I thank Dr. Markman for his comments regarding our article.1 I agree with him that the complex biology of ovarian cancer is poorly understood, and it is not known with certainty if diagnosing ovarian cancer 3 to 6 months earlier will have an impact on overall survival. As is true for all screening modalities, additional research is needed to determine whether screening by a symptom index will improve outcomes for ovarian cancer patients. To my knowledge, to date, screening using conventional strategies has not impacted the morbidity or mortality of this disease. Additional research is also needed to determine whether guilt and anger from ignorance of symptoms occurs in a significant percentage of women, as suggested by Dr. Markman.
Although the goal of any screening or early detection program is to diagnose patients in the earliest stage of disease, for ovarian cancer there is also a survival advantage in detecting stage III disease early enough to allow optimal surgical cytoreduction. Cure rates are approximately twice as high for women when optimal cytoreductions can be accomplished. These women can also be offered intraperitoneal chemotherapy, resulting in a further improvement in survival.2 Supported by the literature and my personal experience as a surgeon who has performed hundreds of these procedures, the most important factor in an optimal cytoreduction is the amount of disease confronted by the surgeon when entering the patient's abdomen.3
Ultimately, Dr. Markman's comments raise a philosophical question: is early detection through an understanding of symptoms better or worse than the anger and guilt that women may feel from not acting on their symptoms? In the accompanying editorial written by leaders of the survivor community,4 it is very clear on which side of the debate they stand. And I agree with the survivor community: until there is a valid screening test, awareness is best. Fortunately, Johanna's Law was recently passed, which provides funding for gynecologic cancer awareness and education. Reportedly, only 15% of women are familiar with ovarian cancer symptoms,4 and that fact should give urgency to efforts to improve this knowledge deficit. Our current study provides guidance for primary care physicians regarding which symptoms are most predictive of ovarian cancer. Finally, I do believe that, working together, well-informed women and well-educated primary clinicians may offer the best hope, at least for now, for the earliest possible detection of this deadly cancer.