Ovarian cancer is the most fatal of all cancers involving a woman's reproductive tract. Most ovarian cancer develops after menopause; about half of ovarian cancers occur in women over age 60. Unfortunately, only 15 percent of ovarian cancers are diagnosed at an early stage, when the disease is confined to the ovary and is most easily treated. Women diagnosed in the early stages have an 89 to 94 percent chance of surviving at least five years.
About 75 percent of women with ovarian cancer survive one year after diagnosis, and 46 percent survive five years after being diagnosed. The survival rate drops as the stage of the cancer increases, with an 18 percent five-year survival rate in women whose cancer has spread beyond the abdomen. Younger women (below age 65) have a better five-year survival rate than older women.
An estimated 22,280 American women will be diagnosed with ovarian cancer in 2012, according to the American Cancer Society, and about 15,500 will die of the disease.
The ovaries are the part of the female reproductive organs that produce eggs every month during a woman's reproductive cycle. The ovaries are about the size and shape of an almond (1 1/2 inches long), but after menopause, they shrink to about half their original size. They are located on either side of the lower abdomen.
Women who still have periods can develop cysts on the ovary, which can be felt on a pelvic exam or seen via X-rays or other tests. They are rarely cancerous, particularly in younger women.
Cysts are less common in women who have already gone through menopause. If cysts occur in these women, they're more likely to be cancerous. A cyst or an enlarged ovary in a woman who has gone through menopause should always be evaluated quickly to make sure it is not a cancer.
In ovarian cancer, the cells of the ovary grow and divide uncontrollably. The cells may form a tumor on the ovary, parts of which can break off and spread to other parts of the body.
Although ovarian cancer can spread throughout the body and affect other organs and systems (brain, lungs, breast and lymph nodes, for example), in most cases it stays in the abdomen and affects organs such as the intestines, liver and stomach.
There are three main types of ovarian cancer. Most cancers of the ovary (about 90 percent) come from the cells that make up the outer lining of the ovary and are called epithelial ovarian cancers. Although most epithelial ovarian cancers occur in women without a family history of the disease, about 10 percent to 15 percent of women with ovarian epithelial cancer have other family members who also had the same cancer or have a family history of breast cancer, ovarian cancer and/or colon cancer.
The symptoms of ovarian cancer (particularly in its early stage) are often not obvious or intense. They include:
- pelvic or abdominal pain, pressure or discomfort
- vague but persistent gastrointestinal upsets such as gas, nausea and indigestion
- frequency and/or urgency of urination in absence of an infection
- changes in bowel habits
- weight gain or loss; particularly weight gain in the abdominal area
- pelvic or abdominal swelling, bloating or a feeling of fullness
- back or leg pain
- pain during intercourse
- ongoing fatigue
Diagnosis
Who gets ovarian cancer? A woman can inherit an increased risk for this disease, particularly if a "first-degree" relative (a mother, sister or daughter) has or had ovarian, breast or colon cancer. In fact, if a woman has a strong family history of ovarian cancer, she is more likely to develop the disease at an early age (on average, 10 years younger than women without genetic risk factors for the disease). Other risk factors include:
- Being of Eastern European Jewish ethnicity (Ashkenazi) if the condition has already affected one or more family members
- Having
a mutation in the BRCA1 or BRCA2 gene; the lifetime risk of a woman
with the BRCA1 mutation is between 35 percent and 70 percent, and the
lifetime risk of a woman with the BRCA2 mutation is between 10 percent
and 30 percent
- Having a personal history of breast, endometrial or colon cancer
- Never having been pregnant
- A high-fat diet
- Obesity
- Starting your periods at a young age (before age 12) or going through menopause at an older than average age (after age 50)
Even with significant risk factors such as family history, the overall chances of getting ovarian cancer are still small. Nonetheless, you should talk to your health care professional if you know you have any risk factors.
To date, only about 10 percent of ovarian cancer cases are caused by inherited defects in the BRCA1 and BRCA2 genes. Genes, the pieces of the chemical DNA within your cells that are inherited from your parents, determine many aspects of your body's makeup. Scientists have known for years that genes help determine the risk for developing a disease like cancer.
