This publication describes current knowledge of the incidence, possible causes and prevention, detection and diagnosis, and treatment of ovarian cancer. The information presented here was gathered from medical textbooks, recent articles in scientific journals, researchers at the National Cancer Institute (NCI), the NCI's PDQ (Physician Data Query) database, and various scientific meetings. This Report expands upon the NCI pamphlet What You Need To Know About Ovarian Cancer
Knowledge about cancer of the ovary is increasing steadily. Up-to-date information on this and other cancer-related subjects is available from the toll-free Cancer Information Service at 1-800-4-CANCER.
Description and Function of the Ovaries
The ovaries are a pair of female reproductive organs, each about the size and shape of an unshelled almond. They are located in the upper pelvic cavity (the area between the hip bones) just below the abdominal cavity (the area containing the stomach, intestines, liver, spleen, pancreas, bladder, kidneys, and gallbladder). One ovary is found on either side of the uterus, or womb. They are held in place by ligaments and protected by a mass of fat. One fallopian tube leads from each ovary to the uterus. The ovaries have two main functions: ovulation (the release of an egg) and production of estrogen and progesterone, hormones that regulate menstruation and pregnancy and control the development of female physical traits.
At birth, the undeveloped ovaries already contain the specialized cells that eventually become ova, or egg cells. The pituitary gland, located at the base of the brain, produces hormones that stimulate the release of one new egg each month from puberty until menopause. Ovulation alternates between the two ovaries. When an egg is released, it travels through the fallopian tube to the uterus. If the egg is not fertilized, menstruation begins about 2 weeks later.
The ovaries produce estrogen, the hormone that plays a role in the fertilization of an egg, its implantation in the uterus, and the nutrition of the developing embryo. As the egg matures, a large amount of estrogen is produced. If the egg is not fertilized, the output of estrogen drops sharply after ovulation. Estrogen also influences certain female physical characteristics. For example, this hormone regulates a number of changes that occur during puberty, such as alterations in voice pitch and pelvic structure, growth of body hair, and redistribution of fat to the breasts, abdomen, and hips.
Progesterone is another hormone that plays an important part in the menstrual cycle. At ovulation, the ovaries secrete progesterone into the bloodstream. Progesterone works with estrogen to prepare the uterus for implantation of the fertilized egg and to prepare the breasts to produce milk. If fertilization does not take place, the level of progesterone drops. However, if a woman becomes pregnant, the level of progesterone rises.
Like all organs, the ovaries are made up of several types of cells. Some carry out the organ's main functions, while others provide physical support. For example, a layer of cube-shaped cells called the germinal epithelium covers the surface of the ovary. Under this layer is the tunica albuginea, a protective capsule of connective tissue. Another region of connective tissue known as the stroma lies beneath the tunica albuginea. The stroma (a part of the outer framework of the ovary) is made up of a dense outer layer called the cortex and a loose inner layer called the medulla.
Types of Ovarian Cancer
Normally, the cells of the ovaries, like all cells, divide and reproduce in an orderly way to repair wornout or injured tissues and to allow for growth. If cell division is not controlled, abnormal growth takes place, forming masses of tissue known as tumors. Tumors may be benign (noncancerous) or malignant (cancerous). Because they can crowd nearby structures, benign tumors may interfere with normal functions, but they do not spread to other parts of the body and generally do not threaten life.
Cancers, by contrast, can invade and destroy the normal tissues in which they arise and can extend into surrounding structures. Cancer cells can also break away from the primary tumor in the ovary and metastasize, or spread, to other parts of the body and form secondary (metastatic) tumors. When ovarian cancer spreads, it usually travels first to nearby organs. Sites of early metastasis may be the opposite ovary, the uterus, the fallopian tubes, and all the surfaces of the organs in the peritoneal cavity. Ovarian cancer can also spread to nearby lymph nodes and to distant organs, including the liver, lungs, pleura (the membrane surrounding the lungs), kidneys, adrenal glands, bones, bladder, and spleen. When viewed under a microscope, the cancer cells that form these secondary tumors are usually identical to the cells of the primary (original) cancer. As such, they have many of the characteristics of the original cancer, despite their location in another part of the body. These secondary tumors are referred to as "metastatic ovarian cancer" to indicate that they are all part of a single disease and do not represent new cancers originating in these organs.
