What Is Ovarian Cancer

What Is Ovarian Cancer 2

What Is Ovarian Cancer 3

What Is Ovarian Cancer 4

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      What Is Ovarian Cancer?

Ovarian cancer is cancer that begins in the ovaries. In women, the ovaries produce eggs (ova) for reproduction. The eggs travel through the fallopian tubes into the uterus where the fertilized egg implants and develops into a fetus. Cancer can also begin in the fallopian tubes. The ovaries are also the main source of the female hormones estrogen and progesterone. One ovary is located on each side of the uterus in the pelvis.

The ovaries contain 3 kinds of tissue.

Germ cells, which produce eggs (ova) that are formed on the inside of the ovary. Each month from puberty until menopause women normally produce an egg that makes its way to the surface, where it is shed into the fallopian tube.

Stromal cells, which produce most of the female hormones estrogen and progesterone.
Epithelial cells, which cover the ovary. Most ovarian cancers start in this epithelial covering.

Types of Ovarian Tumors

Many types of tumors can start growing in the ovaries. Some are benign (non-cancerous) and never spread beyond the ovary. Women with these types of tumors can be treated successfully by removing one ovary or the part of the ovary that contains the tumor. Other types of ovarian tumors are malignant (cancerous) and can spread to other parts of the body. Their treatment is more complex and is discussed later in this document.

In general, ovarian tumors are named according to the kind of cells the tumor started from and whether the tumor is benign or cancerous. There are 3 main types of ovarian tumors:

Germ cell tumors start from the cells that produce the ova (eggs).

Stromal tumors start from connective tissue cells that hold the ovary together and produce the female hormones estrogen and progesterone.

Epithelial tumors start from the cells that cover the outer surface of the ovary.

Epithelial Ovarian Tumors

Benign epithelial ovarian tumors: Most epithelial ovarian tumors are benign, do not spread, and usually do not lead to serious illness. There are several types of benign epithelial tumors including serous adenomas, mucinous adenomas, and Brenner tumors.

Tumors of low malignant potential: When looked at under the microscope, some ovarian epithelial tumors do not clearly appear to be cancerous. These are called tumors of low malignant potential (LMP tumors). They are also known as borderline epithelial ovarian cancer. These differ from typical ovarian cancers in that they do not grow into the supporting tissue of the ovary (called the ovarian stroma). Likewise, if they spread outside the ovary, for example, into the abdominal cavity, they do not usually grow into the lining of the abdomen.

These cancers affect women at a younger age than the typical ovarian cancers. LMP tumors grow slowly and are also a less life-threatening disease than most ovarian cancers. Although they can be fatal, this is not common.

Epithelial ovarian cancers: Cancerous epithelial tumors are called carcinomas. About 85% to 90% of ovarian cancers are epithelial ovarian carcinomas. Epithelial ovarian carcinoma cells have several features that can be seen under the microscope. These features are used to classify epithelial ovarian carcinomas into serous, mucinous, endometrioid, and clear cell types. The serous type is by far the most common.

Undifferentiated epithelial ovarian carcinomas don't look like any of these 4 subtypes, and they also tend to grow and spread more quickly. Epithelial ovarian carcinomas are classified by cell type and are also given a grade and a stage.

The grade is on a scale of 1, 2, or 3. 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.

The tumor stage describes how far the tumor has spread from where it started in the ovary. Staging is explained in detail in a later section.

Primary Peritoneal Carcinoma

Primary peritoneal carcinoma is a cancer closely related to epithelial ovarian cancer. It is also sometimes called also called extra-ovarian (meaning outside the ovary) primary peritoneal carcinoma (EOPPC) or serous surface papillary carcinoma. It develops in cells from the peritoneum, which is the membrane that lines the walls and organs of the pelvis and abdomen. These cells are very similar to epithelial cells on the surface of the ovaries. Because EOPPC tends to spread along the surfaces of the pelvis and abdomen, it is often difficult to tell exactly where the cancer first started. Under a microscope, EOPPC looks just like epithelial ovarian cancer. Women who have had their ovaries removed can still develop this type of cancer.

Symptoms of EOPPC are similar to those of ovarian cancer, including abdominal pain or bloating, nausea, vomiting, indigestion, and a change in bowel habits. Also, like ovarian cancer, EOPPC may cause an elevation in the amount of CA-125 in the blood. This is a tumor marker for ovarian cancer (discussed later in this document).

Treatment for women with EOPPC usually includes surgery to remove as much of the cancer as possible, followed by chemotherapy like that given for ovarian cancer. Its outlook is similar to widespread ovarian cancer.

Germ Cell Tumors

About 5% of ovarian cancers are germ cell tumors. Germ cells are the cells that usually form the ova or eggs. There are several subtypes of germ cell tumors. Most germ cell tumors are benign, although some are cancerous and may be life threatening. The most common germ cell tumors are teratoma, dysgerminoma, endodermal sinus tumor, and choriocarcinoma.

Teratoma: This germ cell tumor has a benign form called mature teratoma and a cancerous form called immature teratoma. The mature teratoma is by far the most common ovarian germ cell tumor and usually affects women of reproductive age (teens through forties). It is often called a dermoid cyst because its lining resembles skin. These tumors or cysts also contain a variety of other benign tissues that may resemble adult respiratory passages, bone, nervous tissue, teeth, and other tissues. The patient is cured by surgically removing the cyst.

Immature teratomas occur in girls and young women, usually younger than 18. These are rare cancers that resemble embryonic or fetal tissues such as connective tissue, respiratory passages, and brain. Tumors that are not very immature (grade 1 immature teratoma) and have not spread beyond the ovary are cured by surgical removal of the ovary. When they have spread beyond the ovary and/or much of the tumor has a very immature appearance (grade 2 or 3 immature teratomas), chemotherapy is recommended in addition to surgical removal of the ovary.

Dysgerminoma: This is the most common ovarian cancer of germ cells. However, it is a rare cancer. It usually affects women in their teens and twenties. Although dysgerminomas are considered malignant (cancerous), most do not grow or spread very rapidly. When they are limited to the ovary, more than 75% of patients are cured surgically removing the ovary, without any further treatment. Even when the tumor has spread further (or if it recurs, or comes back) surgery and/or chemotherapy is effective in controlling or curing the disease in about 90% of patients.

