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Expanding the public health research agenda for ovarian cancer. September 17, 2009

Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, uterine cancer, vaginal cancer.
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Expanding the public health research agenda for ovarian cancer.

J Womens Health (Larchmt). 2009 Sep

Trivers KF, Stewart SL, Peipins L, Rim SH, White MC.

Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA. ktrivers@cdc.gov

Since the year 2000, the Centers for Disease Control and Prevention (CDC) has undertaken an active public health research agenda in ovarian cancer, focused mainly on research related to earlier recognition of symptoms, methods for earlier diagnosis, and optimization of treatment and end-of-life care. Much of this work was guided by external input from two workshops in 2000 and 2002 with ovarian cancer experts in clinical and epidemiological research, public health leaders from federal and state agencies, and ovarian cancer survivors. In November 2008, the CDC convened a third informal workshop of experts to comment on CDC’s work to date and to help expand the public health research agenda for the future. The purpose of the workshop was to identify and discuss urgent and emerging issues related to ovarian cancer and how public health organizations, and specifically CDC, might address these issues through research. This article provides a summary of some of the issues discussed and potential areas for future research, including genetic, screening, and diagnostic tests for ovarian cancer; ways of improving the quality of care for patients; symptom recognition; public awareness; and other emerging issues related to ovarian cancer.

PubMed

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Straight talk about ovarian cancer November 16, 2008

Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, uterine cancer, vaginal cancer.
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Straight talk about ovarian cancer

VIRGINIA R. MARTIN RN, AOCN, MSN

Nursing2005 April 2005 Volume 35 Number 4 Pages 36 – 41

Abstract

Learn how to help patients recognize and defeat this insidious malignancy.

Learn how to help patients recognize and defeat this insidious malignancy.

ACCORDING TO AMERICAN Cancer Society (ACS) estimates for 2005, 22,220 women will develop ovarian cancer and 16,210 will die of it. The leading cause of death from gynecologic cancer in the United States, ovarian cancer has historically had a poor prognosis, largely because over 70% of women affected have advanced disease at diagnosis.

But medical science is gaining ground. Thanks to improved diagnosis, staging, and treatments, 5-year survival improved from 37% in the 1970s to 53% in 1998. Let’s review how this insidious disease progresses, how you can help someone who has it, and what you need to know about promising screening methods that could lead to earlier detection and treatment.

Deep, changing organs

The ovaries are solid, slightly nodular, almond-shaped organs lying deep in the pelvis. Their hidden location, plus the fact that their size, shape, position, and histology change over a woman’s lifetime, help explain why ovarian cancer isn’t readily detected in the early stages. According to the National Comprehensive Cancer Network (NCCN), the median age at diagnosis is 63. This malignancy is rare in women under age 30.

Three major theories about the causes of ovarian cancer prevail:

* The incessant-ovulation theory zeroes in on how the monthly ovulatory cycle affects the ovaries. This theory holds that the epithelium may be more apt to mutate with each ovulation, so failure to break the cycle, as with pregnancy, increases the chance of mutation.

* The pituitary/gonadotropin hypothesis implicates elevated gonadotropin levels. Normally, the ovarian epithelium invaginates and forms inclusion cysts and clefts, but overstimulation by gonadotropins might trigger proliferation with subsequent malignant transformation.

* The inflammation theory considers monthly ovulation a possible cause of chronic inflammation and mutation in the epithelial cells that lead to ovarian cancer.

The causes of ovarian cancer are unclear, but genetic and endocrine factors raise the risk. (See How the problem starts .) The most significant link is a positive family history, which is present in 10% of women with the disease. Three hereditary syndromes in which ovarian cancer occurs more commonly affect certain families with a history of early breast and ovarian malignancies and hereditary nonpolyposis colorectal cancer.

Other factors associated with ovarian cancer include nulliparity, giving birth for the first time when over age 35, exposure to talc or asbestos, endometriosis, pelvic inflammatory disease, and living in a western industrialized country. On the bright side, researchers have identified seemingly protective factors, including a history of oral contraceptive use, giving birth before age 25, tubal ligation, breast-feeding, and hysterectomy.

Most commonly, ovarian cancer spreads via the peritoneal fluid that continuously circulates through the abdomen. Other routes for metastases are through the lymphatic fluid or by direct tumor extension. Bloodborne metastasis is rare, and this cancer rarely spreads beyond the abdomen, even when advanced.

Early signs

Retrospective studies indicate that over 70% of women with ovarian cancer have symptoms for 3 months or longer before diagnosis. But the early signs and symptoms can be nonspecific, including increased abdominal size, bloating, early satiety, abdominal pain, indigestion, vaginal bleeding, and changes in bowel and bladder habits. Because these symptoms can be vague, a woman may not pay much attention to them.