Cancer can also spread to the ovary from another part of the body. An example is the Krukenberg tumor, a cancer that originates in the stomach and metastasizes to the ovary. The cells in the secondary tumor in the ovary are stomach cancer cells. Treatment for cancer that has spread to the ovary depends primarily on the location and type of the original tumor.
Cancer may begin in any of the cells that make up the ovary. Approximately 85 to 90 percent of ovarian cancers are epithelial carcinomas, which arise in the ovary's outer layer. Based on their microscopic appearance, epithelial ovarian cancers are classified as serous cystadenocarcinoma, mucinous cystadenocarcinoma, endometrioid adenocarcinoma, or clear cell cystadenocarcinoma.
Stromal (also called sex cord) tumors and germ cell tumors make up less than 10 percent of ovarian cancers. The most frequently seen stromal tumors are granulosa cell tumors and Sertoli-Leydig tumors, which develop in granulosa cells and Sertoli-Leydig cells found in the stroma. The most common germ cell tumors, found primarily in children and young women, are dysgerminoma, endodermal sinus tumor, embryonal carcinoma, malignant teratoma, and choriocarcinoma. Germ cell tumors affect the special cells that give rise to the ovaries during fetal development.
Among women in the United States, cancer of the ovary is the eighth most common cancer and the fifth most frequent cause of death from cancer. It accounts for about 27 percent of all cancers affecting the female reproductive organs. One out of every 70 American women (1.4 percent) will develop this disease at some time during her life. The incidence of ovarian cancer increases steadily with age, with most cases found in women 55 to 75 years old. It occurs with equal frequency in each of the two ovaries.
The highest rates of ovarian cancer are reported in white women living in Europe and North America. Asian women have a relatively low incidence of this type of cancer. Although Chinese and Japanese women who live in the United States tend to have higher rates of ovarian cancer than their Asian counterparts, the disease is still less common among this group than among the native white population of the United States. Rates among black women in all parts of the world are low.
Although a number of factors have been associated with an increased risk of developing ovarian cancer, the exact cause or causes of this disease remain unknown. Researchers have studied a number of possible risk factors, including nulliparity (no pregnancies), a history of breast cancer, radiation exposure, and exposure to asbestos or talc.
A history of few or no pregnancies has been linked to an increased risk for ovarian cancer, suggesting that hormones play a role in the development of this disease. Women who have been pregnant are half as likely to develop ovarian cancer as women who have not, and protection appears to increase with the number of pregnancies. The use of oral contraceptives (birth control pills) appears to reduce the risk of ovarian cancer by 10 to 50 percent, perhaps because they create a hormonal balance similar to that found during pregnancy.
Women who have had breast cancer have twice the average risk of developing ovarian cancer. Conversely, women who have had ovarian cancer are three to four times more likely to develop breast cancer.
Ovarian cancer has been reported in several members of the same family; however, this is a rare occurrence. Even when two or more women from a single family are affected by ovarian cancer, it has not been possible to determine whether these cancers are due to genetic factors or whether they occur merely by chance. Studies of Japanese women exposed to high levels of radiation following the atomic bomb explosion in Hiroshima at the end of World War II revealed almost twice the expected number of ovarian cancer cases. However, the relatively small amount of radiation to which most women are exposed is not likely to increase the chance of developing this disease.
Particles of asbestos have been found in both normal and cancerous ovarian tissue. Moreover, exposure to asbestos was linked to ovarian cancer in one study of women working in asbestos-contaminated industrial areas. However, researchers believe that the low levels of asbestos to which most women are exposed do not increase the risk of ovarian cancer.
Particles of talc have also been found in normal and cancerous ovaries. However, despite extensive testing, talc has not been shown to cause tumors in animals, and at this time most researchers do not believe that talc plays an important role in the development of ovarian cancer in humans.
Detection and Diagnosis
Early detection of ovarian cancer is difficult because cancer that is limited to the ovary usually does not cause symptoms. An ovarian tumor can grow for some time without causing pressure, pain, or other problems. When symptoms do appear, they are generally so vague that they are often ignored.
The most common signs of ovarian cancer are abdominal swelling or bloating, lower abdominal discomfort, a feeling of fullness even after a light meal, and loss of appetite. Other complaints may include gas, indigestion, nausea, and weight loss.
As the cancer grows, it may affect nearby organs such as the bladder and large bowel, causing frequent urination and constipation. Occasionally, vaginal bleeding can be a symptom of ovarian cancer. These problems are not a sure sign of cancer, but any woman with persistent symptoms like these should see her doctor for a thorough physical examination.