Endodermal sinus tumor (yolk sac tumor) and choriocarcinoma: These very rare tumors typically affect girls and young women. They tend to grow and spread rapidly but are usually very sensitive to chemotherapy. Choriocarcinomas more commonly start in the placenta (during pregnancy) rather than in the ovary. Placental choriocarcinomas usually respond even more to chemotherapy than ovarian choriocarcinomas.

Stromal Tumors

More than half of stromal tumors are found in women over age 50, but some occur in young girls. Some, but not all, of these tumors produce female hormones or, less often, male hormones. They can cause vaginal bleeding to start again after menopause, or can cause menstrual periods and breast development in young girls. If male hormones are produced, the tumors can disrupt normal periods and cause facial and body hair to grow. Types of malignant (cancerous) stromal tumors include granulosa cell tumors, granulosa-theca tumors, and Sertoli-Leydig cell tumors, which are usually considered low-grade cancers. Thecomas and fibromas are benign stromal tumors.

Ovarian Cysts

An ovarian cyst is a collection of fluid inside an ovary. Many cysts are completely normal. These are called functional cysts and occur as a normal part of ovulation. The fluid will usually be absorbed and over a few months, the cyst will disappear without any treatment. If you develop a cyst, your doctor may want to check it again after a period of time to see if it has gotten smaller. If, however, the mass is large, occurs in childhood or after menopause, or does not go away, your doctor will usually recommend that you have more tests, since a small number of these cysts may be cancer. Benign cysts are treated by observation (follow-up with physical exams and imaging tests), medications, or surgical removal.

Fallopian Tube Cancer

This is an extremely rare cancer. It begins in the fallopian tube, The symptoms are similar to those in women with ovarian cancer, except that there may be more pelvic pain. Treatment and outlook is similar to that for ovarian cancer. There are no reliable statistics for this cancer because it is so rare.

What Are the Risk Factors for Ovarian Cancer?

A risk factor is anything that increases your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, unprotected exposure to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for cancers of the lung, mouth, larynx, bladder, kidney, and several other organs.

Researchers have discovered several specific factors that increase a woman's likelihood of developing epithelial ovarian cancer. These risk factors do not apply to other less common types of ovarian cancer such as germ cell tumors and stromal tumors.

Most women with ovarian cancer do not have any known risk factors. Risk factors increase the odds of getting a disease but do not guarantee it will occur. Only a small number of women who have risk factors will develop ovarian cancer.
Age: Most ovarian cancers develop after menopause. A woman is considered to be menopausal when she has gone a year without a menstrual period. Half of all ovarian cancers are found in women over the age of 63.

Obesity: A study from the American Cancer Society found a higher rate of death from ovarian cancer in obese women. The risk was increased by 50% in the heaviest women.

Reproductive history: Women who started menstruating at an early age (before age 12), had no children or had their first child after age 30, and/or experienced menopause after age 50 may have an increased risk of ovarian cancer. There seems to be a relationship between the number of menstrual cycles in a woman's lifetime and her risk of developing ovarian cancer.

Fertility drugs: In some studies, researchers have found that prolonged use of the fertility drug clomiphene citrate, especially without achieving pregnancy, may increase the risk for developing ovarian tumors, particularly a type known as "tumors of low malignant potential" (LMP tumors). If you are taking this drug, you should discuss its potential risks with your doctor. However, infertility also increases the risk of ovarian cancer, even without use of fertility drugs. More research to clarify these relationships is now underway.

Family history of ovarian cancer, breast cancer, or colorectal cancer:Your ovarian cancer risk is increased if your mother, sister, or daughter has (or have had) ovarian cancer, especially if she developed ovarian cancer at a young age. Two-thirds of women who develop ovarian cancer are over 55 years old. If your relative had ovarian cancer when she was younger than 55, that may be a sign that your risk is even higher. The younger your relative was when she developed ovarian cancer, the higher your risk. You can inherit an increased risk for ovarian cancer from relatives on your mother's side or father's side of the family. About 10% of ovarian cancers result from an inherited tendency to develop the disease. If there is a family history of cancer caused by an inherited mutation (change) of the breast cancer gene BRCA1 or BRCA2, you have a very high risk of ovarian cancer. Also, a mutation leading to inherited colorectal cancer can increase the risk of ovarian cancer. Many cases of familial epithelial ovarian cancer are caused by inherited gene mutations that can be identified by genetic testing.

Women with ovarian cancers caused by these inherited gene mutations tend to have a better prognosis than patients who do not have any family history of ovarian cancer. (See the section on causes of ovarian cancer for information on these gene mutations.)

Genetic counseling, genetic testing, and strategies for preventing ovarian cancer in women with an increased familial risk are discussed in the prevention section of this document.

Personal history of breast cancer: If you have had breast cancer, you also have an increased risk of developing ovarian cancer. There are several reasons for this. Some of the reproductive risk factors for ovarian cancer may also increase breast cancer risk. Also, if you have a strong family history of breast cancer, you may have an inherited mutation of the BRCA1 or BRCA2 gene (see the section, "Do We Know What Causes Ovarian Cancer?").

Talcum powder: It has been suggested that talcum powder applied directly to the genital area or on sanitary napkins may be carcinogenic (cancer-causing) to the ovaries. Most, but not all, studies suggest a slight increase in risk of ovarian cancer in women who used talc on the genital area. In the past, talcum powder was sometimes contaminated with asbestos, a known cancer-causing mineral. This may explain the association with ovarian cancer in some studies. Body and face powder products have been required by law for more than 20 years to be asbestos-free. However, proving the safety of these newer products will require follow-up studies of women who have used them for many years. There is no evidence at present linking cornstarch powders with any female cancers.

