Ovarian cancer

Introduction

Women have two ovaries, one on each side of the uterus. The ovaries — each about the size of an almond — produce eggs (ova) as well as the female sex hormones estrogen and progesterone. Ovarian cancer occurs when cells grow in an uncontrolled, abnormal manner and produce tumors in one or both ovaries.

Ovarian cancer is the fifth most common cancer in women. It's diagnosed in more than 25,000 women in the United States each year, and about 16,000 women die of the disease annually.

Your chances of surviving ovarian cancer are better if the cancer is found early. But because the disease is difficult to detect in its early stage, only about 29 percent of ovarian cancers are found before tumor growth has spread into tissues and organs beyond the ovaries. Most of the time, the disease has already advanced before it's diagnosed.

Until recently, doctors thought that early-stage ovarian cancer rarely produced any symptoms. But new evidence has shown that many women do have signs and symptoms before the disease has spread. Being aware of them may lead to earlier detection.

Female reproductive system

Female reproductive system

Ovarian cancer can occur in one or both ovaries, located on either side of the uterus.

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Signs and symptoms

The symptoms of ovarian cancer tend to mimic those of other conditions, including digestive disorders, and it's not unusual for a woman with ovarian cancer to be diagnosed with another condition before finally learning she has cancer. The key seems to be persistent or worsening signs and symptoms. With a digestive disorder, they tend to come and go, or they occur in certain situations or after eating certain foods. With ovarian cancer, there's typically little fluctuation — signs and symptoms are constant and will gradually worsen.

Recent studies have shown that women with ovarian cancer are more likely than are other women to consistently experience the following symptoms:

• Abdominal pressure, fullness, swelling or bloating
• Urinary urgency
• Pelvic discomfort or pain

Additional signs and symptoms that women with ovarian cancer may experience include:

• Persistent indigestion, gas or nausea
• Unexplained changes in bowel habits, including diarrhea or constipation
• Changes in bladder habits, including a frequent need to urinate
• Loss of appetite
• Unexplained weight loss or gain
• Increased abdominal girth or clothes fitting tighter around your waist
• Pain during intercourse (dyspareunia)
• A persistent lack of energy
• Low back pain

Causes

An ovarian tumor is a growth of abnormal cells that may be either noncancerous (benign) or cancerous (malignant). Although benign tumors are made up of abnormal cells, these cells don't spread to other body tissues (metastasize). Ovarian cancer cells metastasize in one of two ways. Most often, they spread directly to other organs in the pelvis and abdomen. Rarely, they can spread through your bloodstream or lymph nodes to other parts of your body.

The causes of ovarian cancer remain unknown. Some researchers believe it has to do with the tissue-repair process that follows the monthly release of an egg through a tiny tear in an ovarian follicle (ovulation) during a woman's reproductive years. The formation and division of new cells at the rupture site may set up a situation in which genetic errors can occur. Others propose that the increased hormone levels before and during ovulation may stimulate the growth of abnormal cells.

Three basic types of ovarian tumors exist, designated by where they form in the ovary. They include:

• Epithelial tumors. About 90 percent of ovarian cancers develop in the epithelium, the thin layer of tissue that covers the ovaries. This form of ovarian cancer generally occurs in postmenopausal women.
• Germ cell tumors. These tumors occur in the egg-producing cells of the ovary and generally occur in younger women.
• Stromal tumors. These tumors develop in the estrogen- and progesterone-producing tissue that holds the ovary together.

Risk factors

Several factors may increase your risk of ovarian cancer. Having one or more of these risk factors doesn't mean that you're sure to develop ovarian cancer, but your risk may be higher than that of the average woman. These risk factors include:

• Genetic mutations. The most significant risk factor for ovarian cancer is having an inherited mutation in one of two genes called breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2). These genes were originally identified in families with multiple cases of breast cancer, which is how they got their names, but they're also responsible for about 5 percent to 10 percent of ovarian cancers. You're at particularly high risk of carrying these types of mutations if you're of Ashkenazi Jewish descent. Another known genetic link involves an inherited syndrome called hereditary nonpolyposis colorectal cancer (HNPCC). Individuals in HNPCC families are at increased risk of cancers of the uterine lining (endometrium), colon, ovary, stomach and small intestine. Risk of ovarian cancer associated with HNPCC is lower than is that of ovarian cancer associated with BRCA mutations.
• Family history. Sometimes, ovarian cancer occurs in more than one family member but isn't the result of any known inherited gene alteration. Having some family history of ovarian cancer increases your risk of the disease, but not to the same degree as does having an inherited genetic defect. If you have one first-degree relative — a mother, daughter or sister — with ovarian cancer, your risk of developing the disease is 5 percent over your lifetime.
• Age. Ovarian cancer generally develops after menopause. Your risk of ovarian cancer increases with age through your late 70s. Although most cases of ovarian cancer are diagnosed in older women, the disease can occur in younger women.
• Childbearing status. Women who have had at least one pregnancy appear to have a lower risk of developing ovarian cancer. Similarly, the use of oral contraceptives appears to offer some protection against ovarian cancer.
• Infertility. If you've had trouble conceiving, you may be at increased risk. Although the link is poorly understood, studies indicate that infertility increases the risk of ovarian cancer, even without use of fertility drugs. The risk appears to be highest for women with unexplained infertility and for women with infertility who never conceive. Research in this area is ongoing.
• Ovarian cysts. Cyst formation is a normal part of ovulation in premenopausal women. However, cysts that form after menopause have a greater chance of being cancerous. The likelihood of cancer increases with the size of the growth and with age.
• Hormone replacement therapy (HRT). Findings regarding use of the hormones estrogen and progestin after menopause and ovarian cancer risk have been inconsistent. Some studies indicate a slightly increased risk of ovarian cancer in women taking estrogen after menopause. Taking HRT as a combination therapy — estrogen plus progestin — also can result in serious side effects and health risks. If you're considering HRT, work with your doctor to evaluate the options and decide what's best for you.
• Obesity in early adulthood. Studies have suggested that women who are obese at age 18 are at increased risk of developing ovarian cancer before menopause.

When to seek medical advice

See your doctor if you have persistent swelling, bloating, pressure or pain in your abdomen or pelvis. If you've already seen a doctor and received a diagnosis other than ovarian cancer, but you're not getting relief from the treatment, schedule a follow-up visit with your doctor or get a second opinion.

If you have a history of ovarian cancer in your family, strongly consider seeing a doctor trained to care for ovarian cancer patients so that you can talk about screening and treatment options while you are disease-free.

If your primary care physician suspects you have ovarian cancer, he or she may refer you to a specialist in female reproductive cancers (gynecologic oncologist), or you may ask for a referral yourself. A gynecologic oncologist is an obstetrician and gynecologist (OB-GYN) who has additional training in the diagnosis and treatment of ovarian and other gynecologic cancers.

Screening and diagnosis

No standardized screening test exists to reliably detect ovarian cancer. Researchers haven't yet found a screening tool that's sensitive enough to detect ovarian cancer in its early stages and specific enough to distinguish ovarian cancer from other, noncancerous conditions. If you're at average risk of ovarian cancer, the routine use of available diagnostic tests is much more likely to identify false-positive than true-positive results, leading to needless worry, expense and the possibility of unnecessary surgery.

If you're at high risk of ovarian cancer, doctors recommend that you have a pelvic exam, a CA 125 blood test and an ultrasound twice a year beginning at age 30 and continuing for the rest of your life, or until your have your ovaries removed. Don't let these regular screenings begin to slide just because you've had a series of negative exams.

Your doctor may also perform these tests if you have signs or symptoms suggestive of ovarian cancer.

• Pelvic examination. Your doctor examines your vagina, uterus, rectum and pelvis, including your ovaries, for masses or growths. Start having pelvic exams at the same time as your first Pap test — within three years of your first sexual encounter or by age 21, whichever comes first. Talk with your doctor about the right screening schedule for you going forward. If you've had your uterus removed (hysterectomy) but still have your ovaries, continue getting regular pelvic exams.

Pelvic examination

Pelvic examination

As part of the pelvic examination, your physician will insert two gloved fingers inside your vagina. While simultaneously pressing down on your abdomen, he or she can examine your uterus, ovaries and other organs.

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Treatment

Treatment of ovarian cancer usually involves a combination of surgery and chemotherapy.

