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Health Tips
Ovarian Cancer
Statistics
Johns Hopkins Pathology: Ovarian Cancer Research
Ovarian Cancer National Alliance
Ovarian cancer is a serious and under-recognized threat to women's health.
- Ovarian cancer kills more women than all the other gynecologic cancers combined.
- Ovarian cancer is the fifth leading cause of cancer death among women in the United States.
- Ovarian cancer occurs in 1 in 57 women, up from 1 in 70 several years ago.
- 14,500 women will die this year alone. More than 25,500 will be diagnosed.
Ovarian cancer is very treatable when it is detected early, but the vast majority of cases are not diagnosed until the cancer has spread beyond the ovaries.
- In cases where ovarian cancer is detected before it has spread beyond the ovaries, more than 90 percent of women will survive longer than five years.
- Only 25 percent of ovarian cancer cases in the U.S. are diagnosed in the beginning stages.
- When diagnosed in advanced stages, the chance of five-year survival is only about 25 percent.
Ovarian cancer may be difficult to diagnose because symptoms are easily confused with other diseases, and because there is no reliable, easy-to-administer screening tool.
Ovarian cancer is difficult to diagnose
- There is no reliable screening test for the early detection of ovarian cancer. The Pap smear only checks for cervical cancer.
- Symptoms are often vague and easily confused with other diseases. However, new studies indicate that ovarian cancer has recognizable symptoms, even early stage disease. Knowing those symptoms can help save women's lives.
Anatomy and Physiology
Johns Hopkins Pathology: Ovarian Cancer Research
The ovaries are a woman's reproductive organs. There are two ovaries, both located within the pelvis (lower region of the abdomen, between the hip bones), one on each side of the womb (uterus). The ovaries have a size and shape comparable to a large olive. The role of the ovaries is to produce eggs and also the female hormones. The primary female hormones released by the ovaries are estrogen and progesterone. These hormones regulate the menstrual cycle, pregnancy and development of a woman's physical appearance including breasts, shape and hair.
Symptoms of Ovarian Cancer
National Ovarian Cancer Coalition
Ovarian cancer is difficult to detect, especially, in the early stages. This is partly due to the fact that these two small, almond shaped organs are deep within the abdominal cavity, one on each side of the uterus. These are some of the potential signs and symptoms of ovarian cancer:
- Unexplained change in bowel and/or bladder habits such as constipation urinary frequency, and/or incontinence
- Gastrointestinal upset such as gas, indigestion, and/or nausea
- Unexplained weight loss or weight gain
- Pelvic and/or abdominal pain or discomfort
- Pelvic and/or abdominal bloating or swelling
- A constant feeling of fullness
- Fatigue
- Abnormal or postmenopausal bleeding
- Pain during intercourse
Because these signs and symptoms of ovarian cancer have been described as vague or silent, only around 10% of ovarian cancer is found in the early stages. Symptoms typically occur in advanced stages when tumor growth creates pressure on the bladder and rectum, and fluid begins to form.
Risk Factors
Johns Hopkins Pathology: Ovarian Cancer Research
Ovarian cancer occurs more frequently under the following conditions:
- History of ovarian cancer in your immediate family
- Age (over 50 years)
- No children (the greater the number of pregnancies, the lower the risk for developing ovarian cancer)
- Past history of breast cancer
- Race-ovarian cancer occurs 50% more frequently in white women than African American women.
- Jewish descent
- Hormone replacement therapy in post-menopausal women very slightly increases the risk for ovarian cancer
- Infertility drug use- a nearly 3-fold increase in risk was found, with a substantially greater risk in those who fail to conceive. However, this is not a consistent finding and most of these "carcinomas" are borderline tumors.
- High fat diet is associated with higher rates of ovarian cancer in industrialized nations, but the link remains unproven.
- Talc-use of cosmetic talc in feminine hygiene sprays or in sanitary napkins has been suggested as a risk factor. However, this is not a consistent finding.