Estrogen replacement therapy and hormone replacement therapy: Some studies suggest women using estrogens after menopause have an increased risk of developing ovarian cancer, but other studies have not found any effect on ovarian cancer risk. A recent study suggested that using estrogen replacement therapy (ERT) increases the risk of developing ovarian cancer, and that the risk increases with continued use. The risk among women who used ERT for longer than 10 years was almost double that of women who had never used it, and the risk among those who used it for 20 years or more was tripled. (Remember, however, that the average lifetime risk for ovarian cancer is only about 2%.) Most of these findings have been for women taking estrogen alone, not for those taking combined progesterone and estrogen. The increased risk is less certain for women taking both drugs. Because there have not been enough women studied, doctors are not sure that estrogens do increase the risk of ovarian cancer.

Smoking and alcohol use: These do not increase the risk for most ovarian cancers, but some studies have found an increased risk for the mucinous type.

Do We Know What Causes Ovarian Cancer?

We do not yet know exactly what causes most ovarian cancers, but we do know some factors that make a woman more likely to develop epithelial ovarian cancer, the most common type of ovarian cancer. Much less is known about risk factors for germ cell and stromal tumors of the ovaries. See the risk factor section of this document for more information.

Researchers have made great progress in understanding how certain mutations (changes) in DNA can cause normal cells to become cancerous. DNA is the chemical that carries the instructions for nearly everything our cells do. We usually resemble our parents because they are the source of our DNA. However, DNA affects more than our outward appearance. Some genes (parts of our DNA) contain instructions for controlling when our cells grow and divide. Certain genes that promote cell division are called oncogenes. Others that slow down cell division, cause cells to die at the appropriate time, or help repair DNA damage are called tumor suppressor genes. We know that DNA mutations (defects) that turn on oncogenes or turn off tumor suppressor genes can cause cancer.

Inherited Genetic Factors

Scientists have learned a lot about how certain genes you inherit from your parents can greatly increase your ovarian cancer risk. These include the BRCA1 and BRCA2 genes and several genes related to hereditary nonpolyposis colon cancer (see section below).

BRCA1 and BRCA2 genes: Although these inherited gene mutations were first found in women with breast cancer, they are also responsible for about 9% of ovarian cancers. Normally, these genes help to prevent cancer by making proteins that keep cells from growing abnormally. But if you have inherited a mutated gene from either parent, this cancer-preventing protein is less effective, and your chances of developing breast and/or ovarian cancer increase.

The lifetime ovarian cancer risk for women with BRCA1 or BRCA2 mutations has been estimated to be between 40% and 50% by age 70. This mutation also increases the risk for extra-ovarian primary peritoneal carcinoma.

In comparison, the ovarian cancer lifetime risk for the general population of women is about 1.5%.
Hereditary nonpolyposis colon cancer (HNPCC): This syndrome is also caused by inherited gene mutations that reduce the body's ability to repair damage to its DNA. This results in very high risks for colorectal cancer and endometrial (lining of the uterus) cancer, as well as a somewhat increased risk for developing ovarian cancer. The risk for ovarian cancer with HNPCC syndrome is much less than with BRCA1 or BRCA2 defects. This gene mutation causes about 1% of all ovarian epithelial cancers.

Acquired Genetic Changes

Most DNA mutations related to ovarian cancer are not inherited but instead occur during a woman's life. In some cancers, acquired mutations of oncogenes and/or tumor suppressor genes may result from radiation or cancer-causing chemicals, but there is no evidence for this in ovarian cancer. So far, studies have not been able to specifically link any single chemical in the environment or in our diets to mutations that cause ovarian cancer. The cause of most acquired mutations remains unknown.

Most ovarian cancers have several acquired gene mutations. Research has suggested that tests to identify acquired changes of certain genes, such as the p53 tumor suppressor gene or the HER2 oncogene, in ovarian cancers may help in predicting a woman's prognosis. The role of these tests is still not certain, and some cancer specialists feel that more research is needed

Can Ovarian Cancer Be Prevented?

Most women have one or more risk factors for ovarian cancer. However, most of the common factors only slightly increase your risk, so they only partly explain the frequency of the disease. So far, knowledge about risk factors has not been translated into practical ways to prevent most cases of ovarian cancer.

There are several ways you can reduce your risk of developing epithelial ovarian cancer. Much less is known about ways to lower the risk of developing germ cell and stromal tumors of the ovaries. The remainder of this section refers to epithelial ovarian cancer only. It is important to realize that some of these strategies reduce the risk only slightly, while others decrease it much more. Some strategies are easily followed, and others require surgery. If you are concerned about your risk of ovarian cancer, you may want to discuss this information with your health care professionals. They can help you consider these ideas in the context of your own situation.

Oral contraceptives: Using oral contraceptives (birth control pills) decreases the risk of developing ovarian cancer, especially among women who use them for several years. Women who used oral contraceptives for 3 or more years have about a 30% to 50% lower risk of developing ovarian cancer compared to women who have never used oral contraceptives.

Recent research suggests that contraceptives reduce risk in women who have mutations of the BRCA1 and BRCA2 genes. But this is not certain, as some studies have shown no decrease in risk.
Tubal ligation or hysterectomy: Tubal ligation is a surgical procedure to "tie" the fallopian tubes to prevent pregnancy. When performed after childbearing, tubal ligation may reduce the chance of developing ovarian cancer by up to 67%. A hysterectomy (removal of the uterus) may also reduce your risk.

Tubal ligation has also been shown to be effective in reducing the risk of ovarian cancer in women who have the BRCA1 mutation. It is not certain if it will decrease the risk for women with the BRCA2 mutation.

No one knows for certain why tubal ligation and hysterectomy decrease the risk of ovarian cancer. One theory is that some cancer-causing substances may enter the body through the vagina and pass through the uterus and fallopian tubes to reach the ovaries. This may explain the effect on ovarian cancer risk of removing the uterus or blocking the fallopian tubes.

We emphasize that these operations should be done only when there are valid medical reasons and not exclusively for their effect on ovarian cancer risk.

If you are having a hysterectomy for a valid medical reason and you have a strong family history of ovarian or breast cancer, you may wish to consider having both ovaries removed (bilateral oophorectomy) as part of that procedure.

If you have been through menopause (postmenopausal) or are near menopause (perimenopausal), the ovaries should be removed at the same time as the hysterectomy even if you do not have an increased risk of ovarian cancer. If you are having a hysterectomy and are older than 40, you should discuss having your ovaries removed with your doctor.

