ovarian cancer

Ovarian Cancer

 

Definition

Ovarian cancer is cancer of the ovaries, the egg-releasing and hormone-producing organs of the female reproductive tract. Cancerous, or malignant, cells divide and multiply in an abnormal fashion.

Description

The ovaries are small, almond-shaped organs, located in the pelvic region, one on either side of the uterus. When a woman is in her childbearing years, the ovaries alternate to produce and release an egg each month during the menstrual cycle. The released egg is picked up by the adjacent fallopian tube, and continues down toward the uterus. The ovaries also produce and secrete the female hormones estrogen and progesterone, which regulate the menstrual cycle and pregnancy, as well as support the development of the secondary female sexual characteristics (breasts, body shape, and body hair). During pregnancy and when women take certain medications, such as oral contraceptives, the ovaries are given a rest from their usual monthly duties.

Types of ovarian cancers

Ninety percent of all ovarian cancers develop in the cells lining the surface, or epithelium, of the ovaries and so are called epithelial cell tumors. About 15% of epithelial cancers are considered low malignant potential or LMP tumors. These tumors occur more often in younger women, and are more likely to be caught early, so prognosis is good.

Germ cell tumors develop in the egg-producing cells of the ovary, and comprise about 5% of ovarian tumors. These tumors are usually found in teenage girls or young women. The prognosis is good if found early, but as with other ovarian cancers, early detection is difficult.

Primary peritoneal carcinoma (PPC) is a cancer of the peritoneum, the lining of the abdominal cavity where the internal organs are located. Although it is a distinct disease, it is linked with ovarian cancer. This is because the ovarian and peritoneal cells have the same embryonic origin. This means that the very early cells of the embryo that will ultimately develop into the ovaries and the peritoneum share a common origin. The term "primary" means that the cancer started first in the peritoneum, as opposed to the cancer starting in the ovary and then moving, or metastasizing, into the peritoneum.

Ovarian cancer can develop at any age, but is most likely to occur in women who are 50 years or older. More than half the cases are among women who are aged 65 years and older. Industrialized countries have the highest incidence of ovarian cancer. Native American and Caucasian women, especially Caucasians of Ashkenazi Jewish descent, are at somewhat higher risk; Hispanic, African-American, and Asian women are at a slightly lower risk. The risk of developing the disease increases with age. Ovarian cancer is the fifth most common cancer among women in the United States, and the second most common gynecologic cancer. It accounts for 4% of all cancers in women. However, because of poor early detection, the death rate for ovarian cancer is higher than for that of any other cancer among women. About 1 in 70 women in the United States will eventually develop ovarian cancer, and 1 in 100 will die from it. The American Cancer Society estimates that 26,000 new cases of ovarian cancer will be diagnosed in the United States in 2004, and that 16,000 women will die from the disease.

Only 50% of the women who are diagnosed with ovarian cancer will survive five years after initial diagnosis. This is due to the cancer being at an advanced stage at the time of diagnosis. With early detection, however, survival at five years post diagnosis may be 95%.

Causes and symptoms

Causes

The actual cause of ovarian cancer remains unknown, but several factors are known to increase one's chances of developing the disease. These are called risk factors. Women at a higher risk than average of developing ovarian cancer include women who:

• have never been pregnant or had children,
• are Caucasian, especially of Northern European or Ashkenazi Jewish descent,
• are over 50 (half of all diagnosed cases are in women over 65),
• have a family history of breast, ovarian, endometrial (uterine), prostate, or colon cancer,
• have had breast cancer,
• have a first-degree relative (mother, daughter, sister) who has had ovarian cancer. (The risk is greater if two or more first-degree relatives had the disease. Having a grandmother, aunt or cousin with ovarian cancer also puts a woman at higher-than-average risk.)
• have the genetic mutation BRCA1 or BRCA2. (Not all women with these genetic breast cancer mutations will develop ovarian cancer. By age 70, a woman who has the BRCA1 mutation carries about a 40-60% risk of developing ovarian cancer. Women with the genetic mutation BRCA2 have a 15% increased risk of developing ovarian cancer. However, heredity only plays a role in about 5-10% of cases of ovarian cancer.)

Women who have a strong familial history may benefit from genetic counseling to better understand their risk factors.

In addition to the above risk factors, the following factors appear to play a role in affecting a women's chances of developing ovarian cancer.

Reproduction and hormones. Early menstruation (before age 12) and late menopause seem to put women at a higher risk for ovarian cancer. This appears to be because the longer, or more often, a woman ovulates, the higher her risk for ovarian cancer. As mentioned above, women who were never pregnant have a higher risk of developing the disease than women with one or more pregnancies. It is not yet clear from research studies whether a pregnancy that ends in miscarriage or stillbirth lowers the risk factor to the same degree as the number of term pregnancies. The use of postmenopausal estrogen supplementation for 10 years or more may double a woman's risk of ovarian cancer. Short-term use does not seem to alter one's risk factor.

Infertility drug-stimulated ovulation. Research studies have reported mixed findings on this issue. It appears that women who take medications to stimulate ovulation, yet do not become pregnant, are at higher risk of developing ovarian cancer. Women who do become pregnant after taking fertility drugs do not appear to be at higher risk. One study reported that the use of the fertility drug clomiphene citrate for more than a year increased the risk of developing LMP tumors. LMP tumors respond better to treatment than other ovarian tumors.

Talc. The use of talcum powder in the genital area has been implicated in ovarian cancer in many studies. It may be because talc contains particles of asbestos, a known carcinogen. Female workers exposed to asbestos had a higher-than-normal risk of developing ovarian cancer. Genital deodorant sprays may also present an increased risk. Not all studies have brought consistent results.

Fat. A high-fat diet has been reported in some studies to increase the risk of developing ovarian cancer. In one study the risk level increased with every 10 grams of saturated fat added to the diet. This may be because of its effect on estrogen production.