The diagnosis of ovarian cancer begins with a review of the woman's symptoms and her medical history, as well as a complete physical examination. The physician will perform a pelvic exam, which is a physical examination of the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum, to check for firm, fixed, or enlarged ovaries; an irregular growth on or near the ovaries; swollen abdominal or pelvic lymph nodes; indications of abdominal fluid (ascites); or a growth in the abdomen, pelvis, or rectum. The pelvic examination should include a Pap test. The Pap test is not a reliable test for ovarian cancer, although on some occasions it can detect cancer cells that have migrated from the ovary down the fallopian tube through the uterus to the cervix or vagina.
A number of other procedures may be used to diagnose ovarian cancer. These tests (and the order in which they are done) depend on the woman's symptoms and on the results of her initial physical exam. For example, blood and urine tests, plus an ultrasound exam, may be necessary. During the ultrasound examination, high-frequency sound waves are projected into the body, and the echoes produced are converted by a computer into a picture. Ultrasound can be useful in distinguishing ascites from an ovarian cyst (a closed sac or capsule containing a liquid or semmisolid substance).
Patients may have a chest x-ray and one or more special x-ray exams, including computed tomography (CT scanning), of the abdomen, liver, and lungs. This procedure combines x-rays and computer processing to produce pictures of cross sections of the body. Lymphangiography, an x-ray exam of the lymphatic system after the injection of a contrast medium (a substance that shows up on the x-ray), also may be helpful. Intravenous pyelography (IVP) and barium enema (also known as a lower GI series) may be used to evaluate the urinary tract and large bowel. An IVP is an x-ray examination performed after injection of a contrast medium, which usually contains iodine. This test is used to evaluate the urinary tract, including the kidneys, ureters, bladder, and neighboring lymph nodes. For a barium enema, the bowel is filled with barium, a chalky substance that appears white on x-ray film. The x-rays can reveal abnormal growths, as well as narrowed or displaced areas in the large intestine.
The only conclusive way to diagnose ovarian cancer is with an operation called an exploratory laparotomy. The surgeon examines the abdomen thoroughly and removes any abnormal-looking fluid or tissue for microscopic evaluation. If no fluid is found, several washings are taken from the abdomen and pelvis in an attempt to pick up any cancer cells present. A saline solution (a solution of salt in purified water) is put into the abdomen and then removed to see if it contains cancer cells. The liver, small intestine, and large intestine are also examined for evidence of metastatic disease, and areas that look abnormal are biopsied (tissue is removed for microscopic examination). In addition, multiple "blind" biopsies (removal and examination of normal-looking tissue) are performed.
Some cancers produce substances called tumor markers that can be detected in the blood. Researchers hope to develop ways to use these markers to screen women who are at increased risk of developing ovarian cancer so that the disease can be diagnosed at an earlier stage than is now possible. A number of tumor markers currently are under study. For example, research has suggested that about 80 percent of ovarian epithelial cancer cells produce a marker, called CA 125. An elevated CA 125 level after treatment suggests a high probability of residual disease (disease remaining following initial treatment), and a rising level may precede the clinical detection of recurrent disease. However, a negative CA 125 level does not rule out the possibility that cancer is present; sometimes the level falls into the normal range even though cancer remains in the body.
An increased level of the protein carcinoembryonic antigen (CEA) is found in some patients with advanced ovarian cancer. However, the presence of this marker does not always indicate ovarian cancer, because elevated levels of CEA are also found in cigarette smokers and in patients with other types of cancer, noncancerous tumors, inflammatory disorders, liver disease, or lung infections. When CEA levels are elevated before treatment and fall to normal after therapy, they may be useful in monitoring patients for disease recurrence. The hormone human chorionic gonadotropin (HCG) also may be used to evaluate the response of patients treated for ovarian choriocarcinoma and some other germ cell tumors.
Alpha-fetoprotein (AFP), another blood protein, has been used to follow patients with endodermal sinus tumors. After surgery, AFP levels gradually decline. A subsequent rise may indicate a recurrence of the disease, even before symptoms appear. In addition, AFP may be helpful in diagnosing endodermal sinus tumors in women who have a rapidly enlarging, solid ovarian mass. However, AFP is not a specific test for ovarian cancer; AFP also may be elevated in patients with noncancerous diseases of the liver.
