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Ovarian Cancer

WHAT IS OVARIAN CANCER?

Ovaries

The ovaries are two small, almond-shaped organs located on either side of the uterus (the hollow muscular organ, commonly called the womb, in which the fetus develops). They are key components of a woman's reproductive system:

Ovaries store between 200,000 and 400,000 follicles, tiny sacs, present from birth, that nurture immature eggs, or ova.
During each normal (usually monthly) reproductive cycle, a follicle in one ovary bursts and releases a mature or "ripened" egg. The egg travels down the fallopian tube into the uterus, where it either is fertilized by a man's sperm or, if unfertilized, breaks down and is excreted as part of the menstrual cycle.
Ovaries also secrete the important reproductive hormones estrogen and progesterone.

Ovarian Cancers

Ovarian cancers are potentially life-threatening malignancies, that develop in one or both ovaries. Malignant ovarian tumors generally fall into three primary classes:

Epithelial tumors.
Germ cell tumors.
Stromal tumors.

Epithelial Tumors. Epithelial tumors account for up to 90% of all ovarian cancers and therefore are the primary focus of this report. These cancers develop in a layer of cube-shaped cells known as the germinal epithelium , which surrounds the outside of the ovaries.

Germ Cell Tumors. Germ cell tumors, which account for about 3% of all ovarian cancers, are found in the egg-maturation cells of the ovary. They occur most often in teenagers and young women. Although they progress rapidly, they are very sensitive to treatments. About 90% of patients with germ cell malignancies can be cured, often preserving fertility.

Stromal Tumors. Stromal tumors, which account for 6% of all ovarian cancers, develop from connective tissue cells that hold the ovary together and that produce the female hormones, estrogen and progesterone. Stromal tumors do not usually spread, in which case the prognosis is good. If they spread, however, they can be more difficult to treat.

Ovarian Cancer Progression

By the time symptoms appear, the ovarian tumor may have grown large enough to shed cancer cells throughout the abdomen. At such an advanced stage, the cancer is more difficult to cure.

Ovarian cancer cells that have spread outside the ovaries are referred to as metastatic ovarian cancers. Ovarian tumors tend to spread to the following locations:

The diaphragm.
The intestine.
The omentum (a fatty layer that covers and pads organs in the abdomen).

Cancer cells can also spread to other organs through lymph channels and the bloodstream.

Other Ovarian Growths

Not all ovarian tumors are malignant. Benign cysts, dermoid tumors, and borderline malignant tumors all are distinct from ovarian cancer.

Benign Cysts. Benign cysts are common and typically develop in one of two ways:

Follicular Cysts. During normal ovulation, follicles (the little sacs in the ovary) expel eggs. If the egg is not expelled associated fluids and other substances can build up inside the follicle, forming a follicular cyst.
Corpus Luteum Cysts. Benign cysts may form when an egg has been released, but the emptied follicle (now called the corpus luteum) does not break down normally but fills with blood from nearby blood vessels.

Both follicular cysts and corpus luteum cysts are normal parts of the menstrual cycle and nearly always resolve within one or two cycles without treatment.

Dermoid Tumors. Dermoid tumors are benign growths that occur when an egg begins to develop without fertilization by a sperm; they can contain hair, teeth, and cartilage. They are easily removed by surgery.

Borderline Ovarian Tumors. About 15% of ovarian tumors are referred to as "borderline" because their appearance and behavior under the microscope is halfway between benign and malignant. These tumors are often referred to as carcinomas of low malignant potential because they rarely metastasize or cause death. Even when borderline carcinomas do spread outside the ovary, only 10% to 20% are fatal.

WHAT ARE THE SYMPTOMS OF OVARIAN CANCER?

Ovarian cancer may grow for some time before the cancer mass is large enough to cause significant symptoms. Occasionally, some women may experience some symptoms even in early stages, such as pelvic pain. Because the symptoms are vague and often resemble those of common benign conditions, such as menstrual disorders and intestinal illnesses, they often do not raise suspicion.

Symptoms are most evident when the tumor interferes with pelvic organs or spreads into the abdominal cavity. Some include the following:

The most common first symptoms are caused by fluid build-up ( ascites) or masses within the abdominal cavity. These symptoms include bloating, pain, pressure, or discomfort.
If the cancer spreads to the diaphragm, fluid may collect around and under the lungs, causing shortness of breath.
Pressure on the stomach can also cause loss of appetite or a feeling of fullness, even after a very light meal.
Some women describe their symptoms as "feeling about four months pregnant."
When the tumor presses on organs near the ovaries, such as the bowel or bladder, the woman may experience gas, nausea, vomiting, diarrhea, constipation, or frequent urination.
Other symptoms, which are less frequent, include abnormal vaginal bleeding, fever, and lower backache.

WHO GETS OVARIAN CANCER AND WHAT CAUSES IT?

About 23,300 new cases of ovarian cancer are expected in 2002. Evidence suggests that the incidence of ovarian cancer is declining. The average age for the onset of ovarian cancer is about 60, although ovarian cancer can develop in women from the age of 20 to 90. The lifetime risk of ovarian cancer in women with no family history of the disease is approximately one in 70 (1.4%).

Women with a history of ovarian cancer in one first-degree relative have an overall risk of 5% of developing the disease, but it may be higher in women with specific genetic factors. The majority of women with ovarian cancer have no family history of the disease, however, meaning that genetic inheritance is not the only risk factor.

Genetic mutations causing abnormal cell growth and differentiation are the basis for all cancer. The great majority of genetic defects that cause cancer are due to unknown causes. Most likely overexposure to environmental assaults or errors that occur during cell division play a role in many cases.

The Role of Hormones and Ovarian Stimulation

A number of circumstances that create hormonal changes may increase the risk of ovarian cancer.

Number of Ovulations. Risk of ovarian cancer is directly related to the number of times a woman ovulates, which is indicated by the total number of menstrual periods she has had. A lower number of ovulations occur when the menstrual periods are shut off (as in pregnancy), so the risk of developing ovarian cancer is reduced.

