What is Ovarian Cancer
What are ovaries, and what do they do?
The ovaries are part of a woman’s genital tract. They are in the pelvis attached to the top of the uterus (womb). Each ovary is about the size of an almond. The ovaries make the female hormones: oestrogen and progesterone. They also release eggs. An egg travels from an ovary through a fallopian tube to the womb. When a woman goes through her “change of life” (menopause), her ovaries stop releasing eggs and make far lower levels of hormones. They also became much smaller and sometimes are not even detected on ultrasound scan.
What is ovarian cancer?
Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place. Sometimes, this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumour. This process can occur in the ovaries.
Ovarian tumours can be benign or malignant (cancerous, cancer):
Benign tumours are not cancer:
- Benign tumours are rarely life threatening.
- Generally, benign tumours can be removed. They usually do not grow back.
- Benign tumours do not invade the tissues around them.
- Cells from benign tumours do not spread to other parts of the body.
Malignant tumours are cancer:
- Malignant tumours are generally more serious than benign tumours. They may be life threatening.
- Malignant tumours often can be removed. But sometimes they grow back.
- Malignant tumours can invade and damage nearby tissues and organs.
- Cells from malignant tumours can spread to other parts of the body. Cancer cells spread by breaking away from the original (primary) tumour and entering the lymphatic system or bloodstream. The cells invade other organs including lymph nodes (lymph glands) and form new tumours that damage these organs. The spread of cancer is called metastasis.
Benign and Malignant Cysts
An ovarian cyst may be found on the surface of an ovary or inside it. A cyst contains fluid. Sometimes it contains solid tissue too. Most ovarian cysts are benign (not cancer).
Most ovarian cysts go away with time. Sometimes, an ovarian cyst does not go away or gets larger. In this case you may need further tests/procedures to make sure that the cyst is not cancer.
Ovarian cancer can invade, shed, or spread to other organs:
A malignant ovarian tumour can grow and invade organs next to the ovaries, such as the fallopian tubes, uterus, and other pelvic organs including bladder.
Cancer cells can shed (break off) from the main ovarian tumour. Shedding into the abdomen may lead to new tumours forming on the internal lining of the tummy (peritoneum) or surface of nearby organs and tissues. We call them seeds or implants.
Cancer cells can spread through the lymphatic system to lymph nodes in the pelvis, lower and upper abdomen, and chest. Cancer cells may also spread through the bloodstream to organs such as the liver and lungs.
When cancer spreads from its original place to another part of the body, the new tumour has the same kind of abnormal cells and the same name as the original tumour. For example, if ovarian cancer spreads to the liver, the cancer cells in the liver are actually ovarian cancer cells. The disease is metastatic ovarian cancer, not liver cancer. For that reason, it is treated as ovarian cancer, not liver cancer. We call the new tumour “distant” or “metastatic disease”.
Most ovarian cancers develop sporadically, which means we don’t know why it happens. A hereditary or familial component is only involved in 5-10% of women who develop ovarian cancer. There are various things that can increase or decrease your risk of ovarian cancer. However, these risk factors cannot tell you whether you definitely will or won’t get ovarian cancer. A risk factor is something that may increase the chance of developing a disease.
Risk factors for ovarian cancer
Family history of cancer: Women who have a mother, daughter, or sister with ovarian cancer have an increased risk of the disease. Also, women with a family history of cancer of the breast, uterus, colon, or rectum may also have an increased risk of ovarian cancer. If several women in a family have ovarian or breast cancer, especially at a young age, this is considered a strong family history. If you have a strong family history of ovarian or breast cancer, I will discuss this in detail with you and may suggest you to see a medical geneticist to clarify a potential risk of genetic (familial) cancer. The medical geneticist may suggest genetic testing for you and the women in your family. Genetic tests can sometimes show the presence of specific gene changes that increase the risk of ovarian cancer in the family.
Personal History of Cancer
Women who have had cancer of the breast, uterus, colon, or rectum have a higher risk of ovarian cancer.
Age over 55
Most women are over age 55 when diagnosed with ovarian cancer.
Older women who have never been pregnant have an increased risk of ovarian cancer.
