Expanding the Public Health Research Agenda for Ovarian Cancer

Abstract

Since the year 2000, the Centers for Disease Control and Prevention (CDC) has undertaken an active public health research agenda in ovarian cancer, focused mainly on research related to earlier recognition of symptoms, methods for earlier diagnosis, and optimization of treatment and end-of-life care. Much of this work was guided by external input from two workshops in 2000 and 2002 with ovarian cancer experts in clinical and epidemiological research, public health leaders from federal and state agencies, and ovarian cancer survivors. In November 2008, the CDC convened a third informal workshop of experts to comment on CDC's work to date and to help expand the public health research agenda for the future. The purpose of the workshop was to identify and discuss urgent and emerging issues related to ovarian cancer and how public health organizations, and specifically CDC, might address these issues through research. This article provides a summary of some of the issues discussed and potential areas for future research, including genetic, screening, and diagnostic tests for ovarian cancer; ways of improving the quality of care for patients; symptom recognition; public awareness; and other emerging issues related to ovarian cancer.

Introduction

Ovarian cancer is the fifth leading cause of cancer death among women in the United States and is the deadliest form of gynecologic cancer. Each year, approximately 20,000 women are told they have ovarian cancer, and nearly 15,000 die from this disease.¹ As the population ages, these numbers are expected to increase. Despite the progress that has been made in reducing mortality rates and increasing survival times among patients with many cancers, death rates among ovarian cancer patients have changed little since the mid-1970s.² Unlike the situation with cervical cancer, there is no simple screening test to detect ovarian cancer at an early stage. Fewer than 1 in 5 women with ovarian cancer have their disease diagnosed when it is localized and can be treated more successfully (when the relative 5-year survival rate is >92%).³ Two thirds of women with ovarian cancer have their disease diagnosed at an advanced (distant) stage, when the relative 5-year survival rate is only 31%.³ Confronted with these sobering statistics, our challenge is to identify how the public health community can contribute toward meeting the needs of women with ovarian cancer and those who could develop ovarian cancer in the future.

Over the last decade, the Division of Cancer Prevention and Control (DCPC) within the Centers for Disease Control and Prevention (CDC) has undertaken an active public health research program to identify interventions that can improve the quality of life of women with ovarian cancer. To guide the development of these ovarian cancer research activities, CDC sponsored workshops in 2000 and 2002 with outside experts in clinical and epidemiological research, public health leaders from federal and state agencies, and ovarian cancer survivors. The workshop participants identified key areas for research concerning the early symptoms of ovarian cancer, methods of earlier diagnosis, optimization of treatment, and end-of-life care for ovarian cancer patients. The development of these research activities has been described previously,⁴ and examples of current research projects can be found on DCPC's website (www.cdc.gov/cancer/ovarian/what_cdc_is_doing).

In November 2008, CDC convened an informal workshop of experts to solicit feedback about the work that had been done to date and to help define a public health research agenda for the future. These experts included physicians (obstetrician/gynecologists and gynecologic oncologists), researchers from universities, government, and nonprofit organizations, and ovarian cancer advocates. The full list of participants can be found in the Acknowledgments section. This article provides a general overview of the meeting, with a focus on some of the more salient issues discussed.

The purpose of the meeting was to identify and discuss urgent and emerging issues in ovarian cancer and how CDC and the public health community might address these issues through research. Panel discussions of the following three broad topics were scheduled, although discussion was not strictly limited to these topics: (1) the public health response to genetic, screening, and diagnostic tests for ovarian cancer, (2) the public health role in improving access to care for ovarian cancer patients, and (3) symptom recognition and the implications for public health research and awareness. The discussion was open-ended and not intended to produce consensus on any issue. The highlights of panel discussions in these topic areas, along with summaries of additional issues generated through subsequent discussions, are presented below.