The following women have a lower risk for ovarian cancer:

Women with a history of multiple pregnancies.
Women who took birth control pills (which shuts off the menstrual period).
Women who breast-fed. (The body usually does not release eggs while a woman is breast-feeding.)

Some researchers theorize that ovarian cancer develops in women with a higher number of ovulations because of persistent damage to the epithelial cells as the egg passes through during ovulation. Researchers postulate that the recurring cell division needed to heal these tiny wounds to the ovaries, month after month and year after year, creates opportunities for errors in cell reproduction that lead to the formation of cancerous cells. Therefore, the more ovulations, the more risk of ovarian cancer. Ovulation temporarily ceases during pregnancy, breast feeding, and birth control pill use.

Gonadotropins and Fertility Drugs. Gonadotropins are hormones produced in the pituitary gland that stimulate the ovaries to secrete estrogen and cause the follicles to produce and release eggs. In a few studies, elevated levels of gonadotropins have been associated with an increased risk for ovarian cancer. These hormones are the basis for many fertility drugs, including human menopausal gonadotropin (Pergonal, Repronal, Metrodin) and clomiphene (Clomid, Serophene). Although there has been concern about an increased risk for ovarian cancers in women, a growing body of evidence is finding no higher risk from the drugs themselves. Instead, evidence suggest that ovarian cancers are most likely caused by factors contributing to the infertility--not the agents used to treat it.

Hormone Replacement Therapy. Although some studies have reported a weak increased risk for certain ovarian cancers in women taking HRT, others have found no association either with short- or long-term use of HRT.

Inherited Genetic Factors

Family history plays a role in between 5% and 10% of women who have ovarian cancer. Certain genes are being investigated and identified that are responsible for some of these cases. [ See Box Identifying and Screening High-Risk Women for Ovarian Cancer.]

BRCA1 and 2 Genes. Inherited mutations in genes known as BRCA1 or BRCA2 are now believed to be responsible for 30% to 50% of breast cancers, ovarian cancers, or both in patients with a strong family history of these cancers.

The risk each carries appears to be as follows:

Studies indicate that about 25%-40% of women who carry the abnormal BRCA1 gene may develop ovarian cancer.
The risk for women with the BRCA2 gene mutation is generally believed to be lower, about 15%.

The mutated genes are linked to an even higher risk for developing breast cancer. These mutations are present in only about 0.5 of the US or UK population overall but are occur in about 2.5% of all Jewish women of Eastern European (Ashkenazi) descent. This prevalence in a relatively large population makes mutations to BRCA1 and BRCA2 the most common serious genetic disease known in any population group.

These mutations can be passed down to the daughter by either the mother or the father. It should be noted that BRCA mutations may occur in 5% to 10% of ovarian cancer patients who have no family history of breast or ovarian cancer. These mutations are also not restricted to the Ashkenazi population and may occur in women of any ethnicity. A number of studies have suggested that women with BRCA-mutated ovarian cancers tend to have better survival rates than others.

Other Genetic Mutations. The BRCA mutations account for many but by no means all ovarian and breast cancers associated with a family history of these diseases. Women who carry genes for the following disorders have a moderate risk for ovarian cancer:

Hereditary nonpolyposis colorectal cancer (HNPCC). Women who carry the gene that causes this disease have about a 9% chance of developing ovarian cancer.

Identifying and Screening High-Risk Women for Ovarian Cancer

Risk Factors for Inherited Ovarian Cancer

A first-degree relative (mother, sister, or daughter) with ovarian cancer at any age. The risk increases with the number of affected first-degree relatives.
A first-degree relative (or two second-degree relatives on the same side) with early onset breast cancer (occurring before age 50).
A family member with both breast and ovarian cancer.
A family history of male breast cancer (which might indicate a BRCA-2 mutation).
A family history of hereditary non-polyposis colorectal cancer.

Note: When a woman describes her family history to her physician, she should include the history of cancer in women on both the mother's and the father's side. Both are significant.

Screening High-Risk Women

It is now possible to test for genetic mutations in the BRCA1 and BRCA2 genes and for hereditary nonpolyposis colorectal cancer (HNPCC) and Peutz-Jeghers syndrome in high-risk women. Any positive result raises difficult issues:

The presence of a mutation in any of these genes does not predict with absolute certainty that either breast cancer or ovarian cancer will occur. The lifetime risk for BRCA1, for example, is significantly higher (up to 40%) than for BRCA2 (about 10-15%).
Surgical preventive strategies, which can involve both mastectomy and removal of the ovaries, do not completely eliminate the risk for cancer, since malignant cells may occur in nearby regions. Removal of the ovaries will reduce pvarian cancer risk, however, and may also reduce breast cancer risk in mutation carriers.

Experts recommend genetic screening for women in very high-risk families, along with extensive counseling. Such rare families have several affected members with ovarian cancer, breast cancer, or both, usually occurring at a young age.

For women in high-risk groups, consideration of transvaginal ultrasound and CA-125 testing every six months to a year is reasonable, although the benefits of this approach are unproven.

Ethnic Factors

Some research indicates that ovarian cancer occurs more often in North America and Northern Europe and among middle to upper socioeconomic class women from highly industrialized countries. Ovarian cancer is also much more common in Caucasian women than in African American women. Japan has a low, but rising, number of ovarian cancer cases. One study observed that when Japanese women immigrate to the United States, they and their daughters have an incidence of ovarian cancer that approaches that of Caucasian women, although another study found no difference between Asian American women born in Asia and those born in America.

Other Factors

Endometriosis. Women with endometriosis may have some higher risk for ovarian cancer. It should be noted that endometriosis is very common and ovarian cancer is not, so the risk is still very low. Some research suggests that ovarian cancer associated with endometriosis may differ from most ovarian cancer cases, and, in fact, have a better outlook.

Dietary Factors. One study reported that in Japan an increased intake of fats paralleled a significant increase in ovarian cancer. However, the majority of studies have found no correlation between fat intake and ovarian cancer. In any case, such studies are only suggestive and may lead to better research but should not be considered to be evidence.

