Cancer Care Center
Ovarian Cancer
 What Is Ovarian Cancer?
Ovarian cancer begins in the ovaries. Women have
two ovaries, one on each side of the uterus in the pelvis. The ovaries produce eggs
(called ova). They are also the main source of a woman’s female hormones, estrogen
and progesterone. The eggs travel through the fallopian tubes to the uterus.
Here they may be fertilized and develop into a fetus. Ovarian cancer begins in
theh ovaries. It can also begin in the fallopian tubes.
The ovaries contain 3 kinds of tissue:
- Germ cells:
These cells make eggs (ova) inside of the ovary
- Stromal cells:
These cells are inside the ovary, between germ cells. They make most of the
female hormones (estrogen and progesterone)
- Epithelial cells: These cells cover the ovary. Most
ovarian cancers start in this covering.
Many types of tumors can start
in the ovaries. Some are benign (non-cancerous) and never spread beyond the
ovary. Women with these types of tumors can be successfully treated by removing one
ovary or the part of the ovary that has the tumor. Other types
of tumors are cancerous (malignant) and can spread to other parts of the body.
Their treatment is more complicated.
Tumors in the ovary are named for the kinds of cells the tumor started from
and whether the tumor is benign or cancerous. There are three main types of
tumors:
- Germ cell tumors start from the cells that produce the eggs
- Stromal tumors
start from connective tissue cells that hold the ovary together and make the
female hormones
- Epithelial tumors start from the cells that cover the
outer surface of the ovary.
Types of Ovarian Cancer 
Epithelial Ovarian Tumors
Epithelial ovarian tumors are further divided into 3
sub-groups:
- Benign epithelial tumors: These tumors do not spread and usually do not lead to serious
illness.
- Tumors of low malignant potential (LMP tumors): These tunmors do not clearly appear to be
cancerous when looked at under the microscope. They are also known as
borderline tumors
. These tumors affect women at a younger
age than other ovarian cancers. They grow and spread slowly and are much less
serious than most ovarian cancers.
Primary Peritoneal Carcinoma
This condition is a cancer much like
epithelial ovarian cancer but it starts outside of the ovaries. It grows from
the cells that line the pelvis and abdomen. These cells look just like the
cells along the surface of the ovaries. Women who have had their ovaries
removed can still get this type of cancer. Symptoms of this cancer are much
like those of ovarian cancer. Treatment is also similar.
Germ Cell Tumors
About 1 in 20 ovarian
cancers are germ cell tumors. Germ cells make the eggs. Most germ cell tumors
are not cancer, although some can be. There are several sub-types of germ cell
tumors.
Stromal Tumors
Stromal tumors can be either
benign (non-cancerous) or cancerous. More than half are found in women over
age 50. Some of these tumors make hormones. There are many different types of
stromal tumors. Treatment depends on the type.
 Ovarian cysts
An ovarian cyst is formed by fluid that collects inside an
ovary. Many of these cysts are harmless. The fluid will most often be absorbed
and the cyst will disappear in time without any treatment.
-
A very small number
of these cysts are cancerous. If the cyst is large or develops in childhood or
after menopause, the doctor may suggest further tests or treatment.
Fallopian
tube cancer
Fallopian tube cancer is very rare. it begins in
the fallopian tube, and produces symptoms similar to ovarian
cancer, except there may be more pelvic pain. Treatment and prognosis is
also similar to ovarian cancer.
- Epithelial ovarian cancers: Nearly 9 out of 10 ovarian cancers are epithelial ovarian cancer. These cancer cells have certain
features that are visible under a microscope, which allow doctors to further classify them.
Cancer?
Ovarian cancer is
the eighth most common cancer in women (not counting skin cancer). It ranks
fifth as the cause of cancer death in women. The American Cancer Society
estimates that there will be about 20,180 new cases of ovarian cancer in this country in 2006. About 15,310
women will die this year because of the disease. Around two-thirds of women with ovarian
cancer are 55 or older. It is slightly more common in White women that African-American
women.
The rate of ovarian cancer has gone down about 0.7% per year since 1985. A
woman’s risk of getting ovarian cancer during her lifetime is about 1 in 67. The
risk of getting this cancer and dying from it is 1 in 95.
What Causes Ovarian Cancer?