Pregnancy and breast-feeding: Having one or more children, plus prolonged (one year or more) breast-feeding, also may decrease your risk. Although it has been thought that having children early helps to reduce risk, a recent study also shows even lower risk of ovarian cancer in women who have their children after age 35. Although these measures slightly reduce risk, they do not guarantee protection against ovarian cancer. Doctors do not recommend making choices about when to have a child specifically for the purpose of reducing ovarian cancer risk, especially since using oral contraceptives will have a greater impact on this risk.

Diet: A number of studies have shown a reduced rate of ovarian cancer in women who ate a diet high in vegetables. The American Cancer Society recommends eating a variety of healthful foods, with an emphasis on plant sources. Eat at least five servings of fruits and vegetables every day, as well as servings of whole grain foods from plant sources such as breads, cereals, grain products, rice, pasta, or beans. Eat fewer red meats, especially those high in fat or processed. Even though the impact of these dietary recommendations on ovarian cancer risk remains uncertain, following these recommendations can help prevent several other diseases, including some other types of cancer.

Analgesics: In some studies, both aspirin and acetaminophen have been shown to reduce the risk of ovarian cancer. However, the information is not consistent, and women should not take these medicines regularly to prevent ovarian cancer. More research is needed on this issue.

Prevention strategies for women with a family history of ovarian cancer, including breast cancer due to BRCA mutation: Genetic counseling can predict whether you are likely to have one of the gene mutations associated with an increased ovarian cancer risk. If your family history suggests that you might have one of these gene mutations, genetic testing might be considered.

Before having genetic tests, you should discuss their benefits and potential drawbacks. Genetic testing can determine if you or members of your family carry certain gene mutations that cause a high risk of ovarian cancer. For some women with a strong family history of ovarian cancer, knowing they do not have a mutation that increases their ovarian cancer risk can be a great relief for them and their children. Knowing that you do have such a mutation can be stressful, but many women find this information very helpful in making important decisions about certain prevention strategies for them and their children.

Using oral contraceptives is one way that women at average risk of developing ovarian cancer can reduce their risk for this disease. They may also reduce the risk for women with BRCA1 and BRCA2 mutations. This is less certain because of the small numbers of women studied. Also, some studies have indicated that oral contraceptives might increase your breast cancer risk if you have a strong family history of breast cancer. Other studies have not found any increase in breast cancer risk among women with BRCA mutations who take oral contraceptives. Additional research is needed to find out more about the risks and benefits of oral contraceptives for women at high ovarian and breast cancer risk.

Surgery to remove one or both ovaries is called an oophorectomy. A prophylactic oophorectomy is surgery to remove both of the ovaries before an ovarian cancer occurs. This is a controversial operation because it causes premature menopause in premenopausal women and may be unnecessary. Generally, it is recommended only for certain very high-risk patients over age 40. This operation lowers ovarian cancer risk a great deal but does not entirely eliminate it. Women can still develop extra-ovarian primary peritoneal carcinoma.

Women at high risk of ovarian cancer who are having their ovaries removed should also have their fallopian tubes completely removed. These are another place that cancer might start.

Recent research showed that women who have BRCA gene mutations and have their ovaries removed have a substantial reduction in their risk of ovarian and breast cancers. In one study, 98% of these women were free of ovarian or primary peritoneal cancer at 5 years, and 94% were free of breast cancer. In the other study, the risk of ovarian cancer in BRCA positive women who had prophylactic oophorectomy was reduced 85% and the risk of breast cancer was reduced 25%.

Can Ovarian Cancer Be Found Early?

About 20% of ovarian cancers are found at an early stage. When ovarian cancer is found early at a localized stage, about 94% of patients live longer than 5 years after diagnosis. Several large studies are in progess to learn how best to find ovarian cancer in its earliest stage.

Ways to Find Ovarian Cancer Early

Regular women’s health exams: During a pelvic exam, the health care professional feels the ovaries and uterus for size, shape, and consistency. Although a pelvic exam is recommended because it can find some reproductive system cancers at an early stage, most early ovarian tumors are difficult or impossible for even the most skilled examiner to feel. Pelvic exams may, however, help to identify other cancers or gynecologic conditions. Women should discuss the need for these exams with their doctor.

Although the Pap test is effective in detecting cervical cancer early, it is not an effective testing for finding ovarian cancer. Most of the ovarian cancers that are detected through Pap tests are already advanced.

See a doctor if you have symptoms: Early cancers of the ovaries tend to cause symptoms that are relatively vague. These symptoms include abdominal swelling (due to a mass or accumulation of fluid), unusual vaginal bleeding, pelvic pressure, back pain, leg pain, and digestive problems such as gas, bloating, indigestion, or long-term stomach pain. Most of these symptoms can also be caused by other less serious conditions.

By the time ovarian cancer is considered as a possible cause of these symptoms, it may have already spread beyond the ovaries. Also, some types of ovarian cancer can rapidly spread to the surface of nearby organs. Still, prompt attention to symptoms can improve the odds of early diagnosis and successful treatment. If you have symptoms of ovarian cancer, report them to your health care professional right away.

Screening tests for ovarian cancer: Screening tests and exams are used to detect a disease, such as cancer, in people who do not have any symptoms. Perhaps the best example of this is the mammogram, which can often detect breast cancer in its earliest stage, even before a doctor can feel the cancer. Although there has been a lot of research to develop a screening test for ovarian cancer, there hasn’t been much success so far. But there are some tests that might help some women.

Women with a high risk of developing epithelial ovarian cancer, such as those with a very strong family history of this disease, may be screened with transvaginal sonography (an ultrasound test performed with a small instrument placed in the vagina – see "How Is Ovarian Cancer Diagnosed?") and blood tests.

Transvaginal sonography is helpful in finding a mass in the ovary, but it does not accurately detect which masses are cancers and which are benign diseases of the ovary.

Blood tests for ovarian cancer may include measuring the amount of CA-125 (also known as OC-125). The amount of this protein in the blood is higher in many women with ovarian cancer. However, some non-cancerous diseases of the ovaries can also increase the blood levels of CA-125, and some ovarian cancers may not produce enough CA-125 to cause a positive test result. When these test results are positive, it may be necessary to do a transvaginal ultrasound test and take samples of fluid from the abdomen or tissue from the ovaries to find out if a cancer is really present.

