Ovarian | Chris O'Brien Lifehouse

This information has been written to help you understand more about ovarian cancer. Many women feel understandably shocked and upset when they are told they have ovarian cancer. This information is intended to help you understand how ovarian cancer is diagnosed and treated. We also include information about support services. We cannot give advice about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors.

The ovaries

The ovaries are part of the female reproductive system. Women have two ovaries attached to the top of the uterus or womb. Ovaries are small, almond-shaped organs, each about three centimetres long and one centimetre thick. After puberty the role of the ovaries is to release a mature egg (ovum) each month and to produce female hormones (oestrogen and progesterone). Each month when the egg is produced a cyst on the ovary is formed, which is quite normal. This usually occurs in the middle of the cycle. The egg is usually sucked up by the fallopian tube and, if intercourse has occurred recently, will meet the sperm in the tube. The meeting of the egg and sperm is termed fertilization, and once this occurs the fertilized egg, or ovum, moves down the tube and sticks, or implants, in the uterus to eventually form a baby. If fertilization does not occur, the egg is usually absorbed by the body.

The ovaries are covered in a layer of cells called the epithelium. Inside the ovaries are cells called germ cells which turn into eggs and sex-cord stromal cells that produce oestrogen and progesterone.

What is ovarian cancer?

Cancer is a disease that causes cells to act abnormally and multiply. If a cancer or tumour starts in one or both ovaries, it is called ovarian cancer. It is common for ovarian cancer to go undetected for a long time, and many women are diagnosed with advanced stage disease.

Types of ovarian cancer?

There are three types of ovarian cancer:

Epithelial ovarian cancer

  • Starts in the surface of the ovary (epithelium).
  • Is the most common type of ovarian cancer – nine out of 10 women with ovarian cancer have cancer that starts in the epithelium.
  • Types of epithelial ovarian cancers include serous, clear cell, endometrioid and mucinous.

Germ cell ovarian cancer

  • A rare type of ovarian cancer that starts in the egg-producing cells.
  • Affects about 1-2% of women with ovarian cancer.
  • Usually develops in women younger than 30.

Sex-cord stromal cancer

  • A rare tumour that starts in the cells that produce female hormones (oestrogen and progesterone).
  • Can occur at any age.
  • May cause the production of extra hormones, such as oestrogen.

How common is it?

If you would like to read any facts or statistics about ovarian cancer, please refer to the Cancer Institute NSW website:
http://www.cancerinstitute.org.au/cancer-in-nsw/cancer-facts/ovarian-cancer

What is the cause?

The causes of ovarian cancer are largely unknown. Most ovarian cancers develop sporadically, however some factors will increase your risk:

Age

Your risk of ovarian cancer increases:

  • As you get older, particularly once you are over 50.
  • After menopause.
Family history

Your risk of ovarian cancer increases:

  • If you have an inherited faulty gene. Faulty genes, including BRCA1, BRCA2 and Lynch syndrome (formerly known as hereditary non-polyposis colorectal cancer), may cause ovarian cancer in about one in 10 women diagnosed with the condition.
  • If you have any family member who has had breast cancer before age 40, has had breast cancer in both breasts, or has had breast and ovarian cancer.
  • If you have two or more family members on the same side of the family who have been diagnosed with breast or ovarian cancer.
  • If you are less than 60 years of age and have a personal history of some types of ovarian, fallopian tube or peritoneal cancers.
  • If you have been diagnosed with breast cancer.
  • If you are of Jewish ancestry.
Hormonal factors

Your risk of ovarian cancer increases:

  • If you have had many ovulations in your life (e.g. if you started puberty early, went through menopause late, haven’t had children or breastfed, or used a fertility treatment where drugs stimulated ovulation for five years or more).
  • If you had children over the age of 30.
Other diseases or conditions

Your risk of ovarian cancer increases:

  • If you have endometriosis – a condition in which the tissue lining the uterus (endometrium) is also found outside of the uterus.
  • If you have breast cancer.
Lifestyle factors

Your risk of ovarian cancer increases:

  • If you eat a fatty diet.
  • If you are obese.
  • If you smoke.

Several protective factors have also been identified that may reduce your risk of ovarian cancer, including:

  • Having children.
  • Breastfeeding.
  • Using the combined oral contraceptive pill for several years.
  • Having a tubal ligation (i.e. having your fallopian tubes tied).
  • The surgical removal of some female reproductive organs, such as the uterus or fallopian tubes.

What are the symptoms?

You might not experience any obvious signs of ovarian cancer. Women with ovarian cancer often do not develop symptoms until the ovary has become much bigger than normal or the cancer has spread. If you do experience symptoms, you may notice:

  • pressure, discomfort or cramping pain in the abdomen
  • abdominal swelling or bloating
  • heartburn or nausea
  • a change in bowel or bladder habits (e.g. constipation, diarrhoea, frequent urination, increased flatulence)
  • loss of appetite or tiredness
  • unexplained weight loss or weight gain
  • changes in menstrual pattern or postmenopausal bleeding
  • pain during sex

You may have nothing to worry about if you experience these symptoms, as they can all be caused by many other non-cancerous conditions. However, if you notice one or more of these symptoms you should bring it to the attention of your doctor for further investigation.

