Ovarian Cancer

Ovarian Cancer

Cancer refers to a disease in which mutated cells grow abnormally and rapidly in the body and may spread from one organ or area to another. Ovarian cancer is named for where this type of cancer begins, in the female’s ovaries.

Ovarian cancer is the tenth most common cancer in females in the United States and is the fifth leading cause of death due to cancer. A little over 20,000 women are diagnosed with this disease in the US each year. Most women do not find out that they have this cancer until it is at a later stage, as it is not a common disease and there is no good way to screen for or to confirm the disease non-invasively.

What is ovarian cancer?

Ovarian cancer refers to cancer that develops in the ovaries, where the female body matures and releases eggs and produces select hormones. It may also refer to cancers that originate in the fallopian tubes or the peritoneum (tissue lining overlying organs in the abdomen) nearby.

What are the symptoms?

Early on with ovarian cancer, there are no obvious symptoms. As the cancer grows and spreads, symptoms may appear or become more obvious. Some symptoms mimic pregnancy symptoms and include:

  • Bloating
  • Changes in vaginal bleeding or discharge
  • Higher frequency or urgency of urination (suddenly needing to go)
  • Pelvic/abdominal pain or pressure
  • Back pain
  • Feeling full quickly and/or trouble eating
  • Constipation
  • Stomach pain and/or heartburn
  • Pain during sex

It is suggested to consult with your primary care doctor (preferably your gynecologist) about your concerns if the symptoms are new and either (1) last more than 2 weeks, and/or (2) occur more than 12 times in a month.

Is ovarian cancer linked to any genes/inherited?

Both ovarian and breast cancers are linked to breast cancer susceptibility genes 1 and 2 (BRCA1 and BRCA2), and thus the risk factor can be passed on. Genetic mutations in BRCA1 and BRCA2 create an increased risk of developing these two cancer types. There is also a link to increased risk of ovarian cancer with other mutated cancer-associated genes (either tumor suppressors or proto-oncogenes), including PTEN (Cowden disease); MLH1, MLH3, TGFBR2, MSH2, MSH6, PMS1, and PMS2 (hereditary nonpolyposis colon cancer or HNPCC/Lynch syndrome); STK11 (Peutz-Jeghers syndrome); and MUTYH (MUTYH-associated polyposis).

Inherited mutated genes cause 5 to 10% of cancers in general; all others come about through acquired mutations which begin in one cell in a person’s body and are passed to another cell through mitosis when the cell divides.

If I have a family history of the disease, does that mean that I will get it for sure?

Having a family history of ovarian cancer does not mean that you are definitely going to develop it. A family history just means that you are more likely to have inherited a problematic gene (such as BRCA1 or BRCA2) that increases your chances of developing certain types of cancer. The more family members (on your mother OR father’s sides) that you have with ovarian or breast cancers, the higher your personal risk is for developing ovarian cancer.

It is good to be aware of your family’s medical history. This way, if you do have a history of the disease, you can have a conversation with your doctor about preventative measures and/or a screening schedule. Your doctors may want to run some genetic testing to see if you have any of the typical genetic mutations in the cancer-associated genes mentioned above.

Are there links to other diseases or cancers that my family or just I have had that can increase my risk?

A personal history of breast, colorectal, or uterine cancers can mean an increased personal risk of developing ovarian cancer. Family diseases, such as ovarian, breast, and colorectal cancers as well as MUTYH-associated polyposis, HNPCC/Lynch syndrome, Cowden disease, and Peutz-Jeghers syndrome can also mean an increased risk of developing ovarian cancer.

What are other risk factors for ovarian cancer?

