Copyright eContent Management Pty Ltd. Contemporary Nurse (200910) 34(1): 5565.

Symptoms and diagnostic delay in ovarian cancer: A summary of the literature

VICTORIA JAYDE
Doctoral Candidate, Faculty of Nursing and Midwifery, University of Sydney, Sydney, NSW, Australia

KATHRYN WHITE
Sydney Cancer Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia

PENNY BLOMFIELD
Department of Obstetrics and Gynaecology, Royal Hobart Hospital, University of Tasmania, Hobart, TAS, Australia

ABSTRACT
Ovarian cancer is the most common cause of death due to gynaecological cancers in developed countries. The symptoms of ovarian cancer are common female complaints, are non-specic and do not t any easily recognisable pattern. This frequently leads to a delay in diagnosis. Until an effective screening test becomes available for this disease, increasing the education of women and clinicians regarding the symptoms of ovarian cancer must be seen as a priority. Nurses are ideally placed to disseminate information about the symptoms of ovarian cancer to the community and have a responsibility to do so. It is crucial that nurses are aware of the common symptoms and the usual diagnostic pathway in order to provide empathetic, informed nursing care. This paper draws on the results of a narrative systematic review to describe current knowledge of symptoms of ovarian cancer and describes delays women commonly experience in obtaining a diagnosis.
KEYWORDS: ovarian cancer; symptoms; diagnosis; nursing; experience; women

INTRODUCTION
lthough ovarian cancer is relatively uncommon, it remains the foremost cause of death from gynaecological cancer in Australia (National Breast Cancer Centre [NBCC], 2002) and the western world (Chu & Rubin, 2006:307). As a cause of death from cancer in women, it is fth in the world (Salzberg et al., 2005) and was the ninth most commonly diagnosed cancer in women in Australia in 2005 (Australian Institute of Health & Welfare (AIHW) & Australasian Association

of Cancer Registries [AACR], 2008). In Australia in 2005, 1205 women were diagnosed with ovarian cancer and 888 women died from the disease (AIHW & AACR, 2008). This is despite improvements in treatment in the past 30 years (Bhoola & Hoskins, 2006). In Australia, between 1998 and 2004, patients diagnosed with ovarian cancer had an overall survival rate of 39.8% (AIHW, 2008:179; AIHW, Cancer Australia, & AACR, 2008:7). Most women diagnosed with ovarian cancer are symptomatic. Only a small percentage of

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disease compared with late stage, it is imperative that efforts are made to ensure earlier diagnosis. It is critical that nurses are familiar with the subtle symptoms of ovarian cancer as they are ideally placed to facilitate information ow about the symptoms. It has been identied that, in general, womens knowledge of the symptoms of ovarian cancer is limited (NBOCC, 2008c). Nurses have a professional responsibility to provide health education and counseling to members of the community (Australian Nursing & Midwifery Council (ANMC), Royal College of Nursing, Australia (RCNA), & Australian Nursing Federation [ANF], 2008). In addition, nurses play a key role in enabling women to make informed decisions regarding health care (ANMC, 2006, 2008; ANMC, RCNA, & ANF, 2008). Until an efcient and reliable screening test is developed, timely symptom recognition is thought to be one defence against the high mortality associated with ovarian cancer (Ryerson et al., 2007; Vine, Calingaert, Berchuck, & Schildkraut, 2003). Whether this is the case or not, prompt diagnosis will reduce some of the distress of women who are faced with this disease. Given the often convoluted journey undertaken to diagnosis, it is crucial that nurses are aware of the common diagnostic pathway in order to provide empathetic, optimal, informed nursing care to the women and their families. This paper draws upon a systematic review of current research to examine the symptoms and presentations that lead to a diagnosis of ovarian cancer.