Teach your female patients to always investigate any of these symptoms if they occur.

When a woman does seek treatment and an ovarian mass is discovered, the clinical approach depends on clinical findings. If she’s premenopausal, the health care practitioner will probably monitor her for a few ovulatory cycles and investigate further if the mass doesn’t disappear. In a postmenopausal woman, any ovarian mass must immediately be investigated for cancer.

Diagnostic imaging and tumor markers

Diagnostic tests to detect ovarian cancer include the following:

* transvaginal and abdominal ultrasound. A transvaginal approach provides better visualization of the ovaries than the transabdominal method, but the location of the ovaries varies in each woman, so a combination of both approaches is recommended.

* computed tomography (CT) scan of the abdomen and pelvis

* a blood test for the tumor marker cancer antigen 125 (CA-125), which can be elevated in ovarian cancer. Although an ovarian mass can cause an elevated CA-125 level, so can endometriosis, pregnancy, liver disease, or fibroids, so the marker isn’t specific.

Additionally, a woman can have ovarian cancer and a normal CA-125 level; only 50% of women with stage I disease have an elevated level. For this reason, the CA-125 isn’t recommended as a screening tool for healthy women, but it can be useful in women with diagnosed ovarian cancer.

Surgery: First and foremost

Surgery is the mainstay of treatment for ovarian cancer, and a gynecologic oncologist has the most training to perform the exploratory laparotomy. The goals of surgery are to determine a definitive diagnosis, to stage the disease if cancer is present, and to remove as much of the tumor as possible. (See Staging ovarian cancer .) The procedure includes a total abdominal hysterectomy, bilateral salpingo-oophorectomy, scraping the abdominal surface of the diaphragm, peritoneal cytology, omentectomy, pelvic and para-aortic lymph node sampling, and peritoneal and random biopsies.

Although disease stage is the key prognostic factor for ovarian cancer, other factors influence outcome. They include the volume of cancerous tissue remaining after surgery, histologic type and grade, the woman’s age, and her overall condition or performance status. (See Rating performance .) A woman whose performance status is 0 to 2 is more likely to respond to chemotherapy, experience less toxicity, and have better outcomes. Findings associated with a poorer prognosis include a clear cell, mucinous, or poorly differentiated (unclear cell type) tumor, and diagnosis after age 69.

Is additional treatment warranted?

If your patient has well-differentiated stage IA or IB ovarian cancer that’s been surgically removed, she’s considered low risk and needs no further treatment. The oncologist will determine a follow-up plan.

Stage IA or IB ovarian cancer with a poorly differentiated tumor and stages IC, II, III, and IV disease are classified as high risk, and the patient requires chemotherapy. Scientists are still seeking the optimal regimen, but early clinical trials have shown that combination therapy with a platinum compound such as cisplatin or carboplatin is superior to using a single agent. The NCCN states that paclitaxel/carboplatin is the preferred regimen. (See Exploring chemotherapy options for other choices.)

A complete remission from cancer means all signs and symptoms disappear; remission after initial therapy that lasts 5 years may be considered a cure. Although 75% to 80% of women with ovarian cancer achieve a complete remission after initial therapy, 80% of them have a recurrence. Unfortunately, recurrent disease isn’t curable, so researchers are exploring strategies to prevent or delay recurrence, such as improved induction and maintenance regimens and the use of intraperitoneal chemotherapy.

Currently, intraperitoneal therapy is recommended only in the context of a clinical trial, but researchers have been studying it closely because ovarian cancer tends to stay in the abdomen. Study results show higher rates of progression-free survival and overall survival, but the challenges of administering therapy and managing toxicity are formidable.

Remission and monitoring

A typical woman with complete remission from ovarian cancer undergoes regular CA-125 monitoring and periodic abdominopelvic CT scans to check for recurrence. In most cases of recurrent disease, the CA-125 level rises above normal before the woman develops symptoms. Even when the CA-125 level is elevated, most oncologists don’t start chemotherapy unless a pelvic examination or abdominopelvic CT scan indicates disease recurrence; treating measurable disease lets the practitioner identify a response.

If a woman’s cancer recurs, her response to initial chemotherapy and the length of time until recurrence help determine subsequent therapy. If she achieved complete remission and didn’t have a recurrence for more than 6 months after completing initial therapy, her disease is considered drug sensitive and she’ll probably receive the same regimen.