Symptoms

Most of the literature on ovarian cancer states that there are usually no early warning symptoms for the disease. Ovarian cancer is often referred to as a silent killer, because women either are unaware of having it, or have symptoms that are not accurately diagnosed until the disease is in an advanced state. However, a November 2000 study reported in the medical journal Cancer analyzed more than 1,700 questionnaires completed by women with stage III and stage IV ovarian cancer. The researchers found that 95% of the women reported having had early symptoms that they brought to their doctors. Most symptoms were somewhat vague and either abdominal or gastrointestinal in nature, and consequently were either not properly diagnosed or were recognized as being ovarian in nature only after a significant length of time had passed.

The following symptoms are warning signs of ovarian cancer, but could also be due to other causes. Symptoms that persist for two to three weeks, or symptoms that are unusual for the particular woman should be evaluated by a doctor right away.

• digestive symptoms, such as gas, indigestion, constipation, or a feeling of fullness after a light meal
• bloating, distention or cramping
• abdominal or low-back discomfort
• pelvic pressure or frequent urination
• unexplained changes in bowel habits
• nausea or vomiting
• pain or swelling in the abdomen
• loss of appetite
• fatigue
• unexplained weight gain or loss
• pain during intercourse
• vaginal bleeding in post-menopausal women

Diagnosis

In the best-case scenario a woman is diagnosed with ovarian cancer while it is still contained in just one ovary. Early detection can bring five-year survival to near 95%. Unfortunately, about 75% of women (3 out of 4) have advanced ovarian cancer at the time of diagnosis. (Advanced cancer is at stage III or stage IV when it has already spread to other organs.) Five-year survival for women with stage IV ovarian cancer may be less than 5%.

Diagnostic tests and techniques

If ovarian cancer is suspected, several of the following tests and examinations will be necessary to make a diagnosis:

• a complete medical history to assess all the risk factors
• a thorough bi-manual pelvic examination
• CA-125 assay
• one or more various imaging procedures
• a lower GI series, or barium enema
• diagnostic laparoscopy

BI-MANUAL PELVIC EXAMINATION. The exam should include feeling the following organs for any abnormalities in shape or size: the ovaries, fallopian tubes, uterus, vagina, bladder, and rectum. Because the ovaries are located deep within the pelvic area, it is unlikely that a manual exam will pick up an abnormality while the cancer is still localized. However, a full examination provides the practitioner with a more complete picture. An enlarged ovary does not confirm cancer, as the ovary may be large because of a cyst or endometriosis. While women should have an annual Pap test, this test screens for cervical cancer. Cancerous ovarian cells, however, might be detected on the slide. Effectiveness of using Pap smears for ovarian cancer detection is about 10-30%.

CA-125 ASSAY. This is a blood test to determine the level of CA-125, a tumor marker. A tumor marker is a measurable protein-based substance given off by the tumor. A series of CA-125 tests may be done to see if the amount of the marker in the blood is staying stable, increasing or decreasing. A rising CA-125 level usually indicates cancer, while a stable or declining value is more characteristic of a cyst. The CA-125 level should never be used alone to diagnose ovarian cancer. It is elevated in about 80% of women with ovarian cancer, but in 20% of cases is not. In addition, it could be elevated because of a non-ovarian cancer, or it can be elevated with non-malignant gynecologic conditions, such as endometriosis or ectopic pregnancy. During menstruation the CA-125 level may be elevated, so the test is best done when the woman is not in her menses.

IMAGING. There are several different imaging techniques used in ovarian cancer evaluation. A fluid-filled structure such as a cyst creates a different image than does a solid structure, such as a tumor. An ultrasound uses high-frequency sound waves that create a visual pattern of echoes of the structures at which they are aimed. It is painless, and is the same technique used to check the developing fetus in the womb. Ultrasound may be done externally through the abdomen and lower pelvic area, or with a transvaginal probe.

Other painless imaging techniques are computed tomography (CT) and magnetic resonance imaging (MRI). Color Doppler analysis provides additional contrast and accuracy in distinguishing masses. It remains unclear whether Doppler is effective in reducing the high number of false-positives with transvaginal ultrasonography. These imaging techniques allow better visualization of the internal organs and can detect abnormalities without having to perform surgery.

LOWER GI SERIES. A lower GI series, or barium enema, uses a series of x rays to highlight the colon and rectum. To provide contrast, the patient drinks a chalky liquid containing barium. This test might be done to see if the cancer had spread to these areas.

DIAGNOSTIC LAPAROSCOPY. This technique uses a thin hollow lighted instrument inserted through a small incision in the skin near the belly button to visualize the organs inside of the abdominal cavity. If the ovary is believed to be malignant, the entire ovary is removed (oophorectomy) and its tissue sent for evaluation to the pathologist, even though only a small piece of the tissue is needed for evaluation. If cancer is present, great care must be taken not to cause the rupture of the malignant tumor, as this would cause spreading of the cancer to adjacent organs. If the cancer is completely contained in the ovary, its removal functions also as the treatment. If the cancer has spread or is suspected to have spread, then a saline solution may be instilled into the cavity and then drawn out again. This technique is called peritoneal lavage. The aspirated fluid will be evaluated for the presence of cancer cells. If peritoneal fluid is present, called ascites, a sample of this will also be drawn and examined for malignant cells. If cancer cells are present in the peritoneum, then treatment will be directed at the abdominal cavity as well.

RESEARCH AND NEW DIAGNOSTIC TESTS. Many cancer researchers recognize the urgency of developing a new diagnostic test for ovarian cancer that is both sensitive and reliable. Some experts in the field look to proteomics, which is the large-scale identification and analysis of all the proteins in an organism or organ, to lead eventually to the development of a useful new test for ovarian cancer.