If you want to preserve the option to have children and if your tumor is discovered early, your surgeon may remove only the involved ovary and its fallopian tube. However, this situation is rare. The most common type of tumor often occurs in both ovaries. If it isn't evident initially, eventually the other ovary is likely to develop cancer.

If cancer is found during surgical exploration of your abdominal cavity, the surgeon performs definitive surgical treatment at that time. In most cases the ideal treatment requires that your surgeon remove both ovaries and also your uterus, fallopian tubes, nearby lymph glands and a fold of fatty tissue known as the omentum, where ovarian cancer often spreads.

During this procedure, your surgeon also removes as much cancer as possible from your abdomen (surgical debulking). Ideally, less than a total of 1 cubic centimeter of tumor matter remains in your abdominal cavity after surgery (optimal debulking). This often involves removing part of your intestines.

In addition, your surgeon will take many samples of tissue and fluid from your abdomen to examine for cancer cells. This evaluation is critical in identifying the stage of your disease and determining if you need additional therapy.

After surgery, you'll most likely be treated with a combination of drugs. The initial chemotherapy regimen for ovarian cancer includes the combination of carboplatin (Paraplatin) and paclitaxel (Taxol).Years of clinical trials have proved this combination to be the most effective, though studies continue to look for ways to improve on it. The carboplatin-paclitaxel combination reduces tumor volume in about 80 percent of women with newly diagnosed ovarian cancer. Studies have also shown that the combination results in longer survival, compared with that of previously used chemotherapy drugs and combinations.

Standard chemotherapy involves injecting the two drugs into the bloodstream. A study published Jan. 5, 2006, in the New England Journal of Medicine reports, however, that injecting the drugs directly into the abdominal cavity through a catheter can boost survival for women with advanced ovarian cancer.

Abdominal infusion exposes hard-to-reach cancer cells in the abdominal cavity with higher levels of chemotherapy drugs than can be reached intravenously. Treatment typically involves six rounds of both intravenous and abdominal chemotherapy. Severe side effects — including abdominal pain, nausea, vomiting and infection — may leave many women unable to complete a full course of treatment or others to forego treatment entirely. But even an incomplete course of treatment can help women live longer.

The study results were promising enough that the National Cancer Institute is urging doctors to begin using intra-abdominal chemotherapy in addition to intravenous chemotherapy after surgery for ovarian cancer. If you have ovarian cancer, ask your doctor about abdominal chemotherapy. Your doctor can help you weigh the benefits and risks — including serious side effects — to determine if abdominal chemotherapy is appropriate for you.

Other new treatment options being explored include new chemotherapy drugs, vaccines, gene therapy and immunotherapy, which boosts the body's own immune system to help combat cancer. The discovery of genes that are mutated in ovarian cancer also may lead to the development of drugs that specifically target the function of these genes.

Prevention

Several factors appear to reduce the risk of ovarian cancer. They include:

• Oral contraception (birth control pills). Compared with women who've never used them, women who use oral contraceptives for three years or more reduce their risk of ovarian cancer by 30 percent to 50 percent.
• Pregnancy and breast-feeding. Having at least one child lowers your risk of developing ovarian cancer. Breast-feeding a child for a year or longer also may reduce your risk of ovarian cancer.
• Tubal ligation or hysterectomy. The Nurses' Health Study, which followed thousands of women for 20 years, found a substantial reduction in ovarian cancer risk in women who had had tubal ligations. The procedure also has been shown to reduce ovarian cancer risk among women with mutations in the BRCA1 gene. How the procedure reduces risk is uncertain. The Nurses' Health Study also indicated that having a hysterectomy may reduce ovarian cancer risk, but not by as much as tubal ligation.

Women who are at very high risk of developing ovarian cancer may elect to have their ovaries removed as a means of preventing the disease. This surgery, known as prophylactic oophorectomy, is recommended primarily for women who've tested positive for a BRCA gene mutation or women who have a strong family history of breast and ovarian cancers, even if no genetic mutation has been identified.

Studies indicate that prophylactic oophorectomy lowers ovarian cancer risk by up to 95 percent, and reduces the risk of breast cancer by up to 50 percent, if the ovaries are removed before menopause. Prophylactic oophorectomy reduces, but doesn't completely eliminate, ovarian cancer risk. Because ovarian cancer usually develops in the thin lining of the abdominal cavity that covers the ovaries, women who have had their ovaries removed can still get a similar but less common form of cancer called primary peritoneal cancer.

