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Ovarian Cancer

The Ovaries

The ovaries are part of a woman's reproductive system. They are in the pelvis. Each ovary is about the size of an almond. The ovaries make the female hormones -- estrogen and progesterone. They also release eggs. An egg travels from an ovary through a fallopian tube to the womb (uterus). When a woman goes through her "change of life" (menopause), her ovaries stop releasing eggs and make far lower levels of hormones.


Ovarian Cancer

Ovarian cancer is any cancerous growth that may occur in different parts of the ovary. The majority of ovarian cancers arise from the epithelium (outer lining) of the ovary. Ovarian cancer often goes undetected until it has spread within the pelvis and abdomen. At this late stage, ovarian cancer is difficult to treat and is often fatal. Ovarian cancer can sometimes spread more widely in your abdomen (tummy) or more rarely, to other organs, through your bloodstream or lymphatic system. The lymphatic system is the tissues and organs, including your bone marrow, spleen, thymus, and lymph nodes, that produce and store cells that fight infection and disease. The channels that carry lymph are also part of this system. If ovarian cancer spreads to other parts of your body, it can form secondary tumors. The spread of cancer through your body is called metastasis.


Types of Ovarian Cancer

There are four main types of ovarian cancer, and these are named after the type of cells in the ovary where the cancer begins growing:

  • Epithelial ovarian cancer begins in the epithelium: The outer cells that cover the ovary. This is the most common type of ovarian cancer, accounting for about 90% of cases.

  • Borderline tumours are a group of epithelial tumours, which are not as aggressive as other epithelial tumours. Borderline tumours may also be called 'low malignant potential' or LMP tumours. The outlook for women with borderline tumours is generally good regardless of whether the disease is diagnosed early or late.

  • Germ cell ovarian cancer begins in the cells that mature into eggs. These tumours account for about 5% of ovarian cancers and usually affect women under 30 years.

  • Sex-cord stromal cell ovarian cancer begins in the ovary cells that release female hormones. These tumours account for about 5% of ovarian cancers and can affect women of any age. 
    Both germ cell and sex-cord stromal cell ovarian cancers respond well to treatment and are often curable. If either of these cancers affect only one ovary, it may be possible for younger women to have children after treatment.


Staging

Ovarian cancer staging is by the FIGO staging system and uses information obtained after surgery, which can include a total abdominal hysterectomy, removal of (usually) both ovaries and fallopian tubes, (usually) the omentum, and pelvic (peritoneal) washings for cytopathology. The AJCC stage is the same as the FIGO stage. The AJCC staging system describes the extent of the primary Tumor (T), the absence or presence of metastasis to nearby lymph Nodes (N), and the absence or presence of distant Metastasis (M).

  • Stage I - limited to one or both ovaries

  • IA - involves one ovary; capsule intact; no tumor on ovarian surface; no malignant cells in ascites or peritoneal washings

  • IB - involves both ovaries; capsule intact; no tumor on ovarian surface; negative washings

  • IC - tumor limited to ovaries with any of the following: capsule ruptured, tumor on ovarian surface, positive washings

  • Stage II - pelvic extension or implants

    • IIA - extension or implants onto uterus or fallopian tube; negative washings

    • IIB - extension or implants onto other pelvic structures; negative washings

    • IIC - pelvic extension or implants with positive peritoneal washings

  • Stage III - microscopic peritoneal implants outside of the pelvis; or limited to the pelvis with extension to the small bowel or omentum

    • IIIA - microscopic peritoneal metastases beyond pelvis

    • IIIB - macroscopic peritoneal metastases beyond pelvis less than 2 cm in size

    • IIIC - peritoneal metastases beyond pelvis > 2 cm or lymph node metastases

  • Stage IV - distant metastases to the liver or outside the peritoneal cavity


Symptoms of Ovarian Cancer

In the early stages, ovarian cancer usually has vague symptoms, which are not easy to recognize. In fact, doctors used to think that ovarian cancer had no symptoms (unfortunately, many still do). Even though healthcare professionals are much better at identifying ovarian cancer symptoms these days, patients often attribute their symptoms to other conditions, such as pre-menstrual syndrome, irritable bowel syndrome, or a temporary bladder problem. 

The main difference between ovarian cancer and other possible disorders is the persistence and gradual worsening of symptoms. While most digestive disorders have fluctuating symptoms, those of ovarian cancer are more constant and steadily advancing. 

The following are examples of possible early symptoms of ovarian cancer:

  • Pain in the pelvis

  • Pain on the lower side of the body

  • Pain in the lower stomach

  • Back pain

  • Indigestion or heartburn

  • Feeling full rapidly when eating

  • More frequent and urgent urination

  • Pain during sexual intercourse

  • Changes in bowel habits, such as constipation


As ovarian cancer progresses these symptoms are also possible:

  • Nausea

  • Weight loss

  • Breathlessness

  • Fatigue (tiredness)

  • Loss of appetite


Causes of Ovarian Cancer

The exact reasons why you may develop ovarian cancer aren't fully understood at present. However, there are some things that can make it more likely. It's more common in women who live in developed countries for example, and in those who have gone through the menopause. It’s also known that inheriting faulty genes called BRCA1 and BRCA2 increase the risk of ovarian cancer as well as breast cancer.


Other factors that may increase your risk of getting ovarian cancer include:

  • Certain types of hormone replacement therapy (HRT) – especially if you take them for longer than five years

  • Being overweight or obese

  • Having endometriosis or ovarian cysts

  • Smoking

  • Starting the menopause late

  • A possible link to using talcum powder has been suggested but this needs to be confirmed by more research (see our common questions for more information).