Research has questioned whether taking certain fertility drugs, using talcum powder, or being obese are risk factors. It is not clear whether these are risk factors, but if they are, they are not strong risk factors.
Generally speaking, avoiding risk factors and increasing protective factors may help prevent cancer.
The following risk factors may increase the risk of ovarian cancer:
Family History of Ovarian Cancer
A woman whose mother or sister had ovarian cancer has an increased risk of ovarian cancer. A woman with two or more relatives with ovarian cancer also has an increased risk of ovarian cancer.
The risk of ovarian cancer is increased in women who have inherited (passed from parents to offspring) certain changes in the following genes (piece of genetic material):
BRCA1 and BRCA2 genes.
Genes that are linked to the hereditary nonpolyposis colorectal cancer syndrome (HNPCC or Lynch syndrome).
Hormone Replacement Therapy
The use of oestrogen-only hormone replacement therapy after menopause may increase the risk of ovarian cancer. The longer oestrogen therapy is used, the greater the risk may be. It is not clear whether the risk of ovarian cancer is increased with the use of HRT that has both oestrogen and progestin.
The use of fertility drugs may be linked to an increased risk of ovarian cancer.
Talc: The use of talc may increase the risk of ovarian cancer. Talcum powder dusted on the perineum (the area between the vagina and the anus) may reach the ovaries by entering the vagina.
Having too much body fat, especially during the teenage years, is linked to an increased risk of ovarian cancer. Being obese is linked to an increased risk of death from ovarian cancer.
The following protective factors may decrease the risk of ovarian cancer:
The use of oral contraceptives (“the pill”) lowers ovarian cancer risk. The longer oral contraceptives are used, the lower the risk may be. The decrease in risk may last up to 25 years after a woman has stopped using oral contraceptives.
Pregnancy and Breastfeeding
Pregnancy and breastfeeding are linked to a decreased risk of ovarian cancer. Ovulation stops or occurs less often in women who are pregnant or breastfeeding. Some experts believe that women who ovulate less often have a decreased risk of ovarian cancer.
Bilateral Tubal Ligation or Hysterectomy
The risk of ovarian cancer is decreased in women who have a bilateral tubal ligation (surgery to close both fallopian tubes) or a hysterectomy (surgery to remove the womb).
Some women who have a high risk of ovarian cancer may choose to have a prophylactic bilateral oophorectomy (surgery to remove both ovaries when there are no signs of cancer). This includes women who have inherited certain changes in the BRCA1 and BRCA2 genes or in the genes linked to hereditary nonpolyposis colorectal cancer syndrome (HNPCC or Lynch syndrome), or women with a personal and/or family history suggesting higher risk of developing ovarian cancer.
I will discuss with you issues involved if prophylactic surgery is contemplated:
The drop in estrogen levels caused by removing the ovaries can cause early menopause and consequently cause hot flashes, night sweats, trouble sleeping, mood changes, decreased sex drive, heart disease, vaginal dryness, osteoporosis (bone weakness). These symptoms may not be the same in all women and can be treated if necessary.
Risk of Cancer in the Peritoneum (Internal Lining of the Tummy)
Women who have had a prophylactic oophorectomy continue to have a small risk of ovarian cancer in the peritoneum.
Cancer Prevention Clinical Trials are Used to Study Ways to Prevent Cancer
Used to study ways to lower the risk of developing certain types of cancer. Some cancer prevention trials are conducted with healthy people who have not had cancer but who have an increased risk for cancer. Other prevention trials are conducted with people who have had cancer and are trying to prevent another cancer of the same type or to lower their chance of developing a new type of cancer.
New Ways to Prevent Ovarian Cancer are Being Studied in Clinical Trials
It has been taking place in many parts of the country. I will discuss potential trials that may apply to your situation if necessary.
Some screening tests are used because they have been shown to be helpful both in finding pre cancer changes and therefore avoiding development of cancer e.g. Pap smear in cervix cancer. Other tests are used because they have been shown to find early cancer and therefore decreasing the chance of dying from these cancers e.g. mammogram in breast cancer.
Unfortunately there is no standard or routine screening test for ovarian cancer. Screening for ovarian cancer is under study and there are screening clinical trials under way in many parts of the world.