Diagnosis

Most ovarian cancer tumours are present for some time before they are discovered. Sometimes ovarian cancer is found unexpectedly during an operation such as a hysterectomy.

The Pap test does not detect ovarian cancer, but it may show if cancer cells have spread to the cervix.

Tests to find cancer

Diagnostic tests used to identify abnormalities include:

Physical examination

The doctor will check for a mass or lump by feeling your abdomen and doing an internal vaginal examination. If there is a build-up of fluid in the abdomen, a fluid sample may be taken by passing a needle through the skin (paracentesis). The fluid is checked under a microscope for cancer cells.

Blood tests

A blood test can be conducted to measure the presence of chemical proteins produced by cancer cells, also known as tumour markers. The most common tumour marker for ovarian cancer is CA125. CA125 is a protein found on the surface of ovarian cancer cells and some healthy tissue. If you have ovarian cancer you may have an abnormally high level of CA125 in your blood.

However, many non-cancerous conditions such as irritable bowel syndrome, kidney disease or endometriosis may cause an elevation in CA125, and some women have early-stage ovarian cancer and have normal CA125 levels. Therefore, the CA125 test alone cannot be used to diagnose ovarian cancer. It may be more helpful as a means of monitoring how your treatment is going.

Imaging and scans

One or more scans may be undertaken to identify ovarian cancer, or determine if it has spread:

Abdominal ultrasound: A handheld device called a transducer is passed over your abdomen. Echoes from soundwaves are turned into a picture by a computer, allowing the doctor to view your organs.

Transvaginal ultrasound: A transducer is inserted into your vagina and echoes from soundwaves are turned into a picture by a computer. This type of ultrasound produces a clearer image of the ovaries and uterus than the abdominal ultrasound.

Colonoscopy: An examination of the bowel, which is sometimes conducted to ensure that symptoms are not due to a bowel problem.

CT scan: Uses X-ray beams to take pictures of the inside of your body. You may be injected with a dye that makes your organs appear white on the scans.

MRI scan: Uses radio waves and a powerful magnet to create a cross-sectional image of the body. The image can show the difference between healthy and diseased tissue.

PET scan: Uses the emissions from a mild, radioactive glucose solution to create images that explain how certain organs or systems in the body are functioning. The solution circulated throughout the body and is taken up by actively dividing cells, such as cancer cells.

Surgery

It is generally not possible to determine whether any lumps identified during scans are benign (non-cancerous) or malignant (cancerous) without conducting surgery. Many women will undergo a laparotomy during which a diagnosis can be made and, if necessary, further surgery will be carried out to remove the cancer.

Stages of ovarian cancer

Determining the stage of your ovarian cancer can help your health care team work out what treatment is best and what your prognosis (or expected outcome) is.

Your cancer will be assigned a stage (I-IV) which describes whether it has spread beyond your ovaries and to other organs or parts of the body.

Stage I: Ovarian cancer is confined to the ovary or ovaries.
Stage II: Ovarian cancer has spread beyond the ovaries, but is confined to the pelvis (e.g. uterus, bladder or rectum).
Stage III: Ovarian cancer has spread to the peritoneum (the lining of the abdomen), the bowel and/or lymph nodes in the abdomen or pelvis.
Stage IV: Ovarian cancer has spread (metastasised) outside the abdomen, for example, to the liver, lungs or distant lymph nodes.

Women diagnosed with ovarian cancer most frequently have Stage III disease.

Prognosis

Prognosis means the expected outcome of a disease. You will need to talk with you gynaecological oncologist about your own prognosis; however, it is not possible for any doctor to predict the exact course of your illness. Test results, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as age, fitness and your medical history are all important. The earlier the ovarian cancer is diagnosed the higher the chances of successful treatment and cure.

Epithelial cancer: The outcome depends on the stage of the disease. Stage I is usually associated with a good outlook (cancer can usually be cured). Women with advanced cancer may respond well to treatment, but the cancer often comes back at a later time.
Non-epithelial cancer: Can usually be treated successfully.
Borderline tumours: Have a good prognosis regardless of when they are diagnosed.

Which health professionals will I see?