Lactose Intolerance. Women who have an impaired ability to digest lactose, an enzyme found in dairy products, particularly milk, may be at increased risk for ovarian cancer. Galactose, an enzyme involved with this disorder, appears to be toxic to the ovaries and may be responsible for this effect. It should be strongly noted, however, that lactose intolerance is very common and ovarian cancer is uncommon. If such a risk exists in women with this digestive disorder, it still very small.

Talcum Powder and Feminine Deodorants. Some reports suggest that the use of talcum powder used near the genital area may increase the risk for ovarian cancer, although this is controversial.

Smoking. In one study, women with ovarian cancer were more likely to be smokers than those without the disease. Few studies have reported this association, however, and more research is needed.

HOW CAN OVARIAN CANCER BE PREVENTED?

Lifestyle Factors

No life-style factors have proven to protect against ovarian cancer, although the following are some study results that suggest some lower or higher risk;

One study reported that women who consumer fish and vegetables had a lower risk for ovarian cancer. In support, another 2001 study suggested foods high in specific chemicals called alpha carotene (eg. carrots) and lycopene (e.g. tomatoes) may be specifically protective.
Exercise, which protects against many diseases and even some cancers, appears to have no effect on ovarian cancer. Nevertheless, a 2001 study found a higher risk for ovarian cancer in women who were obese, particularly when they were sedentary. Moderate exercise is a good idea and may offer some protection against breast cancer, in any case.
Smokers should quit. Although evidence of an association with ovarian cancer is weak, it is always wise to stop smoking.

These and other studies on life-style factors are generally not considered to be evidence, although they can suggest directions for future research.

Limiting Ovulation

In general, factors or behaviors that limit stimulation of the ovaries or inhibit ovulation appear to be protective.

Pregnancy. The more times a woman has been pregnant the less likely she is to develop ovarian cancer. One study indicated that ovarian cancer was reduced by 40% with one pregnancy and by 14% with each subsequent pregnancy.

Breast Feeding. Breast feeding, even for only one or two months, may also reduce the risk for ovarian cancer by as much as 40%. A longer duration of breastfeeding does not appear to increase its protective benefits.

Oral Contraceptives (OCs) and Progestin. Studies have suggested that routine use of birth control pills that contain the female hormones estrogen and progestin, even low-dose forms, reduces a woman's risk of ovarian cancer by about 50% when compared to women who have never taken oral contraceptives. The longer a woman is on oral contraceptives the greater the protection, although one study reported that taking birth control pills for only three to six months conferred benefits for 15 years. A 2001 study reported that OCs do not protect women with the BRCA1 or BRCA2 genetic mutations, although an earlier study did suggest a possible protective effect.

Birth control pills should not be taken by pregnant women, or by women with breast cancer. Other conditions that may preclude taking oral contraceptives include the following:

Liver disease.
Migraines.
Coronary artery disease and any risk factors for heart disease or stroke (particularly smoking, obesity, high blood pressure, blood clotting disorders, or severe diabetes).

Tubal Ligation. Tubal ligation, a method of sterilization that ties off the fallopian tubes, has been associated with a decreased risk for ovarian cancer in some--but not all--studies. A 2001 study specifically reported a significantly lower risk in women who carried the BRCA1 mutation.

Removal of Ovaries (Oophorectomy)

Surgical removal of the ovaries, called oophorectomy, significantly reduces the risk for ovarian cancer. When it is used to specifically prevent ovarian cancer in high-risk women, the procedure is called a prophylactic oophorectomy.

Some experts now consider prophylactic oophorectomy in the following situations:

Women who have two or more first-degree relatives afflicted with ovarian cancer (or who have a BRCA-1 or BRCA-2 mutation), and who are 35 years old or older and have completed their families.

Considerable controversy still exists, however for the following reasons:

One study reported that oophorectomy might improve survival rates in women carrying the BRCA1 or BRCA2 genes by about half a year to over two years. However, the impact of this procedure on survival is still uncertain.
Even after oophorectomy, women in high-risk groups for ovarian cancer still have a risk for the development of cancer in the peritoneum (the sac inside the abdomen that holds the intestines, uterus, and ovaries).
The procedure causes early menopause in younger women.

HOW IS OVARIAN CANCER DIAGNOSED?

Up to 95% of women diagnosed with ovarian cancer will survive longer than 5 years if their cancers are treated before they have spread beyond the ovaries. Unfortunately, there are no screening tests for ovarian cancer that are the equivalent to mammography for early detection of breast cancer. Therefore, only about 25% of ovarian cancer cases are diagnosed at such early stages. It is possible to perform genetic screening in high-risk women, but this raises some complex issues. [ See Box Identifying and Screening High-Risk Women for Ovarian Cancer.]

Annual Gynecologic Check-Up

Every woman should have a regular annual examination with her physician that includes the following:

Bimanual rectovaginal pelvic examination. Routine pelvic exams are a reasonable precaution, although this is not a perfect screening method due to its low sensitivity. During this exam, the physician inserts a finger into the vagina and another into the rectum. This enables the physician to assess the size of the ovaries as well as the contour and mobility of the uterus and to feel for masses and growths. A mass felt on pelvic exam often requires further evaluation by ultrasound and sometimes requires surgery to make a definitive diagnosis.
Pap smear. This test is specifically designed to detect cervical cancer. In very rare instances, however, it may reveal abnormal ovarian cells, which might indicate the presence of an ovarian cancer.

Unfortunately, ovarian cancer rarely produces changes that are detectable during a regular check-up.

Ruling Out Benign Conditions

Nearly 290,000 women are hospitalized every year in the US for ovarian growths or lesions, and even more women are diagnosed with some ovarian condition during a routine check up. The vast majority of conditions are noncancerous. They include, but are not limited to the following:

Benign functional ovarian cysts.
Abscesses and infection.
Fibroids.
Endometriosis.
Polycystic ovaries.
Ectopic pregnancies.
Meig's syndrome (which involves a benign ovarian growth associated with fluid build-up in the abdomen and around the lungs).
Ovarian hyperstimulation syndrome following fertility treatments.