Topic 1: The Public Health Response to Genetic, Screening, and Diagnostic Tests for Ovarian Cancer

The first discussion began with an overview of current debates surrounding genetic and diagnostic tests, the relevance of these debates to ovarian cancer research, and a description of research being conducted by CDC that touches on these domains. The scientific, practical, and ethical issues surrounding genetic testing and its role in personalized medicine or genomic medicine are continually debated in the press and in the scientific literature in response to the substantial growth of commercially available genetic tests for various health conditions.^5

–8 These debates occur in the face of enormous expectations raised by biotech and pharmaceutical industries for a revolutionary approach to healthcare through whole genome testing or testing for specific conditions. Review articles, editorials, and the media sustain these expectations by describing a future where genomic medicine will facilitate individually tailored prevention and treatment regimens.^9
–11

One way to ground these expectations is to apply a framework for evaluating genetic tests. Among the criteria for such a framework would be an assessment of the analytic validity or the laboratory performance of a test, including its reproducibility and validity; its clinical validity (i.e., its ability to detect or predict a disorder); its clinical utility or the outcomes associated with testing; and the ethical, legal, and social implications of the test, which cut across all the components.^12

–15 The challenges involved in developing a valid and reliable test for ovarian cancer that meet reproducibility and utility criteria, given the disease's low population prevalence, were recognized by several of the panel members. A few panelists questioned whether resources alone or resources plus time could solve this daunting problem. A recent debate surrounding a new proteomic test for ovarian cancer, OvaSure (Lab Corp, Burlington, NC), provides an example of how raised expectations were disappointed when the test did not meet appropriate laboratory and clinical criteria,^16

–19 as did the development and subsequent withdrawal of OvaCheck^® (Correlogic Systems, Bethesda, MD), an earlier serum-based proteomic test for ovarian cancer.^{20, 21}

Unlike many of the newer genetic tests currently being marketed, the test for BRCA1 and BRCA2 has undergone considerable study and evaluation.¹⁴ The U.S. Preventive Services Task Force (USPSTF) recommended genetic counseling and BRCA1 and BRCA2 testing for women with a strong family history of breast or ovarian cancer.²² Although only approximately 10% of ovarian cancers occur in association with genetic mutations, the average cumulative risk of ovarian cancer among such women was estimated to be 39% for those with BRCA1 and 11% for those with BRCA2.²³ The USPSTF recommended against routine screening for ovarian cancer among average-risk women, however.²⁴

One of the research approaches taken by CDC that relates to genetic information and risk has been to study how women perceive their vulnerability to cancer and the processes involved in that perception of risk. A goal of this line of research is to provide information useful in counseling women about cancer risk, in devising decision-making strategies, and in risk communication. With the rapid growth in genetic and molecular medicine, information on susceptibility to a host of diseases is likely to be available to individuals who want to avoid or reduce the severity of potential health problems. Understanding how both objective risk information and the perception of risk may motivate behavioral change is an important step in developing ways to communicate information that it is most useful to women.

The panel discussion of screening, genetic, and diagnostic tests addressed three main issues. First, the panel noted tests will continue to be marketed irrespective of evidence for their validity or utility. As a result, in addition to grading the evidence about the effectiveness of these tests, public health officials will need to convey relevant information about these tests to both consumers and physicians. Possible public health research activities related to these tests range from helping the public understand the value and meaning of genetic tests and how they are evaluated to helping physicians interpret genetic tests and deciding when to recommend them to women.^5,25 As mentioned during the discussion, one public health role would be to limit the public's expectations of these tests through educational efforts. Second, for women with a strong family history, additional research was proposed to address how women respond to information on genetic testing for ovarian cancer, how they interpret the test results, whether they make the choice of prophylactic oophorectomy given positive results, and what the long-term implications of that choice are. Finally, concern about genetic discrimination was also voiced despite recent passage of H.R. 493, the Genetic Information Nondiscrimination Act of 2008 (www.govtrack.us/congress/bill.xpd?bill = h110-493). Panel members also noted that public health professionals may be able to contribute to debates about the development of policies related to the evaluation, oversight, and regulation of direct-to-consumer genetic tests.