The BRCA1 and BRCA2 genes normally help prevent cancer by making a protein that keeps cells from growing too much. But if you have a defect in either of these genes—inherited from either parent—they don't make that protein, and there's nothing to slow down or stop rapidly multiplying cells from becoming cancerous.
There are many questions around genetic testing for a genetic risk for ovarian cancer, both scientific and ethical. If you want to have genetic testing, you should see a specially trained genetic counselor who can accurately and appropriately counsel you about your risk and options.
The genetic counselor, in concert with your physician, can recommend prevention and screening strategies, discuss your options for risk reduction and counsel you about the psychosocial issues around this topic, regardless of family history or inherited susceptibility. Your health care professional can refer you to a certified genetic counselor.
Diagnostic Tests
If you or your doctor suspects you may have ovarian cancer, or you have a very high risk of developing it, you will undergo certain diagnostic tests. Unfortunately, there are no screening tests for ovarian cancer (as there are for other cancers, like breast cancer or colon cancer). The following imaging tests can show whether a mass is present, but cannot tell whether or not the mass is cancerous.
- Abdominal
or transvaginal ultrasound. This test uses sound waves to distinguish
fluid-filled cysts from solid ones. It is often used to rule out or
identify a possible cancer.
- CT scan. This test
produces X-ray images of cross sections of body tissues. It is used to
show the size of the tumor or mass, whether lymph nodes are involved and
whether the tumor has spread to other organs. It is also used to guide a
biopsy needle into a tumor to obtain a tissue sample.
- Chest X-ray. A chest X-ray can determine whether ovarian cancer has spread to the lungs.
- Positron emission tomography (PET scan). During a PET scan, a radioactive glucose is given to look for cancer. Cancers use glucose at a higher rate than normal tissues, so radioactivity will concentrate in the cancer and show up on a scan. In some cases, PET scans are helpful in finding ovarian cancer that has spread, especially when combined with a CT scan.
- Laparoscopy. During a laparoscopy, a physician uses a thin, lighted tube to look at the ovaries and other pelvic organs and tissues. The tube is inserted through a small incision in the abdomen, and it sends images to a video monitor. Laparoscopy can help plan surgery or other treatments that help determine how far ovarian cancer has spread.
- Biopsy. The only way to definitely determine whether or not a tumor is cancerous is to obtain a sample of the tumor and examine it under a microscope during a procedure called a biopsy. For ovarian cancer, biopsies are most frequently done by removing the tumor at surgery.
- Blood tests. To help diagnose ovarian cancer, a health care professional may order blood tests to check for blood counts (red blood cells, white blood cells and platelets), to measure kidney and liver function and to assess overall health status. In addition, the health care professional may order a blood test that checks for CA-125,a protein found in the blood of many women with ovarian cancer. However, other conditions, including normal ovulation, endometriosis and pelvic inflammatory disease can also raise CA-125 levels. And some women with ovarian cancer may still have normal levels of CA-125. Because of these problems, the CA-125 test is not recommended for women at average risk of ovarian cancer, but it may be used for women at high risk or for those with symptoms suggesting ovarian cancer. If the CA-125 is elevated, consultation with a gynecologic oncologist is recommended.
- Lower GI series (barium dye enema). During a barium dye enema, barium sulfate, a chalky substance, is placed into the colon and rectum. The barium outlines the colon and rectum so they are more visible on X-rays. This test enables your health professional to see the bowel on X-ray to detect abnormalities.
If your health care professional suspects ovarian cancer, you will likely undergo an exploratory laparotomy. During a laparotomy, the surgeon makes an incision in your stomach and removes the tumor. The surgeon then performs a biopsy to see if the tumor is cancerous. If the tissue is indeed cancerous, the surgeon will remove as much of the tumor and affected tissue/organs as possible.