Though no risk factor can guarantee that you will develop ovarian cancer, here are a few things (other than genetics and family history mentioned above) that may increase your chances of developing ovarian cancer:

  • Increased age
    • It is most common after age 40.
    • Half of the diagnoses are given to women above 63.
  • Age at certain reproductive milestones
    • If you began menstruating before age 12.
    • If you have not carried a child to term by age 26-30.
    • If you begin menopause after age 50-52.
    • If you carry a child to term after age 35 or have never been pregnant and carried to term.
  • Obesity – women considered obese (have a BMI >30) have an increased risk
  • Smoking – women’s risk increases with smoking, but only for one type of ovarian cancer:  mucinous
  • Using fertility treatments (hormonal) and especially failed attempts
  • Infertility
  • Having endometriosis
  • Using hormone replacement therapy after menopause, especially for over 5-10 consecutive years
  • Using talcum powder (especially asbestos-containing powder before the 1970s) on the genital regions
  • Taking drugs that contain androgens (male hormones) – this has not been confirmed by a larger study

If any or multiple of these apply to you and you are concerned about your symptoms, don’t put off talking to your doctor about your ovarian cancer risk.

Are there ovarian cancer screenings?

The US Preventative Services Task Force (USPSTF) does not suggest regular screenings for those who are not at risk via risk factors or family history. Often, screening techniques can show a false positive result and end in unnecessary surgery.

However, if you do have a family history, mutated BRCA1 or BRCA2 or any of the other genes listed above, or significant risk factors, screenings may be a helpful tool for you. If you notice any ovarian cancer symptoms whether or not you have a family history, some of these screening tests may also be used as diagnostic tools to find the cause of the symptoms:

  1. Pelvic Exam – Using two fingers and/or a speculum, your doctor will palpate your uterus and ovaries to note any enlargement or irregularity.
  2. Imaging – Using a CT scan or ultrasound, your doctor can get a visual of your ovaries (size, shape, and position) to see if there are any concerning anomalies.
  3. Blood Test – Checks for the presence of a protein (CA 125) present on the outer membrane of an ovarian cancer cell.

If any of these tests give abnormal or positive results, surgery may be the next step in order to confirm the presence of a tumor.

Ovarian cancer reproductive tract

How is ovarian cancer diagnosed?

Ovarian cancer is usually only diagnosed after a confirmational surgery. If ovarian cancer is suspected from one of the above tests, the next step is surgery. During surgery, the oncologist will determine if the cancer appears to be malignant, and if so, takes a sample of the tissue and the abdominal fluid surrounding it. He or she will also check the surrounding area to see if the tumor has spread, and to what extent. The biopsy/sample is sent to a pathologist who looks at the cells under a microscope and determines if the tumor is benign (noncancerous) or malignant (cancerous), and determines the grade of cancer. Your doctor may order more testing to determine how far the cancer has spread, its genetic makeup, and how it is affecting your other bodily systems.

Cancer is talked about in two different ways (other than the location at the start):  the grade of cancer (how abnormal the cells have become) and the stage of cancer (how far the cancer has spread).

What are the different grades of cancer, and what do they mean?

The “grade” of any cancer refers to how abnormal the tumor cells have become compared to a normal cell. A normal cell in the body has a specific function (such as a nerve cell) that requires certain proteins, enzymes, RNA, etc. to be present in the cell – this is when a cell is called “differentiated,” since it has a specific makeup and role. In a cancer cell, if there are only minor cellular/DNA changes, then it is considered more “differentiated” still. The more abnormal the cancer cells are, the more “undifferentiated” they are.

GX (undetermined grade):  It is unable to determine how differentiated the cells are.

G1 (low grade):  The cells are well differentiated.

G2 (intermediate grade):  The cells are somewhat differentiated.

G3 (high grade):  The cells are poorly differentiated.

G4 (HIGH grade):  The cells are undifferentiated.

The more normal or differentiated the cells of the tumor are, the better the prognosis. When tumor cells gain new mutations that either shut off genes that act to prevent cancerous growth and activity (tumor suppressor genes) or that turn on or increase production or activity of genes that promote cell growth and division (proto-oncogenes), this “undifferentiates” the cells. This means that the cells can no longer grow and mature fully before dividing, and checkpoints are no longer in place to ensure correct and timely cell division and protein/enzyme/cofactor production. The more undifferentiated the cells become, the more difficult it is to kill and prevent the growth and division of those cells.

