When TV and Life Part Company : Health: ‘thirtysomething’s Nancy Weston may recover from her ovarian cancer. Many other women won’t be so lucky.

When Nancy Weston found out she had ovarian cancer last month, the television character began a Hollywood-style battle with a disease that afflicts 20,000 women in the United States every year.

But, while Nancy’s fate lies in the hands of “thirtysomething” scriptwriters, the ovarian cancer picture in the real world is much more dismal than Nancy’s appears to be. (Her disease is classified as being in stage I C, an early stage that is relatively easy to treat successfully.)

Off the TV screen, ovarian cancer remains the gynecologic cancer that is hardest to detect early, and as a result, it is the one most likely to kill the women who get it.

Eighty-five percent of all cases grow so quietly they aren’t diagnosed until they have spread elsewhere in the abdomen. As a result, 62% of all ovarian cancer patients die within five years, according to the American Cancer Society.

If the cancer could be detected early, however, the five-year survival rate could improve to as much as 85%, the society says.

Given those figures, some gynecologic oncologists are advocating more aggressive screening for the disease among the highest-risk women, even though they know the few screening tools they have can be expensive and are far from perfect.

These tools include pelvic exams at least every six months, twice as often as recommended for other women.

But since pelvic exams detect only about a fourth of early-stage ovarian cancers, gynecologic oncologists say, high-risk women also should be tested with ultrasound visualization of the ovaries and a blood test for elevated levels of CA 125, a cancer cell byproduct.

Typically, these tests are done only when a woman has symptoms of ovarian cancer--timing that decreases her chance of surviving the fast-moving disease if the tests do find it.

Five-year survival rates for the two earliest stages of ovarian cancer are 85% and 45%, according to federal statistics. For stages III and IV, survival drops to 18%. But the disease’s first symptoms, abdominal pain and persistent bloating, usually don’t appear until stage III.

With such grim statistics, the highest-risk women should be aggressively screened beginning no later than age 35, said Dr. H. Steven Piver, an ovarian cancer specialist at the Roswell Park Memorial Institute, a cancer center in Buffalo, N.Y.

“We’re talking about a lethal disease. What choice do we have?” Piver said.

But having these tests done twice yearly over decades would be expensive for high-risk patients.

The screening package could be expected to cost about $500, said Dr. Philip J. DiSaia, a noted ovarian cancer specialist at UC Irvine. And, because the tests are not yet a standard practice in preventing ovarian cancer, insurance companies might balk at paying for them.

“You’d have to show that picking up these women early would lead to more cures, and I’m sure it would, but the research hasn’t been done yet,” DiSaia said. “And if you tried to sell it to Medicare, you’d have to show that the cost of doing this is less than the cost of just taking out the ovaries.”

DiSaia, Piver and other gynecologic oncologists are suggesting surgical removal of ovaries from women older than 35 who have at least two first-degree relatives--mother or sisters--with ovarian cancer.

In women with less extreme risk factors for ovarian cancer, the recommendation for preventive ovary removal is less emphatic, but the doctors said these women might also want to embrace that option.

These factors include being over age 50; never having been pregnant or having had only one pregnancy; having a grandmother, aunt or cousin with ovarian cancer, and previous endometrial or colo-rectal cancer.

DiSaia noted that at least 10% of the patients he sees dying of ovarian cancer had major operations after the age of 40 during which the ovaries could have been removed easily, but weren’t.

Partly this is because of surgeons’ traditional reluctance to remove seemingly healthy organs, doctors said.

Removing the ovaries, called oophorectomy, also requires the woman to take estrogen supplements, which themselves are controversial because of links to endometrial and breast cancer. Without estrogen therapy, though, a woman is at greater risk of cardiovascular disease and osteoporosis.

Still, doctors say that women who have seen loved ones die painfully from ovarian cancer usually have little doubt after their childbearing years that they want their ovaries removed.

“One of the saddest cases I’ve seen recently was a woman in her 30s whose mother and grandmother died of ovarian cancer,” Piver said. “She went around for months searching for doctors to please take out her ovaries, and none would do it. She recently went on vacation, developed abdominal pain and ended up in the emergency room. She has stage III advanced ovarian cancer.”

Until oophorectomy becomes widely accepted and reimbursed as a preventive therapy, the best interim solution is for a high-risk woman to have her ovaries removed during other mid-life abdominal surgeries, DiSaia said.

In this way, the woman would be exposed to neither the risk nor the cost of a separate operation, he said.

“It only takes five more minutes,” DiSaia said. “I let the women decide whether they want it or not.”

Even determining that one has a family risk for the disease can be difficult, though. Piver uses the death of actress Gilda Radner in May, 1989, as an example.

Radner knew of a cousin with ovarian cancer but was aware of no other cases in her family, said Piver, who has treated the cousin and also has Radner’s family listed in his ovarian cancer registry.