A group of researchers in Canada reported in 2003 that human kallikrein gene 14 (KLK14) might serve as a new biomarker for ovarian cancer. Kallikreins are a group of compounds that help to split up complex protein molecules into smaller units; prostate-specific antigen, or PSA, is a kallikrein. Early results of tests for KLK14 indicate that about 65% of women known to have ovarian cancer have elevated levels of this kallikrein.

Treatment

Clinical staging

Staging is the term used to determine if the cancer is localized or has spread, and if so, how far and to where. Staging helps define the cancer, and will determine the course of suggested treatment. Staging involves examining any tissue samples that have been taken from the ovary, nearby lymph nodes, as well as

A stage I tumor of the ovary.

(Illustration by Argosy Inc.)

from any nearby organs or structures where metastasis was suspected. This may include the diaphragm, lungs, stomach, intestines and omentum (the tissue covering internal organs), and any fluid as described above.

The National Cancer Institute Stages for ovarian cancer are:

• Stage I: Cancer is confined to one or both ovaries.
• Stage II: Cancer is found in one or both ovaries and/or has spread to the uterus, fallopian tubes, and/or other body parts within the pelvic cavity.
• Stage III: Cancer is found in one or both ovaries and has spread to lymph nodes or other body parts within the abdominal cavity, such as the surfaces of the liver or intestines.
• Stage IV: Cancer is found in one or both ovaries and has spread to other organs such as the liver or lung.

The individual stages are also further broken down in detail, such as Ia, Ib, etc. Accurate staging is important for several reasons. Treatment plans are based on staging, in part because of trying to duplicate the best results achieved in prior research trials. When staging is inconsistent, it becomes more difficult to know how different research studies compare, so the results themselves cannot be relied upon.

Treatment offered will primarily depend on the stage of the cancer and the woman's age. It is always appropriate to consider getting a second opinion, especially when treatment involves surgery, chemotherapy, and possible radiation. Before the patient makes her decision as to which course of treatment to take, she should feel that she has the information necessary with which to make an informed decision. The diagnostic tools mentioned above are used to determine the course of treatment. However, the treatment plan may need to be revised if the surgeon sees that the tumor has spread beyond the scope of what was seen during diagnostic tests.

Surgery

Surgery is done to remove as much of the tumor as possible (called tissue debulking), utilizing chemotherapy and/or radiation to target cancer cells that have remained in the body, without jeopardizing the woman's health. This can be hard to balance once the cancer has spread. Removal of the ovary is called oophorectomy, and removal of both ovaries is called bilateral oophorectomy. Unless it is very clear that the cancer has not spread, the fallopian tubes are usually removed as well (salpingo-oophorectomy). Removal of the uterus is called hysterectomy.

If the woman is very young, all attempts will be made to spare the uterus. It is crucial that a woman discuss with her surgeon her childbearing plans prior to surgery. Unfortunately, ovarian cancer spreads easily and often swiftly throughout the reproductive tract. It may be necessary to remove all reproductive organs as well as part of the lining of the peritoneum to provide the woman with the best possible chance of long-term survival. Fertility-sparing surgery can be successful if the ovarian cancer is caught very early.

Side effects of the surgery will depend on the extent of the surgery, but may include pain and temporary difficulty with bladder and bowel function, as well as reaction to the loss of hormones produced by the organs removed. A hormone replacement patch may be applied to the woman's skin in the recovery room to help with the transition. An emotional side effect may be the feeling of loss stemming from the removal of reproductive organs.

Chemotherapy

Chemotherapy is used to target cells that have traveled to other organs, and throughout the body via the lymphatic system or the blood stream. Chemotherapy drugs are designed to kill cancer cells, but may also be harmful to healthy cells as well. Chemotherapy may be administered through a vein in the arm (intravenous, IV), may be taken in tablet form, and/or may be given through a thin tube called a catheter directly into the abdominal cavity (intraperitoneal). IV and oral chemotherapy drugs travel throughout the body; intraperitoneal chemotherapy is localized in the abdominal cavity.

Side effects of chemotherapy can vary greatly depending on the drugs used. Currently, chemotherapy drugs are often used in combinations to treat advanced ovarian cancer, and usually the combination includes a platinum-based drug (such as cisplatin) with a taxol agent, such as paclitaxel. Some of the combinations used or being studied include: carboplatin/paclitaxel, cisplatin/paclitaxel, cisplatin/topotecan, and cisplatin/carboplatin. As new drugs are evaluated and developed, the goal is always for maximum effectiveness with minimum side effects. Side effects include nausea and vomiting, diarrhea, decreased appetite and resulting weight loss, fatigue, headaches, loss of hair, and numbness and tingling in the hands or feet. Managing these side effects is an important part of cancer treatment.

After the full course of chemotherapy has been given, the surgeon may perform a "second look" surgery to examine the abdominal cavity again to evaluate the success of treatment.

Radiation

Radiation uses high-energy, highly focused x rays to target very specific areas of cancer. This is done using a machine that generates an external beam. Very careful measurements are taken so that the targeted area can be as focused and small as possible. Another form of radiation uses a radioactive liquid that is administered into the abdominal cavity in the same fashion as intraperitoneal chemotherapy. Radiation is usually given on a daily Monday though Friday schedule and for several weeks continuously. Radiation is not painful, but side effects can include skin damage at the area exposed to the external beam, and extreme fatigue. The fatigue may hit suddenly in the third week or so of treatment, and may take a while to recover even after treatments have terminated. Other side effects may include nausea, vomiting, diarrhea, loss of appetite, weight loss and urinary difficulties. For patients with incurable ovarian cancer, radiation may be used to shrink tumor masses to provide pain relief and improve quality of life.

Once the full course of treatment has been undertaken, it is important to have regular follow-up care to monitor for any long-term side effects as well as for future relapse or metastases.

