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What is ovarian cancer?
The ovaries are part of the female reproductive system and
are located on either side of the uterus, or womb.
They are almond shaped and approximately two to four centimetres
in diameter.The role of the ovaries is to produce ova, or
eggs, as well as the hormones that are involved in the menstrual
cycle and fertility.
While cells in our body usually grow in a controlled and
organised fashion, when they grow abnormally, they form
a growth or a tumour, which can be benign or malignant.
Benign tumours are not cancerous and do not spread uncontrollably,
but a malignant tumour, also known as a cancer or carcinoma,
will continue to spread through the body unless it is treated.
Ovarian cancer is a malignant tumour of the ovary.
How common is ovarian cancer?
Ovarian cancer is the fourth most common cancer affecting
women. Every year approximately 400 women in Victoria are
diagnosed, most of them with an advanced stage of the disease.
This means one in 90 women have a chance of developing ovarian
cancer in their lifetime, equal to a lifetime risk of 1.1%.
Nine out of ten cases occur in women over the age of 40.
Although it is less common than breast cancer (which affects
one in 13 women), because it is usually diagnosed in its
advanced stages, proportionally more women die from ovarian
cancer.
While advances have been made in survival rates for breast
cancer, there have been no recent breakthroughs in ovarian
cancer, and survival rates have barely improved.
What are the risk factors for ovarian cancer?
The cause of ovarian cancer is not known, but some women
are at greater risk. A risk factor increases the chance
of developing ovarian cancer.
Age
Most women develop ovarian cancer after menopause and 50%
are older than 65.
Lifestyle Factors
• Caucasian women in industrialised countries with a higher
standard of living have a higher risk
• Dietary factors such as the consumption of meat, whole
milk and animal fat have been associated with an increased
risk in some studies; others have not found this connection.
• The evidence suggests a small to moderate positive relation
between an increased Body Mass Index (BMI) and occurrence
of ovarian cancer
Ovulatory factors
Women who ovulate less appear to be somewhat protected.
Ovulation is the process by which an egg that has matured
in the ovary is released for fertilisation by sperm.
Risk factors therefore include:
• Having few or no children
• Having started periods at an early age
• Having your first child after the age of 30
• Menopause occurring after the age of 50
The use of the combined oral contraceptive pill and breastfeeding
lowers the risk slightly. Conditions that interfere with
normal ovulation e.g. polycystic ovarian syndrome also lower
the risk slightly.
Genetic factors
• Between 5 and 10% of cases of ovarian cancer are believed
to be attributable to hereditary factors
• Most hereditary ovarian cancer is associated with mutations
in the BRCA1 gene. A smaller proportion of inherited disease
has been traced to another gene, BRCA2.
• Hereditary nonpolyposis colorectal cancer (HNPCC) syndrome
involves a high rate of ovarian cancers and other malignancies
of the gastrointestinal and genitourinary system.
• Women with one first degree relative (mother, aunt or
sister) diagnosed with ovarian cancer and no confirmed family
history have a lifetime risk of ovarian cancer which is
at most moderately above the average for the general population;
more than 97% of women in this group will not develop ovarian
cancer.
• Women with two or more first-degree relatives diagnosed
with ovarian cancer or who have other risk factors like
Ashkenazi Jewish ancestry have a potentially high risk of
developing ovarian cancer and perhaps other cancers, such
as breast cancer. But although the risk may be more than
3 times higher than the population average, the majority
of women in this group will not develop ovarian cancer.
However, 95% of all ovarian cancer occurs in women without
these risk factors and many women who have risk factors
do not develop ovarian cancer.
What are the symptoms of ovarian cancer?
Most women diagnosed with ovarian cancer are already in
advanced stages of the disease. Unfortunately, there is
a marked difference in survival rates if ovarian cancer
is detected early.
Early stage ovarian cancer may not have obvious symptoms
but the following may occur:
• Vague abdominal pain or pressure
• Feeling of abdominal fullness, gas, nausea, indigestion
- different to your normal sensations
• Sudden abdominal swelling, weight gain or bloating
• Persistent changes in bowel or bladder patterns
• Low backache or cramps
• Abnormal vaginal bleeding
• Pain during intercourse
• Unexplained weight loss
The majority of women who experience one or two of these
early symptoms do not have cancer. However, it is important
that you seek medical advice if the symptoms are unusual
or persist.