But Radner’s autobiographical book, “It’s Always Something,” refers to stomach cancer in both her grandmother and an aunt. Piver has since determined from medical records that the aunt actually had ovarian cancer, and he suspects the grandmother did, too.

“What used to happen 20 or 30 years ago was that a doctor would open up a woman’s abdomen, see an advanced cancer and close her back up with a diagnosis of ‘cancer throughout her stomach,’ ” Piver said.

“If Gilda Radner had known that she had two relatives with the disease, her diagnosis probably would have been made much earlier, and she might be alive today,” he said. “Not knowing her history, it took doctors a year to make the diagnosis.”

In ovarian cancer, which commonly doubles its bulk in less than 45 days, just three to six months can be the difference between easily treatable stage I and mostly lethal stage III disease, doctors say.

Piver’s Familial Ovarian Cancer Registry so far includes 786 women from 356 families, and he adds about 30 families a month.

The registry indicates that, while an American woman has a one in 70 chance of getting ovarian cancer in her lifetime, if she has two or more first-degree relatives with the disease, her chance is one in two

If she has one first-degree relative and one second-degree relative--a grandmother, aunt or cousin with ovarian cancer-- her risk is one in four.

The influence of other risk factors, such as number and duration of pregnancies, appears to be less, but overall they are not well understood.

A task force of the American Cancer Society will consider early-detection issues in ovarian cancer when it meets this spring, said Dr. Saul B. Gusberg, distinguished professor emeritus at the Mount Sinai School of Medicine in New York and past president of the society.

Crucial to what the task force does will be the early results expected by then of studies to test the true effectiveness of vaginal ultrasound and CA 125 monitoring in detecting early-stage ovarian cancer in high-risk patients, Gusberg said.

So far, it is known that ultrasound works better if the sonogram is done through the vagina rather than through the abdominal wall, but the test still tends to give false positives. CA 125 tends to give false negatives, so perhaps the two together will be efficacious, doctors suggest.

CA 125 levels generally don’t rise much until after the cancer is past its earliest stages. They also rise in other benign conditions, most notably endometriosis.

However, blood tests for CA 125 are showing promise as part of the treatment regimen for ovarian cancer, doctors say.

In particular, it might give doctors a way to identify the 25% of ovarian cancer patients who will have a relapse even after surgery, radiation and chemotherapy appear to have been successful.

The more slowly the CA 125 level falls after the onset of chemotherapy, the more likely a woman is to have a recurrence of the cancer even after a second-look operation finds no evidence of the disease, DiSaia said.

The use of platinum-containing chemotherapy drugs, cisplatin and the more recent carboplatin, over the last decade is credited for what improvement there has been in survival rates over the last few years. Twenty years ago, fewer than 10% of women with the disease survived it, said Dr. Jonathan Berek, director of the division of gynecologic oncology at UCLA.

The newest twist in chemotherapy is filling the abdominal cavity with the drugs in solution. Some doctors believe this is more effective than administering the drugs intravenously, but others remain unconvinced.

For the future, a newly available drug called Ifosfamide and another on the horizon, Taxol, are seen as promising. Some researchers also hope to use the body’s own immune system against ovarian cancer by giving patients immune proteins such as interferon.

Medical issues around detection and treatment of ovarian cancer will be implicit as Nancy on “thirtysomething” begins chemotherapy in the next month. But the focus will remain on the emotional reverberations cancer has in people’s lives, said Edward Zwick, co-executive producer.

An outpouring of intensely personal letters from cancer patients and their loved ones has confirmed that the show has a strong teaching role to play.

“We realize there is a certain responsibility in that--whether we want it or not--people will take what we do as somehow prescriptive,” Zwick said. “And to that end, we’ve tried to get our information on cancer as right as we can. If the legacy of something like this is that people pay more attention to Pap smears (for cervical cancer) or militate for earlier sonograms, then so much the better.”

OVARIAN CANCER THOSE AT RISK

* Mother, sister or other relative with ovarian cancer. (Remember: It was often mislabeled as “stomach cancer” a few decades ago.)

* Over age 50.

* One or no pregnancies.

* Personal or family history of breast cancer.

* Previous ovarian, endometrial or colon/rectal cancer.

THE RECOMMENDATIONS

* Every woman under age 50 should have an annual pelvic examination.

* Women over age 50 should have a pelvic examination every six months.

* If a woman has a family history or other risk factors for ovarian cancer, she should be checked at least every six months, no matter what her age. Some doctors recommend exams every three months.

* There is growing opinion that exams for high-risk women should include not just a pelvic exam but also vaginal ultrasound testing and a blood test for the cancer-cell byproduct CA 125.

* Some doctors recommend surgical removal of ovaries in women with two first-degree relatives--mother or sisters--with ovarian cancer.