Once a growth is detected, additional tests as outlined below may help the physician gauge the risk for it being cancerous or not.

Transvaginal Ultrasound and Other Imaging Tests

Ultrasound. Ultrasound is a noninvasive diagnostic tool that is used to evaluate tumors and masses discovered during the rectovaginal exam:

Typically, a probe is placed in the vagina that emits sound waves (ultrasound), which bounce off tissues, organs, and masses in the pelvic cavity. These echoes are collected and converted into a picture of the area called a sonogram.
The ultrasound probe may also be placed on abdominal walls above the ovaries ( transabdominal ultrasound ), but it does not provide as clear a picture of the ovaries. Healthy tissue, fluid-filled cysts, and solid tumors produce different sound waves.

Unfortunately, ultrasound does not provide enough specific information to reliably determine which abnormal masses are malignant and which are usually benign.

Studies suggest that small so-called "simple" cysts (i.e., fluid-filled without an associated mass) are usually noncancerous, particularly when they appear in premenopausal women whose blood tests for the protein CA-125 are normal. [ See below for a description of this test.] Such women are sometimes given oral contraceptives and observed for a few months to see if the cyst goes away.
Postmenopausal women with small simple cysts and normal CA-125 levels may sometimes be observed for a time if they have no other risk factors or symptoms of ovarian cancer.
In contrast, a "complex" cyst (one that shows a mass or other abnormalities) is often surgically removed, since it has a higher chance of being malignant. It should be noted, however, that even among these cysts only about a small percentage turn out to be malignant. (In one study 6% of complex cysts were actually cancerous.)

Other Imaging Techniques. Other imaging techniques used less commonly in the diagnosis or evaluation of suspected ovarian cancer include the following:

Computed tomography (CT). Computed tomography records x-ray absorption rates of tissue and bone. This data is converted into clear images on a screen. CT scans are useful to determine if cancer has spread to the lymph nodes, abdominal organs, abdominal fluid, and the liver.
Magnetic resonance imaging (MRI). MRI creates multiple cross-sectional images of the pelvis and abdominal organs, which are assembled into three-dimensional images. They are being investigated for preoperative assessment of patients with possible ovarian cancer. Their value is undefined, however, and most patients do not require them prior to undergoing a definitive surgical procedure.
Abdominal x-rays.

CA-125 Blood Test

CA-125 is a protein that is secreted by ovarian cancer cells and is elevated in over 80% of patients with ovarian cancer. Oncologists will usually obtain a blood test for this protein if ovarian cancer is strongly suspected or has been diagnosed. In general, a CA-125 level is considered to be normal if it is less than 35 U/mL (microns per milliliter).

The test is not useful for diagnosis or early screening, however. In approximately half of women with very early ovarian cancer, CA-125 levels are not elevated above the normal standard at all. Furthermore, an elevated level can be caused by a number of other conditions including the following:

Endometriosis (which may be a risk factor for ovarian cancer).
Fibroids.
Noncancerous ovarian cysts.
Pregnancy.
Pelvic inflammatory disease.
Liver diseases.
Other tumors, such as breast, colon, lung, and pancreatic cancers.
Age and menstrual status can also affect the levels of CA-125.

Investigative Tests

Ongoing research is underway to find better tests that will detect this cancer in early stages. For example, in one study lysophosphatidic acid (LPA) correctly identified 75% of women with ovarian cancers and correctly ruled out 95% of those who didn't have the cancer.

Surgery

An exploratory surgical procedure called laparotomy generally is required for the definitive diagnosis of ovarian cancer. Laparotomy involves the following steps:

It requires general anesthesia and employs standard surgical techniques to make a vertical, midline incision from the pubic bone to the navel.
Such an incision ensures careful evaluation of the entire abdominal area. After the incision is made, the surgeon assesses the fluid and cells in the abdominal cavity.
During this procedure, cysts or other suspicious areas must be removed and biopsied (tested for cancer).
If the lesion is cancerous, the surgeon continues with a process called surgical staging to ascertain how far the malignant tumor has spread and to remove the ovaries and any cancerous tissue. [ See How is Ovarian Cancer Surgically Treated?, below.]
are also studying laparoscopy--a less invasive technique than laparotomy--for initial surgical evaluation.

HOW SERIOUS IS OVARIAN CANCER?

Ovarian cancer ranks behind lung, breast, and colorectal cancer as the fourth most common cause of female cancer death in this country. About 13,900 American women are expected to die from ovarian cancer in 2002.

In, general, however, survival rates increased from 37% in 1974 to greater than 50% currently. (As a comparison, however, the average five-year survival rate for all breast cancer cases is now over 85%, primarily because of early detection.) This rate varies according to when the cancer is detected:

Five-year survival rates are over 90% if the cancer is caught when it is still confined to the ovary.
If it has spread to nearby regions in the pelvis, the survival rate drops to between 60% and 80%.
If it has spread to sites outside the pelvis, the five-year survival rates are only 0% to 30%.

Unfortunately, most patients with ovarian cancer will present with advanced disease, which typically has spread to the upper abdomen. In order to establish a prognosis and determine treatment, the physician needs to know the cell type, stage, and grade of the disease.

Prognosis by Cell Type

About 90% of ovarian epithelial cancers fall into one of four major subtypes based on their origin and shape as viewed under a microscope:

Serous. (This is the most common type.)
Endometrioid. (This is sometimes associated with endometriosis and tends to have a more favorable outlook.)
Mucinous. (The presence of malignant mucinous cells indicates a poorer outlook if the disease is advanced.)
Clear cell. (Clear cell carcinomas are the most difficult to treat even when the malignancy is still confined to the ovary.)

The remaining 10% of common epithelial cancers are referred to as undifferentiated, because their exact cell of origin cannot be determined microscopically. These epithelial ovarian carcinomas tend to grow and spread quickly.