women presenting with early stage disease will have no symptoms. Due to the non-specic and common nature of the complaints caused by ovarian cancer, there are frequently obstacles encountered in obtaining a diagnosis and therefore delays occur. Most women who are diagnosed with the disease are identied only when the disease is widely disseminated (Behtash, Ghayouri, & Fakhrejani, 2008; Bhoola & Hoskins, 2006; Chan & Selman, 2006; Evans, Ziebland, & McPherson, 2007; Fox & Lyon, 2007; Friedman, Skilling, Udaltsova, & Smith, 2005; Kehoe, 2006; National Comprehensive Cancer Network & American Cancer Society [NCCN & ACS], 2004; NBCC, 2005; Olaitan & McCormack, 2007). While diagnostic tools such as abdominal ultrasound, CA125 blood tests (NCCN & ACS, 2004), computed tomography and magnetic resonance imaging (National Breast and Ovarian Cancer Centre [NBOCC], 2008b) might facilitate the diagnosis of clinically suspected ovarian cancer the disease is usually conrmed as a result of histological examination of tissue removed during surgery (Martin & Cherry, 2006; NBOCC, 2008b). At this time, there is no screening test for ovarian cancer recommended for the general public (Australian Cancer Network (ACN) & NBCC, 2004; National Ovarian Cancer Network [NOCN], 2006). The high mortality rate associated with ovarian cancer is attributed to the fact that it is usually diagnosed at a late stage (American College of Obstetricians and Gynecologists [ACOG], 2002; Chu & Rubin, 2006; Kurman, Visvanathan, Roden, Wu, & Shih, 2008). The stage of the disease at diagnosis has a huge impact on the prognosis (Bankhead et al., 2008). An average of 7075% of women with ovarian cancer are diagnosed at a late stage (ACOG, 2002; Gaetano & Lichtman, 2004; NOCN, 2006). These women have an associated 5-year survival rate of 2030%, in contrast to women diagnosed with an early stage disease, who have a 9095% chance of being cured (ACOG, 2002:237). Given the vast difference in prognosis for those women diagnosed with early
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AIM
The aim of this article is twofold. It aims to rstly describe current knowledge regarding symptoms of ovarian cancer and secondly to examine reasons for delays women commonly experience in obtaining a diagnosis.

METHOD
Systematic review is used as a methodology to identify, evaluate and interpret all available research relevant to a particular topic area or

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phenomenon of interest, in order to present an informed summary of the data (National Health & Medical Research Council [NHMRC], 2000). A systematic review is the secondary study of individual studies, commonly referred to as primary studies (Bell-Syer, Foxlee, & Cullum, 2007:283). The rigour of the systematic review is critical, and therefore conducted based on guidelines that outline each step in the review. An initial analysis of the type of research papers for this study highlighted the lack of randomised controlled trials that would be available for data extraction. Given this, a decision was made to undertake a descriptive narrative review of the literature within a systematic framework, using the broad steps outlined by Cochrane to ensure the review was carried out in a systematic, rigorous and transparent way. The major variation in how the review was undertaken is in the type of papers included, and the limited ability to pool data sources. A descriptive systematic review attempts to consider all studies published on a given clinical question with conclusions drawn based on all the available evidence (Green, 2005). It should be noted as the authors elected to include qualitative studies, the intent is not to generalise broadly from the review, but rather to highlight what the research in this area has to date shown.

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Search strategy
In response to the research aims outlined earlier, a search strategy was developed using keyword search terms related to the area of focus; this included terms such as ovarian neoplasms, ovarian cancer, experience, pre-operative period, symptoms and diagnosis. This was combined with an expanded methodological search strategy. The search strategies were run in electronic databases including AMED, CINAHL, EBM Reviews, Medline, Premedline, Proquest, Proquest Dissertation and Theses Full Text and PsychINFO. Additional electronic strategies were utilised for expanding the search depth, such as articles which cite this work and more articles like this. Reference lists of all

articles were reviewed manually to identify additional papers. The search strategy was limited to the time period 19932008. Due to limitations in access to translation, only papers written or translated into English were included. Opinion, editorial or commentary, and any papers not presenting the results of research were also excluded. Literature and systematic reviews were included. A total of 87 papers were examined for this review. Entire papers were obtained, rather than abstracts alone. Editorials, commentaries and unpublished theses identied from the search were subsequently excluded. All eligible papers were included and thus data was extracted from the remaining 56 papers. Of these, 29 were of quantitative design, 11 were literature reviews, one was a systematic review, one used a combination of quantitative and qualitative methods and nine were evidence-based guidelines. Five qualitative studies were also included. This paper will present the data analysis on one aspect of the review presentation, diagnosis and symptom presentations. Data was extracted by the lead author and conrmed by the second author. This data was pooled in six key themes. Discussion of data analysis was ongoing throughout this period. The review of the research will be presented in the six key themes identied from the analysis of the reviewed papers.