Treatment
The first step in treating ovarian cancer is removing as much of the cancerous growth as possible and any tissue to which the cancer has spread.
Often, this involves the removal of one or both ovaries, as well as the fallopian tube (the tube that connects the ovary to the uterus). The removal of one ovary is called a unilateral (one side) salpingo-oophorectomy and the removal of both ovaries is called a bilateral (two sides) salpingo-oophorectomy. The removal of one fallopian tube is called a unilateral salpingectomy, and the removal of both is called a bilateral salpingectomy.
Often, the surgeon removes the uterus (hysterectomy) and the omentum (the fatty lining of the abdominal cavity), where this type of cancer tends to spread (omentectomy).
The surgeon will also check your lymph nodes (small organs that fight infection and disease) for signs of disease and may take tissue samples from various places in the abdominal cavity to check for cancer cells.
It is important to take out as much of the tumor as possible, a procedure called "tumor debulking," because it is associated with increased rate of survival.
If you are diagnosed with ovarian cancer, you should seek treatment from a gynecologic oncologist, a gynecologic surgeon with specialized training in cancers of the reproductive tract. You can find one through the Foundation for Women’s Cancer at
1-800-444-4441 or www.foundationforwomenscancer.org or the Society of Gynecologic Oncologists at 312-235-4060 or www.sgo.org.
Staging Ovarian Cancer
Ovarian cancer is staged based on the surgical findings.
After surgery, your doctor will typically recommend six cycles of chemotherapy administered every three to four weeks, followed by a rest period between cycles.
Anticancer drugs—chemotherapy—travel through the bloodstream to almost every area of the body. Drugs used to treat cancer may be given in different ways: Some are given by mouth; others are injected into a muscle, a vein or an artery. Some chemotherapies are given directly into the abdominal cavity (called intraperitoneal chemotherapy). You will be counseled regarding the best way for you to receive chemotherapy. The combination of both intravenous and intraperitoneal chemotherapy has been shown to increase survival in three large, well-designed studies of women newly diagnosed with ovarian cancer who are undergoing initial chemotherapy. Women with very little disease remaining in the abdomen after surgery are the best candidates for intraperitoneal chemotherapy.
Chemotherapy for ovarian cancer usually consists of a combination of two or more drugs given via IV every three to four weeks. The standard treatment is a combination of a platinum compound, such as carboplatin or cisplatin, and a taxane, such as paclitaxel (Taxol) or docetaxel (Taxotere). The most common combination is carboplatin and paclitaxel.
Loss of appetite can be a serious problem for women receiving chemotherapy. Yet eating well is important, since studies find women who eat well are better able to withstand the side effects of treatment. Eating well means getting enough calories to prevent weight loss and having enough protein in your diet to build and repair skin, hair, muscles and organs. Many women say that eating several small meals throughout the day is easier than eating three large meals.
Your doctor should also prescribe medications such as filgrastim (Neupogen), pegfilgrastim (Neulasta) or sargramostim (Leukine) between chemotherapy cycles to quickly restore reduced white blood cell counts to normal levels to help prevent infection.
In addition to the standard chemotherapy drugs, other available drugs include:
Living with Recurrent Ovarian Cancer
Today, women with ovarian cancer are more likely than ever to live for years after diagnosis, thanks to more aggressive surgical techniques and the use of chemotherapies like paclitaxel and carboplatin. They're also more likely to seek help from health care professionals who specialize in ovarian cancer (gynecologic oncologists).
However, the probability of recurrence in ovarian cancer patients is significant. Most women with this type of cancer experience a recurrence.
For ovarian cancers that have recurred, doctors may use the chemotherapy drugs topotecan (Hycamtin), liposomal doxorubicin (Doxil), etoposide (Etopophos, Vepesid), gemcitabine (Gemzar), vinorelbine (Navelbine), and/or cyclophosphamide (Cytoxan), targeted agents such as bevacizumab (Avastin) and/or other drugs.
It is anticipated that emerging therapies will help increase overall survival time and offer hope to those living with the disease.