In early studies of women at average risk of ovarian cancer, these screening tests did not lower the number of deaths caused by ovarian cancer. For this reason, transvaginal sonography and the CA-125 blood test are not recommended for ovarian cancer screening of women without known strong risk factors. In women at high risk, these tests are often done, but it is not known how helpful they are. Ways to improve ovarian cancer screening tests are being researched. Hopefully, further improvements will make these tests effective enough to lower the ovarian cancer death rate.

There are no tests recommended to screen women for germ cell tumors or stromal tumors. Some germ cell cancers release certain protein markers such as human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) into the blood. After these tumors have been treated by surgery and chemotherapy, blood tests for these markers can be used to determine if the cancer may be coming back.

There are new tests that may be helpful in the future to diagnose ovarian cancer early. Please see the section, "What's New In Ovarian Cancer Research and Treatment."

How Is Ovarian Cancer Diagnosed?

Signs and Symptoms of Ovarian Cancer

Ovarian cancer may cause several signs and symptoms. However, most of these may also be caused by benign (non-cancerous) diseases and by cancers of other organs. The most common symptom is back pain, followed by fatigue, bloating, constipation, abdominal pain and urinary urgency. These symptoms tend to occur very frequently and become more severe with time. Most women with ovarian cancer have at least 2 of these symptoms.

Others symptoms, which tend to occur later in the course of the disease, are prolonged swelling of the abdomen, abdominal pain and cramping, a feeling of pelvic pressure, vaginal bleeding, and leg pain.

If there is reason to suspect you may have ovarian cancer, your doctor will use one or more methods to be absolutely certain that the disease is present and to determine the stage of the cancer.

Consultation With a Specialist

If your pelvic examination or other tests suggest that you may have ovarian cancer, you will need a doctor or surgeon who specializes in treating women with this type of cancer. A gynecologic oncologist is an obstetrician/gynecologist who is specially trained in treating cancers of the female reproductive system.

Imaging Studies

Imaging methods such as computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and ultrasound studies can confirm whether a pelvic mass is present. Although these studies cannot confirm that the mass is a cancer, they are useful if your doctor is looking for spread of ovarian cancer to other tissues and organs.

Ultrasound: Ultrasound (ultrasonography) is the use of sound waves to create an image on a video screen. Sound waves are released from a small probe placed in the woman's vagina or on the surface of her abdomen. The sound waves create echoes as they enter the ovaries and other organs. The same probe detects the echoes that bounce back, and a computer translates the pattern of echoes into a picture. Because ovarian tumors and normal ovarian tissue often reflect sound waves differently, this test may be used to find tumors and determine whether a mass is solid or a fluid-filled cyst.

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of multiple slices of the part of your body that is being studied.

CT scans are useful in showing how large the tumor is, what other organs it may be invading, whether lymph nodes are enlarged and whether the kidneys or bladder are affected.
This test can help tell if your cancer has spread into your liver or other organs. Often after the first set of pictures is taken you will receive an intravenous injection of a "dye" or contrast agent that helps better outline structures in your body. A second set of pictures is then taken.

CT scans can also be used to precisely guide a biopsy needle into a suspected metastasis. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table, while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than 1/8 inch in diameter) is removed and examined under a microscope.

CT scans take longer than regular x-rays and you need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and the most modern ones only take seconds..

You will need to have an IV (intravenous) line through which the contrast "dye" is injected. The injection can also cause some flushing. Some people are allergic and get hives or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays. You may be asked to drink 1 to 2 pints of a solution of contrast material.

Barium enema x-ray: This is a test to see whether the cancer has invaded the colon (large intestine) or rectum (it is also used to look for colorectal cancer). After taking laxatives the day before, the radiology technician puts barium sulfate, a chalky substance, into the rectum and colon. Because barium is impermeable (impossible for x-rays to go through) to x-rays, it outlines the colon and rectum on x-rays of the abdomen.

Colonoscopy: A colonoscopy is also done after the large intestine has been cleaned with laxatives. A doctor inserts a fiberoptic tube into the rectum and passes it through the entire colon. This allows the doctor to see the inside and detect any cancer. It is also used to look for colorectal cancer. Because this is uncomfortable, the patient will be sedated.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of the body. A contrast material might be injected just as with CT scans, but this is done less often. MRI scans are not used often to look for ovarian cancer.

MRI scans are particularly helpful to examine the brain and spinal cord. MRI scans take longer than CT scans, – often up to 30 minutes or more. Also, you have to be placed inside a tube, which is confining and can upset people with claustrophobia (fear of enclosed spaces). The machine also makes a thumping noise that you may find disturbing. Some places will provide headphones with music to block the sound.
Chest x-ray: This procedure may be done to determine whether ovarian cancer has spread (metastasized) to the lungs. This spread may cause one or more tumors in the lungs and often causes fluid to collect around the lungs. This fluid, called a pleural effusion, can be seen with chest x-rays.
Positron emission tomography: Better known as a PET scan, this test uses radioactive glucose to look for the cancer. Cancers use glucose (sugar) at a higher rate than normal tissues. This means that the radioactivity will tend to concentrate in the cancer. In some instances this test has proved useful in finding ovarian cancer that has spread. It is even more valuable when combined with a CT scan (PET/CT scan).

Other Tests

Laparoscopy: This procedure uses a thin, lighted tube through which a doctor can look at the ovaries and other pelvic organs and tissue in the area around the bile duct. The tube is inserted through a small incision (cut) in the lower abdomen and sends the images of the pelvis or abdomen to a video monitor. Laparoscopy provides a view of organs that can help in planning surgery or other treatments and can help doctors confirm the stage (how far the tumor has spread) of the cancer. Also, doctors can manipulate small instruments through the laparascopic incision(s) to remove small tissue samples to examine under the microscope.