RESULTS
A silent disease?
Ovarian cancer has traditionally been referred to as a silent disease, as it was suggested that women do not experience symptoms until the cancer has metastasized widely (Bankhead et al., 2008:10081009; Chan & Selman, 2006; Goff, Mandel, Melancon, & Muntz, 2004; Goff, Mandel, Muntz, & Melancon, 2000; Smith et al., 2005:1398). This may or may not be the case. There is evidence that few women (between 510%) are asymptomatic (Bankhead, Kehoe, & Austoker, 2005; Behtash et al., 2008; Chan, Ng, Lee, Ngan, & Wong, 2003; Fitch, Gray,

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resulting confusion over symptom recognition may lead to difculty and/or delay in the diagnosis of ovarian cancer.

DePetrillo, Franssen, & Howell, 1999; Goff et al., 2000; Lataifeh, Marsden, Robertson, Gebski, & Hacker, 2005; Olson et al., 2001; Partridge & Barnes, 1999; Paulsen, Kaern, Kjaerheim, Trope, & Tretli, 2005) and that most women who have ovarian cancer will describe having symptoms prior to their diagnosis for variable periods of time (Bankhead et al., 2008; Behtash et al., 2008; Ferrell, Smith, Cullinane, & Melancon, 2003; Goff et al., 2004; Lataifeh et al., 2005; Partridge & Barnes, 1999; Paulsen et al., 2005; Webb et al., 2004). Studies comparing women presenting with early and late stage disease do not show major differences in the presence or absence or duration of symptoms. It is suggested that the earlier detection of ovarian cancer would increase the survival rate of women affected with the disease (Goff et al., 2004, 2007; NOCN, 2006; Teneriello & Park, 1995). However, the natural history of ovarian cancer is poorly understood and although women experiencing symptoms often feel let down by the difculties they encounter in establishing a diagnosis, there is no solid evidence to suggest their outcomes would be substantially improved by a more prompt diagnosis. The relationship between the development of symptoms and the extent of ovarian cancers is not well addressed.

Symptoms of ovarian cancer

A number of studies have shown that 81100% of women with ovarian cancer experience at least one symptom prior to diagnosis (Attanucci, Ball, Zweizig, & Chen, 2004; Bankhead et al., 2008; Behtash et al., 2008; Goff et al., 2007; Lataifeh et al., 2005; Ryerson et al., 2007; Vine et al., 2003). The most commonly reported symptoms of ovarian cancer were abdominal (Bankhead et al., 2005; Chan et al., 2003; Ferrell et al., 2003; Smith et al., 2005; Webb et al., 2004; Wynn, Chang, & Peipins, 2007) and/or gastrointestinal in nature (Behtash et al., 2008; Friedman et al., 2005; Goff et al., 2000, 2007; Yawn, Wollan, Klee, & Barrette, 2001). Other commonly reported symptoms include urinary (Lataifeh et al., 2005; Wynn et al., 2007) or bowel problems with the latter being signicantly associated with late stage disease (Chan et al., 2003). Some authors indicated that abdominal (Lataifeh et al., 2005) and/or pelvic pain was a cardinal feature of advanced disease (Portenoy et al., 1994), whilst others noted that it was associated with early stage and borderline ovarian tumours (Eltabbakh, Yadev, & Morgan, 1999). Gynaecologic symptoms (Attanucci et al., 2004; Behtash et al., 2008; Lataifeh et al., 2005; Nelson, Ekbom, & Gerdin, 1999), gastrointestinal symptoms (Friedman et al., 2005; Webb et al., 2004), weight loss (Paulsen et al., 2005), and fatigue (Dawson, 1993; Ferrell et al., 2003; Fitch et al., 2002; Paulsen et al., 2005; Wikborn, Pettersson, & Moberg, 1996) were also reported. Clusters of symptoms have been identied. In one study, 43% of women with ovarian cancer had a combination of abdominal bloating, increased girth and urinary symptoms compared to 10% of women with benign disease (Goff et al., 2004). Making sense of the many reports of symptoms is complicated by the different terms and combinations of terms used to describe the