The cause
of ovarian cancer is not yet known,
but we do know some of the risk factors. These include smoking, age,
and race. It is important to remember that while risk factors
increase the odds of getting a disease, they do not guarantee it will
occur.
Risk factors for epithelial ovarian
cancer:
- Age: Most
ovarian cancers happen after change of life (menopause). Half of all these
cancers are found in women over the age of 63.
- Obesity: A
study from the ACS found a higher rate of death from ovarian cancer in women
who were overweight. The risk went up by 50% in the heaviest women.
- Menstrual periods: There seems to be a link between the number of periods
(menstrual cycles) in a woman’s lifetime and her risk of getting ovarian
cancer. Women who started having periods early (before 12 years of age) or who
went through the change of life (menopause) after the age of 50 have a small
increased risk of ovarian cancer. The same is true for women who have not had
children, or had their first child after they were 30 years old.
- Fertility drugs: Some studies have found that long-time use of one fertility
drug (clomiphene citrate), especially if no pregnancy took place, may increase
the risk of LMP tumors. But infertility also increases the risk, even without
the use of fertility drugs. Research in this area is now going on.
- Family history:
Ovarian cancer risk is higher among women whose close blood relatives (mother,
sister, daughter) have (or had) this disease. The relatives can be from either
the mother’s or father’s side of the family. There is a higher risk if ovarian
cancer happened at an early age. About 1 in 10 cases of ovarian cancers are
linked to gene changes that can be found with certain tests. These changes are
also linked to an increased risk of breast and colorectal cancer.
- Breast cancer:
Women who have had breast cancer also have a higher risk of ovarian cancer.
- Talcum powder:
Some studies have shown a slight increase in risk of ovarian cancer among
women who used talcum powder on the genital area. Asbestos in the powder may
explain the link. But these products have been free of asbestos for more than
20 years.
- Estrogen replacement therapy (ERT): Some studies suggest that women using estrogens after
menopause may have an increased risk of ovarian cancer, but other studies have
not found any effect. Most of these findings have been for women who used
estrogen alone, not those taking combined estrogen and progesterone. The
increased risk is less certain for women taking both drugs. Because of the
small number of studies, doctors are not sure whether estrogens increase the
risk of ovarian cancer.
- Smoking and alcohol use: Some studies have found an
increased risk for one type of ovarian cancer (mucinous).
Can Ovarian
Cancer Be Prevented?
Most women have
one or more risk factors for ovarian cancer., but each risk factor increases
the odds of developing the disease only slightly. To date, current knowledge of the
disease and risk factors has not led to steps to prevent the disease.
Some of the actions listed below may reduce the risk of the most common type
of ovarian cancer (epithelial) only slightly, while others may decrease it much
more. If you are concerned about your risk, especially if you have a family
history of cancer, you should discuss this information with your doctor.
- Birth control pills: Birth control pills reduce the risk of ovarian cancer,
especially among women who use them for several years.
- Tubal ligation or hysterectomy: "Tying" the tubes as a method of birth control, when
done after childbearing, may reduce the chance of ovarian cancer. Removing the
uterus may also reduce the risk. But these surgeries should only be done for a
valid medical reason and not just for their effect on ovarian cancer risk.
- Pregnancy and breast-feeding: Having one or more children plus breast-feeding for a
year or longer may decrease the risk of ovarian cancer. Although these
measures slightly reduce the risk, they don’t offer complete protection.
Doctors do not suggest making these choices about when to have a child simply
for the purpose of reducing ovarian cancer risk. Keep in mind that using the
birth control pill has a greater impact on this risk.
- Diet: A number
of studies have shown a lower rate of this cancer in women who ate a diet high
in vegetables. The American Cancer Society recommends eating a wide variety of
healthful foods, with many from plant sources. Eat at least 5 servings of
fruits and vegetables every day. Limit the amount of red meats, especially
those that are high in fat.
- Aspirin and acetaminophen: Some studies have shown that
both aspirin and acetaminophen (Tylenol) reduce the risk of ovarian cancer.
But there is some doubt about this. Women should not take these drugs simply
to prevent this cancer. More research is needed.
Women with a family history of ovarian cancer might want to think about
genetic counseling and perhaps genetic testing. Before asking for the test, a woman should
discuss the benefits and possible drawbacks with her doctor. Genetic testing can determine if a
woman carries certain gene changes that cause a higher risk of ovarian cancer.