Prognosis by Stage

Cancers are staged according to whether they are still localized (remain in the ovary) or have spread beyond the original site.

In Stage I, the cancer is thought to be confined to one or both ovaries (Stage IA or IB, respectively). The five-year survival rate for this stage is 90%, but the presence of other factors may reduce this rate. For example, Stage IA or IB with non-clear-cell well-differentiated cancer cells or borderline tumors has a favorable prognosis. Clear cells or those that are more poorly differentiated have a worse outlook. If the tumor has involved the capsule of the ovary, or if fluid in the abdomen (ascites) contains malignant cells (Stage IC), the outlook is poorer than average for this stage.
In Stage II, cancer is found outside of the ovary but is still contained within the pelvis. It may have advanced to the uterus or fallopian tubes, or other areas within the pelvis (Stage IIA or IIB, respectively). The five-year survival rate for stage II is approximately 60% to 80%.
In Stage III, one or both of the following are present: (1) The cancer has spread beyond the pelvis to the omentum and other areas within the abdomen, such as the surface of the liver or intestine. (2) The cancer has spread to the lymph nodes. The average five-year survival rate for this stage is 20%.
Stage IV is the most advanced. The cancer may have spread to the inside of the liver or spleen. There may be distant metastases, such as ovarian cancer cells in the fluid around the lungs. The average five-year survival rate for this stage is less than 10%.

Prognosis by Grade

Tumors are also graded according to how well or poorly organized they are (their differentiation). Ovarian tumors are graded on a scale of 1, 2, or 3. Grade 1 tends to closely resemble normal tissue and has a better prognosis than Grade 3, which indicates very abnormal, poorly defined tissue.

Other Prognostic Factors

Age. It is commonly thought that younger women have a better prognosis than older women, although a 1996 study indicated that the stage and grade of the tumor were the main factors in prognosis, while age itself played no role.

BRCA Carriers. Some studies have reported that women who carry mutated BRCA genes may have better survival rates than non-carriers. The survival advantages may be due to having a slower course or being more responsive to therapies than sporadic ovarian cancers, although this is controversial.

Angiogenesis. Experimentally, the level of biochemicals stimulating the formation of new blood vessels that support tumor growth (angiogenesis) appears to correlate with prognosis. The more angiogenic factors present in a tumor population, the more new blood vessels will form, encouraging both tumor growth and metastasis.

Hormone Receptor. In one 2000 study, women with ovarian cancer cells with progesterone receptors had higher survival rates than those with estrogen, both progesterone and estrogen, or no hormone receptors. Nevertheless, assessment of hormone receptor status is not usually necessary in ovarian cancer management.

Consequences for Survivors

Women who survive ovarian cancer have a high risk for psychological stress. Support groups can be very helpful and are recommended for appropriate patients.

WHAT ARE THE GENERAL GUIDELINES FOR TREATING OVARIAN CANCER BY STAGE?

Stage I

Cancer is limited to one or both ovaries.

Treatment Options: Treatment for most women in this stage will include surgical removal of the uterus and both ovaries and fallopian tubes (total hysterectomy and bilateral salpingo-oophorectomy), partial removal of the omentum, and surgical staging of the lymph nodes and other tissues in the pelvis and abdomen. (Carefully selected premenopausal women in stage I with the lowest grade tumors in one ovary may sometimes be treated only with the removal of the diseased ovary and tube in order to preserve fertility.)

If tumor cell types, grade, and other factors indicate a more serious condition, treatment after surgery may include chemotherapy.

Careful observation without immediate treatment (watchful waiting) may be appropriate in selected patients.

Stage II

The cancer is found in one or both ovaries. It may have advanced to the uterus, fallopian tubes, or other areas within the pelvis, but is still limited to the pelvic area.

Treatment Options: Surgical management for most women in this stage is total hysterectomy, bilateral salpingo-oophorectomy, and removal of as much cancer in the pelvic area as possible (tumor debulking). Surgical staging should be performed.

After the operation, treatment with chemotherapy (eg, paclitaxel and carboplatin) is usually necessary in an attempt to eradicate residual cancer.

Stage III

The cancer is found in one or both ovaries, and one or both of the following are present: (1) The cancer has spread beyond the pelvis to the upper abdomen, such as the surface of the liver or intestine. (2) The cancer has spread to the lymph nodes.

Treatment Options: Surgical management for most women in this stage is total hysterectomy and bilateral salpingo-oophorectomy and removal of as much cancer as possible (tumor debulking).

Following surgery, chemotherapy (eg, paclitaxel plus carboplatin) is usually necessary in an attempt to eradicate residual cancer. A number of approaches are under investigation for reducing high rates of recurrence (about 80%), including the following: experimental chemotherapy agents, anti-angiogenic therapies, gene and biological therapies, and intraperitoneally administered high-dose chemotherapy, neoadjuvant therapy (chemotherapy before surgery). df

Stage IV

The cancer may have spread to the inside of the liver or spleen. There may be distant metastases, such as ovarian cancer cells in the fluid around the lungs.

Treatment Options: Tumor debulking before chemotherapy may be performed, although is not yet known if this always improves survival in stage IV patients. Investigative approaches for Stage III are also often appropriate for Stage IV.

Recurrent Ovarian Cancer

Treatment Options: If ovarian cancer returns, chemotherapy is the mainstay of treatment, although it is not generally curative in the setting of relapsed disease.

If the interval between the last platinum-containing chemotherapy (carboplatin or cisplatin) and relapse is long (greater than six months), it is reasonable to attempt a repeat trial of platinum-based chemotherapy, with or without paclitaxel.

If the interval is short, or if these drugs fail to control the tumor, then other second-line drugs may be useful in achieving a response. They include topetecan, liposomal doxorubicin, etoposide, docetaxel, gemcitabine, or tamoxifen. There is no evidence as yet that second-line drug combinations are any more effective than single agents, although they are generally more toxic.

Clinical trials using various investigative approaches are underway. It is not clear if there is a role of a second debulking surgical procedure.