Once ovarian cancer has been diagnosed, it is important to determine the extent (stage) of the disease. Staging is essential in selecting appropriate treatment and in determining prognosis. Accurate staging depends on the findings of the laparotomy, lymphangiography, IVP, barium enema, and other diagnostic procedures.
The most common staging system used in the United States was developed by the International Federation of Gynecology and Obstetrics. In this system, epithelial ovarian cancers, stromal tumors, and germ cell ovarian cancers are divided into four stages.
Treatment for ovarian cancer is changing rapidly, and many clinical trials (research with patients) designed to refine standard therapies and evaluate new approaches are now in progress. More information about clinical trials is found on page 16. Treatment depends on the stage of the disease at the time of diagnosis, the type of cells that make up the tumor, and how fast the cancer is growing.
Surgery, radiation therapy, and chemotherapy, alone or in various combinations, may be used to treat patients with ovarian cancer. Patients usually have surgery to remove as much of the tumor as possible. In most cases, doctors recommend the removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and uterus hysterectomy).
Some patients are also treated with radiation therapy. This form of treatment can be given in two ways: intraperitoneal radiotherapy and external beam radiation therapy. In intraperitoneal radiotherapy, a liquid containing radioactive phosphorus (P32) is placed directly into the pelvic and abdominal cavities. This liquid coats these areas, killing remaining cancer cells. In external beam therapy, a machine located outside the body delivers radiation to the pelvis and abdomen.
Chemotherapy for ovarian cancer patients usually involves the use of combinations of drugs that have cisplatin as a base. Combinations currently in use generally include two or more of the following drugs: cisplatin (Platinol), cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), and hexamethylmelamine. Combinations that include cisplatin are more effective than those that do not.
Treatment by Type and Stage
Epithelial Ovarian Cancers
Stage I. Surgical removal of the ovaries, fallopian tubes, and uterus is the usual treatment for patients with ovarian cancer in stages IA and IB. In some patients with stage IA ovarian cancer who still wish to have children, only the involved ovary and accompanying fallopian tube are removed. In patients with stage IC ovarian cancer, surgery may be followed by chemotherapy (usually a combination of cisplatin and cyclophosphamide) or intraperitoneal P32 radiation therapy.
Stage II. Treatment for stage II ovarian cancer involves total hysterectomy (removal of the uterus and cervix) with removal of both ovaries and fallopian tubes. Cancer that cannot be removed completely by surgery is called residual disease. Patients with a residual cancer less than 3/4 inch in diameter may also receive intraperitoneal P32 radiotherapy or external beam radiation to the pelvis and abdomen. Patients with residual disease larger than 3/4 inch are usually treated with chemotherapy. The most widely tested combination of drugs is CP (cyclophosphamide and cisplatin). Other combinations include:
* CAP: cyclophosphamide, doxorubicin, and cisplatin;
* CHAD: cyclophosphamide, hexamethylmelamine, doxorubicin, and cisplatin; and
* AP: doxorubicin and cisplatin.
Patients with stage II ovarian cancer are encouraged to participate in clinical trials of promising new treatments. For example, researchers are comparing the benefits of intraperitoneal radiotherapy to combination chemotherapy used in addition to surgery in patients with minimal residual disease. Studies also are under way to examine the effectiveness of intraperitoneal chemotherapy (drugs are placed directly into the abdominal cavity rather than injected into a vein).
Stage III. Total hysterectomy and removal of both ovaries and fallopian tubes is standard treatment for patients with stage III ovarian cancer. In patients with minimal postsurgical disease, surgery is followed by combination chemotherapy with the same drug combinations used to treat patients with stage II disease (see above). Occasionally, patients with residual disease of less than 1/5 inch (less than 0.5 centimeter) may be treated with total abdominal and pelvic radiation therapy. Patients with residual disease greater than 3/4 inch receive combination chemotherapy following surgery. Drug combinations used to treat these patients are the same as those used for stage II disease. As with stage II disease, combinations that contain cisplatin produce a better response than do combinations without this drug. In addition, the dose of cisplatin appears to be particularly important.
Clinical trials currently are under way to evaluate the effectiveness of intraperitoneal chemotherapy in combination with standard chemotherapy following surgery in patients with stage III ovarian cancer.
