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Ovarian cancer

LOCATION

Ovaries are reproductive glands found only in females (women). The ovaries produce eggs (ova) for reproduction. The female reproductive system contains two ovaries, one on each side of the uterus. The eggs travel from the ovaries through the fallopian tubes into the uterus where the fertilized egg settles in and develops into a fetus. The ovaries — each about the size of an almond — produce eggs (ova) as well as the hormones estrogen and progesterone.  The ovaries are also the main source of the female hormones estrogen and progesterone. Types:
 

  • Epithelial ovarian cancer​. This type is the most common. It includes several subtypes, including serous carcinoma and mucinous carcinoma. Epithelial ovarian tumors start in the outer surface of the ovaries. These tumors can be benign (not cancer), borderline (low malignant potential), or malignant (cancer).
     

    • ​Benign epithelial ovarian tumors. Epithelial ovarian tumors that are benign don’t spread and usually don’t lead to serious illness. There are several types of benign epithelial tumors including serous cystadenomas, mucinous cystadenomas, and Brenner tumors.
       

    • ​​Borderline epithelial tumors. When looked at in the lab, some ovarian epithelial tumors don’t clearly appear to be cancerous and are known as borderline epithelial ovarian cancer. The two most common types are atypical proliferative serous carcinoma and atypical proliferative mucinous carcinoma. These tumors were previously called tumors of low malignant potential (LMP tumors). These are different from typical ovarian cancers because they don’t grow into the supporting tissue of the ovary (called the ovarian stroma). If they do spread outside the ovary, for example, into the abdominal cavity (belly), they might grow on the lining of the abdomen but not into it. Borderline tumors tend to affect younger women than the typical ovarian cancers. These tumors grow slowly and are less life-threatening than most ovarian cancers.
       

    • Malignant epithelial ovarian tumors. Cancerous epithelial tumors are called carcinomas. About 85% to 90% of malignant ovarian cancers are epithelial ovarian carcinomas. These tumor cells have several features (when looked at in the lab) that can be used to classify epithelial ovarian carcinomas into different types. The serous type is by far the most common, and can include high grade and low grade tumors. The other main types include mucinous, endometrioid, and clear cell.

      • ​​Serous carcinomas (52%)

      • Clear cell carcinoma (6%)

      • Mucinous carcinoma (6%)

      • Endometrioid carcinoma (10%)

        Each ovarian cancer is given a grade, based on how much the tumor cells look like normal tissue:

      • ​​Grade 1 epithelial ovarian carcinomas look more like normal tissue and tend to have a better prognosis (outlook).

      • Grade 3 epithelial ovarian carcinomas look less like normal tissue and usually have a worse outlook.

        ​Other traits are also taken into account, such as how fast the cancer cells grow and how well they respond to chemotherapy, to come up with the tumor's type:

      • Type I tumors tend to grow slowly and cause fewer symptoms. These tumors also seem not to respond well to chemotherapy. Low grade (grade 1) serous carcinoma, clear cell carcinoma, mucinous carcinoma and endometrioid carcinoma are examples of type I tumors.

      • Type II tumors grow fast and tend to spread sooner. These tumors tend to respond better to chemotherapy. High grade (grade 3) serous carcinoma is an example of a type II tumor.

         

  • Stromal tumors. These rare tumors are usually diagnosed at an earlier stage than other ovarian cancers.
     

  • Germ cell tumors. These rare ovarian cancers tend to occur at a younger age.

RISK FACTORS

  • Older age

  • Inherited gene changes

    • A small percentage of ovarian cancers are caused by genes changes you inherit from your parents. The genes that increase the risk of ovarian cancer include BRCA1 and BRCA2. These genes also increase the risk of breast cancer.  Several other gene changes are known to increase the risk of ovarian cancer, including gene changes associated with Lynch syndrome and the genes BRIP1, RAD51C and RAD51D.

  • Family history of ovarian cancer

  • Being overweight or obese

  • Postmenopausal hormone replacement therapy

  • Endometriosis

  • Age when menstruation started and ended

  • Never having been pregnant

SYMPTOMS

Bloating, diarrhea and abdominal pain are three of the most common symptoms of ovarian cancer. They’re also some of the easiest to overlook. They can also be signs many other conditions, including indigestion, stomach virus, and even the cramps that can accompany a woman’s menstrual cycle.

 

  • Abdominal bloating or swelling

  • Quickly feeling full when eating

  • Weight loss

  • Discomfort in the pelvic area

  • Fatigue

  • Back pain

  • Changes in bowel habits, such as constipation

  • A frequent need to urinate

SCREENING

There is no screening test for Ovarian cancer, but if there are signs/symptoms - diagnosis includes testing and procedures below.

 

Tests and procedures used to diagnose ovarian cancer:
 

  • Pelvic exam
    During a pelvic exam, your doctor inserts gloved fingers into your vagina and simultaneously presses a hand on your abdomen in order to feel (palpate) your pelvic organs. The doctor also visually examines your external genitalia, vagina and cervix.
     