Tests that may detect (find) ovarian cancer:
A pelvic exam is an exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum (back passage). It is possible to feel the size, shape, and position of the uterus and ovaries. A speculum is also inserted into the vagina to look for signs of disease.
Transvaginal Ultrasound (TVU)
Procedure used to examine the vagina, uterus, fallopian tubes, and bladder. An ultrasound transducer (probe) is inserted into the vagina and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues.
Test that measures the level of CA125 in the blood. It is a substance released by cells into the bloodstream. An increased CA125 level is sometimes a sign of certain types of cancer, including ovarian cancer, or other conditions including non-cancerous conditions.
Early ovarian cancer may not cause any obvious symptoms. But, as the cancer grows, symptoms may include:
- Pressure or pain in the abdomen, pelvis, back, or legs.
- A swollen or bloated abdomen.
- Nausea, indigestion, gas, constipation, or diarrhoea.
- Feeling very tired all the time.
- Less common symptoms include:
- Shortness of breath.
- Feeling the need to urinate often.
- Unusual vaginal bleeding (heavy periods, or bleeding after menopause).
These symptoms don’t represent cancer most of times, but if persistent, e.g. more than four weeks, are an indication to see a doctor.
Diagnosis and Staging
If you have a symptom that suggests ovarian cancer, I will make sure we will clarify this together. After a detailed personal and family history you may have one or more of the following tests:
To check general signs of health. I may press on your tummy to check for growths or an abnormal buildup of fluid called “ascites”. A sample of fluid can be taken to look for ovarian cancer cells.
To feel your pelvic organs, their shape and size. A Pap smear test is part of a normal pelvic exam, but it is not used to collect ovarian cells. The Pap test detects cervical cancer. The Pap test is not used to diagnose ovarian cancer.
You may have blood tests requested including CA125. CA125 is a substance found on the surface of ovarian cancer cells and on some normal tissues. A high CA125 level could be a sign of cancer or other conditions including benign diseases. The CA125 test is not used alone to diagnose ovarian cancer. It is used to monitor a woman’s response to ovarian cancer treatment and for detecting its return after treatment.
The ultrasound device uses sound waves that people cannot hear. The device aims sound waves at organs inside the pelvis. The waves bounce off the organs. A computer creates a picture from the echoes. The picture may show an ovarian tumour. For a better view of the ovaries, the device may be inserted into the vagina (transvaginal ultrasound – TVU).
A biopsy is the removal of tissue or fluid to look for cancer cells. Based on the results of the blood tests and ultrasound, your doctor may suggest surgery to remove tissue and fluid from the pelvis and abdomen. Surgery is usually needed to diagnose ovarian cancer. I will discuss in details which operation is more appropriate in your situation. This may involve laparoscopy (keyhole surgery), laparotomy (cut through operation), or a combination of both.
Imaging guided biopsy through CT scan or ultrasound from the ovarian/pelvic tumour is not indicated due to the risk of abdominal contamination with cancer cells. The tumour must to be removed intact to avoid any spreading.
A dedicated gynaecologic pathologist uses a microscope to look for cancer cells in the tissue or fluid removed in surgery. This will generate a good amount of information, which will be used to choose the best treatment option.
You may have one or more of the following tests to find out whether the cancer has spread:
It will take pictures of organs and tissues in the pelvis or abdomen. An X-ray machine linked to a computer takes several pictures. You may receive contrast material by mouth and by injection into your arm or hand. The contrast material helps the organs or tissues show up more clearly. Abdominal fluid or a tumour may show up on the CT scan.
It can show tumours or fluid. I have been using more CT scan of the chest due its higher detection rate of chest disease.
It is usually not necessary, but may be needed in a few situations to visualize inside of the rectum and colon (large intestine). This exam can help tell if cancer has spread to the colon or rectum.
The Stages of Ovarian Cancer
Stage I: Cancer cells are found in one or both ovaries. Cancer cells may be found on the surface of the ovaries or in fluid collected from the abdomen.
Stage II: Cancer cells have spread from one or both ovaries to other tissues in the pelvis. Cancer cells are found on the fallopian tubes, the uterus, or other tissues in the pelvis. Cancer cells may be found in fluid collected from the abdomen.