More Risk Factors
National Ovarian Cancer Coalition
Current recommendations for management of women at high risk for ovarian cancer are summarized below:
- Women who appear to be at high risk for ovarian or breast cancer should undergo genetic counseling and, if the risk appears to be substantial, may be offered genetic testing for BRCA1 and BRCA2
- Women who wish to preserve their reproductive capacity can undergo screening by transvaginal ultrasonography every 6 months, although the efficacy of this approach is not clearly established.
- Oral contraceptives should be recommended to young women before they embark on a planned family
- Women who do not wish to maintain their fertility or who have completed their family may undergo prophylactic bilateral salpingooophorectomy. The risk should be clearly documented, preferably established by BRCA1 and BRCA2 testing, before oophorectomy. These women should be counseled that this operation does not offer absolute protection because peritoneal carcinomas occasionally can occur after bilateral oophorectomy.
- In women who also have a strong family history of breast cancer, annual mammography screening should be performed beginning at age 30 years.
- Women with a documented HNPCC syndrome should undergo periodic screening mammography, colonoscopy, and endometrial biopsy.
Prevention
Johns Hopkins Pathology: Ovarian Cancer Research
Prevention means avoiding risk factors that increase the chance of contracting a disease. There are no known simple protective measures that completely prevent ovarian cancer. However, ovarian cancer occurs less frequently under the following conditions:
- Multiple children-women with children have a 45% decrease in risk of ovarian cancer relative to those women who have not born children. Each child is associated with a 10-15% reduction in risk.
- Breast feeding-a reduction in lifetime risk for ovarian cancer of nearly 1% for each month of lactation has been reported.
- Oral contraceptive use-OC use appears to reduce the risk of ovarian cancer by 30-60% depending upon the duration of use.
- Tubal ligation (sterilization)-33% decrease in risk
- Hysterectomy
- Removal of the ovaries (Prophylactic oophorectomy)-this is only considered in patients proven to carry the following inherited cancer syndromes: familial site-specific ovarian cancer, familial breast/ovarian cancer, Lynch II syndrome. The benefits are as yet unproven and should be discussed with a genetic counselor.
Screening
National Cancer Institute
Tests that examine the ovaries, pelvic area, blood, and ovarian tissue are used to detect (find) and diagnose ovarian cancer. The following tests and procedures may be used:
- Pelvic Exam: A procedure to check the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum to find any abnormality in their shape or size. (A Pap test does not help diagnose ovarian cancer.)
- Ultrasound test: A procedure that bounces sound waves off the ovaries and changes the echoes into sonograms (pictures).
- CA-125 assay: A blood test used to measure the level of CA-125, a substance sometimes found in an increased amount in the blood, other body fluids, or tissues and that may be a sign of ovarian cancer.
- Barium Enema (lower GI series): A procedure used to show tumors or other abnormal areas in the pelvis. A liquid containing barium is put into the rectum by way of the anus. Barium is a silver-white metallic compound that helps to show the image of the lower gastrointestinal tract on an x-ray.
- Intravenous Pyelogram: A series of x-rays of the kidneys, ureters, and bladder to help determine if cancer has spread outside the ovaries. The x-rays are taken after a dye is injected into a blood vessel. The dye is concentrated in the urine, which outlines the kidneys, ureters, and bladder on the x-rays.
- CT Scan (CAT scan): A CT scan creates a series of detailed pictures of areas inside the body, taken from different angles. The pictures are created by a computer linked to an x-ray machine. This test is also called computed tomography, computerized tomography, or computerized axial tomography.
- Biopsy: Removal of tissue for examination under a microscope. The tissue is removed in a procedure called a laparotomy (a surgical incision made in the wall of the abdomen).