The first step in treating ovarian cancer is removing as much of the cancerous growth as possible and any tissue to which the cancer has spread.
Often, this involves the removal of one or both ovaries, as well as the fallopian tube (the tube that connects the ovary to the uterus). The removal of one ovary is called a unilateral (one side) salpingo-oophorectomy and the removal of both ovaries is called a bilateral (two sides) salpingo-oophorectomy. The removal of one fallopian tube is called a unilateral salpingectomy, and the removal of both is called a bilateral salpingectomy.
Often, the surgeon removes the uterus (hysterectomy) and the omentum (the fatty lining of the abdominal cavity), where this type of cancer tends to spread (omentectomy).
The surgeon will also check your lymph nodes (small organs that fight infection and disease) for signs of disease and may take tissue samples from various places in the abdominal cavity to check for cancer cells.
It is important to take out as much of the tumor as possible, a procedure called "tumor debulking," because it is associated with increased rate of survival.
If you are diagnosed with ovarian cancer, you should seek treatment from a gynecologic oncologist, a gynecologic surgeon with specialized training in cancers of the reproductive tract. You can find one through the Foundation for Women’s Cancer at
1-800-444-4441 or www.foundationforwomenscancer.org or the Society of Gynecologic Oncologists at 312-235-4060 or www.sgo.org.Staging Ovarian Cancer
Ovarian cancer is staged based on the surgical findings.
- Stage I: Cancer is found in one or both of the ovaries but has not spread.
- Stage
II: Cancer is found in one or both ovaries and/or has spread to the
uterus, and/or the fallopian tubes (the pathway used by the egg to get
from the ovary to the uterus), and/or other body parts within the
pelvis, such as the bladder or rectum.
- Stage III:
Cancer is found in one or both ovaries and has spread to the lymph
nodes, other organs within the peritoneal cavity, the surface of the
liver or the lining of the abdomen. (Lymph nodes, which produce and
store infection-fighting cells, are found throughout the body.)
- Stage
IV: This is the most advanced stage. Cancer is found in one or both
ovaries and has spread outside the abdominal cavity to distant organs
such as the lungs the inside of the liver or the lymph nodes in the
groin, or there are cancer cells in the fluid around the lungs.
- Recurrent
or refractory: Recurrent disease means that the cancer has returned
after treatment. Refractory disease means the cancer no longer responds
to standard treatment.
After surgery, your doctor will typically recommend six cycles of chemotherapy administered every three to four weeks, followed by a rest period between cycles.
Anticancer drugs—chemotherapy—travel through the bloodstream to almost every area of the body. Drugs used to treat cancer may be given in different ways: Some are given by mouth; others are injected into a muscle, a vein or an artery. Some chemotherapies are given directly into the abdominal cavity (called intraperitoneal chemotherapy). You will be counseled regarding the best way for you to receive chemotherapy. The combination of both intravenous and intraperitoneal chemotherapy has been shown to increase survival in three large, well-designed studies of women newly diagnosed with ovarian cancer who are undergoing initial chemotherapy. Women with very little disease remaining in the abdomen after surgery are the best candidates for intraperitoneal chemotherapy.
Chemotherapy for ovarian cancer usually consists of a combination of two or more drugs given via IV every three to four weeks. The standard treatment is a combination of a platinum compound, such as carboplatin or cisplatin, and a taxane, such as paclitaxel (Taxol) or docetaxel (Taxotere). The most common combination is carboplatin and paclitaxel.
- Paclitaxel
(Taxol): Paclitaxel is a first-line treatment for advanced ovarian
cancer. Originally developed from the bark of the Pacific yew tree,
paclitaxel is usually given in combination with other anticancer drugs
through intravenous infusion. You may also receive paclitaxel
intraperitoneally.
Like most cancer drugs, paclitaxel may have serious side effects. Its most serious side effect is damage to the bone marrow, the soft, spongy tissue in the center of large bones that produces blood cells that fight infection. Thus, your body may not make enough white blood cells to protect you from infection, a condition called neutropenia. This makes you more vulnerable to infections.