Workshop participants also discussed the merits of annual ovarian cancer screening among the average-risk population with a combination of the serum biomarker CA-125 and transvaginal ultrasonograhpy (TVU). Preliminary results from the first round of the ongoing Prostate, Lung, Colorectal and Ovarian (PLCO) screening trial showed that 20 invasive neoplasms were detected in more than 28,000 women who were screened with CA-125 or TVU²⁶; 80% of these neoplasms were diagnosed at stage III or IV.²⁶ Of 570 women who underwent surgery on the basis of screening results, 541 did not have a neoplasm.²⁶ Results from subsequent screening rounds of this trial showed that 604 additional surgeries were performed on women with positive screening results; 42 additional invasive cancers were detected in these women, 67% of which were ≥stage III.²⁷ The conclusions of the PLCO trial are generally similar to those from CA-125 and TVU trials in the U.K. and Japan.^27
–29 The very low positive predictive values of these tests suggest that annual screening is not beneficial for the general population at this time and may not even be beneficial for high-risk women.^26,30,31 This may be especially discouraging for high-risk women for whom only prophylactic salpingo-oophorectomy has been shown to substantially reduce the risk of BRCA mutation-related ovarian cancer.^32,33 Because these trials are ongoing, the effect of CA-125 and TVU screening on mortality from ovarian cancer is currently unknown.^26
–28 On the basis of these results and other discussion points, many of the panelists expressed the sentiment that a new ovarian cancer screening test is not likely to be available in the near or possibly distant future and that current USPSTF recommendations against ovarian cancer screening²⁴ would likely not change anytime soon. Some panelists suggested the possibility of a shorter screening interval (6 months) with CA-125 and TVU while also recognizing the attendant difficulty of getting women to adhere to a more demanding screening schedule and the lack of direct data to endorse this. Other avenues to developing a screening test mentioned by panelists included DNA-based tests, which require a large volume of sample, participating in data-sharing collaborations with cohort studies in the U.K.²⁸ and Japan,²⁹ and collecting serum in tumor banks for testing.

Topic 2: The Public Health Role in Improving Access to Care for Ovarian Cancer Patients

This discussion was preceded by a presentation about CDC's Ovarian Cancer Treatment Patterns and Outcomes (OCTPO) study, a retrospective cohort study carried out in collaboration with CDC's National Program of Cancer Registries (NPCR) (www.cdc.gov/cancer/npcr/), which is examining staging, surgery, adjuvant therapy, and survival of women diagnosed with ovarian cancer and the specialty of their treating physician. Data for the study were collected from approximately 3000 patients with ovarian cancer diagnosed from 1998 through 2000 in New York and Northern California. Current analyses probe the factors associated with receipt of standard care for ovarian cancer, with outcomes of epithelial ovarian cancer, with the extent of surgical staging of ovarian cancer patients, and with histology-specific patterns of ovarian cancer presentation and survival. Preliminary results of several of these analyses have been presented at national meetings.^34
–36

Following the presentation, the panel discussion focused on two factors that have been associated with improved outcomes among ovarian cancer patients: (1) optimal surgical cytoreduction and (2) treatment by a gynecologic oncologist. Several retrospective studies have demonstrated an increase in median survival time among ovarian cancer patients when initial cytoreductive efforts are deemed successful.³⁷ A recent meta-analysis of maximal cytoreduction in advanced epithelial ovarian cancer demonstrated that cohorts with ≤25% maximal cytoreduction had a mean weighted median survival time of 22.7 months, whereas cohorts with ≥75% maximal cytoreduction had a mean weighted median survival time of 33.9 months.³⁸ The authors of this meta-analysis concluded that maximal cytoreduction is one of the most powerful determinants of survival in women with advanced epithelial ovarian cancer.³⁸ Although the importance of initial maximal cytoreduction is generally accepted in the clinical community, randomized clinical trials designed to test the effectiveness of this approach have yet to be carried out.^37,39

Numerous studies have shown that ovarian cancer patients who are treated by gynecologic oncologists survive longer than those who are not. Much of the survival advantage is related to the initial cytoreductive surgery. For example, studies have demonstrated that clinical procedures, such as lymph node dissection for stage I patients and debulking surgery, were performed more often when the treating physician was a gynecologic oncologist than when the treating physician was a general gynecologist or general surgeon.^40,41 In addition to surgery, a study among women with early-stage ovarian cancer revealed that those treated by a gynecologic oncologist were more likely to receive standard chemotherapy than those who were not.⁴² The authors of a recent evidence-based review of the potential benefits of subspecialty care in patients with ovarian cancer concluded that gynecologic oncologists were more likely to adhere to treatment guidelines and that this adherence translated into a 6–9-month median survival advantage for women with this disease.⁴³

Given the evidence regarding the importance of surgical procedures and the specialty of the treating physician on the outcomes of ovarian cancer patients, the panel suggested that future treatment studies should incorporate the measurement of this information. Because CDC's ongoing OCTPO study was designed to collect these data, additional CDC studies aimed at measuring clinical care could build from the information obtained from this study. Additional panel suggestions related to physician specialty included conducting formal reviews of the benefits of treatment by a gynecologic oncologist and a cost-assessment (including outcomes) of treatment by a gynecologic oncologist vs. treatment by a medical oncologist, both of which could include data obtained from the OCTPO study.