Types of Tumors
Johns Hopkins Pathology: Ovarian Cancer Research
Cancer is not a single disease, but encompasses well over a hundred distinct diseases of different organs. Normally cells divide only when additional cells are required for normal body function. However, at certain times the controls that regulate when a cell divides are lost. This results in accumulation of more and more cells without order. Eventually these cells grow into a mass and this is termed a 'tumor'. It is important to understand that not all tumors are cancer:
There are THREE main types of ovarian tumors:
- Epithelial ovarian tumors are derived from the cells on the surface of the ovary. This is the most common form of ovarian cancer and occurs primarily in adults.
- Germ Cell ovarian tumors are derived from the egg producing cells within the body of the ovary. This occurs primarily in children and teens and is rare by comparison to epithelial ovarian tumors.
- Sex Cord Stromal ovarian tumors are also rare in comparison to epithelial tumors and this class of tumors often produces steroid hormones.
Cancers derived from other organs can also spread to the ovaries.
Staging
Johns Hopkins Pathology: Ovarian Cancer Research
Staging is an assessment of how far the tumor has spread.
- Stage I - Growth of tumor limited to the ovaries
- Stage II - Growth of tumor in one or both ovaries
- Stage III - Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal lymph nodes. Superficial liver metastasis equals stage III.
- Stage IV - Growth involving one or both ovaries with distant metastases. If pleural effusion is present there must be positive cytology to allot a case to stage IV. Tumor spread inside the liver, equals stage IV.
Recurrent/Refractory - Recurrence means that the tumor has returned after initial therapy. Refractory means that the tumor fails to respond to initial treatment.
Treatment Options
Johns Hopkins Pathology: Ovarian Cancer Research
There are basically three forms of treatment of ovarian cancer. The primary one is surgery at which time the cancer is removed from the ovary and from as many other sites as is possible. Chemotherapy is the second important modality. This form of treatment uses drugs to kill the cancer cells. The other modality is radiation treatment, which is used in only certain instances. It utilizes high energy x-rays to kill cancer cells. Surgical treatment of ovarian cancer is best performed by a gynecologic oncologist who has been specially trained in the diagnosis and management of gynecologic malignancy. The treatment of ovarian cancer depends on the stage of the disease, the histologic cell type, and the patient's age and overall condition. The histologic cell type and the extent of disease based on the biopsies performed by the gynecologic oncologist during surgery (staging) are determined by the pathologist who analyzes tissues with a microscope.
Frequently Asked Questions
Ovarian Cancer National Alliance
Q. Is it true that a woman who has had her ovaries removed cannot get ovarian cancer?
A. Technically, women who have their ovaries removed can't get ovarian cancer, but there is a type of cancer called primary peritoneal carcinoma - a close relative to ovarian cancer. Although it is rare, it can develop without the ovaries. Primary peritoneal carcinoma is cancer of the abdominal lining. It looks the same as epithelial ovarian cancer under a microscope, it has the same symptoms, it spreads in a similar pattern, and it is treated the same way as ovarian cancer. (American Cancer Society)
Q. Is there any way to prevent ovarian cancer?
A. Currently there is no method of preventing ovarian cancer. However, there are several measures things that have been found to reduce a woman's risk of developing the disease. Oral contraceptives can reduce the risk of ovarian cancer by fifty percent if taken for at least 5 years. Research has also shown that pregnancy and breast-feeding significantly reduce ovarian cancer risk. (British Journal of Cancer, March 2001) Tubal ligation and hysterectomy reduce risk, though researchers are unclear exactly how. Finally, prophylactic oophorectomy (removal of the ovaries) also reduces the risk. (Gynecologic Cancer Foundation Slide Presentation, 2000) Health professionals recommend that all options be discussed thoroughly with a physician.