Ovarian cancer that recurs less than 6 months after a woman achieves a complete remission is considered drug resistant . If the cancer doesn’t respond to initial therapy at all, it’s labeled drug refractory . Drug-resistant or drug-refractory disease is typically treated with a different agent, or the woman may be offered the option of participating in a clinical trial. If curing ovarian cancer isn’t possible, the patient may receive salvage therapy , which is chemotherapy to help manage symptoms and possibly prolong survival.

When recommending a treatment approach for recurrent disease, the oncologist considers the woman’s prior responses, quality of life, toxicity profile, current symptoms, disease volume, the ability of her gastrointestinal system to absorb drugs, her age, other illnesses, and social issues.

Radiation therapy may be included in the palliative treatment plan and may help if the patient has uncontrolled vaginal bleeding or pain. Radiation to the entire abdomen isn’t often considered because it’s toxic. For recurrent disease in a specific area, a radiation oncologist should outline a treatment plan. The goal of all palliative treatment is to balance the toxicities with quality of life.

Providing education and support

Research indicates that the more a patient feels threatened or harmed by cancer, the more education and support she needs. With ovarian cancer, her psychosocial and physical challenges might include advanced disease at diagnosis, repeated cycles of aggressive treatment, little respite from therapy, and a poor chance of survival. Your challenges are to address her psychosocial needs while preparing her for treatment and helping her manage adverse reactions to treatment and advanced disease.

Preoperatively, educate your patient and her family about the surgical procedure for ovarian cancer and what to expect afterward. Explain that after surgery, you’ll monitor her for infection, circulatory complications, fluid and electrolyte imbalances, and pain, and that you’ll work with the surgeon to manage any problems.

If your patient will receive chemotherapy, teach her and her family about the major adverse reactions. Explain how to prepare and respond if she develops fatigue, nausea, vomiting, hair loss, diarrhea, constipation, mucositis, neuropathy, arthralgia and myalgia, or myelosuppression.
Problems such as depression and anxiety are common when a patient faces serious illness and possible death. She may need help coping with such issues as premature menopause; loss of fertility; altered body image, sexual function, and family relationships; impaired functional capacity; financial problems; and loss of spiritual well-being.

Assess her for mood changes, feelings of worthlessness, inability to concentrate, fatigue, insomnia, impaired functioning, agitation, restlessness, and apprehensiveness. Review her medical history, current medications and treatments, nutritional status, pain rating, elimination pattern, and sexual history for factors that may contribute to depression.

Listen to her concerns and refer her to support services, such as the local chapter of the ACS. Managing her symptoms, participating in a support group, meeting with a mental health professional, and taking antidepressant or antianxiety medication all can help resolve depression and anxiety.

Finally, if cure isn’t an option, you can give your patient and her family tremendous support when you help them cope with end-of-life decisions and involve the hospice team when the time is right.

Managing the effects of advancing disease

Complications of advancing ovarian cancer can pose significant nursing challenges. Here’s a review of assessment findings and management strategies for common problems.

Ascites , accumulation of fluid in the peritoneal cavity, occurs when channels that normally remove fluid are blocked or when cancer cells prevent absorption of peritoneal fluid. Symptoms include early satiety, dyspnea, increased abdominal girth, constipation, and pain.

Suspect ascites if your patient has a protuberant abdomen with bulging flanks, an everted umbilicus, diminished bowel sounds, shiny or taut abdominal skin, and dullness to percussion in dependent areas of the abdomen. (For details, see “Assessing for Ascites” in the February issue of Nursing2005 .) An abdominal ultrasound usually confirms the diagnosis.
The treatment for ascites is removing the fluid. The oncologist may perform paracentesis in the office or in the radiology department with ultrasound guidance.

Intestinal obstruction involving the small or large intestine may plague a patient with progressing ovarian cancer. Tumor growth in the abdomen or adhesions can cause a partial or complete obstruction that interferes with peristalsis. An obstruction can be acute or chronic. Signs and symptoms of acute obstruction include acute abdominal distension and pain and projectile vomiting. Symptoms of chronic obstruction include abdominal distension and discomfort, constipation, and nausea and vomiting.

Hyperactive bowel sounds may be the first sign of acute intestinal obstruction as the bowel tries to move digestive contents past the blockage. Teach your patient to recognize problems and to immediately contact her health care provider if they occur.

A patient who develops an acute intestinal obstruction may need hospitalization and insertion of a nasogastric tube to decompress her bowel. Because a woman with advanced cancer may already be debilitated, surgery is considered only if conservative interventions fail or she’s in acute distress.

