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Ovarian Cancer

Each year, about 22,000 women in the United States are diagnosed with ovarian cancer. The symptoms of ovarian cancer are often common and vague, which makes it difficult to diagnose.

There are more than 30 different types of ovarian tumors, which are categorized according to the cell type. Some are benign (noncancerous) and do not spread beyond the ovary. Malignant (cancerous) tumors can spread to other parts of the body.

Currently, there is no effective early detection method for ovarian cancer. It is usually diagnosed in advanced stages, and only about half of women survive longer than five years after diagnosis. For the 25 percent of ovarian cancers that are found early, the five-year survival rate is greater than 90 percent.

Studies have shown that prognosis and survival depend largely on how much tumor is left at the time of initial surgery. Patients who have no remaining tumor or with nodules less than one centimeter in diameter have the best chance for cure and long-term survival.

Types

There are more than 30 different types of ovarian cancer, categorized by the type of cell where they originate.

The three most common types of ovarian cancer are:
Epithelial tumors occur in the epithelium, which is the tissue that covers the outside of the ovary. About 90 percent of ovarian cancers are of this type. The risk of epithelial ovarian cancer increases with age and occurs mostly in women over 60, but can develop at any age.

Germ cell tumors originate in the egg-producing cells found within the ovary. This type of ovarian cancer can occur in women of any age, but mostly affects adolescents and young adults under age 30. About 5 percent of all ovarian cancers are germ cell tumors. Sex cord stromal tumors develop in the connective tissue that holds the ovary together and produces the female hormones estrogen and progesterone. Sex cord stromal tumors are relatively rare, representing about 5 percent of all ovarian cancers. Women may feel some pain and abdominal discomfort in the early stages of disease.

Symptoms

Most women with ovarian cancer have some symptoms. However, these symptoms are often vague and may be attributed to less serious ailments such as indigestion, weight gain or the consequences of aging.

Contact your doctor if any of the following symptoms occur:

  • General abdominal discomfort or pain (gas, indigestion, pressure, swelling, bloating, cramps)
  • Bloating and/or a feeling of fullness, even after a light meal
  • Nausea, diarrhea, constipation or frequent urination
  • Unexplained weight loss or gain
  • Loss of appetite
  • Abnormal vaginal bleeding
  • Unusual fatigue

Diagnosis

Unlike a Pap test for cervical cancer or a mammogram for breast cancer, there is currently no reliable test to screen healthy women for ovarian cancer. Diagnosing ovarian cancer may include any or all of the procedures below:

Pelvic Exam

In a pelvic exam, the doctor inserts one or two gloved fingers into the vagina and presses on the lower abdomen with the other hand. Sometimes this exam involves placing a finger in the vagina and rectum at the same time to feel structures deeper in the pelvis. A pelvic exam helps determine if there is a mass on either side of the uterus, which may indicate the presence of an ovarian tumor. If ovarian cancer is diagnosed, the doctor will also need to check to see whether the cancer has spread to other parts of the body.

CA-125 Blood Test

This blood test measures the level of a protein, CA-125, which is produced by ovarian cancer cells. CA-125 is known as a tumor marker because it is usually present at higher levels in women with ovarian cancer. CA-125 is most reliable when used to detect recurrent disease in women previously treated for ovarian cancer. Doctors generally look at the trend in CA-125 levels over time rather than individual test results. If the level is high before treatment, it can be used to monitor the effectiveness of chemotherapy. These levels can help predict treatment outcomes for fallopian tube cancer and primary peritoneal cancer, as well as ovarian cancer.

The CA-125 test alone cannot diagnose ovarian cancer, and is currently not effective in screening healthy women. A high level of CA-125 does not necessarily mean ovarian cancer is present. Conditions such as abdominal inflammation, recent surgery, fibroids, endometriosis, ectopic pregnancy or a ruptured cyst can all cause an increase in CA-125. At the same time, low levels of CA-125 do not mean you are cancer-free, since some types of ovarian cancer produce only low levels of CA-125 or none at all.

Transvaginal Ultrasound

In this procedure, a wand-shaped scanner is inserted into the vagina. It sends out sound waves and receives echoes as they bounce off the ovaries, creating electronic images viewed by the doctor on a small screen. A radiologist interprets the pictures and reports the findings to the doctor. Transvaginal ultrasound can show any growths on or near the ovaries, although doctors cannot determine whether they are cancer just by looking at them. This procedure is usually performed in a doctor's office.

Surgical Biopsy

The only way to confirm a diagnosis of ovarian cancer is for a pathologist to look at the ovarian tissue. A sample of tissue is usually obtained during surgery. Read more about surgery in the Treatment section.

Genetic Testing

Women at high risk for ovarian cancer because of personal or family history may be encouraged by their doctor to undergo additional testing, which may include genetic tests. Many women find this information helpful in making important decisions about prevention strategies for themselves and their children.

There are benefits and risks with genetic testing, so women should discuss it with their doctor. Blood tests are available to determine the presence of the BRCA1 or BRCA2 genes, which also cause breast cancer, and for genes involved in Lynch syndrome, an inherited colon cancer syndrome. In women believed to be carrying one of these mutations, a blood test may help determine whether they are at high risk for ovarian cancer (as well as breast, uterine or colon cancer, depending on the gene).

