BRCA1: Breast Cancer Susceptibility Gene 1; BRCA2: Breast Cancer Susceptibility Gene 2; CA 125: Cancer Antigen 125; CNS: Clinical Nurse Specialist; FIGO: International Federation of Obstetrics and Gynecology; GOPD: Gynecology outpatient department; GP: General Practitioner; HCAS: Health Care Assistants; HNPCC: Hereditary Nonpolyposis Colorectal Cancer; NICE: National Institute for Health and Care Excellence; SPSS: Statistical Package for the Social Sciences; TVUS: Transvaginal Ultrasound Scan; UK: United Kingdom

Ovarian cancer is the second most common gynecological malignancy and the fifth most common in women in the UK with a lifetime risk of 2%. It accounts for 4% of all newly diagnosed cancers in the UK with over 7,000 new cases reported in 2011 [1-3], and it is the most common cause of gynecological cancer death in the UK with 4,271 women dying from the disease in 2012 [4,5]. The 5-year survival rate of this disease is 44% and this varies according to the stage at diagnosis using the International Federation of Gynecology and Obstetrics (FIGO) ovarian cancer staging system, with stage 1 having a 90% 5-year survival and stage 4 with a 4% 5-year survival [4]. Overall mortality is high (despite new treatment) because of its late presentation with more than 80% of patients presenting with advanced (stage 3 or 4) disease [6]. This is largely due to the absence of clearly defined symptoms in its early stages.

Over 90% of ovarian cancers are epithelial in origin and half of those are the serous subtype [7]. Other epithelial cancers include mucinous, clear cell and endometroid (about 10% each). The rest (nonepithelial) are made up of a small number of transitional, Brenner, mixed, undifferentiated and unclassified subtypes [7,8]. The exact cause of ovarian cancer is unknown. Several factors play an important role in its development including heritable (breast cancer susceptibility gene) BRCA1 or BRCA2 gene mutation which is the greatest risk factor and accounts for 5-15% of ovarian cancer cases [9,10], hereditary non-polyposis colon cancer gene (HNPCC) mutation, family history of ovarian cancer and personal history of primary breast cancer and colon cancer [11-19]. Other risk factors for ovarian cancer include age over 45 years (and especially over 60 years), nulliparity, infertility, low parity, early menarche and late menopause or normal menopause with hot flushes [17-19]. Chances of developing ovarian cancer are also greater with long term use of post-menopausal oestrogen-only hormone replacement therapy, high body mass index, endometriosis, and perineal talcum powder application [20-23].

Ovarian cancer cannot be prevented but a woman’s risk for developing ovarian cancer can be reduced by factors that interrupt ovulation such as bilateral salpingo-oophorectomy, pregnancy, breastfeeding and oral contraceptive use [17,24,25]. Women with a history of dysmenorrhea and hysterectomy also have a lower risk of ovarian cancer [17].

The signs and symptoms of early disease are vague and associated with other conditions such as irritable bowel syndrome [26]. These include abdominal pain, bloating or distension, nausea, early satiety, anorexia, weight loss, urinary symptoms (urgency and frequency), abnormal vaginal bleeding and pelvic mass, and most women would have had these symptoms for a while before presentation [27-29]. Ninety-five percent of women with ovarian cancer report having symptoms before diagnosis and there were more symptoms, which occurred more frequently and for a shorter duration of time in ovarian cancer than in benign conditions [26,30]. Of those diagnosed with early stage ovarian cancer, 90% were symptomatic before diagnosis [15].

There is no proven effective screening strategy to detect early-stage ovarian cancer. Cancer antigen 125 (CA-125) is the most commonly used tumour marker in the diagnosis of ovarian cancer but it is limited in both sensitivity and specificity [31-33]. Transvaginal ultrasound (TVUS) and serial measurements of CA-125 are used to monitor treatment response and recurrence of ovarian cancer but have no impact on long term outcomes or mortality rates and might actually cause harm by exposing women without cancer to unnecessary surgery [34]. The exceptions to this are women at high risk of developing ovarian cancer but even in these women, there is no evidence that screening with CA-125 and TVUS reduces their chances of death from ovarian cancer [35]. Recognition of early warning signs of ovarian cancer is therefore important as early detection greatly improves the chances of successful treatment.