HOW IS OVARIAN CANCER SURGICALLY TREATED?

Surgery for ovarian cancer employs laparotomy, which is a major abdominal operation. It is the primary diagnostic tool for ovarian cancer and also plays a role in treatment. Complete surgical intervention includes the following:

Surgical staging (examining all tissues and organs in the pelvic cavity for accurate assessment of the disease stage).
Debulking (removal of as much of the cancerous tissue as possible). This is a critical component of ovarian cancer treatments. The surgeon's skill is very important and patients should be sure their surgeons are experienced in ovarian cancer.

Surgery has been considered necessary for all stages of ovarian cancer, although some medical professionals are questioning its role in certain late-stage cases. In most cases, chemotherapy and sometimes radiation follow surgery. [ See What Are the General Guidelines for Treating Ovarian Cancer by Stage?]

Ovarian cancer patients are urged to seek the expertise of a qualified gynecologic oncologist (a surgical specialist in female reproductive cancers) and a qualified medical oncologist with special expertise in the chemotherapeutic management of gynecologic cancer.

Surgical Staging

Surgical staging includes biopsies of the following:

The undersurface of the diaphragm.
The omentum (the fatty layer that covers and pads organs in the abdomen).
Sometimes lymph nodes along the abdominal aorta.

An abdominal wash is performed by injecting a salt solution into the abdominal cavity to facilitate microscopic detection of malignant cells not visible to the naked eye. The surgeon then evaluates the pelvis and abdomen and removes suspected cancer tissue. The entire affected ovary is usually removed (oophorectomy) during surgical staging if the surgeon believes it might be cancerous. The tissue is sent to a laboratory for an immediate evaluation called a frozen section diagnosis. The physician will also examine the bowel and bladder for cancer invasion.

Preservation Surgery In Premenopausal Women with Early Cancer

If the tumor is in an early stage on one ovary and a young woman wants to retain her ability to have children, the surgeon may be able to remove only the affected ovary and perform surgical staging. Chemotherapy follows in selected patients. Studies indicate that in carefully selected young patients, many can expect normal fertility afterward. It should be noted, however, that most women with ovarian cancer are not candidates for this procedure.

Total Hysterectomy and Bilateral Salpingo-Oophorectomy and Debulking

The goal of surgery is to remove as much of the tumor as possible (called debulking or cytoreductive surgery) for improving symptoms and increasing the effectiveness of chemotherapy. The surgery itself is typically performed as follows:

In premenopausal women in later stages, and in all postmenopausal women, the surgeon usually removes the uterus (a hysterectomy) and both ovaries and fallopian tubes (a bilateral salpingo-oophorectomy).
In addition, the surgeon usually removes the omentum (omentectomy), any growths on the diaphragm and intestine, and possibly certain lymph nodes (lymphadenectomy).

If surgical staging reveals that the cancer has invaded the bowel, a portion of the intestine may have to be removed as well.

Postoperative Care in the First Few Days after Hysterectomy

Postoperative Care. If possible, a patient should ask a family member or friend to help out for the first few days at home. The following are some of the precautions and tips for postoperative care:

For a day or two after surgery, the patient is given medications to prevent nausea and pain killers to relieve pain at the incision site.
As soon as the physician recommends it, usually within a day of the operation, the patient should get up and walk in order to help prevent pneumonia, reduce the risk of blood-clot formation, and to hasten recovery.
Walking and slow, deep breathing exercises may help to relieve gas pains, which can cause major distress for the first few days.
Coughing can cause pain, which may be reduced by holding a pillow over a surgical abdominal wound or by crossing the legs after vaginal surgery.
Patients are advised not to lift heavy objects (including small children), not to douche or take baths, and not to climb stairs or drive for several weeks.
For the first few days after surgery, many women weep frequently and unexpectedly. These mood swings may be due to depression from the loss of reproductive capabilities and form abrupt changes in hormones, particularly if the ovaries have been removed.

The patient should discuss with the physician when exercise programs more intense than walking can be initiated. The abdominal muscles are important for supporting the upper body, and recovering strength may take a long time. Even after the wound has healed, the patient may experience an on-going feeling of overall weakness, which can be demoralizing, particularly in women used to physical health. Some women do not feel completely well for as long as a year; others may recover in only a few weeks.

Complications Following the Procedure. Minor complications after hysterectomy are very common:

Women may develop minor and treatable urinary tract infections.
There is usually light vaginal bleeding and pain after the operation, which can be well-controlled with pain medications.

More serious complications are uncommon but patients should be aware of their symptoms and call the physician immediately if they occur:

Infection occurs in 10% to 15% of patients, with the risk being higher with abdominal than with vaginal surgery. Symptoms might include continuing or increasingly severe pain, fever, heavy discharge, or bleeding. Antibiotics given at the time of surgery help to reduce this risk. Other risk factors for infection appear to be obesity, a longer than normal operative time, and low socioeconomic status.
There is a slight risk for small blood clots, usually in veins of the legs (thrombophlebitis). A sudden swelling or discoloration in the leg can indicate this condition and requires immediate medical attention.
Other serious and even life-threatening complications are rare, but include pulmonary embolism (blood clots that travel to the lung), abscesses, perforation of the bowel, fistulas (a passage that bores from an organ to the skin or to another organ), or dehiscence (the opening of the surgical wound).

Long-Term Complications of Hysterectomy. Women who have had a total hysterectomy are at higher risk for the following:

Muscle weakness in the pelvic area.
Prolapse (descent) of the bladder, vagina, and rectum may occur if the muscle's walls are overly weakened, possibly requiring further surgery.

Treating Menopausal Symptoms and Premature Menopause after Hysterectomy

After hysterectomy women may experience hot flashes, a symptom of menopause. The symptoms come on abruptly and may be more intense than those of natural menopause. Symptoms include hot flashes, vaginal dryness and irritation, and insomnia.