Alternative treatment

The term alternative therapy refers to therapy utilized instead of conventional treatment. By definition, these treatments have not been scientifically proven or investigated as thoroughly and by the same standards as conventional treatments. The terms complementary or integrative therapies denote practices used in conjunction with conventional treatment. Regardless of the therapies chosen, it is key for patients to inform their doctors of any alternative or complementary therapies being used or considered. (Some alternative and complementary therapies adversely affect the effectiveness of conventional treatments.) Some common complementary and alternative medicine techniques and therapies include:

• prayer and faith healing
• meditation
• mind/body techniques such as support groups, visualization, guided imagery and hypnosis
• energy work such as therapeutic touch and Reiki
• Acupuncture and Chinese herbal medicine
• body work such as yoga, massage and t'ai chi
• vitamins and herbal supplements
• diets such as vegetarianism and macrobiotic

Mind/body techniques along with meditation, prayer, yoga, T'ai Chi and acupuncture have been shown to reduce stress levels, and the relaxation provided may help boost the body's immune system. The effectiveness of other complementary and alternative treatments is being studied by the National Institutes of Health's National Center for Complementary and Alternative Medicine (NCCAM). For a current list of the research studies occurring, results of recent studies, or publications available, patients can visit the NCCAM web site or call at (888) 644-6226.

Some programs for treatment of ovarian cancer integrate alternative or complementary treatments with conventional surgery or chemotherapy. As of early 2003, the University of Kansas Medical Center is conducting a study of the effectiveness of adding four well-known antioxidants (vitamins A, C, E, and beta-carotene) to standard chemotherapy regimens for ovarian cancer.

Prognosis

Prognosis for ovarian cancer depends greatly on the stage at which it is first diagnosed. While stage I cancer may have a 95% success rate, stages III and IV may have a survival rate of 17-30% at five years post-diagnosis. Early detection remains an elusive, yet hopeful, goal of research. Also, clinical trials are addressing new drug and treatment combinations to prolong survival in women with more advanced disease. Learning one's family history may assist in early detection, and genetic studies may clarify who is at greater risk for the disease.

Research studies are usually designed to compare a new treatment method against the standard method, or the effectiveness of a drug against a placebo (an inert substance that would be expected to have no effect on the outcome). Since the research is experimental in nature, there are no guarantees about the outcome. New drugs being used may have harmful, unknown side effects. Some people participate to help further knowledge about their disease. For others, the study may provide a possible treatment that is not yet available otherwise. If one participates in a study and is in the group receiving the standard care or the placebo, and the treatment group gets clear benefit, it may be possible to receive the experimental treatment once one's original participation role is over. Participants will have to meet certain criteria before being admitted into the study. It is important to fully understand one's role in the study, and weigh the potential risks versus benefits when deciding whether or not to participate.

Prevention

Since the cause of ovarian cancer is not known, it is not possible to fully prevent the disease. However, there are ways to reduce one's risks of developing the disease.

Decrease ovulation. Pregnancy gives a break from ovulation, and multiple pregnancies appear to further reduce the risk of ovarian cancer. The research is not clear as to whether the pregnancy must result in a term delivery to have full benefit. Women who breastfeed their children also have a lower risk of developing the disease. Since oral contraceptives suppress ovulation, women who take birth control pills (BCPs), even for as little as 3 to 6 months have a lower incidence of the disease. It appears that the longer a woman takes BCPs, the lower her risk for ovarian cancer. Also, this benefit may last for up to 15 years after a woman has stopped taking them. However, since BCPs alter a woman's hormonal status, her risk for other hormonally related cancers may change. For this reason it is very important to discuss all the risks and benefits with one's health care provider.

Key terms

Biomarker — A biochemical substance that can be detected in blood samples and indicates the presence of a cancerous tumor.

Gynecologic oncologist — A physician specializing in the treatment of cancers of the female reproductive tract.

Kallikrein — Any of a group of compounds in the body known as serine endopeptidases that help to break down proteins into smaller units. Prostate-specific antigen belongs to this group of chemicals. A recently discovered kallikrein may be useful as a biomarker for ovarian cancer.

Lymphatic system — A connected network of nodes, or glands, that carry lymph throughout the body. Lymph is a fluid that contains the infection-fighting white blood cells that form part of the body's immune system. Because the network goes throughout the body, cancer cells that enter the lymphatic system can travel to and be deposited at any point into the tissues and organs and form new tumors there.

Paclitaxel — A drug derived from the common yew tree (Taxus baccata) that is the mainstay of chemotherapy for ovarian cancer.

Pathologist — The pathologist is a doctor specializing in determining the presence and type of disease by looking at cells and tissue samples.

Genetic testing. Tests are available which can help to determine whether a woman who has a family history of breast, endometrial, or ovarian cancer has inherited the mutated BRCA gene that predisposes her to these cancers. If the woman tests positive for the mutation, then she may be able to choose to have her ovaries removed. Even without testing for the mutated gene, some women with strong family histories of ovarian cancer may consider having their ovaries removed as a preventative measure (prophylactic oophorectomy). This procedure diminishes but does not completely remove the risk of cancer, as some women may still develop primary peritoneal carcinoma after oophorectomy.

Surgery. Procedures such as tubal ligation (in which the fallopian tubes are blocked or cut off) and hysterectomy (in which the uterus is removed) appear to reduce the risk of ovarian cancer. However, any removal of the reproductive tract organs has surgical as well as hormonal side effects.

Screening. There are no definitive tests or screening procedures to detect ovarian cancer in its early stages, although a blood test for early detection of asymptomatic ovarian cancer is under development as of early 2003. Women at high risk should consult with their physicians about regular screenings, which may include transvaginal ultrasound and the blood test for the CA-125 protein.

The American Cancer Society recommends annual pelvic examinations for all women after age 40, in order to increase the chances of early detection of ovarian cancer.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Ovarian Cancer." Section 18, Chapter 241. In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, "CAM Therapies for Specific Conditions: Cancer." New York: Simon & Schuster, 2002.