The purpose of this study was to evaluate the knowledge and awareness among Gynecology nurses about the signs and symptoms of ovarian cancer and its prevention. It is expected that nurses working in Gynecology will know more about ovarian cancer. They can encourage patients to seek their general practitioner (GP) advice for their symptoms where the GPs following the National Institute for Health and Care Excellence (NICE) recommendations will perform a physical examination and serum CA125 blood test and refer to the hospital if the findings are abnormal [28]. The findings of this study will be useful at educational and policy levels to complement knowledge and awareness about this disease.

Study design

A cross-sectional self-administered questionnaire survey was carried out among 60 volunteer nurses working in the Gynecology department at the Royal Derby Hospital in Derby, UK. Of the 75 nurses working in the Gynecology outpatient department (GOPD) and inpatient ward, 60 agreed to take part in the study. This study was carried out and the participants were chosen because they were expected to have more knowledge about ovarian cancer than their nongynecology colleagues because of the environment they work in and the role they play in the health promotion of women. Verbal informed consent was obtained. The survey took place between April and July 2014 and participation was voluntary and anonymous.

Sample population

Respondents were made up of healthcare assistants (HCAs), staff nurses and clinical nurse specialists (CNS) in Gynecology.

Questionnaire

A questionnaire was designed for the purpose of the study. Minor changes were made after a pilot test with 5 nurses. The self-administered questionnaire, made up of 10 close-ended and open-ended questions took approximately 5 mins to complete and consisted of 3 sections. The first section contained questions about the demographic characteristics of the participants (the job role of the respondents, the department they worked in and the number of years of experience worked).

The second section contained questions about the knowledge of the risk factors, prevention, signs and symptoms of ovarian cancer with multiple responses, which were grouped together for ease of analysis.

The third section contained questions on whether the participants thought the awareness of ovarian cancer was enough and what could be done to increase the awareness. Adequate knowledge of signs and symptoms and risk factors was defined as the ability to name ≥2 ovarian cancer warning signs or symptoms and risk factors. A sample of the questionnaire is shown in the appendix.

Data from each filled questionnaire was entered into the Statistical Package for the Social Sciences (SPSS version 22). Fisher exact test and Chi squared test were used to compare the nominal data. All tests were two-sided.

Sixty questionnaires were filled. Of all the nurses interviewed, 9 were CNS, 33 were staff nurses and 18 were HCAs. Twenty-two nurses worked in the GOPD while 38 worked on the inpatient ward. Twentyseven nurses had less than 10 years’ experience in Gynecology nursing, 18 had 10-20 years’ experience, while 15 nurses had over 20 years’ experience working in Gynecology (Table 1).

Table 1: Demographic data of 60 Gynecology nurses of the Royal Derby Hospital surveyed between April and July 2014.

Knowledge of the signs and symptoms of ovarian cancer

The signs and symptoms described by respondents are presented in Table 2. When asked about the signs and symptoms of ovarian cancer, 32 respondents (53%) had good knowledge, while 28 (47%) had inadequate knowledge. Nineteen (59%) of those with good knowledge were staff nurses, while 8 (25%) were HCAs and 5 (16%) were CNS. Also 5 CNS, 19 staff nurses and 8 HCAs had good knowledge but this was not statistically significant (p>0.05).

Table 2: Distribution of signs and symptoms of ovarian cancer as reported by 60 Gynecology nurses of the Royal Derby Hospital surveyed between April and July 2014.

Significantly more nurses working with inpatients (25 out of 38 nurses, 66%) had knowledge of the signs and symptoms of ovarian cancer than those working in the outpatient department (7 out of 22 nurses, 32%) (p<0.05), and nurses with 11-20 years’ experience (78%) had significantly more knowledge of the signs and symptoms of ovarian cancer than either those with less than 10 years’ experience (44%) or more than 20 years’ experience (40%) (p<0.05).