Vague symptoms
Ovarian cancer is often a problematic disease to diagnose (Evans et al., 2007; Partridge & Barnes, 1999). This is because the symptoms are frequently not initially recognised by women, and/ or their physicians, as representing a serious illness (Reynolds & Moller, 2006). The symptoms of ovarian cancer are typically vague and non-specic (Cannistra, 2004; Chan & Selman, 2006; Goff et al., 2007; Reynolds & Moller, 2006; Rufford, Jacobs, & Menon, 2007). They may mimic symptoms of other conditions (Fitch, Deane, Howell, & Gray, 2002; NBOCC, 2008c; NOCN, 2006) or be attributed to normal bodily changes due to such things as stress, aging or menopause (Bankhead et al., 2008; Evans et al., 2007; Ferrell et al., 2003; Fitch et al., 2002). The
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symptoms. Abdominal symptoms were variously reported as pain, discomfort, bloating, fullness, pressure and swelling (Bankhead et al., 2005; Behtash et al., 2008; Dawson, 1993; Ferrell et al., 2003; Fitch et al., 1999; Friedman et al., 2005; Lataifeh et al., 2005; Olson et al., 2001; Paulsen et al., 2005; Webb et al., 2004; Wikborn et al., 1996). Gastrointestinal symptoms may include nausea, vomiting, diarrhoea and/or constipation (Behtash et al., 2008; Ryerson et al., 2007). In one study abdominal pain was listed as a gastrointestinal symptom and abdominal swelling was included with gynaecologic symptoms (Ryerson et al., 2007). In another study, abdominal pain, abdominal swelling, gastrointestinal symptoms and pelvic pain were all listed as separate groups of symptoms (Smith et al., 2005). Other studies group abdominal and pelvic pain together (Goff et al., 2007); or include increased girth or an abdominal mass in a pelvic group, whilst including vaginal disorders with urinary complaints (Nelson et al., 1999:473474). One study used the term symptoms of mass effect to describe frequency, constipation, palpable mass, pelvic pressure but did not explain the symptoms included in other terms such as gastrointestinal or gynaecological (Attanucci et al., 2004:1436). Care should be also exercised when interpreting reports using the terms bloating and distension as it has been identied that the terms are often used interchangeably (Bankhead et al., 2005, 2008). Persistent abdominal distension has been more commonly associated with ovarian cancer than uctuating bloating (Bankhead et al., 2008; Olson et al., 2001). It is important that health care professionals take meticulous medical histories from clients. Women with ovarian cancer have been identied as having more persistent, frequent and severe symptoms than women attending primary health care clinics with similar complaints (Goff et al., 2004). In an American study, in the year prior to their diagnosis of ovarian cancer, women reported a median of eight symptoms, with between 15

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and 30 episodes of each symptom per month (Goff et al., 2004). Several authors have attempted to differentiate between symptoms of early and late stage disease (Attanucci et al., 2004; Lataifeh et al., 2005; Ryerson et al., 2007; Webb et al., 2004; Wikborn, Pettersson, Silfversward, & Moberg, 1993). A number of studies reported that gynaecological symptoms (eg abnormal bleeding and pelvic pain) were more common with early stage disease (Ryerson et al., 2007; Webb et al., 2004). Another study reported that abdominal pain was experienced by 51% women with early stage ovarian cancer, versus 44% of women with late stage ovarian cancer (Lataifeh et al., 2005). In contrast, advanced disease was associated with greater abdominal swelling (62%) than early stage disease (32%) (Lataifeh et al., 2005). Similarly, advanced ovarian cancer has been associated with more gastrointestinal symptoms than early stage (Attanucci et al., 2004; Ryerson et al., 2007; Webb et al., 2004), contradicting another study, which found they were more common in early stage patients (Wikborn et al., 1993). Several guides have been published which outline the symptoms that women with ovarian cancer commonly experience. (Outlined below in Table 1).