Colonoscopy: A colonoscopy is also done after the large intestine has been cleaned with laxatives. A doctor inserts a fiberoptic tube into the rectum and passes it through the entire colon. The images are sent to a video monitor. This allows the doctor to see the inside and detect any cancer. It is also used to look for colorectal cancer. Because this is uncomfortable, the patient will be sedated.

Tissue sampling:The only way to determine for certain if a growth in the pelvic region is cancer is to remove a sample of the growth from the suspicious area and examine it under a microscope. This procedure is called a biopsy. It can be done during the laparoscopy procedure. Or it can be done with a needle placed directly into the tumor through the abdomen. The skin of the abdomen will be numbed with local anesthetic. Usually the needle will be guided by either ultrasound or CT scanning. This method might be used if the patient cannot have surgery because of advanced cancer or some other serious medical condition. Often, a biopsy is done at the time of surgery.

In patients with ascites (collection of fluid inside the abdomen), samples of fluid can also be used to diagnose the cancer. In this procedure, the skin of the abdomen is numbed and a needle attached to a syringe is passed through the abdomen into the cavity. The fluid is sucked up into the syringe.

In all these procedures, the tissue obtained is sent to the pathology laboratory. There it is examined under the microscope by a pathologist, a doctor skilled in diagnosing cancer.
Blood tests: Your doctor will order blood counts to make sure you have enough red blood cells, white blood cells and platelets (cells that help stop bleeding). There will also be tests to measure your kidney and liver function as well as your general health status. Finally the doctor will order a CA-125 test. If the test is elevated, consultation with a gynecologic oncologist is recommended

How Is Ovarian Cancer Staged?

Staging is the process of finding out how widespread a cancer is. Most ovarian cancers that are not obviously widespread are staged at the time of surgery. The goal of surgery for ovarian cancer is to obtain tissue samples for diagnosis and staging and to remove all deposits of cancer larger than 1 cm (about one-half inch). Samples of tissues are taken from different parts of the pelvis and abdomen and examined under the microscope.

Staging is very important because ovarian cancers have a different prognosis at different stages and are treated differently. The accuracy of the staging may determine whether or not a patient will be cured. If the cancer is not properly staged, then cancer that has spread outside the ovary may be missed and not treated. Once a stage has been assigned it does not change, even when the cancer recurs or spreads to new locations in the body.

Ask your cancer care team to explain the staging procedure. Also ask them if they will perform a thorough staging procedure. After surgery, ask what your cancer's stage is. In this way, you will be able to take part in making informed decisions about your treatment.

Ovarian cancer is staged according to the AJCC/TNM System. This describes the extent of the primary Tumor (T), the absence or presence of metastasis to nearby lymph Nodes (N), and the absence or presence of distant Metastasis (M). This closely resembles the system that is actually used by most gynecologic oncologists, called the FIGO system. Both rely on the results of surgery for the actual stages.

T Categories for Ovarian Cancer

Tx: No description of the tumor's extent is possible because of incomplete information.

T1: The cancer is confined to the ovaries – one or both.

T1a: The cancer is in one ovary and doesn’t penetrate outside the ovary and is not in fluid taken from the pelvis.

T1b: The cancer is in both ovaries but doesn’t penetrate outside them and is not in fluid taken from the pelvis.

T1c: The cancer is in one or both ovaries and has penetrated outside them or is in fluid taken from the pelvis.

T2: The cancer is in one or both ovaries and is extending into pelvic tissues and/or has also spread to the surface of the pelvic lining.

T2a: The cancer has spread to the uterus and/or the fallopian tubes and is not in fluid taken from the pelvis.

T2b: The cancer has spread to other pelvic tissues and is not in fluid taken from the pelvis.

T2c: The cancer has spread to the uterus and/or fallopian tubes and/or other pelvic tissues and is in fluid taken from the pelvis.

T3: The cancer is in one or both ovaries and has spread to the abdominal lining outside the pelvis.

T3a: The spread cancers are very small and can not be seen except under a microscope.

T3b: The spread cancers can be seen but are smaller than 2 centimeters (0.8 inches).

T3c: The spread cancers are larger than 2 centimeters (0.8 inches).

N Categories for Ovarian Cancer

N categories indicate whether or not the cancer has spread to regional (nearby) lymph nodes and, if so, how many lymph nodes are involved.

Nx: No description of lymph node involvement is possible because of incomplete information.

N0: No lymph node involvement.

N1: Cancer cells found in regional lymph nodes close to tumor.

M Categories for Ovarian Cancer

M categories indicate whether or not the cancer has spread to distant organs, such as the liver,
lungs, or non-regional lymph nodes.

Mx: No description of distant spread is possible because of incomplete information.

M0: No distant spread.

M1: Distant spread is present.

Grade Categories

(The higher the grade, the more likely it is that the cancer will spread.)
Grade 1: Well differentiated – looks similar to normal ovarian tissue.

Grade 2: Not as well differentiated – looks less like ovarian tissue.

Grade 3: Poorly differentiated – does not look like ovarian tissue.

Stage Grouping

Once a patient's T, N, and M categories have been determined, this information is combined in a process called stage grouping to determine the stage, expressed in Roman numerals from stage I (the least advanced stage) to stage IV (the most advanced stage). The following table illustrates how TNM categories are grouped together into stages.

What the Stages of Ovarian Cancer Mean

Stage I: The cancer is still contained within the ovary (or ovaries).

Stage IA: Cancer has developed in one ovary, and the tumor is confined to the inside of the ovary. There is no cancer on the outer surface of the ovary. Laboratory examination of washings from the abdomen and pelvis did not find any cancer cells.

Stage IB: Cancer has developed within both ovaries without any tumor on their outer surfaces. Laboratory examination of washings from the abdomen and pelvis did not find any cancer cells.

Stage IC: The cancer is present in one or both ovaries and 1 or more of the following are present:
Cancer on the outer surface of at least one of the ovaries

In the case of cystic tumors (fluid-filled tumors), the capsule (outer wall of the tumor) has ruptured (burst)
Laboratory examination found cancer cells in fluid or washings from the abdomen.

Stage II: The cancer is in one or both ovaries and has involved other organs (such as the uterus, fallopian tubes, bladder, the sigmoid colon, or the rectum) within the pelvis.

