15

Ovarian Cancer

IN THIS CHAPTER YOU’LL DISCOVER

→ What Ovarian Cancer Is

→ Ovarian Cancer Statistics

→ Types of Ovarian Cancer

→ Ovarian Cancer Staging

→ Signs and Symptoms

→ Specific Diagnostic Tests

→ Treatments for Ovarian Cancer

GINNY DIXON WAS JUST 31 when was she was diagnosed with ovarian cancer. Her periods stopped and her doctor was trying hormone treatments to correct the problem, but nothing worked. Dixon had no pain or other problems, and, she says, “I forgot about it,” until she suddenly began to lose weight. She could see the outline of a bump on her abdomen. Her doctor assumed it was a cyst, but just as Dixon was about to undergo surgery to remove it, her preliminary blood tests showed elevated cancer markers. She underwent surgery, along with very aggressive therapy, and now, some 21 years later, she still considers herself lucky, indeed, to have survived this dangerous type of women’s cancer.

What Is Ovarian Cancer?

Ovarian cancer develops in the almond-shaped glands known as the ovaries, which are part of the female reproductive system and situated on either side of the uterus. They produce egg cells (ova), and also provide the main source of the female hormones, which govern the development of female characteristics, including breasts, body shape and body hair, as well as the female reproductive cycle.

Statistics

Each year, more than 22,000 women in the United States are diagnosed with ovarian cancer — the eighth most common cancer (excluding skin cancer), and the fifth leading cause of cancer in women. In all, ovarian cancer constitutes 1.3 percent of all newly diagnosed cancer cases this year.

Any women without risk factors can develop ovarian cancer. Genetics do play a role, as women with a family history of ovarian cancer are at higher risk, and this is also true for those with a personal or family history of breast cancer.

“Genetic factors are linked to about 15 percent of ovarian cancer cases, and those are the only ones that we can detect. The rest are sporadic,” says Dr. Stacey Akers, a gynecologic oncologist and assistant professor of oncology at Roswell Park Cancer Institute in Buffalo, New York. “Sporadic” means that the cancer occurs for no known reason.

Caucasians are more likely to develop ovarian cancer, especially those of Jewish Ashkenazi (Eastern European) background. This heritage makes them more likely to have the BRCA1 and BRCA1 genetic mutations.

HNPCC, or Lynch syndrome (see chapter 8), raises ovarian cancer risk, along with uterine, stomach, and kidney cancer.

Hormonal and other factors play a tiny role, too. Infertile women, those who have never become pregnant, or those who first gave birth after the age of 35 are also at slightly higher risk. There was a concern that using fertility drugs heightened risk, but research findings are contradictory. The use of talcum powder in the genital area also has long been suspected, but no link has been proven.

GOOD ADVICE

If you have been diagnosed with ovarian cancer you should seek out genetic counseling to find if heredity played a role in your disease. If you learn that this is the case, you will also have the opportunity to alert your female relatives that they should be evaluated for a screening program. Remember, especially when it comes to ovarian cancer, that early diagnosis saves lives!

Outcome and Survival Rates

There are nearly 200,000 women in the United States today who are ovarian cancer survivors.

As with most other cancer, the earlier the cancer is diagnosed and treated, the higher the survival rate. The overall, five-year survival rate for ovarian cancer is 44 percent, but this varies widely depending on the extent (stage) of the cancer. If the cancer is diagnosed and treated before it has spread outside the ovaries, the five-year survival rate is 92 percent. If the cancer has spread to the surrounding organs or tissue (regional spread), the five-year survival rate is 72 percent. If the cancer has spread to parts of the body far away from the ovary (distant spread), the five-year survival rate falls to 27 percent. These statistics apply specifically to epithelial cancer, which accounts for up to 90 percent of cases.

The main reason why the mortality rate is higher than some other forms of cancer is because this disease can become very advanced before it causes anything but the vaguest of symptoms. Because the ovaries are located in the roomy pelvic cavity, an ovary can balloon to the size of a grapefruit before creating enough pressure to signal a problem. So, by the time ovarian cancer is diagnosed, it may have spread outside the pelvic region, making treatment much more difficult.

The good news, though, is that more women are surviving than ever before. In fact, 44 percent of women with ovarian cancer survive at least five years, and, according to a new survey, one-third was alive after 10 years, including some with high-risk cancers. This is a dramatic increase from 30 years ago, when the five-year survival rate was 10 to 15 percent.