You will be cared for by a range of health professionals who specialise in different aspects of your treatment. Health professionals who may care for you include:

  • General practitioner (GP) – is a doctor who arranges the first tests to assess your symptoms. A GP can also explain information provided by specialists and other health professionals to help with treatment decisions and direct women with ovarian cancer to sources of practical and emotional support.
  • Gynaecological oncologist – is a specialist surgeon who treats women with cancers of the reproductive system.
  • Medical oncologist – is a specialist doctor who prescribes and coordinates the course of chemotherapy.
  • Radiation oncologist – is a specialist doctor who prescribes and coordinates the course of radiotherapy.
  • Radiologist – a specialist trained to read and interpret diagnostic scans (e.g. CT, MRI and PET scans).
  • Oncology nurses – are trained in cancer care and help administer drugs, including chemotherapy, and provide care, information and support throughout treatment.
  • Cancer nurse coordinator or cancer care coordinator – provides support to patients and families throughout treatment and liaises with other staff.
  • Genetic counsellor – is a health professional that provides advice for women with a strong family history of cancer.
  • Dietitian – is a health professional that recommends an eating plan to follow during treatment and recovery.
  • Psychologist – is a health professional that helps to address the emotional and other impacts of cancer.
  • Social worker, physiotherapist, and occupational therapist – are health professionals that help to link women with support services and help with any emotional, physical or practical problems.

Treatment

Treatment for ovarian cancer depends on what type of cancer you have, the stage, your general health and fitness, your doctors’ recommendations and your wishes.

Epithelial ovarian cancer is commonly treated with surgery, chemotherapy and/or radiotherapy. Borderline tumours are usually treated with surgery, and non-epithelial ovarian cancer is usually treated with surgery and/or chemotherapy.

Surgery

Almost all women with ovarian cancer will have some type of surgery in the course of their treatment. The purpose of surgery is first to diagnose and stage the cancer as outlined above, and then to remove as much of the cancer as possible.

The extent of the cancer in your ovaries will determine which of the following types of surgery you will need:

Laparotomy

An exploratory laparotomy is usually recommended if diagnostic tests suggest that a woman has, or is likely to have, ovarian cancer. The procedure is carried out by a gynaecological oncologist and involves making a long, vertical cut from the bellybutton to the pubic bone under general anaesthetic.

The gynaecological oncologist will initially take tissue and fluid samples (biopsy) which are examined by a pathologist. This is sometimes called a frozen section analysis, as the tissue is snap frozen. If the pathologist confirms the diagnosis of ovarian cancer, further surgery will be undertaken.

Total abdominal hysterectomy

A total abdominal hysterectomy is an operation in which the uterus and cervix are removed. The removal of reproductive organs such as the uterus will impact on a woman’s ability to have children naturally in the future.

Bilateral salpingo-oophorectomy

A bilateral salpingo-oophorectomy is the surgical removal of both ovaries and fallopian tubes. The procedure will impact on a woman’s ability to have children naturally in the future. However, it may be possible to store eggs before treatment, especially if only one ovary is affected.

Omentectomy

The removal of the fatty protective tissue (omentum) covering the abdominal glands.

Colectomy

The removal of all or part of the bowel, where the end of the bowel may be rejoined to a new opening called a stoma (colostomy or ileostomy).

Lymphandenectomy

Unless ovarian cancer is discovered at a very early stage, a pelvic lymphadenectomy (removal of lymph nodes) will be required. A lymphadenectomy is carried out to assess whether the cancer has spread to the lymph nodes. The removal of lymph nodes may cause leg swelling (lymphoedema) particularly if surgery occurs in combination with radiotherapy. For this reason, investigations such as PET and MRI scans are carried out to assess whether the lymph nodes have cancer in them. If the lymph nodes appear to be affected, chemotherapy and radiotherapy may be given without surgery, even for early cancers.

Chemotherapy

Chemotherapy uses drugs called cytotoxins to kill or slow the growth of cancer cells. With the exception of a small number of women with very early stage I ovarian cancer, women with epithelial ovarian cancer usually receive a combination of chemotherapy drugs.

Patients will usually have to attend a clinic (as an outpatient) for chemotherapy treatments because many of the drugs are given through an intravenous drip (i.e. through a vein). The choice of drugs and treatment regimens will vary between patients. However, the current standard treatment of chemotherapy for ovarian cancer involves approximately six treatments, given over 3-4 weeks for 5-6 months.

Blood tests will be taken regularly throughout chemotherapy to make sure healthy cells have had time to recover and also to check the amounts of tumour markers, such as CA125 that are present in the blood.

Palliative treatment

Women with advanced cancer are often referred for palliative care. Palliative care does not try to cure disease but aims to improve quality of life by addressing physical, practical, emotional and spiritual needs associated with cancer.

After treatment: follow-up

If the signs and symptoms of your cancer reduce or disappear for a period of time, you will be in remission. Despite the best efforts of your care team, you may suffer a recurrence (or relapse) of your cancer. Recurrence rates remain high for ovarian cancer, occurring in around 25% of patients with early-stage cancer and around 80% of patients with advanced cancer. Most cancers, if they are going to recur, will do so in the first two years after treatment. Early treatment of these recurrences may still be curative, so it is important for women in remission to be monitored regularly.

Women who have completed treatment for ovarian cancer are initially monitored every three months and then 6 monthly from year 2 to 5 in order to make sure the cancer has not returned. The doctor will ask some question and perform an examination, including a pelvic examination and a CA125 blood test. CT scanning is not a routine part of follow-up care, but may be done if the doctor is unsure about their examination findings or if the blood test shows rising CA125 levels.

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