Melinda Cosman, of Manchester, Conn., thought the hard part was over when she welcomed her husband home from a yearlong deployment to Iraq.
She never imagined the family would have to endure a more difficult challenge. In June 2011, shortly after her husband returned, their 7-year-old daughter Natalie was diagnosed with ovarian cancer.
"Your life is put on a test," said Cosman. "It has made us stronger."
Throughout the previous year, Natalie complained of stomach pains, sometimes so excruciating, she would have to miss school. Her doctors chalked it up to constipation, maybe a stomach bug. But when the pain became unbearable, Cosman took Natalie to the emergency room.
"[The doctors] were shooting for appendicitis and they brought her in for an ultrasound in the morning to confirm that," said Cosman.
Instead of a ruptured appendix, the ultrasound detected a 7-centimeter cyst on Natalie's ovary.
While cysts are common among women of childbearing age, they are considered rare in young girls who have not undergone puberty.
"Especially girls who haven't had their period yet, nothing should grow on their ovary," said Dr. Judith Wolf, division chief of surgery at MD Anderson Cancer in Houston.
Nearly 22,000 women are diagnosed with ovarian cancer each year, according to the National Cancer Institute. Experts estimate that 500 to 1,000 cases occur in females under age 20.
Young girls develop a different type of the disease than adult women, according to Dr. Cynthia Herzog, professor of pediatrics at MD Anderson Cancer Center.
Women more commonly have a form called an epithelial carcinoma, where the cancer begins in the cell on the surface of the ovary. For girls with the disease, the cancer begins in egg cells, and develops into a so-called germ cell tumor.
Germ cell tumors make up about 3 percent of all childhood cancers, according to the National Cancer Institute. Ninety percent of germ cell tumors are found in the ovaries or testicles and are more common in children and adolescents.
A biopsy confirmed a cancerous germ cell tumor in Natalie.
"I kept thinking, 'ovarian cancer in a 7-year-old?'" said Cosman.
It can be difficult for many women to come to terms with an ovarian cancer diagnosis. The process of understanding and accepting the diagnosis is often more difficult for young girls.
"She knows she had cancer and that it was ovarian cancer," said Cosman. "To this day I don't think she gets the extent of it."
For Natalie, undergoing treatment meant missing a year of school and having to sit out on her favorite activity: dance.
"I felt disappointed because I like to dance," said Natalie. "I like to perform in front of people. I also had a lot of friends at school."
Two decades ago, treatment for the disease was devastating to young girls. As a precaution, surgeons removed both ovaries, regardless of where the tumor was found. The method eliminated any chance of childbearing.
In recent years, pediatric oncologists have suggested that perhaps a total removal is unnecessary, preserving these young girls' reproductive health.
While the cause of ovarian cancer in young girls in unclear -- studies have not pointed to a genetic or environmental trigger -- treatment for the disease is effective, said Wolf.
"The good news is that even if they're found when they're advanced, they respond really well to chemotherapy," said Wolf, who has treated nearly two dozen cases.
Chemotherapy is over 90 percent effective at treating germ cell tumors, even if it has spread to lymph nodes, according to Wolf.
"The one ovary is removed that's affected and doesn't necessarily mean infertility," said Wolf. In July 2011, Natalie's surgeons removed her right ovary and right fallopian tube.
"There wasn't a doubt in my mind [to do the surgery] because when you're told that your daughter has cancer and that's what's going to treat it, you do it," said Cosman. "I put her in the palm of the doctors."
Natalie also had her gall bladder removed as part of her treatment. Six rounds of chemotherapy followed, and by January 2012, Natalie completed treatment for the disease.
"I feel a lot better besides all that stuff," said Natalie.
"To this day she jokes that her right side is lighter than her left," said Cosman.
While the disease is rare in young girls, Cosman warned parents not to ignore pain symptoms in their children.
Potential signs of the disease in young girls include a lump that can be felt in the abdominal area, severe abdominal or lower back pain, and prolonged bloating or constipation, Wolf said.
In many cases, the disease goes undetected until either the parent or child notices a protruding mass on the child's abdomen, said Herzog, who sees about three young ovarian cancer patients a year, most of whom are teenagers.
"The mass gets to a critical size where it doesn't fit in the pelvis anymore and protrudes," said Herzog. "That's the thing that triggers most girls to get seen."
The U.S. Preventative Task Force recommends against ovarian cancer screening for women who are not at high risk.
Since it's unclear what type of young girl would be at risk for the disease, Herzog said, "It's too rare to make screening for young girls a reasonable thing."
But if symptoms persist, Herzog recommended that parents take their children to a pediatrician for evaluation.
"I'm very thankful that with everything that happened that we caught it early it enough," said Cosman.
This month, Natalie will return to school and get to attend dance practice again.
"I can't wait," Natalie said.