Runowicz, Carolyn D., Jeanne A. Petrek, and Ted S. Gansler. American Cancer Society: Women and Cancer. New York: Villard Books/Random House, 1999.

Teeley, Peter, and Philip Bashe. The Complete Cancer Survival Guide. New York: Doubleday, 2000.

Periodicals

Almadrones, L. A. "Treatment Advances in Ovarian Cancer." Cancer Nursing 26, Supplement 6 (December 2003): 16S-20S.

Ayhan, A., H. Celik, C. Taskiran, et al. "Oncologic and Reproductive Outcome after Fertility-Saving Surgery in Ovarian Cancer." European Journal of Gynaecological Oncology (March 2003): 223-232.

Balat, O., and M. G. Ugur. "Prolonged Stabilization of Platinum/Paclitaxel-Refractory Ovarian Cancer with Topotecan: A Case Report and Review of the Literature." Clinical and Experimental Obstetrics and Gynecology 30 (February 2003): 151-152.

Borgono, C. A., L. Grass, A. Soosaipillai, et al. "Human Kallikrein 14: A New Potential Biomarker for Ovarian and Breast Cancer." Cancer Research 63 (December 15, 2003): 9032-9041.

Drisko, J. A., J. Chapman, and V. J. Hunter. "The Use of Antioxidant Therapies During Chemotherapy." Gynecologic Oncology 88 (March 2003): 434-439.

Kohn, E. C., G. B. Mills, and L. Liotta. "Promising Directions for the Diagnosis and Management of Gynecological Cancers." International Journal of Gynaecology and Obstetrics 83, Supplement 1 (October 2003): 203-209.

McCorkle, R., J. Pasacreta, and S. T. Tang. "The Silent Killer: Psychological Issues in Ovarian Cancer." Holistic Nursing Practice 17 (November-December 2003): 300-308.

O'Rourke, J., and S. M. Mahon. "A Comprehensive Look at the Early Detection of Ovarian Cancer." Clinical Journal of Oncology Nursing 7 (January-February 2003): 41-47.

Ray-Coquard, I., T. Bachelot, J. P. Guastalla, et al. "Epirubicin and Paclitaxel (EPI-TAX Regimen) for Advanced Ovarian Cancer After Failure of Platinum-Containing Regimens." Gynecologic Oncology 88 (March 2003): 351-357.

See, H. T., J. J. Kavanagh, W. Hu, and R. C. Bast. "Targeted Therapy for Epithelial Ovarian Cancer: Current Status and Future Prospects." International Journal of Gynecological Cancer 13 (November-December 2003): 701-734.

Organizations

American Cancer Society. (800) ACS-2345. http://www.cancer.org.

Cancer Research Institute. 681 Fifth Avenue, New York, NY 10022. (800) 992-2623. http://www.cancerresearch.org.

National Cancer Institute. Building 31, Room 10A31, 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (301) 435-3848. http://www.nci.nih.gov.

National Center for Complementary and Alternative Medicine. NCCAM Clearinghouse, P.O. Box 8218, Silver Spring, MD 20907-8218. (888) 644-6226. http://nccam.nih.gov.

Oncolink at the University of Pennsylvania. http://www.oncolink.upenn.edu.

Women's Cancer Network. c/o Gynecologic Cancer Foundation, 401 N. Michigan Avenue, Chicago, IL 60611. (312) 644-6610. http://www.wcn.org.

Other

Ovarian Cancer Home Page, National Cancer Institute. http://www.nci.nih.gov/cancer_information/cancer_type/ovarian/.

"Ovarian Cancer." OncoLink: University of Pennsylvania Cancer Center. July 5, 2001. [cited July 6, 2001]. 〈http://cancer.med.upenn.edu/specialty/gyn_onc/ovarian/〉.

ovarian

 [o-var´e-an]

pertaining to an ovary.

ovarian cancer cancer of the ovary, one of the leading causes of cancer-related death in women in the United States. Despite advances in treatment, the survival rate has risen only slightly since 1950. Although aggressive treatment in the early stages offers the best prognosis, detection before the malignancy reaches an advanced stage is difficult.

Signs and symptoms become more apparent as the tumor grows. The first finding is usually a pelvic mass noted on pelvic examination. However, if the patient is obese or has difficulty relaxing and cooperating with the examiner, the mass may not be felt. With increased size, the tumor compresses the surrounding pelvic structures, which may cause a feeling of fullness and pain in the pelvis or abdomen, abnormal uterine bleeding, urinary complaints, dyspareunia, and later ascites. Gastrointestinal symptoms such as heartburn, nausea, and anorexia may also be associated. Diagnosis is established when the mass is found during exploratory surgery and peritoneal cytology.

A plan of treatment is developed according to the stage of the disease. The modes of therapy include total abdominal hysterectomy, bilateral salpingo-oophorectomy, and a partial or complete omentectomy. Radiation and chemotherapy are administered after surgery to destroy malignant cells remaining in the abdominal cavity.

Patient Care. Among the major problems associated with ovarian malignancy are those related to abdominopelvic surgery, and the side effects of radiation therapy and chemotherapy. Additionally, the patient with advanced malignancy may suffer from the effects of ascites, which can cause discomfort and shortness of breath, and pleural effusion, which can produce cough, dyspnea, and chest pain. Nutritional problems and emaciation can occur because of a host of factors such as nausea and anorexia, fullness and discomfort of ascites, and tumor involvement of the intestines. Moreover, cancer itself interferes with normal metabolism of nutrients. Intestinal obstruction or other complications related to digestion, absorption, and excretion are the major causes of death in the patient with ovarian cancer.