Deep vein thrombosis (DVT) is a risk for all cancer patients because of prolonged immobility, tumors that decrease or obstruct blood flow, and hypercoagulability associated with cancer. Common signs and symptoms include unilateral leg edema or pain accompanied by tenderness, warmth, and erythema. The treatment for DVT includes anticoagulation therapy and possibly placement of a filter in the inferior vena cava.

Malnutrition is one of the greatest challenges for a woman with ovarian cancer. Treatments or advancing disease may take away her appetite, causing her to lose weight. This wasting syndrome is called cancer cachexia , an advanced state of protein-energy malnutrition. Besides weight loss, signs of cancer cachexia include decreased subcutaneous tissue, edema, abdominal distension, dry skin, and behavioral changes such as irritability. Cancer patients with weight loss generally have poor performance status, poor response to chemotherapy, poor median survival, and possibly a greater infection risk.

Measures to protect the patient from malnutrition include treating the underlying problem, delaying chemotherapy, getting a nutrition consult, and medications (such as corticosteroids, megestrol, hydrazine, dronabinol, nabilone, oxandrolone, growth hormones, and medroxyprogesterone). Advise her to eat frequent, small meals served at room temperature; eliminate disagreeable food odors; get help with food preparation; and use nutritional supplements.

Lymphedema , an accumulation of lymphatic fluid in the interstitial tissue, occurs when the tumor blocks the lymphatic system or when lymph nodes have been removed. Lymphedema associated with ovarian cancer affects the legs. The affected leg maintains full sensation, but with edema, range of motion decreases and the skin feels tight to the patient.

Your patient should be referred to a knowledgeable practitioner in lymphedema management. The severity and grade of lymphedema determine the interventions, which may include range-of-motion exercises, meticulous skin care to reduce the risk of skin breakdown, elevation, massage or physical therapy to manually aid drainage, compression bandaging, or sequential pump therapy.

Pleural effusion occurs when the rate of pleural fluid production exceeds its removal rate from the pleural space, such as when a tumor invades the thoracic duct, or when ascites fluid seeps through the diaphragm. Signs and symptoms may include dyspnea, decreased or absent breath sounds, decreased tactile fremitus, or dullness to percussion. An effusion is treated by draining the fluid via thoracentesis or insertion of a tunneled indwelling pleural catheter.

What about screening and prevention?

Current screening methods for ovarian cancer aren’t sensitive or specific enough for routine use. A woman with a positive family history, however, should have a formal risk assessment with an extensive family history, education, risk estimation and counseling, optional genetic testing, and specific screening and prevention strategies. Screening strategies often include a rectovaginal pelvic exam, a CA-125 blood test, and transvaginal ultrasound.

Scientists are exploring the natural history of ovarian cancer to develop cost-effective, sensitive screening strategies. Researchers studying cell proteins are developing a test that tracks trends in multiple tumor markers specific for ovarian cancer. The first published study reported 18 of 18 stage I cancers and 63 of 66 healthy controls accurately identified, yielding 100% sensitivity and 95% specificity. A yet-unpublished study accurately identified 22 of 22 cases of early stage I disease, 81 of 81 cases of stage II to stage IV disease, and 68 of 68 cases of benign disease. The test must be validated and standardized before being used as a screening tool.

Prevention strategies for ovarian cancer may include a prophylactic bilateral oophorectomy in high-risk women who’ve finished childbearing. Other prevention strategies being used in clinical trials include the use of oral contraceptives and other drugs such as acetaminophen and the synthetic retinoid, fenretinide.

Finally, you have many opportunities to improve the outlook for ovarian cancer. Educate your female patients about the signs and symptoms and emphasize the importance of reporting “insignificant” symptoms that could be early warning signs. Early detection and treatment offer the best chance for survival.

Education, support, and hands-on care

Patient outcomes for ovarian cancer are getting better as detection and treatment methods improve. When you give a woman the education, support, and hands-on care she needs to combat this malignancy, you bolster her ability to successfully fight back.

How the problem starts

Three major categories of ovarian cancer have been identified:

Epithelial cancers , arising from the cells lining or covering the ovaries, account for 90% of ovarian malignancies. Epithelial cancers are further classified as serous (most common), endometrioid, clear cell, mucinous, and poorly differentiated.

Germ cell cancers start in cells destined to become ova.

Stromal cell cancers start in the connective tissue cells that hold the ovaries together and produce female hormones.