Because ovarian cancer mortality rates are so high, this is a cancer that must be diagnosed, staged, and treated absolutely correctly right from the very beginning — there is no room for error.

“Too often, women are inclined to put their trust in their gynecologist or general surgeon, but a woman with ovarian cancer should be treated by a gynecologic oncologist, right from the start,” says Dr. Akers. “This means seeking treatment from a doctor who specializes in the treatment of women with reproductive system cancers.”

In addition, the doctor should have treated a lot of ovarian cancer patients. Since ovarian cancer is so deadly, doctors of this type are found at top cancer centers or large medical centers.

Also, ovarian cancer has a high rate of recurrence, so you need an experienced doctor who not only can deal with the disease the first time around, but also can effectively treat it should it return.

Types of Ovarian Cancer

EPITHELIAL CARCINOMA

This cancer, which develops from the cells that line the ovaries, is by far the most common type of ovarian cancer, and accounts for 85 to 90 percent of cases. Half of all cases of epithelial carcinoma occur in women over the age of 65.

DID YOU KNOW . . .

Ovarian cysts are fluid-filled sacs that develop on the outside of the ovary. They are not cancer. They are benign growths that are common, and which most women experience in the course of their lives. Most ovarian cysts disappear within a few months, although some may grow large and need to be removed.

OVARIAN GERM CELL TUMORS

These develop from the cells that produce the ova (the eggs). This is a more rare form of ovarian cancer that occurs in young women. It has a 90 percent cure rate.

LOW MALIGNANT-POTENTIAL OVARIAN TUMORS

LMPs are ovarian epithelial tumors whose appearance under the microscope does not clearly identify them as cancerous. These are called borderline tumors or tumors of low malignant potential.

OVARIAN STROMAL TUMORS

These exceedingly rare tumors develop from connective tissue cells that hold the ovary together and those that produce the female hormones, estrogen and progesterone.

Stages of Ovarian Cancer

Each stage of ovarian cancer has several sub-classifications, but these are the main stages:

STAGE I

The cancer is limited to one or both ovaries.

STAGE II

The cancer is confined to the pelvis.

STAGE III

The disease has spread outside of the pelvis, but is limited to the abdomen, or lymph node involvement.

STAGE IV

The disease spread to the liver or outside of the abdomen.

Signs and Symptoms

The following symptoms may indicate ovarian cancer:

GOOD ADVICE

The staging of ovarian cancer is very important. Ovarian cancers not only have different prognoses according to their stage, but they also require different treatment, which impacts survival. So, this is why a gynecological oncologist should perform whatever surgery is necessary right from the very beginning.

The symptoms of ovarian cancer can be vague and be mistaken for lesser problems, like the flu. But it’s been found that the first four symptoms on the above list are the ones that occur most often in ovarian cancer. This is why the Ovarian Cancer National Alliance, along with other women’s health organizations, urges women to specifically bring up the possibility of cancer with their doctors if the following four symptoms persist longer than two weeks:

Specific Diagnostic Tests

PELVIC EXAM

The doctor feels the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum to check for any unusual changes.

TRANSVAGINAL ULTRASOUND

An ultrasound wand is inserted in the vagina and sound waves are used to create images of the ovaries, including healthy tissues, cysts, and tumors.

CA-125 TEST

This blood test measures a substance called CA-125 in the blood, which is a tumor marker that is found at elevated levels in women with ovarian cancer. It is also used to monitor the effectiveness of treatment. The other tumor marker tests, HE4 and OVA-1, can also aid in diagnosis.

BIOPSY

If these preliminary tests cited above indicate ovarian cancer may be present, a biopsy will be needed to confirm it. This is the removal of tissue for analysis; however, ovarian cancer is different from most other cancers in that a biopsy is rarely done separately. If ovarian cancer is found, surgery will be performed at the same time to remove as much of the tumor as possible. This is the reason why this procedure should be performed by a gynecological oncologist. What happens at this step may determine all future treatment, and could directly impact survival.

GOOD ADVICE

Ovarian cancer patients should be treated according to National Comprehensive Care Network guidelines. Unfortunately, though, a recent study of ovarian cancer patients in California found that only 35 percent of women were being treated according to these guidelines, and that those who were not missed out on a chance to add a year or more to their lives.