The higher the grade of cancer, the more likely it is to metastasize (move to and grow in new locations) and it is usually deemed more “aggressive” due to this. Depending on the stage and grade of cancer, the treatment regimen may need to be adjusted to most effectively kill and prevent the movement of the cancer.

What do the different stages of ovarian cancer mean?

There are four stages of ovarian cancer with which one might be diagnosed. The staging depends on the extent that the cancer has or has not traveled in the body. Most women with the disease are not diagnosed until Stage II or beyond. The stages described below are specific to ovarian cancer only:

Stage I:  cancer is confined to one or both ovaries (or fallopian tubes)

  • IA:  only one ovary
  • IB:  involves both ovaries
  • IC:  involves one or both, but cancer cells are sloughing off from the ovary(s). [IC1 – rupture of tumor capsule during surgery; IC2 – rupture of tumor capsule prior to surgery; IC3 – cancerous cells found in peritoneal fluid]

Stage II:  cancer in one/both ovaries and has spread to other areas of the pelvis

  • IIA:  includes fallopian tubes and/or uterus
  • IIB:  includes other pelvic organs

Stage III:  cancer is present in the abdomen

Stage IV:  cancer is present in areas outside the pelvis & abdomen

Typically, a higher stage of cancer is associated with a higher grade of cancer. Like mentioned above, your treatment will reflect both the grade and stage of cancer. It will also take into account location of the cancer and how much is able to be removed through surgery.

What treatments are available?

As or before you pursue treatments, be sure to make an appointment with a gynecologic oncologist. These doctors specialize in treating cancers of the female reproductive system. One or more studies have shown that ovarian cancer patients treated specifically by a gynecologic oncologist in surgery experience better outcomes than those whose “debulking” surgery is not performed by an oncologist.

A typical treatment cycle for ovarian cancer first involves a “debulking” surgery in which an oncologist will remove all tumors which are visible in the abdominal region. The surgeon will have additional guidance from any imaging scans taken of your abdominal region in order to remove as much cancer as possible.

Once the surgery is complete, the patient will likely undergo at least 6 chemotherapy sessions with the intent to kill any cancer cells that were not removed during surgery. Though debulking surgery followed by 6 chemo sessions is the suggested treatment for ovarian cancer, fewer than 40% of women diagnosed with ovarian cancer receive this care.

Chemotherapy can be introduced to the body through two main routes:

  1. IV (intravenous):  Chemo medication introduced through a needle inserted into a vein (usually in the arm). The medication is set up as a drip from a bag and through the veins, it will reach your entire system.
  2. IP (intraperitoneal):  First, a “port” and catheter must be surgically placed so that the medication is directly released into your peritoneal cavity (where most of the abdominal organs lie). This way, the chemo drugs can deliver a more concentrated and direct hit to the site of the cancer. This is especially helpful for ovarian cancer treatment since most of the metastases are within the peritoneum.

Sometimes chemotherapy is given through both of these routes, which has become a very effective treatment regimen for many women diagnosed with advanced stage ovarian cancer. Ask your doctor if he or she believes that this is the right option for you. If chemotherapy is used as a treatment before debulking surgery, it is referred to as neoadjuvant chemotherapy.

As for other available treatments, radiation therapy is not usually used to treat ovarian cancer. There may be cases where your doctor may recommend radiation, but it is not as common. There are a few other drugs that may be suggested for your specific diagnosis, including angiogenesis inhibitors (stops the growth of new arteries and veins that would supply nutrition to a cancerous growth) and other specific targeting drugs. Ask your doctor if there are any other additional therapies such as these or clinical trials that would benefit your treatment plan.

Is a hysterectomy or a bilateral salpingo-oophorectomy often suggested?