Stage IV. Patients with stage IV ovarian cancer are treated with combination chemotherapy using the drug combinations listed above. Patients with stage IV disease are encouraged to participate in a clinical trial. Treatment approaches being studied include new drugs that may reduce drug resistance in ovarian cancer patients, new drug combinations, and innovative treatment combinations such as surgery followed by intraperitoneal chemotherapy.
Recurrent Disease. Patients with recurrent ovarian cancer may have surgery to remove as much of the cancer as possible. They also may be treated with drugs that they have not previously received. These patients also should consider the option of participating in clinical trials of new treatments.
A number of such trials are in progress. New drugs under study include carboplatin (a drug similar to cisplatin), DHAC, trimetrexate, taxol, echinomycin, menogaril, ACM-A, and AZQ. Research also is under way with substances that reduce the toxic side effects of cisplatin and other platinum-containing drugs. Substances such as WR2721, which decreases damage to nerves from cisplatin, and diethyldithiocarbamate (DDTC), which may decrease bone marrow damage by carboplatin, are currently under study. Another clinical trial involves the use of the investigational drugs ifosfamide and mesna (which reduces the side effects of ifosfamide) in addition to cisplatin and either vinblastine (Velban) or etoposide (VP-16 or VePesid).
Modern laboratory technology permits researchers to identify and manufacture large amounts of some of the natural substances that the body produces to fight cancer. Some of these substances, known as biological response modifiers (BRMs), are being studied in patients with advanced or recurrent ovarian cancer. This form of treatment, which is also called immunotherapy or biological therapy, is under clinical evaluation. Much research is needed before it can be widely used in patients with ovarian cancer.
Currently, researchers are studying a BRM called interleukin-2 (IL-2), a protein that regulates cell growth. Research with other BRMs, including interferon and monoclonal antibodies, also is under way. Monoclonal antibodies are substances manufactured in the laboratory that are able to locate and bind to tumor cells in the body. Monoclonal antibodies can be linked with a variety of cell-killing substances and can deliver them directly to the cancer cells. Studies using monoclonal antibodies in animals have been promising, and clinical trials with ovarian cancer patients are under way.
Oncotoxins are another new form of treatment currently being studied in some patients with advanced ovarian cancer. Toxins, or poisons, made by bacteria are among the most powerful cell-killing agents. An oncotoxin is a toxin that is attached to a growth factor, which cancer cells need to grow, or to a monoclonal antibody, which binds to cancer cells. Cancer cells are tricked into taking in the oncotoxin, which kills them and leaves healthy cells unharmed.
Ovarian Stromal Tumors
Stromal tumors are usually treated by total hysterectomy and removal of both ovaries and fallopian tubes. When the tumor cannot be completely removed, radiation therapy may follow surgery. Patients with residual disease also may be treated with multidrug chemotherapy. One drug combination that has been studied is CAP, which includes cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), and cisplatin (Platinol). Young patients with early stage Sertoli-Leydig tumors may have only the affected ovary and fallopian tube removed. Sparing the other ovary means that these young women may still be able to bear children. Patients with advanced Sertoli-Leydig tumors are usually treated with surgery to remove the uterus, both ovaries, and both fallopian tubes. This treatment may be followed by chemotherapy. Recurrent stromal tumors are treated with surgery and postoperative radiation therapy (if the tumor involves a limited area) or with surgery and chemotherapy (if the disease is extensive).
Germ Cell Tumors
Dysgerminomas are unique among germ cell tumors because they are very sensitive to radiation therapy. This is also the only ovarian germ cell tumor that commonly affects both ovaries. Patients with early stage dysgerminoma are usually treated with total hysterectomy and removal of both ovaries and fallopian tubes followed by radiation therapy. Younger patients who have a small encapsulated tumor that involves just one ovary may have only the affected ovary and fallopian tube removed. Patients with stage R or M dysgerminoma are treated with surgery and radiotherapy. Those with stage IV disease receive chemotherapy following surgery. Drug combinations that may be used are PEB cisplatin, etoposide, and bleomycin) and PVB (cisplatin, vinblastine, and bleomycin).
Patients with other forms of germ cell tumors are usually treated with surgery followed by chemotherapy. The drug combination VAC (vincristine, dactinomycin, and cyclophosphamide) has been widely studied and found to be effective against this disease. Combinations containing cisplatin, vinblastine, bleomycin, and etoposide also may be used. For patients with extensive disease, chemotherapy may be used to shrink the cancer before surgery.
