Everything You Need to Know About Ovarian Cancer
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Ovaries are only found in women. There is one on each side of the uterus. They are part of the female reproductive system and produce eggs as well as the female sex hormones estrogen and progesterone.
These small, almond-shaped organs can give rise to cancer originating in the cells of one of its three layers:
- Germ Layer: Produces the eggs.
- Stromal Layer: Composes the majority of ovaries and produces hormones.
- Epithelial Layer: The thin layer of tissue that covers the outside of the ovaries.
The American Cancer Society (ACS) reports that ovarian cancer is the fifth most common cause of cancer-related death among females in the United States.
Signs and Symptoms
Ovarian cancer, especially early-stage disease, is notorious for its lack of presenting signs and symptoms. In other words, early-stage ovarian cancer rarely has signs or symptoms. On the other hand, advanced-stage ovarian cancer will likely cause signs and symptoms, many of which are non-specific and mimic other more common but less life-threatening conditions, such as urinary tract infection, premenstrual syndrome, and irritable bowel syndrome.
Signs and symptoms of ovarian cancer may include:
- Pelvic pain, discomfort, and/or pressure;
- Abdominal bloating or swelling;
- Early satiety;
- Abnormal and unexpected vaginal bleeding;
- Changes in urinary and/or bowel habits
- Weight loss;
- Lower back pain;
- Pain during intercourse, and;
- Shortness of breath.
The exact cause of ovarian cancer is not known. However, there are established risk factors for the development of the disease.
The following are well-established risk factors for ovarian cancer:
- Advancing Age: 50 percent of ovarian cancers are diagnosed in women 63 years of age and older.
- Being Overweight or Obese: Ovarian cancer is more common in women with a body mass index (BMI) greater than or equal to 30 kg/m2.
- Pregnancy Later in Life or Never Experiencing Pregnancy: Women who get pregnant after age 35 or never got pregnant have a greater risk of ovarian cancer.
- Family History: If a woman’s mother, grandmother, aunt, or sister had ovarian cancer, they have a greater chance of being diagnosed with it.
- Genetic Mutations: The BRCA1 and BRCA2 genes not only increase your risk of breast cancer but also increase your risk of ovarian cancer).
Other risk factors for ovarian cancer may be:
- In vitro fertilization;
- Long-term hormone replacement therapy (HRT), consisting of only estrogen, after menopause;
- Use of talcum powder;
- Excessive levels of androgens, and;
It’s important to remember that having one or several of the above risk factors for ovarian cancer does not necessarily guarantee that you will eventually be diagnosed with the disease. There are as many women diagnosed with ovarian cancer that have no known risk factors.
Screening refers to a test that is used to detect a disease before it causes any symptoms. In other words, the goal of a screening test is to find early disease, when treatment has the best chance for a cure.
Unless you are deemed at high-risk for ovarian cancer, regular screening is not recommended. This is since many women with the disease do not have signs or symptoms at this stage.
Be careful as some women confuse the Pap test, which is meant to find cervical cancer, as a screening test for ovarian cancer. Besides a thorough pelvic examination, other screening tests for ovarian cancer include:
- Transvaginal Ultrasound: Uses sound waves to detect ovarian tumors.
- The CA-125 Blood Test: Measures the amount of CA-125 in one’s blood. The protein is usually elevated in many women with ovarian cancer.
Currently, there is no scientifically proven way to prevent ovarian cancer. However, there are measures you can employ to possibly reduce your risk. These measures include:
- Oral contraceptives;
- Maintaining a healthy weight;
- Giving birth;
- Avoiding HRT — especially estrogen only — after menopause, and;
- Gynecological surgery.
With the recent advent and growing popularity of testing for the BRCA1 and BRCA2 genes, some women at high risk for ovarian cancer are choosing to undergo elective removal of both ovaries and breasts in an effort to prevent ovarian and breast cancer. While this strategy is risk-reducing, it’s very controversial, as it has recently been thrust into the spotlight by celebrities such as Angelina Jolie. Risk-reducing surgery to remove both fallopian tubes and ovaries reduces ovarian cancer risk by 69 to 100 percent.
When to See a Doctor
If you are experiencing any of signs and symptoms of ovarian cancer, you should make an appointment with your doctor to discuss your concerns as soon as possible. According to a review published by the American Journal of Preventive Medicine, the symptoms with the highest correlation to ovarian cancer included:
- Abdominal/pelvic pain;
- Abdominal bloating;
- Abdominal distention;
- Abdominal mass, and;
- Loss of appetite.
Your evaluation should include a physical examination — most importantly, a pelvic examination — and other diagnostic tests. Furthermore, if you have a significant family history of ovarian cancer, your doctor may want to refer you for genetic counselling with possible testing for genetic mutations.
As with any cancer, early diagnosis of ovarian cancer provides the best chances for successful treatment.