Treatments

SURGERY

The extent of surgery involved in treating epithelial ovarian cancer depends on its stage. Surgery generally involves a hysterectomy, a bilateral salpingo-oophorectomy (removal of both ovaries and both fallopian tubes), the removal of the omentum (the layer of fatty tissue that covers the contents of the abdomen), and removal of lymph nodes. Surgery for advanced ovarian cancer may require removal of other organs including part of the intestine, liver, and/or bladder to achieve “optimal” tumor debulking. In advanced ovarian cancer — a Stage IV cancer, characterized by liver and/or bone metastasis — chemotherapy prior to surgery may be performed in order to shrink the tumor.

Debulking refers to removing all signs of cancer larger then one centimeter. When performed successfully, this is known as complete or “optimal” debulking. If this is only done partially, it is called “sub-optimal debulking.” Patients who are optimally debulked have a better prognosis. Doctors should be asked how often they operate on ovarian cancer patients and the percentage of cases in which they achieve optimal debulking.

DID YOU KNOW . . .

Ovarian cancer surgery is usually more extensive than most other types of cancer surgery due to the way the disease tends to spread. Like other cancers, ovarian cancer spreads from organ to organ. But unlike most other cancers, ovarian tumors also “shed,” sending out cancerous seeds that can blanket the abdomen, for instance. This also raises the possibility of missing cancerous cells, which is why meticulous surgery is so necessary.

Surgery for Germ Cell Ovarian Cancer

Ovarian cell tumors can be treated with a hysterectomy and bilateral salpingo-oophorectomy. If the cancer is in only one ovary, and the woman intends to bear children, only the one ovary containing the cancer and the fallopian tube may be removed, leaving the unaffected ovary, fallopian tube, and uterus in place.

Surgery for Ovarian Stromal Cancer

These cancers are usually confined to just one ovary, so if the tumor is localized, only that ovary may need removal. If the cancer has spread, surgery must be more extensive, and can range from a hysterectomy to a full debulking.

Surgery for Low Malignant-Potential Ovarian Tumor

This type of ovarian tumor can require the removal of the affected ovary, a hysterectomy, an even more involved surgery, or even debulking depending on how widespread the tumor cells are.

CHEMOTHERAPY

Along with surgery, aggressive chemotherapy is the basis of treatment for most types of ovarian cancer. A number of chemotherapy drugs are used in the treatment of ovarian cancer, and the types and number of rounds vary depending on the stage of the cancer.

“Chemotherapy can be administered traditionally, but in some cases, the method of administration can make a big difference, especially when it comes to intraperitoneal (IP) therapy,” says Dr. Akers.

IP Chemotherapy

This is a treatment in which a catheter is placed in the abdomen to deliver chemotherapy directly into the pelvic area. A landmark study in 2006 found that this form of therapy extended survival by more than a year (15.9 months).

The National Cancer Institute took a rare step, one it reserves for major advances. It issued a “clinical announcement” to encourage doctors to use the IP treatment, and to urge patients to ask about it. Cancer specialists predicted that the announcement would lead to widespread changes in treatment, but as of this writing, experts say that is not the case.

“Giving chemotherapy this way gives the most concentrated dose of the drugs to the cancer cells in the abdominal cavity. The chemotherapy drugs are also absorbed into the bloodstream and so can reach cancer cells outside the abdominal cavity. The side effects are often more severe, though. But if you are a candidate for this type of chemotherapy it is important that you be offered it. This type of chemotherapy is also more likely to be offered at a cancer center of excellence,” Dr. Akers notes.

HORMONE THERAPY

Hormones or hormone-blocking drugs are rarely employed to fight epithelial ovarian cancer, but they are more commonly used to treat stromal ovarian cancers. These drugs include luteinizing-hormone-releasing hormone (LHRH) agonists, which lower estrogen levels in premenopausal women, and tamoxifen, the anti-estrogen drug best known as a breast cancer fighter. Aromatase inhibitors, which lower estrogen levels in post-menopausal women, are also used for recurrences of stromal tumors.

TARGETED THERAPY

This newer type of cancer treatment uses drugs or other substances to identify and attack cancer cells while doing little damage to normal cells. Avastin (bevacizumab) is a targeted therapy that has been by far the most studied for ovarian cancer, although others are being researched as well.

RADIATION

Therapy of any type using radiation is rare in the treatment of ovarian cancer.