After removal of ovaries, some women take hormone replacement therapy (HRT) in order to prevent osteoporosis from estrogen deficiency. Long-term use of HRT, however, may be of particular concern for women with family hereditary syndromes because of a possible increased risk for breast cancer from HRT. This area is controversial. Women with such risk factors should ask their physician about alternative agents that might be heart or bone protective. Cholesterol lowering agents called statins, for example, not only protect the heart but may also prevent bone loss. Other bone-protecting agents include bisphosphonates, low-dose parathyroid hormone injections, and selective estrogen-receptor modulators (SERMs), such as raloxifene (Evista).

Second-Look Laparotomy

After chemotherapy has been completed, surgeons sometimes perform an exploratory procedure called second-look laparotomy. Although this procedure is the most sensitive way of detecting residual cancer that remains after chemotherapy, it has no proven impact on patient survival. Its use is presently restricted to patients being treated on clinical trials.

Surgery for Bowel Obstruction

Bowel obstruction is common in ovarian cancer. Surgery can be very helpful for selected patients with this problem.

WHAT IS THE DRUG THERAPY (CHEMOTHERAPY) FOR OVARIAN CANCER?

Following surgery, patients other than those with early-stage, low-grade disease usually undergo chemotherapy. Unlike surgery and radiation, which treat the malignant tumor and the area surrounding it, drug therapy destroys rapidly dividing cells throughout the body and so is known as systemic therapy. Ovarian cancers are very sensitive to chemotherapy and often respond well initially. Unfortunately, in most cases, ovarian cancer recurs. Some of the major challenges in ovarian cancer treatments are developing drug approaches that will help reduce this event.

Drugs Used in Chemotherapy

Standard Chemotherapy. The standard treatment for initial chemotherapy uses a combination of the following:

A platinum agent, such as carboplatin (Paraplatin) or (less commonly) cisplatin (Platinol). At this time carboplatin is preferred over cisplatin in the combination because studies indicate that carboplatin is as effective as cisplatin but is less toxic and can be administered in a more convenient, outpatient regimen.
A taxane, such as paclitaxel (Taxol) and docetaxel (Taxotere). Specifically, the inclusion of paclitaxel in the initial chemotherapy of ovarian cancer commonly is considered to result in higher response rates and improved survivals compared to previous regimens.

Older women (over 60) may benefit as much as younger ones from this regimen. Some ovarian cancers are resistant to platinum drugs, and various approaches for increasing responsiveness to these agents are being investigated.

Approximately 70% of women will experience a response to paclitaxel and carboplatin chemotherapy (i.e., a reduction in tumor size). Unfortunately, the disease often becomes resistant to the drugs and the tumor returns at some point in the future.

Chemotherapy Agents Studied for Relapsed or Refractory Cancer. Investigators are studying two approaches for preventing relapse after remission:

Developing more effective drug combination regimens to increase response rates and duration of the response.
Develop maintenance drugs to prevent or delay relapse.
The following lists some of these agents by drug class and includes some promising studies:
Anthrocyclines, including doxorubicin (Adriamycin, Doxil, Myocet), epirubicin (Ellence). Pegylated liposomal doxorubicin (Doxil, Myocet, Caelyx in Canada) is a liposome-encapsulated form of doxorubicin, that remains in the blood stream longer, tends to spare the bone marrow, and move selectively through the tumor. It is showing promise in clinical trials and also may have a lower risk for toxic effects on the heart than standard doxorubicin.
Topo I inhibitors, including topotecan (Hycamtin), irinotecan (Campto). To date, a major analysis of current studies suggest that topotecan's usefulness is similar to that of Doxil, although it is more difficult to administer and has more side effects.
Nucleoside analogs, including gemcitabine (Gemzar) and tiazofurine. Gemcitabine is showing promise as a single agent in patients resistant to platinum-based agents, and may prove to be helpful in combinations.
Topo II alpha inhibitors, including etoposide (Vepesid).
Alkaloids, including vinorelbine (Navelbine)
Hormonal agents. Tamoxifen is used for breast cancer and is being used for relapsed ovarian cancer. It is helpful insome patients.
Valspodar is a unique oral agent that may help improve response to other drugs, although data are preliminary.

Administration of Chemotherapy

In addition to studying individual drugs in different combinations, investigators are looking for the optimal sequence, dosages and timing of administering them. In general, the typical regimen is as follows:

Paclitaxel and carboplatin are administered in the outpatient clinic within several weeks of the surgery.
The treatment takes about four to five hours to complete.
It is repeated every three weeks for a total of six times. (Each three-week interval is known as a cycle of chemotherapy.)

Such chemotherapy is usually administered intravenously (by vein).

Side Effects of Chemotherapy

Side effects occur with all chemotherapeutic drugs. They are more severe with higher doses and increase over the course of treatment.

Common side effects include the following:

Nausea and vomiting. Drugs known as serotonin antagonists, especially ondansetron (Zofran), can relieve these side effects in nearly all patients given moderate drugs and most patients who take more powerful drugs. In one study, a combination of dexamethasone (a corticosteroid) with ondansetron taken within 24 hours of chemotherapy achieved either a major or complete reduction in nausea and vomiting.
Diarrhea.
Temporary hair loss.
Weight loss.
Fatigue.
Anemia.
Depression.

Serious short- and long-term complications can also occur and may vary depending on the specific agents used. They include the following:

Increased chance for infection from suppression of the immune system.
Severe drops in white blood cells ( neutropenia). Certain agents, such as taxanes, pose a higher risk for this than other chemotherapeutic drugs. White blood cell count may be improved with the addition of a drug called granulocyte colony-stimulating factor (filgrastim and lenograstim).
Liver and kidney damage.
Abnormal blood clotting ( thrombocytopenia).
Allergic reaction, particularly to platinum-based agents.
Rarely, secondary cancers such as leukemia.
Between a quarter and a third of women report problems in concentration, motor function, and memory, which may be long-term. This effect may be due to reductions in estrogen levels after treatments.
Cumulative doses of anthracyclines can damage heart muscles over time and increase the risk for heart failure. An encapsulated form doxorubicin (Myocet, Doxil) may reduce the risk for toxic effects on the heart, but has not been approved for breast cancer use as of the date of this report.)
Taxanes can cause a drop in white blood cells and possible problems in the heart and central nervous system. Allergic reactions can occur, more often in Taxol than Taxotere; taking a steroid before taxane administration can help prevent such reactions. Taxane therapy may also cause severe joint and muscle pain in some patients, relievable with corticosteroids.

