Ovarian cancer

Cancer refers to a disease in which mutated cells grow abnormally and rapidly in the body and can spread from one organ or area to another. Ovarian cancer gets its name from where this type of cancer begins in a woman's ovaries.

What is ovarian cancer?

Ovarian cancer refers to cancer that develops in the ovaries, where a woman's body matures and releases eggs and produces certain hormones. It can also refer to cancer that originates in the fallopian tubes or the peritoneum (the tissue that covers the abdominal organs) nearby.

What are the symptoms?

In the early stages of ovarian cancer, there are no obvious symptoms. As the cancer grows and spreads, symptoms may appear or become more obvious. Some symptoms mimic those of pregnancy 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 recommended that you consult your doctor (preferably a gynecologist) about your concerns if symptoms appear for the first time and last more than 2 weeks and/or occur more than 12 times a month.

Is ovarian cancer related to genes/heredity?

Ovarian and breast cancers are associated with the BRCA1 and BRCA2 breast cancer predisposition genes, so the risk factor can be inherited. Genetic mutations in BRCA1 and BRCA2 create an increased risk of developing these two types of cancer. There is also an association with an increased risk of ovarian cancer with other mutated cancer-associated genes (tumor suppressor or proto-oncogenes), including PTEN (Cowden's disease); MLH1, MLH3, TGFBR2, MSH2, MSH6, PMS1 and PMS2 (hereditary nonpolyposis colon cancer or HNPCC/Lynch syndrome); STK11 (Putz-Jeghers syndrome); and MUTYH (MUTYH-associated polyposis).

Overall, inherited mutated genes cause 5-10% of cancers; all the rest result from acquired mutations that begin in one cell of the human body and are transmitted to another cell by mitosis during cell division.

If I have a family history of illness, does that mean I will definitely get sick?

Having a family history of ovarian cancer does not mean you will definitely develop it. A family history simply 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 (maternal or paternal) you have with ovarian or breast cancer, the higher your personal risk of developing ovarian cancer.

It is good to know your family's medical history. Thus, if you have a medical history, you can discuss preventive measures and/or a screening schedule with your doctor. Your doctors may want to do genetic testing to see if you have any of the typical genetic mutations in the cancer-related genes mentioned above.

Are there any links to other illnesses or cancers that I or my family have had that could increase my risk?

Having a history of breast cancer, colorectal cancer, or uterine cancer may 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, may also mean an increased risk of developing ovarian cancer.

What are other risk factors for ovarian cancer?

While no single risk factor can guarantee that you will develop ovarian cancer, here are some factors (other than the genetics and family history mentioned above) that can 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 body mass index>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 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 screenings for ovarian cancer?

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

Pelvic Exam. Using two fingers and/or a mirror, your doctor will feel your uterus and ovaries to check for enlargement or abnormalities.
Imaging . Using a CT scan or ultrasound, your doctor can visualize your ovaries (size, shape, and position) to see if there are any abnormalities to worry about.
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 to confirm the presence of a tumor.

How is ovarian cancer diagnosed?

Ovarian cancer is usually only diagnosed after confirmatory surgery. If ovarian cancer is suspected based on any of the above tests, the next step is surgery. During surgery, the oncologist will determine if the cancer is malignant and, if so, will take a sample of abdominal tissue and fluid around it. He or she will also check the area to see if the tumor has spread and how far. The biopsy/sample is sent to a pathologist who examines the cells under a microscope and determines if the tumor is benign (noncancerous) or malignant (cancerous) and determines the grade of the cancer. Your doctor may order other tests to determine how far the cancer has spread, its genetic makeup, and how it affects other systems in your body.

We talk about cancer in two different ways (besides where it started): the grade of the cancer (how abnormal the cells have become) and the stage of the cancer (how far the cancer has spread).

What are the degrees 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 the presence of certain proteins, enzymes, RNA, etc. in the cell - this is when a cell is said to be "differentiated" because it has a certain composition and role. In a cancer cell, if there are only minor cellular/DNA changes, it is considered even more "differentiated". 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 tumor cells, the better the prognosis. When tumor cells acquire new mutations that block genes that prevent cancer growth and activity (tumor suppressor genes), or that turn on or increase the production or activity of genes that promote cell growth and division (proto-oncogenes), these cells are "undifferentiated". This means that cells can no longer fully grow and mature before dividing, and there are no longer checkpoints to ensure proper and timely cell division and protein/enzyme/cofactor production. The more cells that become undifferentiated, the harder it is to kill and prevent those cells from growing and dividing.