Q. Are fertility drugs safe?
A. Women with fertility problems often worry that taking fertility drugs might bring on ovarian cancer in the future since these drugs send the ovaries into overdrive. While some research has shown that increased risk of ovarian cancer was found only in women treated with ovulation drugs for twelve cycles or more (it should be noted that doctors no longer give the drugs for such extended periods), other research suggests that infertility itself may be the problem. The issue is unresolved at this time. (National Cancer Institute)
Q. Does the use of talc (talcum powder) as a feminine powder increases the risk of ovarian cancer?
A. Some research has shown a potential association between talc exposure in the genital area with a slightly increased risk of ovarian cancer. Talcum powder is produced from talc, which in its natural form may contain asbestos, a known carcinogen. Because of this association with asbestos, all talc products marketed for use in the home have been required to be asbestos free since 1973 (i.e. baby powders, body powders, facial powders). Studies suggest that talcum powder (including "asbestos-free" talc) may affect the outer layer of the ovaries when applied to the genital area, sanitary napkins, diaphragms, or condoms. Although several studies have examined the relationship between talcum powder and ovarian cancer, findings are mixed (Women’s Cancer Network). Some experts recommend that until more conclusive research is available, women should consider avoiding talc products.
Q. Is there a connection between hormone replacement therapy and ovarian cancer?
A. Risk factors surrounding hormone replacement therapy (HRT) remain highly controversial. A recently released study, the largest to date, concluded that women who take unopposed estrogen for 10 or more years significantly increase their risk of developing ovarian cancer. (Journal of the American Medical Association, March 21, 2001) Yet today, combination therapy, taking estrogen plus the hormone progestin, is far more commonly used than estrogen-only therapy. As a result, more research is needed to determine if there is a link between the current formulation of hormone replacement therapy and ovarian cancer. In the meantime, a woman considering HRT should discuss the risks and benefits for her particular circumstances with her doctor.
Q. What are ovarian cysts?
A. Ovarian cysts are fluid filled sacs on the surface of the ovary that are quite common in women during their childbearing years. Most cysts result from the changes in hormone levels that occur during the menstrual cycle and the production and release of eggs from the ovaries. Most are harmless and go away on their own. Your doctor will want to keep track of any cyst to be sure that it does not grow and become cancerous. (ACOG Patient Education: Ovarian Cysts, 1996)
Q. If someone in my family has had ovarian cancer, can genetic screening tell me if I am going to get the disease?
A. Approximately one out of every ten ovarian cancer cases is hereditary. Most hereditary ovarian cancer can be attributed to two genes, BRCA 1 and BRCA2. Women who inherit a mutation in these genes are at greater risk of developing epithelial ovarian cancer. A thorough evaluation of family history (i.e. a history of breast, colon, or ovarian cancer) can identify women most likely to have a hereditary cancer risk, and genetic testing can determine if these mutations exist. However, although having these mutations increases risk for the disease, it doesn't mean a woman will definitely get it. Furthermore, it is important to keep in mind that while genetic testing can indicate where there is increased risk and help determine appropriate monitoring, women should consider the psychological and possible insurance ramifications before proceeding with testing. Experts suggest that all genetic testing be done in conjunction with genetic counseling. (Cancer Control, July 1999; Genetic Testing, 2000)
Q. Is there a link between breast cancer and ovarian cancer?
A. Both breast and ovarian cancer can be caused by mutations in the BRCA1 and BRCA2 genes. Women with a family history of breast and ovarian cancer, or a personal history for either, particularly if diagnosed before age 50, should be aware of increased risk for the other. Women who have had breast cancer before the age of 50 are twice as likely to develop ovarian cancer, as are women who have not. (NCI - What You Need To Know About Ovarian Cancer, 1998) Additionally, ovarian cancer has also been linked to colon cancer (via different genes).
Q. Who is best trained to treat ovarian cancer?
A. Gynecologic oncologists. Research has shown that the five-year survival rate is greater when the initial surgery is performed by a gynecologic oncologist. (NCI) The initial surgery and staging of ovarian cancer is critical to determining the appropriate course of treatment, and ultimately survival outcomes. A gynecologic oncologist is an ob/gyn who is further trained in oncology to specialize in the diagnosis and treatment of women with gynecologic cancers. To find a gynecologic oncologist in your area, visit the Women’s Cancer Network Web site and select "Find a Doc," or call 1-800-444-4441.
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