Studies looking at whether the birth control pill could lower the risk of
ovarian cancer have shown mixed results. For women at average risk, the pill
does lower the risk. But for women at high risk because of gene changes, the
results are mixed. More research is needed to make clear the pros and cons of
the pill for women at high risk of ovarian or breast cancer.
Surgery to remove one or both ovaries is called oophorectomy. It can be done
before a cancer develops in order to lower the risk. But whether or not a woman
should have this surgery is open to question because it causes change of life
(menopause) to take place early. Often, doctors suggest it only for certain
women over the age of 40 who are at very high risk. While this operation lowers
ovarian cancer risk a great deal, cancer can still form in the cells lining the
pelvis where the ovaries were located.
How Is Ovarian Cancer Found?
About one fifth of
ovarian cancers are found at an early stage. Finding the cancer early improves
the chances that it can be treated successfully. Nine out of 10 women treated
for early ovarian cancer will live longer than 5 years after the cancer is
found. Unfortunately, there is no reliable test for finding this cancer early,
but several large studies are in progress 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 doctor will feel the
female organs to check their size and shape. But most ovarian tumors are hard to
find early because the ovaries are deep within the body and the doctor cannot
feel them easily. While the Pap test helps to find cervical cancer early, it is
not really useful for finding ovarian cancer at an early stage.
By the time ovarian cancer is thought of as a possible cause of these
symptoms, it may already have spread beyond the ovaries. Also, some types of
ovarian cancer can quickly spread to the surface of nearby organs. Still,
prompt attention to symptoms can improve the odds of finding the cancer early
and treating it successfully. If you have any of the symptoms above, report
them to your doctor right away.
- Screening tests: These tests and exams are used to find a disease such as
cancer in people who don’t have any symptoms. Women with a high risk of
ovarian cancer (such as those with a strong family history of the disease) may
be screened with ultrasound and with blood tests. But early studies of women
at average risk of ovarian cancer show that these tests did not lower the
number of deaths caused by ovarian cancer. For this reason, these tests are
not used for routine screening of women who don’t have strong risk factors.
If there is any reason to suspect ovarian cancer, the doctor will use one or
more methods to find out if the disease is really present. One of the first
steps will be a meeting with a doctor who has special training in treating women
with this type of cancer (a gynecologic oncologist). Following are some of the
tests that could be done:
- Imaging Studies : These tests can show whether there is a mass in the pelvis, but
they cannot tell whether it is cancer.
- Ultrasound:
This test uses sound waves to create an image on a video screen. Because
tumors and normal tissue reflect sound waves differently, this test may be
useful in finding tumors and in telling whether a mass is solid or a
fluid-filled cyst.
- CT scans (computed tomography): These scans use an
x-ray beam to take a series of pictures of the body from many angles. A
computer combines the pictures to form a detailed image. CT scans are
useful in showing how large the tumor is, whether lymph nodes are
enlarged, and whether the tumor has spread to other organs. CT scans can
also be used to guide a biopsy needle into a tumor in order to remove a
sample of tissue.
CT scans take longer than regular x-rays. You will need to lie still on a
table while they are being done. Also, some contrast dye will be injected or you
may be asked to drink a contrast fluid.
- Barium enema x-rays: These can be done to see whether the cancer has spread to
the large intestine or rectum. A chalky substance (barium sulfate) will be
placed into the rectum and colon. The barium outlines the colon and rectum
on x-rays.
- Colonoscopy: After you have taken a
laxative, the doctor inserts a tube into the rectum and into the colon.
Through this, the doctor can see inside and spot any cancer. Because it is
uncomfortable, you will be sedated. This test is also used to look for
colorectal cancer.
- MRI (magnetic resonance imaging): Like a CT scan, MRIs display a
cross-sectional picture of the body. But an MRI uses radio waves and
strong magnets instead of x-rays. MRI scans are helpful in looking at the
brain and spinal cord. These scans take longer than CT scans, often up to
30 minutes or more.
- Chest x-rays: These may be taken to see if the cancer has spread to the
lungs.