These two surgeries may be suggested if the cancer is still localized only to the ovaries, fallopian tubes, and/or uterus. If the cancer has already spread beyond these organs, it may not be necessary or suggested by a doctor. If the cancer is caught early and/or you are still young and wish to bear children, the doctor may want to forego removing your ovaries and/or uterus. If there are a lot of genetic issues (many cancer susceptibility genes are mutated/there is extensive family history), it might also be suggested on the idea that the cancer may return later if the ovaries are not removed.

This is more often seen as a personal choice than a purely medical preventative measure, so make sure to meet with your gynecologic oncologist to talk about your options and any risks involved.

How can I prevent ovarian cancer?

Though there is no way to completely erase your chances of developing ovarian cancer (short of having your ovaries removed), here are some things that can decrease your risk of developing ovarian cancer:

  • Using hormonal birth control.
    • Women who have been on a combination estrogen and progesterone pill for greater than 3-6 months (more beneficial if 5 years or longer) have a decreased risk.
    • Women who have used the Depo-Provera shot for any amount of time (more beneficial if 3 years or longer) have a decreased risk.
  • Avoiding smoking.
  • Breastfeeding.
  • Becoming pregnant and carrying at least one child to term before age 35, and it most reduces your risk if you have your first before age 26.
  • Eating a healthy and well-balanced diet. Some studies suggest that low-fat, high vegetable, and low red/processed meats diets can reduce a person’s overall cancer risk.

Talk to your doctor before deciding to add in hormonal birth control for this reason. If you are at risk for ovarian cancer, it is also wise to discuss your pregnancy plans with your doctor. It is also suggested to consult with your physician before beginning a new diet or meal plan.

Can I get ovarian cancer if I’ve had a hysterectomy?

Yes, a female can still get ovarian cancer even after a hysterectomy. Since a typical hysterectomy refers to the removal of the uterus (and possibly cervix) and not the ovaries/fallopian tubes, the ovaries are still in the body. One risk factor for developing ovarian cancer that we mentioned above is hormone replacement therapy for more than 5-10 years (especially when estrogen-only) that often occurs after a hysterectomy.

If you’ve had a hysterectomy and hormone replacement therapy, or a hysterectomy that brought on early menopause, speak with your doctor about your risk factors for ovarian cancer. If you have any mutations in cancer susceptibility genes (like BRCA1 and BRCA2), you may want to consider removal of the ovaries (uni- or bilateral salpingo-oophorectomy) as a precautionary measure. This is not a widely suggested surgery, and your doctor will only recommend this if the risk of developing ovarian cancer is high enough to outweigh the risks associated with ovary removal.

For more information:

If you’d like to learn more about ovarian cancer and the resources available to you (including clinical trials, tips on talking with your doctor, and support groups), visit our article Ovarian Cancer Resources. Feel free also to check out the organizations in our Sources list below.

Last updated: September 14, 2017 at 16:46 pm

Compiled using information from the following sources:

1. Ovarian Cancer Research Fund Alliance (OCRFA): About Ovarian Cancer.

https://ocrfa.org/patients/about-ovarian-cancer/

2. American Cancer Society (ACS): Ovarian Cancer.

https://www.cancer.org/cancer/ovarian-cancer.html

3. National Ovarian Cancer Coalition: What is Ovarian Cancer?

http://ovarian.org/about-ovarian-cancer/what-is-ovarian-cancer

4. Mayo Clinic: Ovarian Cancer

http://www.mayoclinic.org/diseases-conditions/ovarian-cancer/basics/definition/con-20028096

5. Medline Plus: “Most Women Should Forego Ovarian Cancer Screening: Panel.”

https://medlineplus.gov/news/fullstory_167271.html

6. Centers for Disease Control and Prevention (CDC): Ovarian Cancer.

https://www.cdc.gov/cancer/ovarian/basic_info/risk_factors.htm