Because chemotherapy can cause side effects, it is desirable to end this form of treatment as soon as a complete response has been achieved. "Second-look" laparotomy (surgery to inspect the abdomen) may be used to evaluate patients taking chemotherapy who have no further clinical evidence of tumor. The second-look procedure, similar to the original diagnostic laparotomy, includes close inspection of the abdomen, pelvic and abdominal washings, and biopsies of any abnormal-looking areas. The second-look operation is primarily a diagnostic procedure that is of value in determining subsequent treatment. Second-look surgery helps the physician determine how well a patient has responded to chemotherapy and whether drug treatment should be discontinued. It also can provide an opportunity to remove any remaining cancer. In addition, this surgery helps the physician determine-tine which other forms of treatment might be used in patients with residual disease.
Although some doctors have recommended second-look surgery following postoperative radiation therapy, this procedure is not widely accepted because of possible complications of surgery in patients previously treated with radiation.
Clinical Trials and PDO
To improve the outcome of treatment for patients with ovarian cancer, the NCI supports clinical trials at many hospitals throughout the United States. Patients who take part in this research make an important contribution to medical science and may have the first chance to benefit from improved treatment methods. Physicians are encouraged to tell their patients about the option of participating in such trials. To help patients and doctors learn about current trials, the NCI has developed PDQ (Physician Data Query), a database designed to give doctors quick and easy access to:
* descriptions of ongoing clinical trials that are accepting patients, including information about the objectives of the study, medical eligibility requirements, details of the treatment program, and the names and addresses of physicians and facilities conducting the study;
* the latest treatment information for most types of cancer; and
* names and addresses of physicians and organizations involved in cancer care.
To access PDQ, doctors may use an office computer with a telephone hookup and a PDQ access code or the services of a medical library with online searching capability. Most Cancer Information Service offices (1-800-4-CANCER) provide PDQ searches and can tell doctors how to obtain regular access to the database. Patients may ask their doctor to use PDQ or may call 1-800-4-CANCER to request a search themselves. Information specialists at this toll-free telephone number use a variety of sources, including PDQ, to answer questions about cancer prevention, diagnosis, treatment, and research.
The materials marked with an (*) are distributed free of charge by the NCI. Ordering information is provided at the end of this publication. The other items listed are not available from the NCI. They can be found in medical libraries, many college and university libraries, and some public libraries.
Alberts, D.S. and Surwit, E.A., eds. Ovarian Cancer Boston: Martinus Nijhoff Publishers, 1985.
Barber, H.R.K. "Ovarian Cancer," CA-A Cancer Journal for Clinicians, Vol. 36(3), May/June 1986, pp. 149-183.
* Chemotherapy and You: A Guide to Self-Help During Treatment. Office of Cancer Communications, National Cancer Institute. NIH Publication No. 86-1136.
DeVita, V.T., et al., eds. Cancer: Principles and Practice of Oncology. 2nd ed. Philadelphia: J.B. Lippincott Co., 1985.
Haskell, C.M., ed. Cancer Treatment. 2nd ed. Philadelphia: W.B. Saunders Co., 1985.
Hudson, C.N., ed. Ovarian Cancer Oxford: Oxford University Press, 1985.
Ozols, R.F. and Young, R.C. "Ovarian Cancer," Current Problems in Cancer, Vol. 11(2), March/April 1987, pp. 61-122.
Ozols, R.F. "Chemotherapy of Ovarian Cancer," Principles & Practice of Oncology Updates, Vol. 2(l), January 1988, pp. 1-13.
* Radiation Therapy and You: A Guide to Self-Help During Treatment. Office of Cancer Communications, National Cancer Institute. NIH Publication No. 86-2227.
* What Are Clinical Trials All About? Office of Cancer Communications, National Cancer Institute. NIH Publication No. 86-2706.
* What You Need to Know About Cancer of the Ovary. Office of Cancer Communications, National Cancer Institute, NIH Publication No. 84-1561.
For additional Information on this subject and to request other National Cancer Institute publications, please write to the Office of Cancer Communications, National Cancer Institute, Bethesda, Maryland 20892, or call the Cancer Information Service (CIS) toll-free at
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This Research Report was written by Karen McCrory Pocinki, and its contents were approved by NCI scientists. Please direct questions or comments to the Editor, Research Reports, Office of Cancer Communications, National Cancer Institute, Bethesda, Maryland 20892.
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