While specific measures to prevent ovarian cancer are not known, health care providers can encourage early detection by stressing the importance of regular gynecologic examinations and teaching women to recognize the signs and symptoms of ovarian tumors.

ovarian vein syndrome obstruction of the ureter, usually on the right side, due to compression by an enlarged or varicose ovarian vein; typically the vein becomes enlarged during pregnancy, the symptoms being those of obstruction or infection of the upper urinary tract.

ovarian cancer

Cancer of ovary, ovarian carcinoma Oncology The 5^th most common malignancy in ♀–US, 22,000 new cases/yr, and 13,300 deaths/yr Risk factors ↑ Risk with nulliparity or first birth after age 35; ↓ risk with childbirth < age 25 or use of oral contraceptives; familial ovarian cancer accounts for 5% of ovarian cancers Clinical Generally vague Sx in early disease–the silent killer; advanced disease presents with abdominal fullness
and early satiety due to ascites and omental tumor implants; OC is rarely confined to the pelvis; early diagnosis is fortuitous Screening Serum assays for markers of OC are useless Diagnosis Physical examination–eg, pelvic exam, ultrasound, x-ray tests, CA-125 serum test, biopsy Types Epithelial tumors/carcinomas comprise 90% of ovarian CAs and are more common > age 40, often asymptomatic; non-epithelial tumors–eg, stroma cell and germ cell tumors are more common in younger ♀; OC use may ↓ the risk of ovarian CA; 5–10% of are familial; 3 hereditary patterns are identified: ovarian CA alone, ovarian & breast CAs, ovarian & colon CAs Therapy–limited disease (stage I, II): TAH-BSO and omentectomy with examination of peritoneal surface Therapy–advanced disease (stage III, IV) Debulking of peritoneal tumors, followed by platinum–eg, cisplatin–or the less toxic carboplatin, or taxol-containing regimens; 'compassionate' protocols that may improve survival include intraperitoneal chemotherapy and autologous BM transplantation

FIGO* Staging, epithelial cancer of Ovary

Stage I Tumor limited to ovary

A One ovary, no ascites, intact capsule

B  Both ovaries, no ascites, intact capsule

C  Both ovaries, malignant ascites (positive peritoneal washings), ruptured capsule (capsular involvement)

Stage II Tumor extends beyond ovary into pelvis

A  Pelvic extension to uterus or fallopian tubes

B Pelvic extension to other pelvic organs, eg bladder, rectum, vagina

C Pelvic extension + IC findings

Stage III Extrapelvic extension or positive lymph nodes

A Microscopic seeding outside of pelvis.

B Gross lesions ≤ 2 cm

C Gross lesions > 2 cm and positive lymph nodes

Stage IV Distant/extraperitoneal organ involvement, eg liver, pleura  

* Federation of Gynecology and Obstetrics

o·var·i·an can·cer

(ō-var'ē-ăn kan'sĕr)

A malignancy that arises from the female reproductive organ; one of the most common gynecologic malignancies and one of the most frequent causes of cancer death in women, with 50% of all cases occurring in women older than age 65.

Ovarian Cancer

DRG Category:	737
Mean LOS:	6.4 days
Description:	SURGICAL: Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy With CC
DRG Category:	755
Mean LOS:	5 days
Description:	MEDICAL: Malignancy, Female Reproductive System With CC

Ovarian cancer is the primary cause of death from reproductive system malignancies in women. According to the American Cancer Society, in 2013 in the United States, 22,240 new cases of ovarian cancer were diagnosed. The survival rate is 77% at 1 year and 44% at 5 years. Only 19% of the cases are diagnosed before metastasis has occurred. Because of the lack of early detection and the rapid progression of the disease, the number of deaths caused by ovarian cancer has risen. No long-term improvement in the survival rate has occurred in the past 30 years.

Three types of ovarian cancers exist owing to the three types of tissue in the ovary: primary epithelial tumors, germ cell tumors, and gonadal stromal (sex cord) tumors. Primary epithelial tumors comprise approximately 90% of all ovarian cancers and include serous and mucinous cystadenocarcinomas, endometrioid tumors, and mesonephric tumors. They arise in the ovarian epithelium (known as müllerian epithelium). Germ cell tumors, which arise from an ovum, include endodermal sinus malignant tumors, embryonal carcinoma, immature teratomas, and dysgerminoma. Sex cord tumors, which arise from the ovarian stroma (the foundational support tissues of an organ), include granulosa cell tumors, thecomas, and arrhenoblastomas.

Because of the location of the ovaries in the abdominal cavity, ovarian cancers grow and spread silently until they affect the surrounding organs or cause abdominal distention. At the appearance of these symptoms, metastases to the fallopian tubes, uterus, ligaments, and other intraperitoneal organs occur. Tumors can spread through the lymph system and blood into the chest cavity.

As the disease progresses, the patient experiences multiple system complications. Peripheral edema, ascites, and intestinal obstruction can complicate the course of the disease. Patients develop severe nutritional deficiencies, electrolyte disturbances, and cachexia. If the lungs are involved, the patient develops malignant recurrent pleural effusions.

Causes

Although several theories exist, the exact cause of ovarian cancer is unknown; many factors, however, seem to play a role in its development. A family history of ovarian cancer places the patient at risk, as does a diet high in saturated fats. It appears that ovarian cancer occurs in women who have more menstrual cycles (i.e., early menarche, late menopause, nulliparity, infertility, and celibacy). Exposure to asbestos and talc may place the patient at risk. Late menarche, early menopause, pregnancy, and oral contraception may offer a protective benefit by effecting ovulation suppression.

Genetic considerations

Only 10% of ovarian cancer cases are believed to be genetic in etiology. Susceptibility to ovarian cancer coexists with breast cancer susceptibility when BRCA1/2 mutations are present and may be associated with Lynch’s syndrome. Breast/ovarian cancer can be transmitted through families as an autosomal dominant trait from either the mother’s or the father’s side of the family. The likelihood that ovarian cancer is inherited increases if two or more relatives are affected with ovarian cancer or if several relatives are affected with breast and/or ovarian cancer. Genetic risk is also increased if breast and ovarian cancer occur in the same person, if there is Ashkenazi Jewish heritage, or if there are family members who carry the BRCA1/2 or HNPCC gene mutations. Other candidate loci are being pursued.