Symptom recognition by women

Most women follow a complex route to obtain a diagnosis of ovarian cancer (Dawson, 1993; Ferrell et al., 2003; Fitch et al., 2002; Goff et al., 2000; Koldjeski, Kirkpatrick, Swanson, Everett, & Brown, 2005). The process typically begins with recognition by the woman that something is amiss, although this can vary from person to person. Once symptoms have been acknowledged, women do not always seek a medical diagnosis immediately (Chan et al., 2003; Goff et al., 2000, 2004; Paulsen et al., 2005; Webb et al., 2004). This may be because they ignored the symptoms or have not recognised their implications (Goff et al., 2000; Power, Brown, & Ritvo, 2008). The time taken to seek medical advice

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TABLE 1: SUMMARY OF CURRENT AUSTRALIAN GUIDES TO THE SYMPTOMS OF OVARIAN CANCER, FOR HEALTH PROFESSIONALS
AND THE PUBLIC

Reference ACN and NBCC (2004:65) NBCC (2005) NBCC (2006)

Most common symptoms Abdominal bloating; increased abdominal girth; indigestion, lack of appetite; change in bowel habits; constipation; urinary frequency or incontinence; fatigue; abdominal and/or pelvic pain Abdominal, gastrointestinal, constitutional, urinary, pelvic Abdominal bloating/feeling full, appetite loss, unexplained weight gain, constipation, heartburn, back pain, frequent urination, abdominal/pelvic pain, fatigue Abdominal bloating, abdominal or back pain, appetite loss or feeling full quickly, changes in toilet habits, unexplained weight loss or gain, indigestion or heartburn, fatigue Swollen abdomen, abdominal pain/pressure/discomfort, diarrhoea/constipation, frequency/urgency, unusual vaginal bleeding, early satiety or bloating, indigestion/feeling sick, weight gain/loss, lower back pain, unexplained fatigue, loss of appetite, atulence, dyspareunia Abdominal bloating/feeling full, appetite loss, unexplained weight loss, constipation, heartburn, back pain, frequent urination, abdominal/pelvic pain, fatigue

NBOCC (2008a)

NBOCC (2008b:3)

NBOCC (2009:1)

Abbreviations: ACN Australian Cancer Network; NBCC National Breast Cancer Centre; NBOCC National Breast and Ovarian Cancer Centre.

varied widely between 2 or 3 weeks (Chan et al., 2003) to over 12 months (Goff et al., 2000, 2004; Paulsen et al., 2005). In one study, almost 50% of women waited more than a month before seeking a diagnosis (Thulesius, Lindgren, Olsson, & Hakansson, 2004). In Australia, women sought medical advice for their symptoms after a median of 4 weeks (Webb et al., 2004). A diagnosis of ovarian cancer was an incidental nding for some women (Schaefer, Ladd, Lammers, & Echenberg, 1999; Webb et al., 2004; Yawn et al., 2001). For asymptomatic women the diagnosis is often made at the time of undergoing investigations or treatment for unrelated issues (Vine et al., 2003) such as having a pap smear. Lack of symptoms was more strongly associated with early stage disease: 11% for women with early stage versus 3% for late stage (Goff et al., 2000). In addition, it has been found that women who ignored or rationalised their symptoms were signicantly more likely to be diagnosed with late stage ovarian cancer (Goff et al., 2000).
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Communication between women and doctors

The quality of the doctorpatient relationship has been highlighted as a key ingredient in the timely diagnosis of ovarian cancer (Evans et al., 2007; Ferrell et al., 2003). In a number of studies women identied a poor relationship with their doctor as a barrier to timely diagnosis (Fitch et al., 2002; Goff et al., 2000). To facilitate a correct diagnosis, the woman must accurately describe symptoms to their doctor. This can be challenging when the symptoms are experienced as vague and non-specic. Identication of the number, type, frequency, severity and duration of presenting symptoms might facilitate the identication of possible disease (Goff et al., 2004, 2007). This can be achieved with the use of a symptom diary in which women can record the frequency, duration and severity of their symptoms (Koldjeski et al., 2005; Ovarian Cancer Australia, 2008). Diagnosis is further complicated by the common nature of the presenting symptoms and their