Staging ovarian cancer

Stage I: Tumor limited to the ovaries

IA , limited to one ovary, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsule intact

IB , limited to both ovaries, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsules intact

IC * , limited to one or both ovaries, tumor on ovarian surface, capsule ruptured, ascites or peritoneal washings containing malignant cells

Stage II: Tumor involving one or both ovaries with pelvic extension

IIA , extension or metastasis to the uterus or tubes, no malignant cells in ascites or peritoneal washings

IIB , extension to other pelvic tissues, no malignant cells in ascites or peritoneal washings

IIC * , pelvic extension, ascites fluid or peritoneal washings containing malignant cells

Stage III: Tumor involving one or both ovaries, peritoneal implants outside the pelvis or regional lymph node metastasis

IIIA , gross tumor limited to the true pelvis, negative nodes, microscopic peritoneal metastasis beyond the pelvis

IIIB , macroscopic peritoneal metastasis 2 cm or less in greatest dimension beyond the pelvis

IIIC , abdominal implants greater than 2 cm in greatest dimension or positive regional nodes

Stage IV: Tumor involving one or both ovaries, metastasis greater than 2 cm in greatest dimension beyond the pelvis. If pleural effusion is present, cytologic test results must be positive. Parenchymal liver metastases equals stage IV.

Rating performance

The Eastern Cooperative Oncology Group established the following scale to rate the effects of cancer and its treatments on the patient.

0 Normal activity, asymptomatic

1 Symptomatic, fully ambulatory

2 Symptomatic, in bed less than 50% of the time

3 Symptomatic, in bed more than 50% of the time but not bedridden

4 100% bedridden

SELECTED WEB SITES

National Ovarian Cancer Coalition

Ovarian Cancer National Alliance

SHARE: Self-help for Women with Breast or Ovarian Cancer

Women’s Cancer Network and CancerSource
Last accessed on March 3, 2005.

Virginia R. Martin is the clinical director of ambulatory care at Fox Chase Cancer Center in Philadelphia, Pa.

The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.

Exploring chemotherapy options

The current standard regimen for advanced ovarian cancer is paclitaxel (Taxol) and the platinum compound carboplatin. Alternatives are docetaxel (Taxotere) with carboplatin or paclitaxel with cisplatin, another platinum compound.

Recent clinical trials found no difference in survival between patients receiving carboplatin with either docetaxel or paclitaxel, but the docetaxel/carboplatin group had a greater incidence of myelosuppression. Those receiving paclitaxel/carboplatin had more neuropathy. Newer drugs being combined with carboplatin and paclitaxel are topotecan, liposomal doxorubicin, and gemcitabine.

The Gynecologic Oncology Group (GOG), a research group funded by the National Cancer Institute, is currently conducting a clinical trial for high-risk early-stage disease comparing three cycles of paclitaxel/carboplatin followed by surveillance versus paclitaxel alone weekly for 24 weeks. The GOG is also proposing a clinical trial on the use of carboplatin and paclitaxel combined with bevacizumab to treat advanced ovarian cancer.

To take this test online, visit: Nursing Center.com

SELECTED REFERENCES

Bookman MA, et al. Optimal therapy of advanced ovarian cancer: Carboplatin and paclitaxel vs. cisplatin and paclitaxel (GOG 158) and an update on GOG0 182-ICON5. International Journal of Gynecological Cancer . 13(6):735–740, November/December 2003.
Cunningham RS, Bell R. Nutrition in cancer: An overview. Seminars in Oncology Nursing . 16(2):90–98, May 2000.
Ferrell B, et al. Psychological well being and quality of life in ovarian cancer survivors. Cancer . 98(5):1061–1071, September 1, 2003.
Howell D, et al. Impact of ovarian cancer perceived by women. Cancer Nursing . 26(1):1–9, February 2003.
Howell D, et al. Women’s experience with recurrent ovarian cancer. Cancer Nursing . 26(1):10–17, February 2003.
Jemal A, et al. Cancer Statistics 2005. CA: A Cancer Journal for Clinicians . 55(1):10–30, January/February 2005.
Martin VR. Ovarian cancer. Seminars in Oncology Nursing . 18(3):174–183, August 2002.
Ozols RF. Future directions in the treatment of ovarian cancer. Seminars in Oncology . 29(1: Suppl. 1):32–42, February 2002.
Ozols RF, et al. Focus on epithelial ovarian cancer. Cancer Cell . 5(1):19–24, January 2004.

Source
Federation Internationale de Gynecologie et d’Obstetrique (International Federation of Gynecology and Obstetrics).