- PET (Positron emission tomography): PET scans use a
form of radioactive sugar (glucose) to look for the cancer. Cancers use
sugar at a higher rate than normal tissues. This means that the
radioactivity will tend to collect in the cancer which will make it
visible on the scan. This test is sometimes useful to find ovarian cancer
that has spread.
- Other Tests
- Laparoscopy: This is another method that
lets the doctor take pictures of the ovaries and other pelvic organs. A
thin, lighted tube is placed through a small cut (incision) into the
lower
abdomen.
- Tissue sampling: The only way to tell for certain if a growth in the
pelvis is cancer involves removing a sample of tissue or fluid to see if
cancer cells are present. This is called a biopsy and is often done at the
time of surgery. It can also be done as a test separate from the surgery,
such as during a laparoscopy.
- Blood tests: These tests are done to make sure you
have the right number of the different kinds of blood cells. The tests
also measure kidney and liver function, and look for a substance called
CA-125. CA-125 is a protein in the blood that may be higher than normal in
some women with ovarian cancer. It is sometimes called a tumor marker for
ovarian cancer.
Staging
Staging is the process of finding out
how far the cancer has spread. This is very important because ovarian cancers at
different stages are treated differently. Once a stage has been assigned, it
doesn’t change, even if the cancer spreads to other areas of the body or comes
back later. Staging is usually done during surgery.
One goal of surgery is to obtain tissue samples and to remove all cancer
tumors larger than about ½ inch. Surgery and an examination of the tissues under
a microscope will help the doctor decide the stage of the tumor. The AJCC/TNM
system is used to stage the cancer. This system describes the cancer in terms of
the extent of the tumor (T), whether or not it has spread to nearby lymph nodes
(N), and whether it has spread to organs farther away (or metastasized, M).
Once the TNM groups have been decided, the information is combined to give a
number from 1 to 4. The stage is expressed as a Roman numeral. In general, the
lower the number, the less the cancer has spread. A higher number, such as stage
IV (4), means a more serious cancer.
Summary of Ovarian Cancer Stages
Stage I: The cancer is contained within the ovary (or ovaries)
Stage II: Cancer is in one or both ovaries and has spread
to other organs in the pelvis, such as the bladder, colon, rectum, or
uterus.
Stage III: The cancer is in one or both ovaries and has
spread to the lining of the abdomen or to the lymph nodes.
Stage IV: This is the most advanced stage. The cancer has
spread from one (or both) ovaries to distant organs, such as the liver or
lungs, or there may be cancer cells in the fluid around the lungs.
Recurrent: The cancer has come back (recurred) after
treatment.
The above stages can be further divided into sub-groups. Ask your doctor to
explain the exact stage of your cancer in terms you can
understand
How Is
Ovarian Cancer Treated?
After the tests are done, your doctor will suggest one or
more options for treatment. The choice of treatment depends largely on the type of
cancer and the stage of the disease. If you have not had surgery
yet, the exact stage may not be known. In that case, treatment is based
on what is known.
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 limiting factor. Studies
have shown that older women can take ovarian cancer treatments well. Be sure you
understand all the risks and side effects of different treatments before you
make a decision.
The main treatments for ovarian cancer are surgery, chemotherapy, and
radiation therapy. In some cases 2 or even all 3 of these treatments will be
used.
How much and what type of surgery a woman has depends
on how far the cancer has spread, her general health, and whether or not
she still hopes to have children.
There are several different types of surgery for ovarian cancer. If both
ovaries or the uterus are removed, you will not be able to get pregnant. It
also means that you will go through change of life if you haven’t already.
Most women will be in the hospital for 3 to 7 days after surgery. Recovery
usually takes about 4 to 6 weeks.
If all of the tumor can’t be removed, the surgeon might remove as much as
possible in a procedure called debulking (or cytoreduction). Most doctors
believe this greatly improves a woman’s chance for survival.
Your surgeon
should be experienced in ovarian cancer surgery. For this reason, many doctors refer
their patients to doctors with special training called gynecologic oncologists.
A gynecologic oncologist is a doctor who works with women who have cancer of the
uterus, ovary, breast, or other part of the female system.
Chemotherapy refers to the use of drugs to kill cancer cells. Usually the
drugs are given into a vein or by mouth. Once the drugs enter the bloodstream,
they spread throughout the body. This treatment is especially useful when cancer
has spread beyond the ovaries.