Gender, ethnic/racial, and life span considerations

The incidence of ovarian cancer is highest in postmenopausal women, with 50% of the cases occurring in women who are older than 63 years. In rare instances, the disease can occur in childhood and during pregnancy. In the general population, ovarian cancer occurs in 1 in 70 women; the risk is increased to 5% if one first-degree relative has the disease. Women with European ancestry have higher rates of ovarian cancer than other groups, and Asian women have increased rates of ovarian cancer when the immigrate to North America or Europe from Asia.

Global health considerations

The global incidence of ovarian cancer is approximately 7 per 100,000 females per year. Women who live in developed countries have a higher risk than those in developing countries, where women have high parities. The incidence is five times higher in developed than in developing countries. Scandinavian women have high rates as compared to women in other regions of Europe.

Assessment

History

Elicit a detailed family history of all cancer-related illnesses, paying particular attention to the history of female relatives. The patient’s descriptions of the signs and symptoms vary with the tumor’s size and location; symptoms usually do not occur until after tumor metastasis. The symptoms patients most commonly report are back pain, fatigue, bloating, constipation, abdominal pain, and urinary urgency. Most patients with ovarian cancer have at least two of these symptoms. Other symptoms include urinary frequency, abdominal distention, pelvic pressure, vaginal bleeding, leg pain, and weight loss. Pelvic discomfort and acute pelvic pain may occur, and if infection, tumor rupture, or torsion has resulted, the pain may resemble that of acute appendicitis.

Physical examination

Early signs are vague such as bloating, abdominal distention, changes in bowel patterns, and vaginal bleeding. The patient often appears thin and chronically ill. Her abdomen may be grossly distended, but her extremities are thin and even wasted. When you palpate the abdominal organs, you may be able to feel masses. During the vaginal examination, you may be able to palpate an ovary in postmenopausal women that feels like the size of an ovary in premenopausal women. An ovarian tumor may feel hard like a rock or pebble, may feel rubbery, or may have a cyst-like quality. Palpation of an irregular, nodular (“handful of knuckles”), insensitive bilateral mass in the pelvis strongly suggests the presence of an ovarian tumor.

Psychosocial

If the patient is a young woman who needs to undergo surgery and loses her childbearing ability, determine the meaning of children to her and her partner. Consider the patient’s developmental level, financial resources, job responsibilities, home-care responsibilities, and the degree of independence of any children. If the patient is a child, determine whether her parents have told her she has cancer. If the prognosis of the patient’s cancer is poor, determine the patient’s degree of understanding of the gravity of the prognosis. Determine the effect of the patient’s religion and spirituality on the course of the disease.

Diagnostic highlights

General Comments: None of the tumor markers is specific enough to be considered for routine screening, but they are helpful in differential diagnosis of pelvic masses and to follow up treated cases.

Test	Normal Result	Abnormality With Condition	Explanation
Cancer antigen 125 (CA-125)	0–35 U/mL	Elevated in 80% of the patients	Serial measured; elevation indicates tumor progression; decrease indicates effective antitumor treatment; limited value for screening
Transvaginal ultrasound	No masses noted	Mass visible	Used to detect and evaluate ovarian masses
Human chorionic gonadotropin; serum α-fetoprotein	Normally are not present in nonpregnant women	Elevated in embryonal cell carcinoma and dysgerminoma	Serially measured; elevation indicates tumor progression; decrease indicates effective antitumor treatment
Exploratory laparotomy	Negative study	Tumor is visualized	Accurate diagnosing and staging

Other Tests: Computed tomography scan, magnetic resonance imaging, and sonography are useful for monitoring the course of the disease. Upper and lower bowel series and intravenous pyelography are done to determine the extent of the disease and whether the cancer is primary or metastatic. Liver function studies, blood chemistries, and chest x-rays are also done.

Primary nursing diagnosis

Diagnosis

Pain (acute) related to tumor invasion, tissue destruction, and organ compression

Outcomes

Pain control; Pain: Disruptive effects; Well-being

Interventions

Analgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation; Hypnosis; Heat/cold application

Planning and implementation

Collaborative

surgical.

Aggressive surgical treatment is usually used. If there is a desire to preserve the fertility of young women or girls, however, a conservative approach may be used if they have a unilateral encapsulated tumor. In this approach, the surgeon may resect the ovary, biopsy structures such as the omentum and uninvolved ovary and perform peritoneal washings for cytologic examination of pelvic fluid. These patients need careful follow-up with periodic diagnostic tests to determine if the tumor is metastasizing.

More typically, the surgeon performs a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection. In addition, the surgeon performs an omentectomy, appendectomy, lymph node palpation with possible lymphadenectomy, and other biopsies and washings as necessary. Sometimes, the surgeon is unable to remove the tumor completely if it is wrapped around or has invaded vital organs. Monitor the patient carefully after surgery for complications such as wound infection, hemorrhage, fluid and electrolyte imbalance, and poor gas exchange.

If a young girl has had both ovaries removed, she needs hormonal replacement beginning at puberty so that she develops secondary sex characteristics. Chemotherapy after surgery prolongs survival time but is primarily palliative rather than curative, although it does provide remissions in some patients.

Although radiation therapy is uncommon because it depresses the bone marrow, sometimes patients receive it as an option to other treatments.

pain management.