* Knowing whether rupture of the capsule was spontaneous or caused by the surgeon and whether peritoneal washings or ascites was the source of malignant cells helps the clinician decide whether a case should be categorized as stage IC or IIC. [Context Link]

Nursing Center.com

Ovarian Cancer Facts November 14, 2008

Posted by patoconnor in cancer, gynecological cancer, ovarian cancer.
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The ovaries

The ovaries are two small, oval-shaped organs that are part of the female reproductive system. They are in the lower part of the tummy (abdomen), which is known as the pelvis. Other organs are very close to the ovaries (see diagrams below). These include:

  • The ureters, which drain urine from the kidneys to the bladder.
  • The bladder.
  • The back passage (rectum).
  • The lower part of the small bowel.
  • The omentum (a membrane which surrounds all of the pelvic and abdominal organs and keeps them in place). It is also called the peritoneum.
  • Groups of lymph nodes.

Each month, in women of childbearing age, one of the ovaries produces an egg. The egg passes down the fallopian tube to the womb (uterus). If the egg is not fertilised by a sperm it passes out of the womb and is shed, along with the lining of the womb, as part of the monthly period.

The ovaries also produce the female sex hormones, oestrogen and progesterone. As a woman nears the menopause (‘change of life’) the ovaries make less of these hormones and periods gradually stop.

 ovaries1

 

ovarias2

Types of Ovarian Cancer

Most ovarian cancers are a type called epithelial cancer. Epithelial ovarian cancer means the cancer has started in the cells that cover the surface of the ovary. There are several types of epithelial cancers of the ovary. The most common types are:

  • serous
  • endometrioid.

Less common types of epithelial ovarian cancer are:

  • mucinous
  • clear cell
  • undifferentiated or unclassifiable.

They are currently all treated in a similar way.

There are also less common types of ovarian cancer. These include germ cell tumours (ovarian teratomas) and sarcomas. Germ cell tumours tend to affect younger women and behave very differently to other types of ovarian cancer.

Risk factors and causes of ovarian cancer

Each year, about 6600 women in the UK are diagnosed with ovarian cancer. The causes are not yet completely understood. The risk of developing ovarian cancer is very low in young women and increases as women get older. Over eight out of ten (85%) ovarian cancers occur in women over the age of 50. Most ovarian cancers occur in women who have had their menopause.

Some factors are known to affect a woman’s chance of developing ovarian cancer – they may increase the risk or decrease it. These are described below.

Hormonal Factors

  • Women who have not had children are slightly more likely to develop ovarian cancer than women who have, although the risk is still very low. Having two or more children may provide more protection than just one.
  • Breast feeding your children may slightly decrease your risk.
  • Starting your periods early or having a late menopause slightly increases your risk of ovarian cancer.
  • Women who take the contraceptive pill are less likely to develop ovarian cancer.
  • Using oestrogen-only hormone replacement therapy (HRT) can slightly increase the risk. When HRT is stopped the risk of ovarian cancer gradually reduces to the same level as women who haven’t taken HRT.
  • Infertility and fertility treatments

    Research has shown that infertility treatment may slightly increase the risk of developing ovarian cancer. However, other research doesn’t support this.

    Health Factors

    Having endometriosis may increase your risk of ovarian cancer.

    Lifestyle factors

    Being overweight may increase your risk of developing ovarian cancer.

    Eating a diet high in animal fats and low in fresh fruit and vegetables may increase your risk.

    Genetic factors

  • About 5–10 in 100 (5–10%) ovarian cancers are caused by an inherited faulty gene in the family.
  • Women who have had breast cancer have an increased risk of ovarian cancer. This is because breast and ovarian cancer can be caused by the same faulty genes.
  • If any of the following are present in one side of your family, it is possible that there may be an inherited faulty gene:

    • Ovarian cancer in at least two close relatives (mother, sisters or daughters).
    • One close relative with ovarian cancer and one close relative with breast cancer diagnosed when they were under the age of 50 (or both cancers in the same person).
    • Ovarian cancer in one close relative and breast cancer in two family members diagnosed when they were under the age of 60.
    • Three close relatives with colon (bowel) or womb (endometrial) cancer, and one relative with ovarian cancer.

    Having one elderly relative with ovarian cancer doesn’t necessarily increase your risk of ovarian cancer.

    Women who are worried that they may have an increased risk of developing ovarian cancer, because of cancer in their family, can be referred to a genetic counselling clinic. Contact your GP or our information service for more details about genetic counselling clinics. The clinics are based in hospitals and you will be seen by a genetics specialist who can check your family history to see whether you are likely to be at increased risk.

    If two or more of your close relatives have had ovarian cancer you may want to consider having testing (screening) for ovarian cancer. However, it is not yet known how effective screening is at detecting ovarian cancer (screening).