  • Imaging tests
    Tests, such as ultrasound or CT scans of your abdomen and pelvis, may help determine the size, shape and structure of your ovaries.
     

  • Blood tests
    Blood tests might include organ function tests that can help determine your overall health.
    Your doctor might also test your blood for tumor markers that indicate ovarian cancer. For example, a cancer antigen (CA) 125 test can detect a protein that's often found on the surface of ovarian cancer cells. These tests can't tell your doctor whether you have cancer, but they may provide clues about your diagnosis and prognosis.
     

  • Surgery
    Sometimes your doctor can't be certain of your diagnosis until you undergo surgery to remove an ovary and have it tested for signs of cancer.
     

  • Genetic testing
    Your doctor may recommend testing a sample of your blood to look for gene changes that increase the risk of ovarian cancer. Knowing you have an inherited change in your DNA helps your doctor make decisions about your treatment plan. You may wish to share the information with your blood relatives, such as your siblings and your children, since they also may have a risk of having those same gene changes.

    • The cancer antigen 125 (CA 125) blood test generally isn't recommended if you have an average risk of ovarian cancer.
       

Sometimes ovarian cancer causes a higher level of CA 125 in the blood. But that doesn't happen in everyone with ovarian cancer. Having a high level of CA 125 doesn't mean that you have ovarian cancer.

Many other conditions can raise your CA 125 level, including:

  • Endometriosis

  • Liver cirrhosis

  • Menstruation

  • Pelvic inflammatory disease

  • Uterine fibroids
     

For these reasons, health care providers don't recommend CA 125 testing in those with an average risk of ovarian cancer. Providers sometimes recommend CA 125 testing if you have a high risk of ovarian cancer. But not all providers agree on this advice. Your risk might be high if the genes that increase the risk of breast and ovarian cancers run in your family. These genes include BRCA1 and BRCA2.

treatment

Once it's confirmed that you have ovarian cancer, your doctor will use information from your tests and procedures to assign your cancer a stage. The stages of ovarian cancer range from 1 to 4, which are often indicated with Roman numerals I to IV. The lowest stage indicates that the cancer is confined to the ovaries. By stage 4, the cancer has spread to distant areas of the body.

 

Treatment of ovarian cancer usually involves a combination of surgery and chemotherapy. Other treatments may be used in certain situations.
 

  • Surgery

    • Remove one ovary. For early-stage cancer that hasn't spread beyond one ovary, surgery may involve removing the affected ovary and its fallopian tube. This procedure may preserve your ability to have children.

    • Remove both ovaries. If cancer is present in both your ovaries, but there are no signs of additional cancer, your surgeon may remove both ovaries and both fallopian tubes. This procedure leaves your uterus intact, so you may still be able to become pregnant using your own frozen embryos or eggs or with eggs from a donor.

    • Remove both ovaries and the uterus. If your cancer is more extensive or if you don't wish to preserve your ability to have children, your surgeon will remove the ovaries, the fallopian tubes, the uterus, nearby lymph nodes and a fold of fatty abdominal tissue (omentum).

    • Advanced cancer. If your cancer is advanced, your doctor may recommend surgery to remove as much of the cancer as possible. Sometimes chemotherapy is given before or after surgery in this situation.
       

  • Chemotherapy is a drug treatment that uses chemicals to kill fast-growing cells in the body, including cancer cells. Chemotherapy drugs can be injected into a vein or taken by mouth.
     

  • Hormone therapy uses drugs to block the effects of the hormone estrogen on ovarian cancer cells. Some ovarian cancer cells use estrogen to help them grow, so blocking estrogen may help control the cancer.
     

  • Immunotherapy uses the immune system to fight cancer. The body's disease-fighting immune system may not attack cancer cells because they produce proteins that help them hide from the immune system cells. Immunotherapy works by interfering with that process.
     

  • Supportive (palliative) care - is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as surgery and chemotherapy.

HOW TO REDUCE RISK FACTORS?

There's no sure way to prevent ovarian cancer. But there may be ways to reduce your risk:
 

  • Consider taking birth control pills
    Ask your doctor whether birth control pills (oral contraceptives) may be right for you. Taking birth control pills reduces the risk of ovarian cancer. But these medications do have risks, so discuss whether the benefits outweigh those risks based on your situation.
     

  • Discuss your risk factors with your doctor
    If you have a family history of breast and ovarian cancers, bring this up with your doctor. Your doctor can determine what this may mean for your own risk of cancer. You may be referred to a genetic counselor who can help you decide whether genetic testing may be right for you. If you're found to have a gene change that increases your risk of ovarian cancer, you may consider surgery to remove your ovaries to prevent cancer.
     

  • Consider removal of ovaries in case of genetic abnormalities such as a positive BRCA result or Lynch syndrome

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