No matter which treatment is chosen to manage the patient’s cancer, pain management is an issue. Monitor the patient’s pain (location, duration, frequency, precipitating factors) and administer analgesics as needed. Determine the patient’s response to analgesia by asking the patient to rate her pain on a scale of 0 to 10, with 0 indicating no pain and 10 indicating the worst pain she has experienced. Collaborate with the physician to develop a pain-management strategy that effectively keeps the patient free of pain and yet awake and alert without respiratory complications. Consider patient-controlled analgesia (PCA) as a possibility if intravenous medications are needed. If the patient’s disease is terminal, manage the pain so that the patient has a comfortable and dignified death.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
BEP (bleomycin, etoposide, Platinol-cisplatin)	Drugs are often given in combination, and dosage depends on the stage of the disease, patient status, etc.	Chemotherapy and antineoplastic agents	Used after surgery to destroy cancer cells that may have spread into the abdominal cavity; palliative
VIP (vinblastine, ifosfamide, and Platinol-cisplatin)	Varies with drug	Chemotherapy and antineoplastic agents	Used after surgery to destroy cancer cells that may have spread into the abdominal cavity; palliative
Doxorubicin, vincristine, paclitaxel, and cyclophosphamide	Varies with drug	Chemotherapy and antineoplastic agents	Used after surgery to destroy cancer cells that may have spread into the abdominal cavity; palliative
Acetaminophen; NSAIDs; opioids; combination of opioid and NSAID	Depends on the drug and patient condition and tolerance	Analgesics	Analgesics used are determined by the severity of pain

Independent

Prevention and early detection are difficult in ovarian cancer because of the disease’s lack of obvious signs and symptoms. Encourage all adolescent girls and women to have regular pelvic examinations as part of an annual checkup. When the patient is diagnosed with ovarian cancer, she has to manage a host of physical and emotional problems. Help the patient manage any accompanying physical discomfort with nonpharmacologic strategies and pain medications. Teach the patient relaxation techniques or guided imagery. Explain the role of diversions as a mechanism to control pain. If the patient requires hospitalization for surgery or chemotherapy, teach her about the route, dosage, action, and complications of her analgesics so that she can manage her pain at home knowledgeably. If the patient is discharged with a PCA system, arrange for her to rent the equipment and obtain the prescriptions she needs to continue using it. If the patient’s family does not have the financial resources to manage the needed equipment, discuss her needs with a social worker or contact the American or Canadian Cancer Society for assistance.

Depression, grief, or anger is common in women who have been diagnosed with ovarian cancer. To determine the patient’s ability to cope, encourage her to discuss her feelings and monitor her for the physical signs of inability to cope, such as altered sleep patterns. Encourage her to express her feelings without fear of being judged. Note that surgery and chemotherapy may profoundly affect the patient’s and partner’s sexuality. Answer any questions honestly, provide information on alternatives to traditional sexual intercourse if appropriate, and encourage the couple to seek counseling if needed. If the woman’s support systems and coping mechanisms are insufficient to meet her needs, help her find other support systems and coping mechanisms. Provide a list of support groups.

Evidence-Based Practice and Health Policy

Buys, S.S., Partridge, E., Black, A., Johnson, C.C., Lamerato, L., Isaacs, C., …Berg, C.D. (2011). Effect of screening on ovarian cancer mortality: The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. The Journal of the American Medical Association, 305(22), 2295–2303.

• Investigators suggest that annual screening for ovarian cancer among women ages 55 to 74 may not decrease the rate of cancer-related mortality, yet may increase the rate of procedure-related complications.
• In a randomized controlled trial, in which 39,105 women who received annual screening for ovarian cancer were compared to 39,111 women who received usual medical care (no annual screening), there were no significant differences in mortality between the two groups (3.1 and 2.6 per 10,000 person-years, respectively).
• However, in this study, 3,285 women received a false-positive diagnosis, and 32.9% of these women underwent an oophorectomy as part of the diagnostic work-up, resulting in a complication rate of 20.6 per 100 surgical procedures.

Documentation guidelines

• Physiological response: Vital signs, intake and output if appropriate, weight loss or gain, sleep patterns, incisional healing
• Comfort: Location, onset, duration, and intensity of pain; effectiveness of analgesics and pain-reducing techniques
• Response to therapy: Drugs, surgery, radiation

Discharge and home healthcare guidelines

prevention.

Teach the patient the need to have regular gynecological examinations and to report any symptoms to her healthcare provider.

medications.

Ensure that the patient understands the dosage, route, action, and side effects of any medication she is to take at home. Note that some of the medications require her to have routine laboratory tests following discharge to monitor her response.

coping.

Discuss with the woman helpful coping mechanisms. Encourage her to be open with her partner, her family, and her friends about her concerns. Help the patient cope with hair loss. Teach her cosmetic techniques to deal with hair and body changes. Explore alternative methods to medication to manage nausea and vomiting.

postoperative.

Discuss any incisional care. Encourage the patient to notify the surgeon of any unexpected wound discharge, bleeding, poor healing, or odor. Teach her to avoid heavy lifting, sexual intercourse, and driving until the surgeon recommends resumption.

radiation.

Teach the patient to maintain a diet high in protein and carbohydrates and low in residue to decrease bulk. If diarrhea remains a problem, instruct the patient to notify the physician or clinic because antidiarrheal agents can be prescribed. Encourage the patient to limit her exposure to others with colds because radiation tends to decrease the ability to fight infections. To decrease skin irritation, encourage the patient to wear loose-fitting clothing and avoid using heating pads, rubbing alcohol, and irritating skin preparations.

Patient discussion about ovarian cancer

Q. What Are the Risk Factors for Ovarian Cancer? My neighbor has recently found out she has ovarian cancer. Are there any known risk factors for this disease?

A. Well I was diagnosed with ovarian cancer, at the age of 41, was on birth control pills, no family history of it ,was pregnant x2. I had no risk factors.

Q. Does ascites mean it's the end? My mother, age 65 was diagnosed with ovarian cancer in a routine US examination. It was also diagnosed she already has mild ascites. Does that mean her cancer is metastatic?

A. Ascites can render the staging of the cancer as metastatic, but it depends on the specific characters of the ascites, so further testing is needed here.