In addition, prophylactic oophorectomy is controversial because it induces early menopause and may have a substantial negative impact on your quality of life. If you're considering having this procedure done, be sure to discuss the pros and cons with your doctor.

Self-care

Eating well, managing stress and exercising are ways to promote your overall health and cope with any form of cancer.

Eating well
Good nutrition is especially important for people undergoing cancer treatment. But eating well can be difficult if your treatment includes chemotherapy or radiation therapy. You may feel nauseated or lose your appetite, and foods may seem tasteless. You may find that the last thing you want to do is plan meals.

Even so, eating well during cancer treatment can help you maintain your stamina and your ability to cope with the side effects of treatments. Good nutrition may also help you prevent infections and remain more active.

Remember these strategies for eating well when you don't feel well:

• Eat protein-rich foods. Foods high in protein can help build and repair body tissues. Choices include eggs, yogurt, cottage cheese, peanut butter, poultry and fish. Kidney beans, chickpeas and black-eyed peas also are good sources of protein, especially when combined with rice, corn or bread.
• Keep an open mind about the foods you might eat. Something that is unappealing today might taste better to you next week.
• When you do feel well, make the most of it. Eat as many healthy foods as you can. Prepare meals that you can easily freeze and reheat. Also look for low-fat frozen dinners and other prepared foods.
• Give meals a pleasant atmosphere. Whenever possible, eat at a table set with attractive dishes and flowers.
• Pack calories into the foods you eat. For example, spread butter, jam or honey on bread. Sprinkle foods with chopped nuts.
• Eat smaller amounts of food more frequently. If you can't face the thought of a large meal, try eating small amounts of food more often. Keep fruits and vegetables handy for snacking.
• Stay active. Even if you don't feel well, try to stay physically active. A short walk or climbing the stairs can keep your muscles from deteriorating due to lack of use.

Managing stress
Methods for reducing physical tension can help you manage stress. One simple and powerful technique is to close your eyes and notice your breathing. Pay attention to each inhalation and exhalation. Your breathing will become slower and deeper, promoting relaxation. Another technique is to lie down, close your eyes and mentally scan your entire body for any points of tension.

In addition, activities that require repetitive movement, such as swimming, can produce a mental state similar to that achieved with meditation. The same is true of yoga and other stretching exercises.

Your doctor may have more specific suggestions about how to best care for yourself before, during and after treatment for ovarian cancer.

Coping skills

A diagnosis of cancer can be extremely challenging. Even when a full recovery is likely, you may worry about a recurrence of the disease. But no matter what your concerns or prognosis, you're not alone. Here are some strategies and resources that may make dealing with cancer easier:

• Know what to expect. Find out everything you can about your cancer — type, stage, treatment options and side effects. The more you know, the more active you can be in your own care. In addition to talking with your doctor, look for information at your local library and on Web sites affiliated with reputable organizations. You can also obtain reliable information by contacting the National Cancer Institute at (800) 4-CANCER, or (800) 422-6237, or the American Cancer Society at (800) 227-2345.
• Be proactive. Although you may feel tired and discouraged, don't let others — including your family or your doctor — make important decisions for you. It's vital that you take an active role in your treatment.
• Maintain a strong support system. Strong relationships can play an important role in surviving cancer. Although friends and family can be your best allies, they may sometimes have trouble dealing with your illness. When this is the case, the concern and the understanding of a formal support group or other cancer survivors can be especially helpful. Although support groups aren't for everyone, they can be a good source of practical information. You may also find that you develop deep and lasting bonds with people who are going through the same things you are. Support groups for the families of cancer survivors are also available.
• Set reasonable goals. Having goals helps you feel in control and can give you a sense of purpose. But don't choose goals you can't possibly reach. You may not be able work a 50-hour week, for example, but you may be able to work at least half-time. In fact, many people find that continuing to work can be helpful.
• Take time for yourself. Eating well, relaxing and getting enough rest can help combat the stress and fatigue of cancer. Also, plan ahead for the downtimes when you may need to rest more or limit what you do.
• Look for a connection to something beyond yourself. Having a strong faith or a sense of something greater than yourself seems to be a key factor in coping with and surviving cancer.