So while you're receiving paclitaxel, your doctor will recommend that you stay away from crowds and people with colds, flu or other infections. Discuss with your doctor the need for any vaccines, such as flu shots.
Common side effects may include:
- hair loss
- bleeding gums
- burning or tingling in hands or feet
- nausea and vomiting (rarely)
- pain in joints or muscles
- skin rash or itching
- fatigue
- Carboplatin
(Paraplatin). This chemotherapy medication is also administered via
intravenous infusion, usually in combination with paclitaxel.
Carboplatin and cisplatin can also be infused intraperitoneally. Make
sure your health care professional gives you medication to reduce nausea
and vomiting before starting the infusion.
- pain
- diarrhea
- constipation
- change in taste
- hair loss or brittle hair
- lowered blood counts
- Numbness, burning or tingling in your fingers/toes
- changes in kidney function (cisplatin only)
- diminished hearing (cisplatin only)
Loss of appetite can be a serious problem for women receiving chemotherapy. Yet eating well is important, since studies find women who eat well are better able to withstand the side effects of treatment. Eating well means getting enough calories to prevent weight loss and having enough protein in your diet to build and repair skin, hair, muscles and organs. Many women say that eating several small meals throughout the day is easier than eating three large meals.
Your doctor should also prescribe medications such as filgrastim (Neupogen), pegfilgrastim (Neulasta) or sargramostim (Leukine) between chemotherapy cycles to quickly restore reduced white blood cell counts to normal levels to help prevent infection.
In addition to the standard chemotherapy drugs, other available drugs include:
- Topotecan
(Hycamtin): This drug is used to treat metastatic (cancer that has
spread) ovarian cancer after initial or subsequent chemotherapy has
failed. This is one of the first of a relatively new kind of drugs that
kills cancer cells by inhibiting an enzyme essential to the replication
of human DNA. It is infused or given intravenously by a health care
professional experienced in administering anticancer (chemotherapeutic)
drugs.
- Doxorubicin liposome (Doxil).
This drug is also used to treat metastatic ovarian cancer that no longer
responds to paclitaxel or carboplatin. Doxorubicin liposome stays in
the blood longer than other chemotherapy drugs so it has more time to
reach the tumor and shrink and delay its progression. Note: There is a
risk of severe heart damage with prolonged use of doxorubicin liposome,
even years after you stop taking the drug. Discuss this risk with your
health care professional and be sure to tell him or her about any other
previous chemotherapy treatments and all drugs you are taking. You may
also experience swelling or blistering of the bottoms of your feet or
palms of your hands.
- Additional chemotherapy drugs, including gemcitabine (Gemzar), cyclophosphamide (Cytoxan), vinorelbine (Navelbine), ifosfamide (Ifex) and etoposide (VP-16) may also be used.
- severe constipation or diarrhea
- difficulty breathing
- fever, chills, cough or urinary frequency
- mouth sores
- nausea, vomiting
- pain, swelling, redness or irritation at the injection site
- stomach pain
- unusual bleeding or bruising, pinpoint red spots on the skin
- unusual tiredness or weakness
Living with Recurrent Ovarian Cancer
Today, women with ovarian cancer are more likely than ever to live for years after diagnosis, thanks to more aggressive surgical techniques and the use of chemotherapies like paclitaxel and carboplatin. They're also more likely to seek help from health care professionals who specialize in ovarian cancer (gynecologic oncologists).
However, the probability of recurrence in ovarian cancer patients is significant. Most women with this type of cancer experience a recurrence.
For ovarian cancers that have recurred, doctors may use the chemotherapy drugs topotecan (Hycamtin), liposomal doxorubicin (Doxil), etoposide (Etopophos, Vepesid), gemcitabine (Gemzar), vinorelbine (Navelbine), and/or cyclophosphamide (Cytoxan), targeted agents such as bevacizumab (Avastin) and/or other drugs.
It is anticipated that emerging therapies will help increase overall survival time and offer hope to those living with the disease.
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