In addition to recommending continuation of research on patterns and quality of care, such as the OCTPO study, with special emphasis on optimal cytoreduction and treatment by a gynecologic oncologist, some panelists also recommended monitoring treatment for recurrent ovarian cancer. OCTPO was designed to measure only the first course of treatment; however, some panelists suggested that second-line, third-line, and fourth-line treatments and greater should also be measured, as disease will recur in most patients with advanced ovarian cancer. Although a platinum-based agent plus taxane combination is the generally accepted standard first-line treatment for ovarian cancer, treatment for relapsed ovarian cancer is less well defined.⁴⁴ A number of chemotherapeutic agents have demonstrated sufficient activity to be considered in treatment strategies. As noted by some panel members, however, many parameters should be considered in treatment selection, including the patient's quality of life and the cost of treatment. Several studies have examined the benefits of chemotherapy agents, such as gemcitabine, topotecan, and pegylated liposomal doxorubicin in treatment for recurrent ovarian cancer in individual institutions⁴⁵ or health maintenance organizations.⁴⁶ One suggestion was to conduct a population-based study to measure the costs of using second-line, third-line, and fourth-line agents, as well as quality of life of patients treated with these agents. The results of such a study could potentially yield a set of guidelines concerning what type of additional chemotherapeutic options would be beneficial to patients with recurrent ovarian cancer and when such chemotherapy use is appropriate.

Topic 3: Symptom Recognition and the Implications for Public Health Research and Awareness

The third panel discussion addressed potential research related to CDC's gynecologic cancer awareness campaign, Inside Knowledge: Get the Facts About Gynecologic Cancer (www.cdc.gov/cancer/knowledge). Inside Knowledge was developed and implemented by CDC, in collaboration with the U.S. Department of Health and Human Services' Office on Women's Health, in response to the Gynecologic Cancer Education and Awareness Act of 2005 (Johanna's Law, HR 1245) (www.cdc.gov/cancer/gynecologic/pdf/JohannasLaw.pdf). The campaign has three main objectives: (1) provide information about the five major gynecologic cancers: cervical, ovarian, uterine, vaginal, and vulvar, (2) disseminate materials conveying the key message that when many cancers are found early, treatment is most effective, and (3) educate women and healthcare providers about the signs and symptoms of gynecologic cancer, available screening tests, risk factors, and prevention strategies. Central campaign messages relevant to ovarian cancer are (1) pay attention to your body: know what is normal for you—gynecologic cancers have warning signs, (2) if you have any unexplained signs or symptoms, see a doctor right away, and (3) if you are diagnosed with a gynecologic cancer, see a gynecologic cancer specialist.

To date, campaign research has focused on the analysis of data from the HealthStyles and DocStyles surveys, annual consumer and physician surveys conducted by Porter Novelli (New York, NY).⁴⁷ These analyses will provide baseline and monitoring data about patient and provider perceptions and knowledge about gynecologic cancers and will inform future campaign development. For example, campaign researchers will be examining women's knowledge about, familiarity with, and past use of gynecologic cancer tests, their concern about gynecologic, cancer, and care seeking for symptoms associated with gynecologic cancer. They will also examine physicians' beliefs about the utility of screening methods (e.g., CA-125, pelvic examination) and the extent to which they use these methods. Focus groups will be conducted to assess target audiences' behaviors, attitudes, and knowledge related to gynecologic cancers and will also test campaign concepts, messages, and materials with target audiences. Focus group results will be used to develop additional strategies to increase public awareness about gynecologic cancer, including broadcast and print public service announcements, an internet campaign, and an educational slide set for healthcare providers.

The topic of symptom recognition and management sparked much discussion among the invited experts. Studies suggest that women with ovarian cancer do experience symptoms prior to development of ovarian cancer. These symptoms are typically nonspecific abdominal and gynecologic complaints, such as bloating, abdominal pain, early satiety, genital organ pain, and postmenopausal bleeding.^48

