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Types of ovarian cancers
Causes and symptoms
- 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.)
- 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
- unexplained weight gain or loss
- pain during intercourse
- vaginal bleeding in post-menopausal women
Diagnostic tests and techniques
- 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
- 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.
- prayer and faith healing
- 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
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.
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 cancerCancer of ovary, ovarian carcinoma Oncology The 5th 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
o·var·i·an can·cer(ō-var'ē-ăn kan'sĕr)
|Mean LOS:||6.4 days|
|Description:||SURGICAL: Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy With CC|
|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.
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.
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.
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.
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.
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.
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
DiagnosisPain (acute) related to tumor invasion, tissue destruction, and organ compression
OutcomesPain control; Pain: Disruptive effects; Well-being
InterventionsAnalgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation; Hypnosis; Heat/cold application
Planning and implementation
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.
|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|
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.
- 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?
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?