Thirty-nine nurses (65%) said that ovarian cancer didn’t have symptoms in its early stages, 8 nurses (13%) said that it did while 13 nurses (22%) had no idea. Thirty three respondents (55%) knew about the signs and symptoms of ovarian cancer from work alone, 2 (3%) from the media alone, 3 (5%) from knowing someone with ovarian cancer and 22 respondents (37%) from more than one source which included work and one or more of the following–media, courses, books and knowledge of someone with ovarian cancer, but there was no significant difference between the source of information and knowledge of the signs and symptoms of ovarian cancer.

Knowledge of the risk factors for ovarian cancer

Forty-four respondents (70%) reported that they knew the risk factors of ovarian cancer, while 16 (27%) didn’t know any. Twenty (46%) out of the forty-four respondents who said they knew these risk factors had good knowledge, while 24 (56%) had inadequate knowledge. Of the 20 respondents who had good knowledge, five (25%) were CNS, 11 (55%) staff nurses and 4 (20%) were HCAs. There was however no statistical difference between the knowledge of the respondents on the risk factors for ovarian cancer based on their job roles, where they worked or number of years’ experience in Gynecology (p>0.05) (Table 3).

Table 3: Distribution of the risk factors for ovarian cancer of 60 Gynecology nurses of the Royal Derby Hospital surveyed between April and July 2014.

Knowledge of the prevention and risk reduction of ovarian cancer

Nineteen out of sixty respondents (32%) said that ovarian cancer could be prevented, 18 (30%) said it couldn’t be prevented, while 23 (38%) didn’t know. Thirty-five (59%) however reported that the risk for developing ovarian cancer could be reduced, 5 (8%) said the risk couldn’t be reduced, while 20 nurses (33%) didn’t know if the risk for developing ovarian cancer could be reduced. Of those who said the risk for ovarian cancer could be reduced, only 13% had good knowledge of how this could be done and this knowledge wasn’t significantly different between the respondents based on their job roles, where they worked or number of years’ experience in Gynecology (p>0.05).

Ovarian cancer awareness

Seventy-two percent of the respondents didn’t think that there was enough awareness of ovarian cancer, while 5% thought there was (23% didn’t know) (Table 4).

Table 4: Awareness of ovarian cancer of 60 Gynecology nurses of the Royal Derby Hospital surveyed between April and July 2014.

Of those who said there wasn’t enough awareness, 5% wanted only more media awareness, while 30% wanted more awareness in the media and by distribution of posters and patient information leaflets in Gynecology clinics and GP practices.

Identifying signs and symptoms is necessary for the early diagnosis and optimum treatment of ovarian cancer. Early diagnosis is very important as the stage at diagnosis affects survival outcome [31]. Most women with ovarian cancer would have had these non-specific symptoms occurring frequently for months before presentation. Bankhead et al reported that 93% of women diagnosed with ovarian cancer had symptoms before diagnosis [36]; therefore more awareness of the early warning symptoms of ovarian cancer is needed [28]. Nurses play an important role in health promotion and education apart from being involved in the day-to-day management and care of patients. They are easily available to patients than doctors during their hospital stay and so most patients’ questions are often aimed at them. Most women are also more willing to discuss symptoms and concerns with nurses - they feel it is easier to talk to the nurses and that they have more time. This means that Gynecology nurses can give the correct support and help women identify the red flags of ovarian cancer [37].

In our study, over half of the nurses described gastrointestinal symptoms as the possible symptoms of ovarian cancer with about one-quarter describing no symptoms. A study by Goff et al. reported the symptoms of ovarian cancer as new onset abdominal pain, bloating early satiety, anorexia and urinary symptoms occurring almost daily and lasting over three weeks [30]. Overall, about half of the nurses knew what the signs and symptoms of ovarian cancer were, but we expected more knowledge from them, this deficiency may be due to a lack of awareness about ovarian cancer.

Successful identification of the symptoms didn’t differ according to job role of the respondents, but the nurses working on the wards had more knowledge than those in the Gynecology clinics. This could be due to the fact that the inpatient nurses had more regular and prolonged contact with patients with ovarian cancer than the outpatient nurses. The knowledge of the nurses with between 11-20 years’ experience was more than those over 20 years and those less than 20 years meaning that experience is not the same as knowledge. Those with over 20 years’ experience may be stuck in their ways and may not think or know they need to learn new things.