The drugs can also be given directly into the abdomen. This approach aims the
drugs right at the cancer cells and limits the amount reaching the rest of the
body. This helps reduce side effects.
Chemotherapy is usually given in cycles of treatment followed by a rest
period. Chemotherapy is prescribed by an oncologist (cancer doctor).
While chemotherapy drugs kill cancer cells, they also damage some normal
cells, causing side effects. These side effects will depend on the type of drugs
given, the amount taken, and how long treatment lasts. Temporary side effects
might include the following:
- nausea and vomiting
- loss of appetite
- hair loss
- hand and foot rashes
- kidney or nerve damage
- mouth sores
- an increased chance of infection (from a shortage
of white blood cells)
- bleeding or bruising after minor cuts (from a
shortage of platelets)
- tiredness (from low red blood cell counts)
Most side effects go away when treatment ends. Hair will grow back,
although it may look different. Some side effects, such as menopause and
infertility, can be permanent. Rarely, some cancer drugs may cause another
cancer to develop. The small chance that this might happen should be weighed
against the positive effects of treating the ovarian cancer. Anyone who has
problems with side effects should talk with their doctor or nurse as there are
often ways to help.
 Radiation therapy uses high energy x-rays to kill or shrink cancer cells. The
radiation may come from outside the body or from radioactive materials placed
directly into or near the tumor. However, radiation therapy is rarely used in
this country as the main treatment for ovarian cancer.
Radiation therapy may cause side effects. The skin in the area treated may
look and feel sunburned. The skin returns to normal within 6 to 12 months. Many
women also feel tiredness, nausea or diarrhea. Be sure to talk with the doctor
about any side effects. Often there are ways to help.
Treatment for Epithelial Ovarian Cancer
The treatment for epithelial ovarian cancer depends on how far the cancer has
grown. Usually the first option is surgery to remove one or both ovaries. The
doctor may also advise surgery to remove other female organs. Treatment may
include chemotherapy or radiation therapy for early stage cancers. For stage III
and IV cancers, the tumor will also be debulked.
Chemotherapy is often given after surgery. If cancer returns after treatment,
more surgery and chemotherapy may be given.
After treatment, blood tests will be done to see if your CA-125 tumor marker
levels are normal.
The most common problems that can occur in women whose cancer has come back
are fluid build-up and blockage of the intestinal tract. Numbing the skin and
inserting a needle to draw off the fluid can relieve fluid build-up. This will
often need to be done again from time to time. This can extend life and relieve
symptoms for some women.
Dealing with the intestinal blockage can be harder. Often the cancer has
grown so much that surgery doesn’t fix the problem. Doctors can place a tube
through the skin and into the stomach to relieve fluid build-up in the digestive
tract. The goal is to relieve pain and keep the woman comfortable.
High dose chemotherapy with stem cell rescue (bone marrow transplant) has
been used for women with cancer that has come back or not gone away at all. This
approach has serious side effects. And it has not helped patients to live
longer. It should only be done as part of a clinical trial.
Treatment for Low Malignant Potential (LMP)
Tumors
For LMP (borderline) tumors, the ovary with the tumor and the fallopian tube
on the affected side are usually removed. In certain cases, just the ovarian
cyst with the tumor is removed. If the woman might want to become pregnant in
the future, and if there appears to be no cancer beyond the one ovary, no
further surgery is done at that time.
If the woman is not concerned about being able to have children, the ovaries,
fallopian tubes, and the uterus are removed. Chemotherapy and radiation are not
generally used at first for treatment of these tumors, although they may be used
if the tumor comes back after surgery.
Treatment for Germ Cell Tumors of the
Ovary
Women with benign germ cell tumors are cured by removing part or all of the
ovary and the fallopian tube on the affected side. It’s a good idea to consult
with a specialist since these tumors are so rare.
The treatment for germ cell cancers of the ovary depends on the exact type
and the stage of the cancer. Surgery will reveal the stage and which organs
should be removed. Most women with germ cell cancers will also have
chemotherapy.
Treatment for Stromal Cell Tumors
Most stromal cell tumors are confined to the ovary. They are treated by
removing the ovary with the tumor. If the tumor returns, more surgery and
chemotherapy may also be used. Rarely, radiation therapy may be used.
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