    Screening for ovarian cancer

    Research trials are being carried out to see whether ovarian cancers can be detected early so that they can be treated more effectively. The trials are testing women who have no symptoms of ovarian cancer, to see if testing can detect a cancer at an early stage. This is known as screening. Currently it is not known whether screening can help to detect ovarian cancers at an earlier stage, so there is no national screening programme for ovarian cancer in the UK.

    Women who may have an increased risk of ovarian cancer can ask their GP to refer them to take part in an ovarian cancer screening research trial.

    A recent research study is looking at the benefits of screening postmenopausal women with either a blood test for a protein called CA125 or a vaginal ultrasound (see diagnosis). The aim of the trial is to see if either of these tests will help doctors diagnose women with ovarian cancer when their cancer is at an early stage. The trial has recently closed and it will be a few years before we know the results.

    Symptoms of ovarian cancer

    Most women with early-stage cancer of the ovary don’t have any symptoms for a long time. When symptoms occur they may include any of the following:

    • loss of appetite
    • vague indigestion, nausea, excessive gas (wind) and a bloated, full feeling
    • unexplained weight gain
    • swelling in the abdomen – this may be due to a build up of fluid (ascites), which can cause shortness of breath
    • pain in the lower abdomen
    • changes in bowel or bladder habits, such as constipation, diarrhoea or needing to pass urine more often
    • lower back pain
    • pain during sex
    • abnormal vaginal bleeding, although this is rare.

    If you have any of the above symptoms it is important to have them checked by your doctor, but remember they are common to many other conditions and most women with these symptoms will not have cancer.

    Diagnosis

    Usually you begin by seeing your GP, who will examine you and arrange for you to have any tests (usually ultrasound scans and/or blood tests) that may be necessary. If your GP suspects that you have ovarian cancer they will refer you to a cancer centre to be seen by a specialist gynaecology cancer team for the tests and for specialist advice and treatment.

    At the hospital

    At the hospital, the gynaecologist (specialist in women’s illnesses) will ask you about your general health and any previous medical problems, before examining you. This will include an internal (vaginal) examination to check for any lumps or swellings.

    The specialist may arrange for you to have a blood test and chest x-ray to check your general health.

    You may have a specific blood test to check whether there are higher than normal levels of the CA125 protein in your blood. CA125 is a protein that most women have in their blood. The level may be higher in women with ovarian cancer, as it is sometimes produced by ovarian cancer cells. However, CA125 is not specific to ovarian cancer, and the level can also be raised in women who have other non-cancerous conditions.

    Several tests may be used to diagnose cancer of the ovary. The tests may also show the stage of the cancer – whether or not it has spread to other parts of the body. These tests help your doctor to know the best way to treat the cancer.

    Ultrasound scan          

    An ultrasound uses sound waves to build up a picture of the inside of the abdomen, the liver and the pelvis. It will be done in the hospital scanning department.

    If you have a pelvic ultrasound you will be asked to drink plenty of fluids so that your bladder is full. This helps to give a clearer picture. Once you are lying comfortably on your back a gel is spread onto your abdomen. A small device, which produces sound waves, is then rubbed over the area. The sound waves are converted into a picture by a computer.

    If you have a vaginal ultrasound scan, a probe with a rounded end is put into your vagina. The probe produces sound waves, which are then converted into a picture by a computer. Although this type of ultrasound scan may sound uncomfortable, many women find it more comfortable than having a pelvic ultrasound, as it is not necessary to have a full bladder.

    Pelvic or vaginal ultrasound can be used to check for any enlargement or abnormalities of the ovaries which may be due to a cyst or tumour. It can also be used to show the size and position of a cancer.

    CT scan

    A CT (computerised tomography) scan takes a series of x-rays which builds up a three-dimensional picture of the inside of the body. The scan is painless but takes from 10 to 30 minutes. CT scans use a small amount of radiation, which will be very unlikely to harm you and will not harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan.

    You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand. You will probably be able to go home as soon as the scan is over.

    MRI scan

    An MRI (magnetic resonance imaging) scan is similar to a CT scan, but uses magnetic fields instead of x-rays to build up a series of cross-sectional pictures of the body. During the test you will be asked to lie very still on a couch inside a metal cylinder that is open at both ends. The whole test may take up to an hour and is painless – although the machine is very noisy. You will be given earplugs or headphones to wear.

    The cylinder is a very powerful magnet, so before going into the room you should remove all metal belongings. You should also tell your doctor if you have ever worked with metal or in the metal industry or if you have any metal inside your body (for example, a cardiac monitor, pacemaker, surgical clips, or bone pins). You may not be able to have an MRI because of the magnetic fields.