Stage IIA: The cancer has spread to or has actually invaded the uterus or the fallopian tubes, or both. Laboratory examination of washings from the abdomen did not find any cancer cells.

Stage IIB: The cancer has spread to other nearby pelvic organs such as the bladder, the sigmoid colon, or the rectum. Laboratory examination of fluid from the abdomen did not find any cancer cells.

Stage IIC: The cancer has spread to pelvic organs as in stages IIA or IIB and laboratory examination of the washings from the abdomen found evidence of cancer cells.

Stage III: The cancer involves 1 or both ovaries, and 1 or both of the following are present: (1) cancer has spread beyond the pelvis to the lining of the abdomen; (2) cancer has spread to lymph nodes.

Stage IIIA: During the staging operation, the surgeon can see cancer involving the ovary or ovaries, but no cancer is grossly visible (can be seen without using a microscope) in the abdomen and the cancer has not spread to lymph nodes. However, when biopsies are checked under a microscope, tiny deposits of cancer are found in the lining of the upper abdomen.

Stage IIIB: There is cancer in one or both ovaries, and deposits of cancer large enough for the surgeon to see, but smaller than 2 cm (about 3/4 inch) across, are present in the abdomen. Cancer has not spread to the lymph nodes.

Stage IIIC: The cancer is in one or both ovaries, and one or both of the following are present:
Cancer has spread to lymph nodes.

Deposits of cancer larger than 2 cm (about 3/4 inch) across are seen in the abdomen.

Stage IV: This is the most advanced stage of ovarian cancer. The cancer is in one or both ovaries. Distant metastasis (spread of the cancer to the inside of the liver, the lungs, or other organs located outside of the peritoneal cavity) has occurred. Finding ovarian cancer cells in pleural fluid (from the cavity that surrounds the lungs) is also evidence of stage IV disease.

Recurrent ovarian cancer: This means that the disease has come back (recurred) after completion of treatment.

Survival by Stage
The numbers below are based on patients diagnosed from 1995 to 1998. These numbers come from the American College of Surgeons, National Cancer Data Base.

Stage Relative 5-Years Survival Rate

IA 92.7%
IB 85.4%
IC 84.7%
IIA 78.6%
IIB 72.4%
IIC 64.4%
IIIA 50.8%
IIIB 42.4%
IIIC 31.5%
IV 17.5%

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Five-year rates are used to produce a standard way of discussing prognosis. Of course, many people live much longer than 5 years. Five-year relative survival rates assumes that people will die of other causes and compares the observed survival with that expected for people without ovarian cancer. That means that relative survival only talks about deaths from ovarian cancer.

How Is Ovarian Cancer Treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

After the diagnostic tests are done, your cancer care team will recommend 1 or more treatment options. Consider the options without feeling rushed. If there is anything you do not understand, ask to have it explained. The choice of treatment depends largely on the type of cancer and the stage of the disease. In patients who did not have surgery as their first treatment, the exact stage may not be known. Treatment then is based on other available information.

Other factors that could play a part in choosing the best treatment plan might include your general state of health, whether you plan to have children, and other personal considerations. Age alone is not a determining factor since several studies have shown that older women tolerate ovarian cancer treatments well. Be sure you understand all the risks and side effects of the various therapies before making a decision about treatment.

The main treatments for ovarian cancer are surgery, chemotherapy, and radiation therapy. In some cases 2 or even all of these treatments will be recommended.

Surgery

How much surgery you have depends on how far your cancer has spread and on your general health. For women of childbearing age who have certain kinds of tumors and whose cancer is in the early stage, an effort will be made to treat the disease without removing both ovaries and the uterus.
Several surgical techniques are used to treat ovarian cancer. The main procedure is to remove the uterus (called a hysterectomy) and both ovaries and fallopian tubes (called a bilateral salpingo-oophorectomy). Sometimes, in younger women who wish to become pregnant and have very early stage cancer, only the affected ovary may be removed. Another structure that is typically removed is the omentum, a layer of fatty tissue that covers the abdominal contents like an apron. Ovarian cancer can often spread to the omentum. Finally the surgeon will often remove lymph nodes in the pelvis and abdomen to see if they contain cancer spread from the ovary.

The other important surgical procedure is cytoreduction or debulking in women in whom the cancer has spread widely throughout their abdomen. Debulking means the surgeon removes as much tumor as possible, even though all of it can't be removed. Most doctors feel this greatly improves a patient's outlook for survival.

It is important that your surgeon is experienced in ovarian cancer surgery. Many general gynecologists are not prepared to do the appropriate cancer operation, which requires careful staging and perhaps, debulking. For this reason, many general gynecologists refer such patients to gynecologic oncologists. Ask your doctor if he or she is experienced in treating ovarian cancer, will stage your cancer properly, and can perform a debulking procedure if that is needed. Otherwise you may need a second operation if debulking is required.

Removing both ovaries and/or the uterus means that you will not be able to become pregnant. It also means that you will go into menopause if you have not done so already. Most women will remain in the hospital for 3 to 7 days after the operation and can resume their usual activities within 4 to 6 weeks.

Chemotherapy

Systemic chemotherapy uses drugs that are injected into a vein or given by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment potentially useful for cancers that have metastasized (spread) beyond the organ they started in.

For intraperitoneal (IP) chemotherapy a thin tube or catheter is placed through the skin into the abdomen and the drugs are injected directly into the abdomen.The tube can be placed at the time of surgery or after surgery. If it is done after surgery, many doctors place it using laparoscopy. It will usually be connected to a “port.” A port is a half dollar-sized disk topped with a pliable diaphragm. The chemotherapy can be injected through this diaphragm. The port is placed in the fatty tissues of the abdominal wall just below the skin. This approach concentrates the dose of chemotherapy reaching the cancer cells on the abdominal lining. Still, the drugs do get into the bloodstream and can cause the same side effects as if they were given through an IV. Another possible problem is that the tube used to give the chemotherapy can become plugged or infected because it is kept in place for the several months it takes to complete the course of treatment. Sometimes the catheter can even damage the bowel.

Chemotherapy drugs kill cancer cells but also damage some normal cells. Therefore, careful attention must be given to avoiding or minimizing side effects, which depend on the type of drugs, the amount taken, and the length of treatment.