–51 Fatigue and back pain are also commonly reported by ovarian cancer patients prior to their cancer being diagnosed.⁴⁸ However, these symptoms are also common among women without ovarian cancer, including those with benign ovarian conditions and irritable bowel syndrome.⁴⁸ Several panel participants noted that the value of symptom recognition as an early detection strategy is largely unknown and that encouraging women to recognize such symptoms as possible indications of ovarian cancer is somewhat controversial, given the commonality of the symptoms in the general population and the relative rarity of ovarian cancer. Thus, one research topic proposed by panelists was whether increased awareness of symptoms associated with ovarian cancer will cause decreased ovarian cancer morbidity or mortality. The complexity of assessing the benefits of symptom recognition is exacerbated by a lack of information about the natural history of ovarian cancer. Thus, it is difficult to know when cancer symptoms develop in the course of disease progression and if a focus on symptoms is an appropriate way to increase early detection of ovarian cancer. We do not know if all ovarian cancers progress linearly from early to late stage or if some ovarian tumors are more aggressive from the beginning, how long ovarian cancers progress before they can be detected,^52,53 or if there are preneoplastic lesions for ovarian cancer, as in breast or cervical cancer.^52,53 Unresolved questions about ovarian cancer that are especially pertinent to public health include: What happens when women are symptomatic but do not have ovarian cancer? How do women perceive and process information about such symptoms? How, if at all, do women act on such information? For example, there are limited data on the prevalence of oophorectomy among symptomatic women and how an oophorectomy affects one's long-term risk of ovarian cancer or primary peritoneal cancer or other chronic diseases, such as heart disease and osteoporosis.

A related topic is how primary care providers and physicians in general practice respond to women with the nonspecific symptoms often associated with ovarian cancer. Panel members cited a need to collect information about the current practices of such physicians. There is currently no consensus on how physicians should treat women with symptoms, but the American Cancer Society (ACS) has convened a work group with representation from provider and advocacy groups as well as clinical and research experts to address this controversial topic. One research suggestion was to conduct a prospective cohort study of the behavior of women experiencing symptoms associated with ovarian cancer^48

–51,54 to better understand the medical care pathways for women with ovarian cancer. Given the low incidence of ovarian cancer, this type of study may be prohibitively expensive to undertake, but at a minimum, performing a comprehensive literature review could be an important first step toward understanding care seeking and treatment. Additional research activities that panel members suggested included obtaining data necessary to develop diagnostic and treatment paradigms for physicians (particularly primary care physicians) of women with symptoms of ovarian cancer. CDC was encouraged to work with primary care physicians to design and implement such research.

Panel members also discussed the need for more efforts to educate the general public, not just ovarian cancer patients, about ovarian cancer risk and to educate providers about the importance of recognizing symptoms and appropriate and timely referrals to gynecologic oncologists. Educational efforts targeting the general public possibly could be aided by working with comprehensive cancer control programs (www.cdc.gov/cancer/ncccp/) and other existing infrastructure. Although widespread education campaigns and awareness efforts are important, such campaigns should be mindful of the relatively low number of new cases of ovarian cancer diagnosed per year in the general population (12.4 per 100,000 women¹) and balance the benefits of such campaigns against the unnecessary worry and alarm that such campaigns could create in women who will never have ovarian cancer.

Additional Discussion

Throughout the workshop, particularly toward the end, the discussion identified additional areas for public health research on ovarian cancer. Although the causes of ovarian cancer are not well understood, research has demonstrated that parity, oral contraceptive use, tubal ligation, prophylactic oophorectomy, and hysterectomy are associated with a decreased risk for ovarian cancer^55
–57 and that hormone replacement therapy and a family history of ovarian cancer are associated with an increased risk.^58
–60 Some panelists emphasized the need for stronger epidemiological evidence about some of the factors associated with a decreased risk for ovarian cancer (such as oral contraceptive use, tubal ligation, and prophylactic oophorectomy), given uncertainties over their mechanism of action, benefits, and possible association with other adverse health outcomes, such as breast cancer and heart disease. Panelists suggested that in the absence of an effective screening strategy or early detection test, more targeted research in areas of primary ovarian cancer prevention may be of value. CDC could contribute to such research by summarizing and evaluating evidence of modifiable factors associated with ovarian cancer.

Another recurrent theme in the discussion was the need for research and data that could be used in establishing healthcare policy and drafting healthcare legislation. Several panelists noted the value of funded projects, such as the OCTPO study, and national cancer registry programs, such as CDC's NPCR, in identifying factors that could be modified to reduce ovarian cancer incidence, improve the quality of treatment, and increase survival. Cancer surveillance programs, such as NPCR and the National Cancer Institute's (NCI's) Surveillance, Epidemiology and End Results (SEER) program, can provide important descriptive and analytic statistics about the relationship of ovarian carcinomas to fallopian tube and primary peritoneal cancers and to cancers that may have a similar molecular pathogenesis.^61,62 A better understanding of patterns of ovarian cancer incidence, issues affecting patients' access to quality care, and predictors of survival may help identify opportunities to improve the prognosis of ovarian cancer patients and the quality of care they receive.