How is ovarian cancer diagnosed?
There is no simple or effective screening test for ovarian
cancer. A conclusive diagnosis cannot be made until the
tissue is looked at under a microscope following biopsy
or surgery. Prior to this though, a diagnosis can be assisted
by:
• Physical examination:
A general check up of the body which will include an internal
pelvic examination and perhaps a Pap smear.
• Blood tests:
A full blood count may be done and a measure of the blood
protein CA 125, which is often raised in women with ovarian
cancer. Other special 'tumour markers' may also be tested
for, but some tumours will not have elevations of these
markers and the type of marker depends on the type of tumour.
• Imaging tests:
A chest and/or abdominal x-rays and an ultrasound scan of
the lower abdomen is usually done. Ultrasound scanning cannot
give a definite diagnosis though. A CAT scan may see if
the cancer has spread to other parts of the body, but this
cannot definitely diagnose ovarian cancer either.
• Biopsy:
This is sometimes done during the operation. A sample of
tissue is sent to the laboratory to be looked at under the
microscope to confirm or exclude the diagnosis
Types of Ovarian Cancer
Although they all affect the ovaries, there are different
types of ovarian cancer. When a diagnosis is made, the type
of cancer is identified. The types are:
• Epithelial
Epithelial ovarian cancers are derived from cells covering
the surface of the ovary and comprise over 90% of ovarian
cancers. Epithelial ovarian cancer is further divided into
subtypes being serous, mucinous, endometrioid, clear cell,
and undifferentiated. Epithelial ovarian cancers can also
be divided into grades depending on how abnormal the cancer
looks under the microscope.
• Germ cell
Germ cell ovarian cancers arise from the eggs within the
ovary and can also be classified into several subtypes.
Germ cell cancers are uncommon, and tend to occur in women
less than 30 years of age. Generally this type responds
well to treatment, and young women may still have children
afterwards if only one ovary is affected.
• Sex-cord stromal
Sex-cord stromal ovarian cancers originate from the tissue
that releases female hormones. These are uncommon and can
occur at any age. They respond well to treatment and young
women may still have children if only one ovary is affected.
• Borderline
Borderline ovarian cancers are a group of epithelial cancers
that are not as aggressive or malignant as the others. They
generally have a better outcome, whether diagnosed early
or late.
The treatment and likely outcome for a particular type of
ovarian cancer will vary with each individual case and needs
to be discussed with a gynaecological oncologist.
How does ovarian cancer spread?
Ovarian cancer spreads to other parts of the body by shedding
cancerous cells which may then attach to the abdominal lining
and continue to grow. Cancerous (malignant) cells can also
implant on:
• The liver
• The omentum, which is the curtain of fatty tissue that
hangs from the stomach and intestines
• The bladder
• The diaphragm, situated under the lungs
Ovarian cancer may spread via the lymph glands which are
part of the immune system and often swell when our bodies
are fighting an infection. These glands are all over the
body, but it is those in the pelvis, around the aorta and
in the groin and neck that are usually affected with ovarian
cancer.
Another way of spreading is via the bloodstream or through
the diaphragm, affecting the lungs and causing fluid to
collect.
The stages of ovarian cancer
Ovarian cancer can be classified into four 'stages', depending
on the extent of spread of the disease. This requires an
operation to obtain some samples of tissue, which is then
examined under a microscope.
• Stage I: cancer is limited to the ovaries only.
• Stage II: one or both ovaries are affected, as well as
other pelvic tissues.
• Stage III: involves one or both ovaries; the cancer is
in the abdominal cavity but outside the pelvis, or there
is cancer in the lymph nodes in the pelvis, or around the
aorta or in the groin.
• Stage IV: involves one or both ovaries with spread to
distant organs, such as the liver or diaphragm.
How is Ovarian Cancer treated?
Surgery
Unfortunately, by the time ovarian cancer is diagnosed,
the disease is usually well advanced. This means that often
there are significant deposits of tumour outside the pelvis,
perhaps on the surface of the bowel, and a large deposit
of tumour is frequently found in the fatty apron, known
as the 'omentum', which hangs down from the large bowel.