The stage of ovarian cancer describes the extent to which the tumor has spread outside the ovary to nearby tissues and other parts of the body. Staging is done during the surgical biopsy, and generally requires removing lymph nodes, samples of tissue from the diaphragm and other abdominal organs, and fluid from the abdomen. When diagnosed early (Stage I), a woman has a 95 percent chance of being cured. However, only 25 percent of ovarian cancer cases are diagnosed in early stages. Ovarian cancer staging is as follows:

The stage of ovarian cancer describes the extent to which the tumor has spread outside the ovary to nearby tissues and other parts of the body. Staging is done during the surgical biopsy, and generally requires removing lymph nodes, samples of tissue from the diaphragm and other abdominal organs, and fluid from the abdomen. When diagnosed early (Stage I), a woman has a 95 percent chance of being cured. However, only 25 percent of ovarian cancer cases are diagnosed in early stages. Ovarian cancer staging is as follows:

Stage I: The cancer is limited to the ovary or ovaries.

Stage IA: The tumor is limited to the inside of one ovary.

Stage IB: The tumor is limited to the inside of both ovaries.

Stage IC: The tumor is limited to one or both ovaries. In addition, it appears on the surface of the ovary, a fluid-filled capsule has burst or cancer cells are found in abdominal fluid.

Stage II: The cancer is in one or both ovaries and has spread to other parts of the pelvis.

Stage IIA: The tumor has spread to the uterus, fallopian tubes or both.

Stage IIB: The tumor has spread to the bladder, rectum or colon.

Stage IIC: The tumor has spread to any of the above. Also, it appears on the surface of the ovary, a fluid-filled capsule has burst, or cancer cells are found in abdominal fluid.

Stage III: The cancer is in one or both ovaries and has spread to nearby lymph nodes or other abdominal organs, not including the liver.

Stage IIIA: The tumor has spread to the lining of the abdomen but cannot be seen. The cancer has not spread to the lymph nodes.

Stage IIIB: The cancer has spread into the abdomen and is visible (less than two centimeters, about 3/4 of an inch, in size). The cancer has not spread to the lymph nodes.

Stage IIIC: The cancer has spread into the abdomen and the deposits measure larger than two centimeters. The cancer has spread to the lymph nodes.

Stage IV: The cancer has spread to the lung, liver or other distant organs.

Recurrent ovarian cancer: The cancer has come back after it has been treated. It may appear in other parts of the body, but is still considered ovarian cancer.

Treatment

Women with ovarian cancer are usually treated with surgery and chemotherapy. Radiation may be used in some cases.

Treatment of ovarian cancer depends on a number of factors, including:

  • The stage of the cancer
  • The size of the tumor after debulking
  • Patient's desire to have children
  • Age and overall health

Surgery

Surgery is the primary treatment for ovarian cancer. The first step is a surgical biopsy to take a sample of the suspicious tissue. Once cancer is confirmed, the surgeon determines the stage of the cancer based on how far it has spread from the ovaries. If the disease appears to be limited to one or both ovaries, the surgeon will take samples of nearby tissues from the pelvis and abdomen to determine whether the cancer has spread.

If there is obvious spread, the surgeon will attempt to remove as much of the tumor as possible during the biopsy. This procedure is called debulking or surgical cytoreduction. Debulking involves removing the ovaries, uterus, cervix, fallopian tubes and omentum (fatty tissue around these organs), and any other visible tumors in the pelvic and abdominal areas. This may include the removal or partial removal of other organs such as the spleen, lymph nodes, liver or intestines. Reducing tumor size improves the efficiency of chemotherapy and radiation therapy, since there is less tumor to treat. While debulking is generally performed during the surgical biopsy, the patient's overall health may not allow it or the tumor may be attached to critical organs. For these patients, any remaining tumor will be treated with chemotherapy.

Chemotherapy

Most ovarian cancer patients will require chemotherapy after surgery to destroy any lingering tumor cells. The standard chemotherapy treatment for ovarian cancer is paclitaxel plus a platinum-based drug such as carboplatin or cisplatin. Most chemotherapy treatments are given on an outpatient basis in a three- to four-week cycle. The length of treatment and the dose will vary depending on the stage of the disease. Chemotherapy can also be delivered directly into the abdominal cavity, a procedure known as intraperitoneal therapy or IP therapy. The chemotherapy is infused into the peritoneal space, where it will come in direct contact with the cancer. IP therapy can be used to treat ovarian cancer if only a small amount of tumor remains after debulking. IP therapy can be given in an outpatient or inpatient setting through an implanted port or external catheter. The treatment takes about two hours.

Radiation Therapy

Although radiation therapy is rarely used to treat ovarian cancer, it may be used to kill any remaining cancer cells in the pelvic area if the cancer has returned after other treatments. In most cases, the main goal of radiation therapy is to control symptoms such as pain, not to treat the cancer.

Clinical Trials

New treatments are always being tested in clinical trials and some patients with cancer may want to consider participating in one of these research studies. These studies are meant to help improve current cancer treatments or obtain information on new treatments. Talk to your doctor about the clinical trials that may be right for you.