Gauging Success

Physical Exam and CA-125 Blood Test. During treatment, the effectiveness of the chemotherapy is evaluated primarily with a physical examination and the CA-125 blood test. Falling CA-125 levels indicate effective treatment and persistently elevated levels indicate resistance to the chemotherapy.

Second Look Laparotomy. Second-look laparotomy is sometimes considered after completion of chemotherapy for patients who are participating in clinical trials.

Comparative CT Scans. Another method for evaluating the success of chemotherapy is to compare CT scans of the pelvis and abdomen before and after chemotherapy to check the size of any residual tumors that persisted after the original surgery. CT scanning is not always required, however.

Investigative Procedures for Increasing Effectiveness

Intraperitoneal Chemotherapy. With this approach chemotherapy can be instilled directly into the abdominal cavity at higher than standard doses. There is no good evidence to suggest that it is superior to intraveneous therapy. More work is needed.

Whole-Body Hyperthermia. In one study, heating the patient's body to a temperature of 107 degrees increased her response to platinum-based agents without increasing toxicity of the drug. More research is warranted.

Experimental Agents

Patients with any stage of ovarian cancer are candidates for clinical trials. In addition to testing high-dose or combinations of chemotherapy, agents with unique actions are being investigated.

LH-RH Agonists. Drugs known as luteinizing hormone-releasing hormones (LH-RH) agonists (also called GnRH agonists) are being investigated. They include leuprolide (Lupron), goserelin (Zoladex), and deslorelin. These agents are able to block the release of two major reproductive hormones, and there is some indication that this action may help prevent cell-proliferation. Early studies found no benefit with the use of these drugs, but some experts believe that the doses used were too low and that higher doses or more potent LH-RH agonists may improve results.

Immunotherapy. A number of therapies are under investigation that use agents that boost the body's own immune response to specifically attack ovarian cancer cells. Experimental therapies that are in clinical trials include a vaccinations that use specially designed antibodies (called monoclonal antibodies) to boost the immune responses against tumor-associated factors, such as CA125 or HER-2/neu.

Gene Therapy. Gene therapies generally work in one of two ways:

One approach involves genes that are used to convert inactive agents into cancer-fighting drugs.
The other major approach uses genetic therapies to repair molecular defects that are causing uncontrolled cell proliferation. For example, some investigators are using normal p53--a tumor suppressing factor--to offset genetically defective p53 genes.

Antiangiogenesis Agents. Angiogenesis, the formation of new blood vessels that feed the growth of a cancerous tumor, is a critical process in the spread of ovarian cancer. Endostatin and squalamine are agents that inhibit or block this process and are being studied for ovarian cancer include.

Retinoids. Laboratory studies have found that retinoids, which are compounds derived from vitamin A, inhibit ovarian cancer cell growth. Certain retinoids, including fenretinide, are being investigated for treating ovarian cancer.

WHAT IS RADIATION THERAPY FOR OVARIAN CANCER?

Radiation therapy is not typically used in ovarian cancer. This is due to the fact that radiation needs to be given to the entire abdomen and pelvis, increasing its toxicity. Radiation is sometimes useful to treat isolated areas of tumor that are causing pain and are no longer responsive to chemotherapy.

WHERE ELSE CAN HELP BE FOUND FOR OVARIAN CANCER?

The Gilda Radner Familial Ovarian Cancer Registry, Department of Gynecologic Oncology
Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263-0001. Call (800-OVARIAN) or (800-682-7426) or on the Internet (http://www.ovariancancer.com).

The Gilda Radner Familial Ovarian Cancer Registry is a national computer tracking system that stores the names of women with two or more close relatives who have been diagnosed with ovarian cancer as an aid to early detection of the disease.

National Cancer Institute, Bldg 31, #10A03, 31 Center Drive, MSC 2580, Bethesda, MD 20892. Call (800-4-CANCER) or on the Internet at (http://cancernet.nci.nih.gov/) or for clinical trials (http://cancertrials.nci.nih.gov/).

The NCI also offers CancerFax (call 301-402-5874). National Cancer Institute has a help line open during working hours (call 1-800-422-6237). It also offers CancerFax (call 301-402-5874). To use this service, the call must be made directly from a fax machine.

American Cancer Society, 1599 Clifton Road, NE, Atlanta, GA 30329. Call (800-ACS-2345) or (404-320-3333) or on the Internet (http://www.cancer.org) and (http://www.ca-journal.org).

National Ovarian Cancer Coalition (NOCC), PO Box 4472, Boca Raton, FL 33429. Call(561-393-0005) or (888-OVARIAN) or on the Internet (http://www.ovarian.org).
Provides information for newly diagnosed women, survivors, and family members.

Ovarian Cancer National Alliance (OCNA), P.O. box 33107, Washington, DC 20033. Call (202-331-1332). Or on the Internet (www.ovariancancer.org).
Write to obtain ovarian cancer symptoms check list.

Society of Gynecologic Oncologists (SGO), 401 N. Michigan Avenue, Chicago, IL 60611. Call (312-644-6610) or (800-444-4441) or on the Internet (http://www.sgo.org).
Provides the names of local gynecologic oncologists.

The Helix service (www.hslib.washington.edu/helix).
An up-to-date directory of clinical laboratories performing tests for the genes responsible for hereditary ovarian cancer.

FOR CLINICAL TRIALS

Government site for clinical trials.(http://cancernet.nci.nih.gov/trialsrch.shtml)

Centerwatch (http://www.centerwatch.com) On this site, patients can sign up and receive e-mail notices on new trials. From their main menu, choose Oncology, then scroll down to Ovarian Cancer postings.