    Some people are given an injection of dye into a vein in the arm, but this usually does not cause any discomfort. You may feel claustrophobic inside the cylinder, but you may be able to take someone with you into the room to keep you company. It may also help to mention to the staff beforehand if you do not like enclosed spaces. They can then offer extra support during your test.

    Abdominal fluid aspiration

    If there has been a build up of fluid in the abdomen, a sample of the fluid can be taken to check for any cancer cells. The doctor will use a local anaesthetic to numb the area before passing a small needle through the skin. Some fluid is drawn off into a syringe and examined under a microscope.

    Laparoscopy                                                                             

    This operation allows the doctor to look at the ovaries, fallopian tubes, the womb and the surrounding area. It’s done under a general anaesthetic. Most women usually go home the same day but you may have to stay in hospital overnight.

    While you are under anaesthetic, the doctor makes 3–4 small cuts, approximately 1cm (½ inch) in length, in the skin and muscle of the lower abdomen. A thin fibre-optic tube (laparoscope) is then inserted. By looking through the laparoscope the doctor can look at the ovaries and take a small sample of tissue (biopsy) for examination under a microscope.

    During the operation, carbon dioxide gas is passed into the abdominal cavity and this can cause uncomfortable wind and/or shoulder pains. The pain is often eased by walking about or by taking sips of peppermint water. If the pain continues when you are at home you should contact the hospital for advice.

    After a laparoscopy you will have one or two stitches in your lower abdomen. You should be able to get up as soon as the effects of the anaesthetic have worn off.

    Eploratory laparotomy                 

    Sometimes cancer of the ovary cannot be diagnosed before a full operation (laparotomy) is carried out.

    It will probably take several days for the results of your tests to be ready and a follow-up appointment will be arranged for you before you go home. Obviously, this waiting period is an anxious time and it may help you to talk things over with a close friend, a relative, the hospital specialist nurse, or a support organisation.

    Staging and grading of ovarian cancer

    Staging       

    The stage of a cancer is a term used to describe its size and whether it has spread beyond its original area of the body. Knowing the extent of the cancer and the grade helps the doctors to decide on the most appropriate treatment. It’s often not possible to stage an ovarian cancer before a laparotomy is done and the results of any biopsies are known (see diagnosis). A commonly used staging system is described below.

    Borderline tumours are made up of low-grade cells that are unlikely to spread. They are usually completely cured by surgery and rarely require further treatment.

    Stage 1 ovarian cancer only affects the ovaries. This stage is divided into three sub-groups:

    • Stage 1a The cancer is only in one ovary
    • Stage 1b There are tumours in both ovaries.
    • Stage 1c The cancer is either at stage 1a or 1b, and there are cancer cells on the surface of one of the ovaries, or in the fluid taken from within the abdomen during surgery, or the ovary has burst (ruptured) before or during surgery.

    Stage 2 ovarian cancer has begun to spread outside the ovaries within the pelvis. There are three sub-groups:

    • Stage 2a The cancer has spread to the womb or fallopian tubes.
    • Stage 2b The tumour has spread to other structures within the pelvis, such as the rectum or bladder.
    • Stage 2c The cancer is either at stage 2a or 2b, and there are cancer cells on the surface of one of the ovaries, or in the fluid taken from within the abdomen during surgery, or the ovary has burst (ruptured) before or during surgery.

    Stage 3 The cancer has spread beyond the pelvis to the lining of the abdomen (a fatty membrane called the omentum), and/or to abdominal organs such as the lymph nodes in the abdomen, or the upper part of the bowel.

    • Stage 3a The tumours in the abdomen are very small and cannot be seen except under a microscope.
    • Stage 3b The tumours in the abdomen can be seen but they are smaller than 2cm.
    • Stage 3c The tumours in the abdomen are larger than 2cm.

    Stage 4 The cancer has spread to other parts of the body such as the liver, lungs, or distant lymph nodes (for example in the neck).

    If the cancer comes back after initial treatment this is known as recurrent cancer.

    Grading

    Grading refers to the appearance of the cancer cells when they are looked at under the microscope. The grade gives an idea of how quickly the cancer may develop. There are three grades: grade 1 (low-grade), grade 2 (moderate-grade) and grade 3 (high-grade).

    • Low-grade means that the cancer cells look very like the normal cells of the ovary. They usually grow slowly and are less likely to spread.
    • Moderate-grade means that the cells look more abnormal than low-grade cells.
    • High-grade means that the cells look very abnormal. They are likely to grow more quickly and are more likely to spread.