Ovarian Cancer
Ovarian cancer begins in the ovaries. The ovaries produce eggs (called ova). They are also the main source of a woman’s female hormones, estrogen and progesterone.
The ovaries contain three 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).
al cells: These cells cover the ovary. Most ovarian cancers start in this covering.
As a rule, 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 three 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 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.
Epithelial ovarian cancers: Nearly 9 out of 10 ovarian cancers are this type. Cancer cells of this type have certain features that can be seen under a microscope which allow doctors to further classify them. These tumors are also given a grade depending on how much the cells look like normal cells. Grade 1 means the cells look more normal; grade 3 look less normal, and grade 2 is in between. Usually the higher the grade the worse the outlook.
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 fluid that collects inside an ovary. Many of these cysts are harmless. The fluid will most often be absorbed and the cyst will go away in time without any treatment. But if the cyst is large or happens in childhood or after menopause, the doctor may suggest further tests or treatment. This is because a very small number of these cysts can be cancerous.
Fallopian Tube Cancer
This is an extremely rare cancer. The cancer begins in the fallopian tube. The symptoms are similar to those in women with ovarian cancer, except that there may be more pelvic pain. Treatment and outlook is similar to that for ovarian cancer.
Risk Factors:
Here are some of the risk factors for the most common type, 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. If you are taking this drug, you should talk to your doctor about the possible risks.
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. Please see the section on prevention to learn about genetic counseling and testing.
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. Proving the safety of newer products will require further follow-up studies.
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
Early Detection:
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.
See a doctor if you have symptoms: Early cancers of the ovaries tend to cause somewhat vague symptoms. These symptoms might include:
- swelling of the stomach (abdomen) or bloating caused by a buildup of fluid
- pelvic pressure or stomach (abdominal) pain
- trouble eating or feeling full quickly
- having to urinate often or feeling like you have to "go" right away
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. The patient needs to lie still on a table while scans 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 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.
Treatment:
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.
Surgery
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. Don’t be afraid to ask your doctor to explain your condition and your surgery choices in simple, non-medical terms.
There are several different types of surgery for ovarian cancer. The names of these operations are based on the Greek or Latin names of the organs that are removed. When something is removed, the name of the operation often ends in "---ectomy." So, removing the uterus is a hysterectomy. Because there are two ovaries, we need to show whether one or both have been removed. Removing one ovary is a unilateral (one side) oophorectomy, and removing both is a bilateral (two sides) oophorectomy. Likewise, removing one or both fallopian tubes is a unilateral salpingectomy or a bilateral salpingectomy.
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. Many gynecologists are not prepared to do this kind of cancer operation, which calls for careful staging and, perhaps, debulking. 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
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
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.
Treatment Centers in Georgia:
Support Groups:
Gynecologic Cancer
- Loran Smith Center for Cancer Support, Athens. Ovarian Cancer Chat Group Cancer Center, 2nd Tuesday , 1:00 p.m.. Contact: (706) 475-4900
- Wellness Community, Atlanta. Wellness Community, 3rd Tuesday, 12:00 noon. Contact: Rachel Newby (404) 843-1880
- Woman to Woman, Columbus. John B. Amos Cancer Ctr, 2nd Thursday, 1:30 p.m.. Contact: Deborah Johnson (706) 571-1368
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