Small deposits of tumour that look like boiled grains of
white rice are often seen over wide areas of the internal
abdomen.
In the pelvis, in advanced stage ovarian cancer, the ovaries
and uterus are often stuck to the surface of the large bowel
and bladder. Removal of these tumour deposits offers a patient
the advantage that the chemotherapy which will follow is
more likely to be effective than if the deposits are not
removed. This maximum surgery is known as radical debulking
surgery, the aim of which is to remove as much tumour as
possible, leaving tumour deposits of less than 1cm in diameter
in any one location. This gives chemotherapy the best chance
of having a significant effect and gives the patient a possible
complete remission from their cancer.
A small percentage of patients will have cancer that is
confined to the ovary, in which case conservative surgery
may be possible. This is especially desirable in young women
wishing to preserve their fertility. In this situation it
is important to identify whether there is any spread of
cancer outside the ovary, which involves searching for hidden
deposits of tumour.
It is very important to discover whether there is any disease
outside the ovary to establish whether recurrence is likely.
Thorough staging (see 'The Stages of Ovarian Cancer' under
'How Does Ovarian Cancer Spread?') will enable patients
who require further treatment to receive timely chemotherapy
to try and afford a long-term cure. Patients who have been
found to have the cancer isolated to a single ovary and
have had the appropriate surgery may remain fertile and
long-term survival should be greater than 90%.
Chemotherapy
Chemotherapy for ovarian cancer has shown only small incremental
improvement in survival over the past thirty years. In the
middle 1970s Cisplatin chemotherapy became available and
improved response rates quite dramatically, giving approximately
70% of patients a significant reduction in their tumour
size, compared to patients treated with the previous treatment
schedule.
Since the early 1990s platinum (Carboplatin/Cisplatin) has
been combined with taxanes (Paclitaxel/Taxotere) and a combination
of these drugs is now regarded as the best first line chemotherapy.
Some patients who are unable to receive combination chemotherapy
due to co-existing illnesses may be offered single agent
platinum based chemotherapy, which is well tolerated, even
in elderly patients.
About 70% of patients will achieve a significant response
to first line chemotherapy and 50% or more will have no
evidence of cancer at the completion of their chemotherapy.
Response rates are measured both by a physical examination,
CT scans etc, as well as measuring the tumour markers in
the blood. Tumour markers are proteins, which are released
by tumours and can be measured in the blood to evaluate
response to treatment and can be helpful in diagnosis of
ovarian tumours.
There are a number of other drugs used for patients with
ovarian cancer, mainly when the disease recurs. These include
Topotecan, Liposomal doxorubicin, Gemcitabine, Etoposide
or Tamoxifen. Occasionally patients will be offered new
drugs as part of a clinical trial.
Side Effects of Chemotherapy
The main reason why patients feel anxious about receiving
chemotherapy is the fear of side effects such as hair loss,
nausea and vomiting, bowel disturbances and the effects
that the chemotherapy has on peripheral nerves and bone
marrow. These side effects may cause numbness and tingling
in the hands and feet, as well as a susceptibility to infections
if the bone marrow is significantly impaired and the number
of white (infection fighting) blood cells are reduced to
very low levels.
Antidotes to Chemotherapy Side-Effects
Anti-nausea drugs have greatly improved in the last ten
years and the mainstay of treatment now includes the use
of steroids, and ondansetron (Zofran) or granisetron (Kytril).
These drugs are very powerful and have greatly controlled
the nauseating effects of chemotherapy. Other anti-nausea
drugs such as Maxolon and Stemetil are also still in use
and are quite effective.
There are new drugs being developed to combat the effects
on peripheral nerves and there is hope that in the future
these side effects of chemotherapy will also be significantly
improved
What is the survival rate for ovarian cancer?
Every woman with ovarian cancer is treated as an individual
case, depending on the stage of the disease and other personal
factors, and so it is difficult to give a general prognosis.
If the cancer is diagnosed and treated early, between 80-100%
of patients will survive for more than five years. Approximately
20% of women diagnosed at later stages will survive for
more than five years. This figure, however, is improving
all the time with better treatment. See 'How is Ovarian
Cancer Treated?' for further discussion about survival rates.
http://www.ocrf.com.au/
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