Ovarian cancer is generally less common in women who have:

  • Used the contraceptive pill

  • Had children – the more children, the lower the risk

  • Breastfed their children

  • Had a hysterectomy or been sterilized


Diagnosing Ovarian Cancer

A doctor examining for the signs of ovarian cancer will carry out a full pelvic examination, feeling for the presence of an abnormal lump. However, it's only as a tumor grows and spreads that the symptoms become clearer and the problem easier to diagnose.

Your GP may request some tests, including:

  • Blood tests

  • Ultrasound

  • Laparoscopy - keyhole surgery to look at the ovaries, fallopian tubes and uterus. A biopsy, which means a small piece of tissue is taken from the ovary, will also be done

  • Chest x-ray to check for spread of the cancer into the lungs

  • CT or MRI scan, also to look for any possible spread

If any problems are suspected with the digestive system, an endoscopy will be arranged, to look at the stomach, or a colonoscopy, to look at the lower bowel. If there is a lot of fluid within the abdomen due to ovarian cancer, the consultant will do an abdominal tap, which allows some of the fluid to be drawn off under a local anesthetic and then the fluid examined under a microscope for cancer cells, or drained off to make the patient more comfortable.


Treatment for Ovarian Cancer

The treatment of ovarian cancer is based on the stage of the disease which is a reflection of the extent or spread of the cancer to other parts of the body. There are basically three forms of treatment of ovarian cancer. The primary one is surgery at which time the cancer is removed from the ovary and from as many other sites as is possible. Chemotherapy is the second important modality. This form of treatment uses drugs to kill the cancer cells. The other modality is radiation treatment, which is used in only certain instances. It utilizes high energy x-rays to kill cancer cells.

  • Surgery

    • Laparotomy. Doctors perform laparotomy through a large abdominal incision, most often removing your ovaries, uterus, fallopian tubes, nearby lymph glands, a fold of fatty tissue called the omentum and as much of the tumor as possible. This process is known as surgical debulking or cytoreductive surgery.

    • Frozen section tissue analysis. The frozen section technique, which allows for rapid analysis of your tissue under a microscope. Surgeons determine in minutes whether your tumor is noncancerous or cancerous, dramatically increasing their ability to perform the most appropriate procedure during the first surgery.

    • Laparoscopy and robotic-assisted laparoscopy. Laparoscopy is a minimally invasive surgery that may be used depending on the extent of cancer present when your cancer is diagnosed. Researchers are studying this procedure with the goal of using it more frequently.

Radiation Therapy

In external beam radiation therapy, a large machine is used to carefully aim a beam of radiation at the tumour. The radiation damages the cells in the path of the beam – normal cells as well as cancer cells. In brachytherapy, or internal radiation therapy, radioactive material is placed directly into or near the tumour. For ovarian cancer, a radioactive fluid may be put into the abdomen through a plastic tube (intraperitoneal radiotherapy). This fluid stays radioactive for only a few days, so it does not have to be removed from the body.

Side effects will be different depending on what part of the body receives the radiation. You may feel more tired than usual or notice changes to the skin (it may be red or tender) where the treatment was given. These side effects are a result of damage to normal cells. The side effects will usually go away when the treatment period is over and the normal cells repair themselves. 


Chemotherapy

Chemotherapy may be given as pills or by injection. For ovarian cancer, the drugs may be given through a thin tube inserted into the abdomen (intraperitoneal chemotherapy). Chemotherapy drugs interfere with the ability of cancer cells to grow and spread, but they also damage healthy cells. Although healthy cells can recover over time, you may experience side effects from your treatment like nausea, vomiting, loss of appetite, fatigue, hair loss and an increased risk of infection.  


New Therapies

Research into ovarian cancer is constantly ongoing. One of the aims is to improve treatment strategies and a number of these, such as gene therapy and hormone therapy, are in development. These are tested in clinical trials but whether they are better at curing ovarian cancer will not be known for several years.


Gene Therapy

Cancer is thought to result from a number of genetic mistakes in the cells. Some of these are inherited (see familial cancer) but most are caused by exposures to environmental or other factors that can damage DNA, the genetic blueprint of life. Gene therapy is looking into several possibilities:

  • Repairing the damage by putting copies of normal genes into cancer cells

  • Making the cells "commit suicide" in a process called apoptosis

  • Making the cells a target for the immune system to destroy

  • Making the cells more senstive to chemotherapy


Hormone Therapy

The ovaries are sensitive to the actions of hormones and the menstrual cycle is controlled by them. Some ovarian cancers which have become resistant to treatment may respond to hormone therapies. Currently, doctors are investigating the use of hormone treatment but responses have so far been variable and not that effective at managing cancer progression.

Many women who have been through the change of life (menopause) take hormone replacement therapy (HRT). There is currently not enough evidence to say whether HRT is risky or safe for women who have been treated for epithelial ovarian cancer.


Follow Up Care

Follow-up care after treatment for ovarian cancer is vital. This is because, in most women, there is an increased chance of recurrence within 2 years of treatment. Most patients go in for regular checkups once in three months. These checkups generally include a physical examination, a pelvic examination and a Pap smear test.

Additionally, the physician may also perform tests such as a chest x-ray, CT scan, urine analysis, complete blood count, and CA-125 assay. In the case of some women, ovarian cancer may increase the chances of them developing other cancers such as colon or breast cancer. Treatment with certain anticancer drugs may increase the risk of secondary cancers such as leukemia and hence tests for these cancers are necessary.


Prevention

Any factor that prevents ovulation (the release of an egg) seems to decrease the risk of ovarian cancer. 

  • Taking oral contraceptives (birth control pills) 

  • Pregnancy 

  • Starting menstrual cycles later in adolescence 

  • Early menopause 

  • Tubal ligation (having the tubes tied)

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