The higher the grade of the cancer, the more likely it is to metastasize (move and grow to new places), and for this reason it is generally considered more "aggressive". Depending on the stage and grade of the cancer, it may be necessary to adjust the treatment regimen to most effectively kill and prevent the spread of the cancer.

What do the different stages of ovarian cancer mean?

There are four stages of ovarian cancer that can be diagnosed. The stage depends on how far the cancer has or has not spread throughout the body. Most women with this disease are not diagnosed until stage II or higher. The stages described below are specific to ovarian cancer:

Stage I: Cancer limited 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 of one/both ovaries with spread to other pelvic areas

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

Stage III: The cancer is present in the abdomen

Stage IV: The cancer is present in areas outside the pelvis and abdomen.

Generally, a higher stage of cancer is associated with a higher grade of cancer. As mentioned above, your treatment will reflect both the grade and stage of the cancer. He will also take into account the location of the tumor and how much of it can be surgically removed.

What treatments are available?

Continuing treatment, be sure to make an appointment with a gynecologist-oncologist. These doctors specialize in treating cancer of the female reproductive system. One or more studies have shown that patients with ovarian cancer who are specifically treated by a gynecologist-oncologist in surgery achieve better outcomes than those who do not undergo "reduction" surgery by an oncologist.

A typical ovarian cancer treatment cycle first involves "reduction" surgery, in which the oncologist removes all visible tumors in the abdomen. The surgeon will benefit from additional guidance from any images obtained in the abdomen to remove as much of the cancer as possible.

After the surgery is completed, the patient will most likely have at least 6 sessions of chemotherapy to kill any cancer cells that were not removed during the surgery. Although massive reduction surgery followed by 6 sessions of chemotherapy is the recommended treatment for ovarian cancer, less than 40% of women diagnosed with ovarian cancer receive this care.

Chemotherapy can be administered to the body in two main ways:

intravenously: a chemotherapy drug is given through a needle inserted into a vein (usually in the arm). The medicine is given as a dropper from a bag and travels through your veins to your entire system.
Intraperitoneal: First, a “port” and a catheter must be surgically placed so that the medication enters directly into the abdominal cavity (where most of the abdominal organs are located). Thus, chemotherapy drugs can have a more targeted and direct effect on the cancer site. It is especially useful in the treatment of ovarian cancer since most metastases are found in the peritoneum.

Sometimes chemotherapy is given both ways, which has become a very effective treatment regimen for many women diagnosed with advanced ovarian cancer. Ask your doctor if he thinks this is the right option for you. If chemotherapy is used as a treatment before volume reduction surgery, then it is called neoadjuvant chemotherapy.

Like other treatments available, radiation therapy is not commonly used to treat ovarian cancer. There may be times when your doctor may recommend radiation therapy, but this is not common. There are several other drugs that may be suggested for your specific diagnosis, including angiogenesis inhibitors (stops the growth of new arteries and veins that will feed the cancer) and other specific drugs. Ask your doctor if there are other complementary treatments, such as these, or clinical trials that might help your treatment plan.

Is hysterectomy or bilateral salpingo-oophorectomy often suggested?

These two surgeries may be suggested if the cancer is still only in the ovaries, fallopian tubes, and/or uterus. If the cancer has already spread beyond these organs, this may not be necessary or suggested by a doctor. If the cancer is found early and/or if you are still young and want to have children, your doctor may decide not to have your ovaries and/or uterus removed. If there are many genetic problems (many cancer predisposition genes are mutated/great family history), it can also be assumed that the cancer may return later if the ovaries are not removed.

This is more often considered a personal choice than a purely medical preventive measure, so be sure to meet with your gynecologist/oncologist to discuss your options and the associated risks.

How can I prevent ovarian cancer?

While there is no way to completely negate your chances of developing ovarian cancer (unless you have had your ovaries removed), here are some things that can reduce 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 birth control injection 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 hormonal contraceptives for this reason. If you are at risk of developing ovarian cancer, it is also wise to discuss your pregnancy plans with your doctor. It is also recommended that you consult your doctor before starting any new diet or meal plan.

Can I get ovarian cancer if I had a hysterectomy?

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

If you've had a hysterectomy and hormone replacement therapy or a hysterectomy that led to early menopause, talk to your doctor about risk factors for ovarian cancer. If you have mutations in cancer predisposition genes (such as BRCA1 and BRCA2), you may consider having your ovaries removed (single or double salpingo-oophorectomy) as a precaution. This is not a widely recommended surgery and your doctor will only recommend it if the risk of developing ovarian cancer is high enough to outweigh the risks associated with spaying.