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possible link to various benign conditions (Evans et al., 2007:53; NBOCC, 2008c). The use of a symptoms index by doctors has been suggested to facilitate the timely diagnosis of ovarian cancer (Anderson et al., 2008; Goff et al., 2007). Some women reported that their health care professionals did not listen to, or respond to, their concerns (Fitch et al., 2002; Schaefer et al., 1999). Others experienced difculty in convincing their doctor/s of the abnormal nature of their symptoms (Ferrell et al., 2003; Fitch et al., 2002; Schaefer et al., 1999). In addition, women reported that doctors frequently failed to recognise the implications of the symptoms (Dawson, 1993; Evans et al., 2007; Power et al., 2008). Some doctors misdiagnosed women with other conditions before their nal diagnosis of ovarian cancer (Evans et al., 2007; Fitch et al., 2002; Goff et al., 2000; Koldjeski et al., 2005; Power et al., 2008). This was illustrated in a study of a Norwegian hospital, where 38% of women with ovarian cancer were initially sent to wards other than gynaecological (Paulsen et al., 2005:33). These ndings are no doubt due to the common, vague and nonspecic nature of the presenting symptoms making it challenging for the physicians involved. The time taken for women to be diagnosed with ovarian cancer after consulting a medical practitioner varied between reports. Whilst 54% of women were diagnosed within 4 weeks of consulting a doctor about their symptoms in one report (Fitch et al., 1999), a large North American study reported 30% of women were diagnosed within 2 months (Goff et al., 2000). Between 3078% of women were diagnosed within 3 months of seeking help (Fitch et al., 1999; Goff et al., 2000; Paulsen et al., 2005; Vine, Ness, Calingaert, Schildkraut, & Berchuck, 2001; Wikborn et al., 1996). It took up to 6 months for 6588% of women to be accurately diagnosed and over 12 months for 615% of women (Fitch et al., 1999; Goff et al., 2000; Paulsen et al., 2005). This data is supported by two qualitative studies, which reported lengthy delays between rst seeking advice and being diagnosed (Ferrell et al., 2003; Fitch et al., 2002). In contrast,

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in Australia, the median time for diagnosis after seeking medical advice was reported to be 2 weeks (Webb et al., 2004).

Tests for ovarian cancer

At present, there is no reliable screening test for ovarian cancer (Kurman et al., 2008). The available tests lack sensitivity and are unable to detect early stage disease (Kurman et al., 2008:351). The most widely used and most reliable serum marker for ovarian cancer is CA125 (Chu & Rubin, 2006; Nossov et al., 2008; Scottish Intercollegiate Guidelines Network, 2003). However, its use as a diagnostic tool is compromised by the fact that it can be raised for various other cancers and for some benign conditions, for example liver disease (Cannistra, 2004; Chu & Rubin, 2006; Nossov et al., 2008; Partridge & Barnes, 1999; Teneriello & Park, 1995).

CONCLUSION AND IMPLICATIONS FOR

NURSING

Ovarian cancer is the most common cause of death due to gynaecological cancers in women. Although it is not as common as some other cancers, it is associated with signicant morbidity and high mortality rates. Nurses have a responsibility to ensure that their professional practice is based upon current research ndings (ANMC, 2006). Accurate knowledge of the symptoms of ovarian cancer will facilitate their understanding of the diagnosis of the disease thus enabling nurses to provide symptom information and education to members of the community. Nurses can have a signicant impact on community and patient education and on symptom recognition and management (Gaetano & Lichtman, 2004:330). The promotion of community awareness of associated symptoms could facilitate the timely diagnosis of ovarian cancer and thus potentially contribute to reducing the morbidity and mortality of the disease. Until an accurate and reliable screening test is available, the most effective way to diagnose ovarian cancer is for both the woman and her