Stage III: Cancer cells have spread to tissues outside the pelvis or to the regional lymph nodes. Cancer cells may be found on the outside of the liver.
Stage IV: Cancer cells have spread to tissues outside the abdomen and pelvis. Cancer cells may be found inside the liver, in the lungs, or in other organs.
With the information provided by your history, physical examination, blood and imaging tests I will discuss treatment options with you in details.
The best results when treating ovarian cancer are obtained by combining high quality surgery and chemotherapy. Radiation therapy is rarely used to treat ovarian cancer.
Chemotherapy can be given systemically or into the abdominal cavity (tummy). When taken by mouth or injected into a vein, the drugs enter the bloodstream and destroy or control cancer throughout the body (systemic chemotherapy). When given directly into the abdomen and pelvis through a thin tube, the drugs destroy or control cancer in the abdomen and pelvis (Intraperitoneal chemotherapy).
After having either a diagnostic laparoscopy (keyhole operation) or laparotomy (cut through muscle operation), frozen section test is taken (tumour sample used for rapid microscopic intraoperative diagnosis). You will be asleep while this is done to find out whether there are any cancer cells in the ovary or spreading to other organs. If no cancer is found and you are having a laparoscopy, it is likely that you won’t need laparotomy.
If cancer is found, I will make an up and down incision in the abdominal wall to remove:
- Both ovaries and fallopian tubes (salpingo-oophorectomy).
- The uterus (hysterectomy).
- The omentum (the fatty pad of tissue that covers the intestines).
- Pelvic and upper abdominal lymph nodes.
- Samples of tissue from the pelvis and abdomen.
If the cancer has spread, I will aim to remove all visible disease. This is called “debulking” surgery.
If pregnancy is still a plan, and depending on the extend and distribution of disease, I will discuss the possibility of preserving your fertility. Some women with very early ovarian cancer may decide to have only one ovary, one fallopian tube, lymph nodes and the omentum removed. The uterus, cervix, and the other ovary are preserved with the aim of future pregnancy.
Chemotherapy uses anticancer drugs to kill cancerous cells. Most women have chemotherapy for ovarian cancer after surgery. Some women have chemotherapy before surgery.
Usually, a combination of drugs is used. Drugs for ovarian cancer can be given in different ways:
By Vein or Intravenous (IV)
The drugs can be given through a thin tube inserted into a vein.
By Vein and Directly into the Abdomen
Some women get a combination of intravenous and intraperitoneal (IP) chemotherapy. For IP chemotherapy, the drugs are given through a thin tube inserted into the abdominal wall (IP port).
Some drugs for ovarian cancer can be given by mouth, although not frequently done.
Chemotherapy is given in cycles. Each treatment period is followed by a rest period. The length of the rest period and the number of cycles depend on the anticancer drugs used. You may have your treatment in a clinic or hospital. The vast majority of patients don’t have to be admitted to hospital for treatment. You will be seen a specialist medical oncologist while having chemotherapy who will monitor your response and potential toxic effects.
Radiotherapy (also named radiation therapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the body. Radiation therapy is rarely used in the initial treatment of ovarian cancer, but it may be used to relieve pain and other problems caused by the disease down the track. The treatment is given at a hospital or clinic. Each treatment takes only a few minutes.
Your reviews may include a pelvic exam, a CA125 test, other blood tests, and imaging exams.
The usual follow-up for patients who have been treated for ovarian cancer is as follows:
For the first two years: Every three months.
For the next three years: Every six months.
From five years onwards: Every year.
At the follow-up visit a short history is taken covering the time since the last visit. This is followed by physical examination covering lymph node areas, abdomen and pelvis. You may have CA125 test done, other blood test, and imaging tests depending on symptoms and findings on physical exam.
Dr Marcelo Nascimento
MD MSc FRANZCOG CGO
I am a clinical specialist in the treatment of gynaecological pre-cancers, cancersand complex non-cancer gynaecological conditions. I am dedicated to improving the quality of life for women with gynaecological conditions providing the highest quality of diagnosis, treatment and recovery pathways in a caring and supporting environment. I work with fertility-preserving surgery whenever possible which allows women more options for treatment without compromising oncologic outcomes.