Temporary side effects might include nausea and vomiting, loss of appetite, loss of hair, hand and foot rashes, and mouth sores. Some of the drugs used in treating ovarian cancer can cause kidney and nerve damage.

Because chemotherapy can damage the blood-producing cells of the bone marrow, patients may have low blood cell counts. This can result in:

an increased chance of infection (caused by a shortage of white blood cells)

bleeding or bruising after minor cuts or injuries (caused by a shortage of blood platelets)

fatigue (caused by low red blood cell counts)

Most side effects disappear once treatment is stopped. Hair will grow back after treatment ends, although it may look different. There are remedies for many of the temporary side effects of chemotherapy. For example, antiemetic drugs can be given to prevent or reduce nausea and vomiting.

Side effects that may be permanent include premature menopause and infertility (inability to become pregnant).

Rarely, some cancer treatment drugs may cause acute myeloid leukemia (AML), a life-threatening cancer of white blood cells. This is called a secondary malignancy. Your health care team knows which drugs can cause this problem and will discuss this possibility with you. Their positive effects against ovarian cancer offset the small chance that any of these drugs will cause leukemia.

The typical course of chemotherapy for epithelial ovarian cancer involves 6 cycles. A cycle is a schedule that allows regular doses of a drug, followed by a rest period. Different drugs have varying cycles; your oncologist (cancer doctor) will prescribe the particular cycle or schedule for your chemotherapy.

These drugs are usually given intravenously in a 3- to 4-week cycle. If chemotherapy treatment is chosen, you will probably receive a combination of drugs. Most oncologists in the United States believe that combination chemotherapy is more effective in treating ovarian cancer than one drug alone.

Combination therapy using a platinum compound, such as cisplatin or carboplatin, and a taxane, such as paclitaxel or docetaxel, is the standard approach. Most doctors favor carboplatin over cisplatin because it has fewer side effects and is just as effective.

Although epithelial ovarian cancer tends to respond to chemotherapy, the cancer cells may eventually begin to grow again. Tumor recurrence is sometimes treated with additional cycles of a platinum compound and/or a taxane. In other cases, recurrence is treated with other drugs. Some of these are topotecan, anthracyclines such as doxorubicin (Adriamycin) and liposomal doxorubicin (Doxil), gemcitabine, cyclophosphamide, vinorelbine (Navelbine), hexamethylmelamine, ifosfamide, and etoposide.

Different drug combinations are often used to treat germ cell tumors and are described in the section on treatment of germ cell tumors.

Radiation Therapy

Radiation therapy uses high energy x-rays to kill cancer cells. These x-rays may be given in a procedure that is much like having a diagnostic x-ray. Although in the past it was often used, radiation therapy is now only rarely used in this country as the main treatment for ovarian cancer.

External beam radiation therapy: In this procedure, radiation from a machine outside the body called a linear accelerator is focused on the cancer. This is 1 type of radiation therapy recommended for people with ovarian cancer. Treatments are given 5 days a week for several weeks. Each treatment lasts only a few minutes and is similar to having a diagnostic x-ray test. As with a diagnostic x-ray, the radiation passes through the skin and other tissues before it reaches the tumor. The actual radiation exposure is very short, and most of the time is spent precisely positioning the patient so that the radiation is aimed accurately at the cancer.

During the course of external beam radiation therapy, skin in the treated area may look and feel sunburned. This gradually fades, returning to a normal appearance in 6 to 12 months. Because the abdomen and pelvis are sensitive to radiation, many women also notice tiredness, nausea, or diarrhea. If you are having side effects from radiation, discuss them with your cancer care team. There may be things you can do to obtain relief.

Brachytherapy: Radiation therapy also may be given as an implant of radioactive materials, called brachytherapy, placed near the cancer. This is rarely done for ovarian cancer.

Radioactive phosphorus: This is a solution of radioactive phosphorus that is instilled into the abdomen. The radioactive phosphorus gets into cancer cells lining the surface of the abdomen
and kills them. It has little immediate side effects but can cause scarring of the intestine and lead to some digestive problems, including bowel blockage.

Clinical Trials
The purpose of clinical trials: Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions:

Is the treatment helpful?

How does this new type of treatment work?

Does it work better than other treatments already available?

What side effects does the treatment cause?

Are the side effects greater or less than the standard treatment?

Do the benefits outweigh the side effects?

In which patients is the treatment most likely to be helpful?

Types of clinical trials: There are 3 phases of clinical trials in which a treatment is studied before it is eligible for approval by the FDA (Food and Drug Administration).

Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment and how much of it can be given safely. The cancer care team watches patients carefully for any harmful side effects. The treatment has been well tested in lab and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug.

Phase II clinical trials: These studies are designed to see if the drug works. Patients are given the highest dose that doesnÂ’t cause severe side effects (determined from the phase I study) and closely observed for an effect on the cancer. The cancer care team also looks for side effects.

Phase III clinical trials: Phase III studies involve large numbers of patient – often several hundred. One group (the control group) receives the standard (most accepted) treatment. The other group receives the new treatment. All patients in phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had much better results than the others.

If you are in a clinical trial, you will have a team of experts taking care of you and monitoring your progress very carefully. The study is especially designed to pay close attention to you.

However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to find out. While most side effects disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial.

Deciding to enter a clinical trial: Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study does not prevent you from getting other medical care you may need.

To find out more about clinical trials, ask your cancer care team. Among the questions you should ask are:
Is there a clinical trial for which I would be eligible?

What is the purpose of the study?

What kinds of tests and treatments does the study involve?

What does this treatment do? Has it been used before?

Will I know which treatment I receive?

What is likely to happen in my case with, or without, this new treatment?

What are my other choices and their advantages and disadvantages?

How could the study affect my daily life?

What side effects can I expect from the study? Can the side effects be controlled?

Will I have to be hospitalized? If so, how often and for how long?

Will the study cost me anything? Will any of the treatment be free?

If I am harmed as a result of the research, what treatment would I be entitled to?

What type of long-term follow-up care is part of the study?

Has the treatment been used to treat other types of cancers?

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