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Australian Institute of Health and Welfare (AIHW), & Australasian Association of Cancer Registries (AACR). (2008). Cancer in Australia: An overview, 2008. Cancer series no. 46. Cat. No. CAN 42. Canberra: AIHW. Australian Institute of Health and Welfare (AIHW), & Cancer Australia and Australasian Association of Cancer Registries (AACR). (2008). Cancer survival and prevalence in Australia: Cancers diagnosed from 1982 to 2004. Cancer Series no. 42. Cat. No. CAN 38. Canberra: AIHW. Australian Nursing and Midwifery Council (ANMC). (2006). National competency standards for the registered nurse. ANMC. Retrieved March 23, 2009, from http://www.anmc.org.au/professional_standards/index.php. Australian Nursing and Midwifery Council (ANMC). (2008). Code of professional conduct for nurses in Australia. ANMC. Retrieved March 23, 2009, from http://www.anmc.org.au/professional_standards/index.php. Australian Nursing and Midwifery Council (ANMC), & Royal College of Nursing, Australia (RCNA) and Australian Nursing Federation (ANF). (2008). Code of ethics for nurses in Australia. ANMC. Retrieved March 23, 2009, from http://www.anmc.org.au/professional_standards/index.php. Bankhead, C., Collins, C., Stokes-Lampard, H., Rose, P., Wilson, S., Clements, A., et al. (2008). Identifying symptoms of ovarian cancer: A qualitative and quantitative study. BJOG: An International Journal of Obstetrics and Gynaecology, 115(8), 10081014. Bankhead, C., Kehoe, S., & Austoker, J. (2005). Symptoms associated with diagnosis of ovarian cancer: A systematic review. BJOG: An International Journal of Obstetrics and Gynaecology, 112(7), 857865. Behtash, N., Ghayouri, A., & Fakhrejani, F. (2008). Symptoms of ovarian cancer in young patients 2 years before diagnosis, a case-control study. European Journal of Cancer Care, 17(5), 483487. Bell-Syer, S., Foxlee, R., & Cullum, N. (2007). The Cochrane Wounds Group: Systematically reviewing the wound care literature. Advances in Skin and Wound Care, 20(5), 2837.

doctor to suspect possible ovarian cancer if the woman presents with symptoms (ACOG, 2002; Behtash et al., 2008; Vine et al., 2003). Although the symptoms of ovarian cancer are common and nonspecic, when they are persistent, severe and frequent, prompt investigation should be initiated. Women thus need to be informed and educated about the cluster of ovarian cancer symptoms to enable them to be their own health care advocates (Koldjeski et al., 2005). By having a thorough understanding of the issues associated with the diagnosis of ovarian cancer, nurses will be in a better position to provide informed, optimal health care, to women and their families. This article has described some of the difculties women experience in obtaining a denitive diagnosis and points to how nurses can use their knowledge of the diagnostic process to help women and families cope with the diagnosis and subsequent treatment of ovarian cancer.

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Received 04 May 2009 Accepted 26 October 2009

SPECIAL ISSUES WOMENS HEALTH

Symposium on Womens Health Edited by Lynne Hunt (Edith Cowan University) and Beverley McNamara (University of Western Australia) a special issue of Health Sociology Review vol 13/1 ISBN 978-1-921348-29-7 April 2004 108 pages
This edition of Health Sociology Review features a symposium on womens health and covers a diverse range of topics including teenage pregnancy; heart disease; the health status of rural and remote women, in Australia and in Papua New Guinea; the emotional torment of many women refugees to Australia from Africa; and changes in drinking patterns among immigrant women from Poland.

Innovative Approaches to Family Violence Edited by Margot J. Schoeld and Rae Walker (Director of Research for the Psychotherapy and Counselling Federation of Australia (PACFA) and School of Public Health, La Trobe University, Melbourne) a special issue of Journal of Family Studies vol 14/2-3 ISBN 978-1-921348-05-1 October 2008 ii+256 pages
Organised into sections on understanding the experience and impact of family violence, systemic and government responses to family violence, and therapeutic responses to family violence, this comprehensive double issue of Journal of Family Studies addresses pressing public health priorities of interpersonal family violence, in 16 innovative research articles across several immigrant cultures.

Symposium on Womens Health: Breast Health - Health and Ageing Edited by Lynne Hunt (Edith Cowan University), Beverley McNamara (University of Western Australia) and Eileen Clark (La Trobe University) a special issue of Health Sociology Review vol 12/2 ISBN 978-1-921348-49-5 December 2003 88 pages
This issue of Health Sociology Review is an important contribution to womens health and health and ageing. The symposium format allows readers to gain insight into the many ways in which various scholars theorise and understand the social issues being examined.

Women and Rural Issues Edited by Jennifer McKinnon and Christine Ferrari (Centre for Rural Social Research, Charles Sturt University) a special issue of Rural Society vol 8/3 ISBN 978-1-921348-30-3 December 1998 i+135 pages
This special womens issue of Rural Society raises the prole of rural women on a global scale to honour World Rural Womens Day. Several strong themes emerge from the articles, which include womens relationship to the landscape; the necessity for self reliance and condence; the strength of women in overcoming adversity; balancing the demands of the family with rural work and / or leadership roles; the importance of female networks, and the overwhelming need to achieve parity at all levels of rural society.

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