What is Ovarian Cancer

Our body is constantly producing new cells to allow us to grow and replace old or injured cells. These cells usually grow in a predictable and organized way. But sometimes cells behave and grow abnormally and form a growth or lump called a 'tumor'. The ovaries are two small (about 2–4 cm) almond shaped organs that are part of the female reproductive system. They sit on either side of the uterus (womb). Other parts of the female reproductive system include the fallopian tubes, cervix and vagina. Each ovary contains germ cells that eventually develop into eggs (ova). In women who are having periods, a mature egg is released by the ovary each month (this is called 'ovulation'). Your ovaries also produce the hormones oestrogen and progesterone, which regulate your menstrual cycle and affect the development of female body characteristics – such as breasts, body hair and body shape. Ovarian cancer is a general term used to describe a cancerous (malignant) tumor starting in one or both ovaries. The ovaries are made up of three main kinds of cells – epithelial cells, stromal cells and germ cells. Each of these cells can develop into a different type of tumor. The average age of women when they are diagnosed with ovarian cancer is age 64. It is mainly diagnosed in women over the age of 50; however, there are cases diagnosed in younger women.

Risk Factors

Increasing Age

Getting older is the biggest risk factor for developing ovarian cancer. Ovarian cancer can happen at any age, but it is usually in women who have been through menopause, with the average age of diagnosis being 64.

Hereditary Factors

These account for approximately 20% of ovarian cancers. Hereditary factors include: Inheriting a faulty gene such as a mutation in BRCA1 or BRCA2 genes. Women of Ashkenazi Jewish descent have a higher incidence of BRCA mutations than the general population Having a strong family history of ovarian, breast or some other cancers (colorectal or endometrial).

Other Factors That May Increase The Risk Of Ovarian Cancer Include:

Having endometriosis, previous breast cancer or diabetes Use of hormone replacement therapy (HRT) (this applies to some ovarian cancer types) Being overweight Smoking, which may slightly increase the risk of developing mucinous ovarian cancer Not having had children – Women who have not had children are at a slightly higher risk.

OVARIAN CANCER SYMPTOMS

There is a range of possible symptoms, which may include:

  • ⇒ Pain in the lower abdomen or pelvic area.
  • ⇒ Bloating and a full feeling in the tummy (abdomen).
  • ⇒ Having the feeling of needing to pass urine more urgently and more frequently.
  • ⇒ Loss of appetite.
  • ⇒ In addition, the following symptoms may be present.
  • ⇒ Vaginal bleeding after menopause.
  • ⇒ Irregular periods or bleeding outside of regular menstruation before menopause.
  • ⇒ Painful sex.
  • ⇒ Back pain.
  • ⇒ Constipation.
  • ⇒ Feeling or being sick.
  • ⇒ Extreme tiredness/fatigue.
  • ⇒ Breathing problems – shortness of breath.
  • ⇒ Abdominal swelling.
  • ⇒ Severe weight loss.
  • ⇒ Swollen abdomen due to a build-up of fluid in the abdomen (ascites).

It is important to remember that these symptoms can also be caused by other medical conditions. However, if you have any of them, you should see your doctor, especially if the symptoms are persistent and troublesome. They will be able to examine you and if necessary do further tests to find the cause of your problems.

STAGING & GRADING

Staging and grading of cancer is the next step after diagnosis. The stages of ovarian cancer are decided based on the extent to which it has spread. The four stages of ovarian cancer decided by the American cancer society are-

Stage I: In this stage cancer is confined to one or both the ovaries and has not spread to other areas.

Stage II: Cancer has spread from the ovaries to the nearby organs like uterus, fallopian tubes and more.

Stage III: Cancerous growth has made way into abdominal lining and lymph nodes in the rear of the abdomen.

Stage IV: The fourth stage of ovarian cancer is the easily diagnosable stage. Fourth stage cancer spreads to distant organs and has less scope of survival.

STAGING & GRADING

The staging system is used for all ovarian cancers and for primary peritoneal cancer. Primary peritoneal cancers are usually either stage 3 or stage 4. Knowing the stage of your cancer is important because it helps your specialist to decide on the best treatment for you. It also gives a guide to the chances of cancer coming back. Ovarian cancer tumors are graded as well as staged. They are graded as either high or low grade. Low-grade tumors are more similar to normal tissue, whereas high-grade tumors are less like normal tissue and may be more aggressive and faster growing. Serous cancers are commonly high grade and the most common type of advanced stage of ovarian cancer.

TYPES OF OVARIAN CANCER

Ovarian cancer is classified on the basis of the site of origin

There are several types of ovarian cancers:

Epithelial Tumors (Most Common)
Germ Cell Tumors
Stromal Cell & Other Rare Types

These different types of ovarian cancer behave differently and are treated differently. Within these types, there are different subtypes of tumors. If you have been diagnosed with a rare form of ovarian cancer, it might be difficult to find specific information on your cancer. You may find it helpful to visit the Rare Cancers website (www.rarecancers.org.au).

Epithelial ovarian cancer

This is cancer that starts in the cells lining the surface layer (epithelial) of the ovary. It is the most common type of ovarian cancer, accounting for 9 out of 10 cases. It most often affects women over 50; the average age of diagnosis is the early 60s.

There are several subtypes of epithelial ovarian cancers, which include:

1. High-grade serous (the most common type)
2. Low-grade serous
3. Mucinous
4. Endometrioid
5. Clear cell
6. Undifferentiated or unclassified.

Low-grade serous cancers

These occur typically in younger women but can start in older women as well. They start in the ovaries and have often spread to the upper abdomen at diagnosis.