The first steps in the diagnosis of ovarian cancer should include a thorough medical history and physical examination by your doctor.
As part of your medical history, your doctor may ask you a series of pointed questions, such as:
- What are your symptoms and how long have you been experiencing them?
- What is the severity of your symptoms and what makes them better or worse?
- Do you have a family history of ovarian cancer and/or breast cancer?
- Have you ever been pregnant?
- Have you ever been prescribed HRT or had any type of gynecological surgery?
Next, a physical examination, including calculation of a BMI and rectal examination, should be carried out to look for any signs of disease. Special emphasis will be placed on the pelvic examination. Your doctor will perform a gloved pelvic examination evaluating your pelvic organs, external genitalia, vagina, and cervix for any discernible abnormalities.
Again, a Pap test cannot be used to screen for to diagnose ovarian cancer, so it is usually not a part of this process. Unless you are presenting for your yearly physical and it is recommended.
Blood and Imaging Tests
If your doctor’s suspicion remains piqued, your doctor may order more testing in the form of blood and imaging tests.
Since CA-125 may be elevated in the blood of women with ovarian cancer, a CA-125 blood test is usually recommended. Other specific blood tests, which could be related to the presence of ovarian cancer, include:
- Human chorionic gonadotropin;
- Lactate dehydrogenase;
- Human epididymis protein 4;
- Inhibin A/B;
- Estrogen, and;
- Testosterone levels.
All these biomarkers have the potential to be elevated in cases of ovarian cancer.
Other blood tests, which are more indicative of overall health, that may be ordered include a complete blood count and liver and kidney function tests.
Imaging tests that may be useful in the diagnosis of ovarian cancer include:
- Transvaginal ultrasound;
- Computed tomography scan;
- Magnetic resonance imaging, and;
- Positron emission tomography.
Of course, these imaging tests performed on the abdomen and pelvis can give your doctor information on the size, shape, and structure of your ovaries. Additionally, they can provide information for staging for a confirmed case of ovarian cancer.
It should be noted that the only way to definitively diagnose ovarian cancer is with a biopsy. A biopsy collects a sample of tissue/cells to be viewed under the microscope by a pathologist.
If you are indeed diagnosed with ovarian cancer, your doctor may order the following tests to check for spread of cancer to other parts of the body:
- Urinalysis: Checks if cancer has spread to the kidneys and/or bladder.
- Chest X-ray: Checks if cancer has spread to the lungs.
- Barium Enema: Checks if cancer has spread to the colon and/or rectum.
The stage of the cancer gives insight into how much or how little it has spread from the primary tumor site. As a result, the stage of your ovarian cancer is one of the most important determinants of the treatment plan devised by your doctor.
In the case of cancers in general, the following factors are considered when determining your stage:
- Size of the tumor;
- Whether or not the tumor has invaded tissues, and;
- Whether or not the cancer has undergone metastasis.
Based on these observations, your ovarian cancer can be categorized into one of four stages:
- Stage I: Confined to one or both ovaries.
- Stage II: Confined to the pelvis.
- Stage III: Spread into the abdomen, whether to organs or lymph nodes.
- Stage IV: Spread to distant parts/organs of the body, including lymph nodes.
Alternatively, ovarian cancer can be categorized as:
- Localized: Stage I ovarian cancer.
- Regional: Stages II and III ovarian cancer.
- Distant: Stage IV ovarian cancer.
As mentioned earlier, there are three distinct cell types that comprise an ovary — epithelial, stromal, and germ.
Accordingly, each of these ovarian cells can give rise to a particular type of carcinoma, or cancerous tumor. The three major types of ovarian cancer are:
- Epithelial Carcinoma: This is the most common type and most invasive form of ovarian cancer. Usually diagnosed at an advanced stage, this type accounts for 90 percent of cases.
- Stromal Carcinoma: At seven percent, this type of ovarian cancer is less common. However, it is often diagnosed at an earlier stage than other forms of ovarian cancer.
- Germ Cell Carcinoma: This is one of the rarer forms of ovarian cancer. In fact, this type accounts for less than two percent of cases. It is typically diagnosed in women in their 20s.
If you are newly diagnosed with ovarian cancer, one of the first concerns is your prognosis, the outlook for survival.
The ACS utilizes information from the Surveillance, Epidemiology, and End Results database to provide five-year relative survival rates for ovarian cancer. In other words, the five-year relative survival rate compares women diagnosed with ovarian cancer with women who don’t have ovarian cancer and their chances of living at least five years after their cancer diagnosis. Your prognosis is heavily dependent on the type of ovarian cancer and its stage.