From the study, it was clear that a good number of respondents believed that ovarian cancer had no symptoms in its early stage but there is evidence that significant number of women have symptoms in the early stage of ovarian cancer. Smith et al reported that 75% of women diagnosed with ovarian cancer had symptoms and 90% didn’t report then because they assumed that these symptoms were due to some menstrual and other minor conditions [38]. About one in three respondents knew what the risk factors of ovarian cancer were and there was a deficiency in the knowledge of how the risk factors for ovarian cancer could be reduced.

Gynecology nurses are specially trained to provide nursing care for women; therefore one can assume that they will have very good knowledge about conditions like ovarian cancer. The results of this study are not characteristically representative of the knowledge of Gynecology nurses in other hospitals in the UK but this study has shown that there is a lack of awareness and this should be addressed as soon as possible.

Clinical nurse specialists were introduced to provide care specific to patient’s needs. They are clinical experts in evidence-based nursing practice that also provide support and education for patients to manage their symptoms. They are care managers that act as a link between doctors, specialists and patients [39], and their presence in Gynecology has led to the increase in the provision of high quality and patientcentered care. The expectation is an increased knowledge of the signs and symptoms of diseases with their addition but this was not reflected in this study most probably due to the small size of the population studied. Future plans will include increasing the sample size to obtain more representative data.

Teaching programs on gynecological cancers should be developed, focused on strengthening knowledge, attitude and practices of Gynecology nurses highlighting the signs and symptoms of ovarian cancer. Study days and training courses already exist for Gynecology nurses and these can be improved to incorporate lectures, seminars and workshops on ovarian cancer. Learning goals will be set at the start of the sessions with active participation encouraged, and an assessment session will be included to gauge knowledge and understanding with feedback to the nurses to raise their attitude towards learning. Posters can also be produced to raise nurses’ awareness of the importance of ovarian cancer highlighting its signs and symptoms, risk factors and risk reducing ways. These will be displayed in various clinical areas and an audit can be further performed after a period of time to assess their knowledge following the display of the posters.

With evidence that nurses play an important helping role useful in public ovarian cancer education and awareness, it is important that nurses themselves are aware of the red flags of ovarian cancer if they are going to promote health as confidence in one’s detection capability is strongly associated with early detection and improving survival rates. Our results suggest that there is need for improvement in the level of knowledge of ovarian cancer among the Gynecology nurses, and with specially designed training programs directed towards these nurses, awareness can be improved (Tables 5-13).

Table 5:Cross tabulation of knowledge of signs and symptoms of ovarian cancer by job role.

Table 6: Cross tabulation of knowledge of signs and symptoms of ovarian cancer by area of gynecology.

Table 7: Cross tabulation of knowledge of signs and symptoms of ovarian cancer by nursing experience.

Table 8: Cross tabulation of knowledge of risk factors for ovarian cancer by job role.

Table 9: Cross tabulation of knowledge of risk factors for ovarian cancer by area of gynecology.

Table 10: Cross tabulation of knowledge of risk factors for ovarian cancer by nursing experience.

Table 11: Cross tabulation of knowledge of methods of reducing risk factors for ovarian cancer by job role.

Table 12: Cross tabulation of knowledge of methods of reducing risk factors for ovarian cancer by area of gynecology.

Table 13: Cross tabulation of knowledge of methods of reducing risk factors for ovarian cancer by nursing experience.

A limitation of this study was the sample size. We felt that the nonsignificant results were probably due to the small sample size and might not be representative of a larger population.

The study was conducted by structured interview. The interviews were therefore not flexible and an interview schedule had to be followed and impromptu questions couldn’t be asked. The closed questions in the interview made it difficult to obtain detailed data on attitudes and opinions.

‘The authors would like to thank Dr. Sam Dobson for his help in collecting some of the data. No writing assistance was obtained for this article’.

This survey research has received no grant from any funding agency in the public, commercial or not-for-profit sectors; neither does it have any other competing financial interests.

Conflicts of interest: none to declare

Voluntary participation and informed consent was obtained from all the participants. A written statement regarding the survey was provided informing the participants of the survey and its anonymity.