brochure.pdf.

Christa L.P. Slatnik is a nurse practitioner at Cancer Care Manitoba, Gynecologic Oncology Department, Winnipeg, Manitoba.

Elsie Duff is an NP instructor at the University of Manitoba, Faculty of Nursing, Winnipeg, Manitoba, Canada.

The authors have disclosed that they have no fi nancial relationships related to this article.

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