What Wit Can Teach Us About Ovarian Cancer and Clinical Trials

The professor in the hospital gown

Margaret Edson's Wit was first staged in 1995 and won her a Pulitzer Prize. It was her first and only play. The Guardian's review describes its subject plainly: Vivian Bearing, an American professor who studies the poetry of John Donne, is diagnosed with late-stage ovarian cancer and admitted to a New York teaching hospital for a punishing course of experimental treatment.

The 2001 HBO film stars Emma Thompson. What makes the story useful to people who are not in a theater is that it is built around two things almost nobody understands until they are in the room: how ovarian cancer gets found, and what being in a trial actually means.

Why this cancer is usually found late

Ovarian cancer is not one disease with one starting point. NCI's guidance for clinicians treats ovarian epithelial cancer, fallopian tube cancer, and primary peritoneal cancer as one group. They behave alike, they are staged alike, and they are treated alike.

The reason is anatomy. Many high-grade serous cancers — the most common kind — appear to begin in the fimbriae, the fringed ends of the fallopian tubes that reach toward the ovary. From there, cells shed straight into the abdominal cavity. NCI calls early spread across the peritoneum, the lining of the abdomen, the hallmark of these cancers.

So there is often no lump to feel and no stage where the disease sits quietly in one place. NCI states it directly: these cancers may cause no early signs, and when signs appear the cancer is often advanced.

SEER, the federal cancer surveillance program, bears that out. Of ovarian cancers diagnosed in the United States, 54 percent have already reached distant sites when they are found. Only 22 percent are still confined to the ovary.

Why there is no screening test

This is the part people find hardest to accept. NCI reports that pelvic examination, vaginal ultrasound, and the CA-125 blood test all have low predictive value for finding ovarian cancer in women without particular risk factors.

Low predictive value means most abnormal results are not cancer. Screening a whole population with those tools produces far more false alarms — and more surgery on healthy ovaries — than cancers found. So no routine screening is offered.

Risk changes the calculation. Inherited changes in the BRCA1 and BRCA2 genes raise ovarian cancer risk substantially, and women who carry them are offered risk-reducing surgery rather than screening. A family history of ovarian, breast, or related cancers is a reason to ask about genetic counseling.

What treatment involves

For advanced disease, treatment is surgery plus platinum-based chemotherapy — usually carboplatin with paclitaxel, given before surgery, after it, or both.

The surgery has a name worth knowing: cytoreduction, also called debulking. The aim is to remove as much visible tumor as possible. NCI lists the amount of tumor left behind after that operation among the strongest predictors of how someone does. Bevacizumab, a drug that starves tumors of new blood vessels, may be added. PARP inhibitors, which block a repair pathway that BRCA-altered cancer cells depend on, are used as maintenance in some cases.

Our explainer on ovarian cancer covers the types and stages in more detail.

What a trial phase actually means

Vivian's ordeal is an experimental protocol. That word covers very different things, and the difference is the whole point.

NCI describes four phases. A phase 1 trial asks whether a treatment is safe and what the highest tolerable dose is, in about 15 to 30 people. A phase 2 trial, with 50 to 100 people, asks whether it seems to work. A phase 3 trial randomly assigns people between the new treatment and the current standard, sometimes across thousands of participants. A phase 4 trial follows an approved treatment over the long run.

Trials also have eligibility criteria — health, medical history, age, prior treatment, tumor genetics. NCI says these exist to limit risk and to make the results interpretable.

Two things are true at once. Trials are how every treatment that works today was proven. And an early-phase trial is a study of safety, not a promise of benefit. Our page on what clinical trials are explains how to ask which phase you are being offered.

Symptoms worth a second appointment

These are common complaints with dull, ordinary explanations most of the time. What matters is persistence — roughly a couple of weeks of something new that does not settle.

• Bloating or a swollen abdomen that does not come and go with meals.
• Pelvic or abdominal pain, pressure, or a lump you can feel.
• Feeling full after only a few mouthfuls, or losing interest in food.
• Needing to pass urine more often or more urgently than usual.
• Persistent gas, indigestion, or constipation that is new for you.

Bring the pattern and how long it has lasted. NCI notes these symptoms often go unrecognized, which is exactly how the delay happens.

What this does not mean

• Wit is a play. Vivian is a character, written to make an argument about how patients are spoken to, not a case study.
• Advanced does not mean untreatable. Treatment for stage III and IV ovarian cancer is standard, established care.
• SEER puts five-year relative survival at 91.9 percent when this cancer is found while still localized and 31.5 percent once it has spread to distant sites, with 52.0 percent overall, counting cases diagnosed from 2016 to 2022. These are averages across large groups diagnosed years ago. They describe populations, not any one person.
• A trial in a 1995 play is not a trial today. Consent rules, dose-finding methods, and supportive care have all changed.
• No symptom on the list above means cancer. The list means "get it looked at," not "assume the worst."

Sources

• Wit (HBO Films)
• The Guardian: Wit review, January 2016
• NCI PDQ: Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer Treatment (Health Professional Version)
• NCI: How Do Clinical Trials Work?
• NCI SEER Cancer Stat Facts: Ovarian Cancer

How this article was prepared

An AI-assisted editorial system helped prepare this page. No named medical reviewer has reviewed it unless one is listed.

Cancer Explained is published by the National Cancer Information Foundation. It is not medical advice and does not suggest a test or treatment.

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