For epithelial ovarian cancer, the five-year relative survival rates are:
- Localized: 92 percent
- Regional: 76 percent
- Distant: 30 percent
- All Stages Combined: 47 percent
For stromal ovarian cancer, the five-year relative survival rates are:
- Localized: 98 percent
- Regional: 89 percent
- Distant: 54 percent
- All Stages Combined: 88 percent
Lastly, for germ cell ovarian cancer, the five-year relative survival rates are:
- Localized: 98 percent
- Regional: 94 percent
- Distant: 74 percent
- All Stages Combined: 93 percent
It should be noted that these numbers can be misleading, as other individualized factors such as age at diagnosis, access and response to treatment, and overall health can affect survival rates.
With regard to ovarian cancer, both the disease and its treatment can lead to complications — some of which are major. Complications are usually caused by late-stage disease spreading to other areas of the body, such as the abdomen, lungs, and bones.
Common complications of ovarian may include:
- Fatigue or weakness;
- Nausea and/or vomiting;
- Swelling of the lower extremities, and;
In addition to the above complications, women with ovarian cancer may experience some major complications, such as:
- Bowel obstruction;
- Pleural effusion;
- Bladder obstruction, and;
Many of the complications can make those diagnosed with ovarian cancer more susceptible to infection. For example, bowel obstruction may lead to bowel perforation. This complications happen because the contents of the intestines spilling into the abdominal cavity causing an infection. Also, pleural effusions can drastically reduce breathing function.
Fortunately, many of the complications of ovarian cancer are treatable. In fact, many of the major complications are amenable to surgery.
Options for the treatment of ovarian cancer may be categorized as local treatments and systemic treatments.
Local treatments include surgery and radiation therapy. On the other hand, systemic treatments include chemotherapy, targeted therapy, and hormone therapy.
Surgery is the main treatment for ovarian cancer. Surgical options for its treatment include:
- Removal of one ovary;
- Removal of both ovaries, or;
- Removal of both ovaries and the uterus.
If fertility is a concern, the former two surgical options may preserve the possibility of having children.
In addition to potentially being curative, surgery may also be used for staging and debulking of cancerous ovarian tumors.
Chemotherapy refers to the use of drugs/chemicals to kill cancer cells.
If you are diagnosed with stage II or higher ovarian cancer, chemotherapy after surgery is necessary. It may also be administered before surgery, although there is no advantage over its administration after surgery. Chemotherapy for ovarian cancer may be administered by mouth, within the veins, or into the abdominal cavity.
This method of treatment may have side effects, including nausea, vomiting, fatigue, and hair loss.
Targeted therapy refers to using substances, most likely drugs, to kill cancer cells while minimizing damage to normal cells. While the agents used for targeted therapy differ, they usually affect the vital functions in cancer cells, such as growth, division, or repair, the same way.
Hormone therapy utilizes hormones or drugs that block hormones to battle ovarian cancer. Examples include tamoxifen, aromatase inhibitors, and luteinizing hormone-releasing hormone agonists.
Potential side effects include blood clots in the legs, hot flashes, and thinning/weakening of bone.
Radiation therapy uses X-rays to kill cancer cells. It may be used to treat ovarian cancer in one of two forms: external beam or internal radiation. External beam radiation therapy is the most common type used for treating women with ovarian cancer.
Common side effects of radiation therapy include changes in skin, fatigue, nausea/vomiting, and diarrhea.
Living with Ovarian Cancer
Whether you are cancer-free after treatment or too far advanced for curative treatment of your ovarian cancer, there are measures to be taken and decisions to be made while living with the disease.
Care after being pronounced cancer-free is termed posttreatment care or survivorship care. The pillars of survivorship care are promotion of well-being, emotional support, and monitoring for complications or recurrence of disease.
The Society of Gynecologic Oncologists recommends a minimum of at least five years posttreatment care, which should be provided by a gynecologic oncologist. An example for survivorship care would be follow-up with your specialist every two to four months for two years, then every three to six months for three years, with annual visits after five years.
Other aspects of posttreatment care should entail periodic blood tests, genetic counseling, and imaging as clinically indicated. All of this is to prevent or at least sound an early alarm for the recurrence of the ovarian cancer. However, there is limited evidence for the effectiveness of posttreatment care for preventing or minimizing outcomes related to ovarian cancer.
If your ovarian cancer is too far advanced for treatment, both palliative and hospice, or end-of-life, care should be the focus of discussion shortly after diagnosis. The goal of palliative care is maximizing your quality of life by aggressively managing complications and other distressing symptoms. Hospice care is typically provided if you deemed as having less than six months to live. Its goal is comfort. Hospice care may be administered in various venues, including your home, a designated hospice facility, nursing home, or hospital.
Ovarian cancer is a significant cause of cancer-related death for women in the United States. In general, the earlier the diagnosis and stage of ovarian cancer, the better the chances you will be alive in five years. For example, if you are diagnosed with stage I ovarian cancer, your five-year relative survival is 92 percent.
This underscores the need for more research, which could lead to more effective treatment, screening, and prevention programs.