The efforts to advance ovarian cancer research to improve the prognosis of the disease is closely tied to the final important observation of the discussion, that CDC efforts should complement and contribute to the work of other federal agencies, such as the Food and Drug Administration (FDA), the Centers for Medicare and Medicaid Services (CMS), and the NCI. For example, participants discussed the challenges of educating people about and enrolling patients in clinical trials. A collaborative role for CDC, other federal agencies, and public health partners could be to identify resources that remove barriers to clinical trial participation and increase efforts to educate the public about the potential value of clinical trials. One CDC and NCI-funded program, the Education Network to Advance Cancer Clinical Trials (ENACCT), helps provide patients access to high-quality cancer treatment, including clinical trials, and educates providers and patients about enrollment in clinical trials (www.enacct.org). Because policies and regulations affecting clinical trials differ from state to state, the help of other federal agencies may be critical in accomplishing this objective. As another example, CDC could provide objective data on the public health impact of current reimbursement policies and clinical practices to draw attention to problems and advance policy discussions in areas where other agencies may be unable to initiate action.

Panel members also suggested that CDC expand work with advocacy organizations to help reach not only women with ovarian cancer but also their families and the larger population of women without ovarian cancer. More direct collaboration between the advocacy community and researchers could lead to better communication of scientific information and improved advocacy for survivors.

Conclusions

During the course of the meeting, several participants observed that CDC should use its standing as an independent, science-based agency to gather and compile evidence to inform healthcare policy and recommendations. One way for CDC to achieve its ovarian cancer research goals would be to expand work with advocacy organizations. Participants also stressed the need to identify ways to communicate about ovarian cancer with primary care doctors, who play a critical role in deciding when further follow-up and referral to a specialist are appropriate.

Taken together, the suggestions of the participants at the November 2008 workshop of ovarian cancer experts provided a range of ways in which public health professionals can address ovarian cancer. The CDC welcomes the valuable input and thanks the meeting participants for their time and assistance.

Participants

Michael Berman, M.D., University of California, Irvine Medical Center; Deborah Bowen, Ph.D., Boston University; Saundra Buys, M.D., Huntsman Cancer Institute at the University of Utah; Sue Friedman, D.V.M., FORCE: Facing Our Risk of Cancer Empowered; Barbara Goff, M.D., University of Washington School of Medicine; Marc Goodman, M.D., M.P.H., Cancer Research Center, University of Hawaii; Thomas C. Hamilton, Ph.D., Fox Chase Cancer Center; Jennifer L. Hay, Ph.D., Memorial Sloan-Kettering Cancer Center; Carolyn M. Johnston, M.D., University of Michigan Hospitals and Clinics; Maurie Markman, M.D., University of Texas M.D. Anderson Cancer Center; Patricia G. Moorman, Ph.D., Duke University Medical Center; Karen Orloff Kaplan, M.S.W., M.P.H., Sc.D., Ovarian Cancer National Alliance; Harvey A. Risch, M.D., Ph.D., Yale University School of Public Health; Debbie Saslow, Ph.D., American Cancer Society; Antoinette M. Stroup, Ph.D., Utah Cancer Registry; Edward Trimble, M.D., M.P.H., National Cancer Institute.

Footnotes

Acknowledgments

Janet Bobo, Ph.D., served as the project leader for the contract that funded the workshop and the discussion facilitator. Herschel W. Lawson, M.D. (former Senior Medical Adviser, DCPC, now retired), was a valuable member of the planning committee. Janet L. Collins, Ph.D., director of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), and Barbara A. Bowman, Ph.D., acting director of the Division of Cancer Prevention and Control (DCPC), NCCDPHP, helped to foster constructive discussion among the panelists. Cynthia Gelb, B.S.J., and Lindsey Polonec, M.A., from the Office of Program and Policy Information, DCPC, contributed to the discussion around Johanna's Law and public information campaigns. Denita Dean, M.P.H., Epidemiology and Applied Research Branch, DCPC, was instrumental in the early preparations for the workshop.

This article is a summary of the issues discussed at the CDC workshop, Defining the Public Health Research Agenda for Ovarian Cancer, and does not necessarily reflect the views of all participants or a consensus on any particular issue.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Disclosure Statement

The authors have no conflicts of interest to report.

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