Germ cell ovarian cancer

This begins in the cells eventually developing into eggs. This type of ovarian cancer is rare and accounts for approximately 5% of ovarian cancers. Germ cell tumors affect mainly teenagers and women in their 20s. They respond well to treatment and are curable in most women.

Stromal cell and other rather types of ovarian cancer

Rare types of ovarian cancer include sex-cord stromal cell ovarian cancer, stromal tumors, and sarcomas. Sex-cord stromal tumors often only affect one ovary and can be cured. Younger women can usually still have children after treatment.

Cancer that begins in the fallopian tube or peritoneum

The fallopian tubes link the ovaries to the uterus. Cancer may begin in the fallopian tube and spread to the ovary or the peritoneum. Cancer that begins in a fallopian the tube is sometimes called 'fallopian tube cancer' (FTC). The peritoneum is the abdominal cavity. Cancer may begin in the peritoneum: this is called 'primary peritoneal cancer' (PPC).

Borderline ovarian tumors

These are ovarian tumors that are not considered to be cancerous. They can turn into cancer, but this is extremely rare. They are treated in a different way to ovarian cancers, and usually, surgery alone can cure them.

DETECTION & DIAGNOSIS

Your medical expert is usually the first person you go to if you have symptoms. They will examine you, ask about your symptoms and possibly order a CA125 blood test and an ultrasound. They may also want to do an internal vaginal examination to see if your uterus and ovaries feel normal. If you prefer, you can ask for a female doctor to do this. It is your choice: do not be afraid to ask.

An ultrasound creates a picture of your internal organs (ovaries and uterus) on a computer by using echoes from sound waves. This test is done by a sonographer. It can be done in two ways:

Abdominal Ultrasound

You will lie on an examination table and the sonographer will move the ultrasound device (transducer) over your abdominal area. Trans-vaginal ultrasound.

You will lie on an examination table and the sonographer will insert the transducer covered in gel into your vagina. Although uncomfortable, this will not be painful. This way is preferred when doing the ultrasound. If you have concerns about it being done this way talk to your specialist.

If the ultrasound and other tests indicate you have cancer, your GP will refer you to a specialist in women's health and cancer (a gynecological oncologist). You should be seen within two weeks. The specialist will do a physical examination and take a detailed health history. They will also ask you about your family history of cancer. They will most likely also order further tests.

This will be to work out:

1. How far cancer has grown
2. If cancer has spread to other parts of your body
3. Which treatment is best for you?

Abdominal ultrasound

The results of these tests will help your doctor to confirm your diagnosis and the stage of your cancer. Further tests may include:

Computerized Tomography (CT) Scan

This will give a three-dimensional (3D) image of your internal organs. It will help find out if cancer has spread, but it may not pick up all ovarian tumors.

Biopsy

Under anesthetic, a needle will be inserted into the tumor. A small sample of tissue (biopsy) will be taken and tested to help confirm the cancer diagnosis.

Chest X-Ray

This can check if a cancer has spread to the lungs.

Removal Of Fluid From Your Abdomen

This is done if there is a fluid build-up in the abdomen (ascites). The fluid is extracted and tested for cancer cells.

Laparoscopy

This is a small operation done under general anesthetic. A small cut will be made in the abdomen, and a thin fiber-optic tube with a small camera is inserted.

Laparotomy

This operation will be offered if laparoscopy is not suitable for you. If cancer is found, the surgeon may continue with the operation to remove cancer. This would only happen if you had consented to this possibility before the laparotomy. If you need further tests, your doctor will discuss them in more detail with you.

BRCA TESTING/FAMILIAL OVARIAN CANCER

Ovarian cancer caused by inheriting a faulty gene is called hereditary cancer. To have a personal or family history of ovarian, breast, colon or endometrial cancer may mean you have inherited an increased risk of developing ovarian cancer.

Generally, the more relatives from the same side of the families who have had these related cancers, the greater your risk of having hereditary cancer. Yet, it is still possible to inherit a faulty gene without having a family history of these cancers.

Inheriting a faulty BRCA1 or BRCA2 gene is involved in most reported cases of hereditary ovarian cancer. These gene faults are named for their connection to breast cancer (Breast Cancer genes 1 and 2) but are also associated with inherited ovarian cancer as well as fallopian tube, prostate, peritoneal, pancreatic and male breast cancer.

These genes normally help to prevent cancer, but when a woman inherits a damaged version of either gene, she is less protected against cancer. Women who inherit a faulty BRCA1 gene have approximately a 40% lifetime risk of developing ovarian cancer, while women who inherit a faulty BRCA2 gene have approximately an 18% lifetime risk of developing ovarian cancer up to the age of 70.

BRCA TESTING/FAMILIAL OVARIAN CANCER

Many women who have a faulty BRCA1 or BRCA2 gene do not have a known family history of ovarian or breast cancer. This can happen for many reasons:

1. Other family members may have inherited a faulty gene but not have developed ovarian or breast cancer.
2.There may be few females in a family, making it difficult to see a pattern of family history.
3. A new gene fault may develop.

Your gene status may provide you with an option to enter certain clinical trials. There are new drugs called 'PARP (poly ADP ribose polymerase) inhibitors' that can be offered to women who have BRCA gene faults. If you choose to have genetic testing, a sample of your blood will be taken out and tested.

If a faulty gene associated with a higher risk of ovarian cancer is found, the genetic counselor will suggest offering genetic testing to other family members. If other family members have inherited a faulty gene associated with an increased risk of ovarian cancer, a gynecological oncologist can advise about ways to reduce their risk.

USEFUL LINKS

https://www.cancer.org/cancer/ovarian-cancer/about.html

https://www.nhs.uk/conditions/ovarian-cancer/

http://ovarian.org/about-ovarian-cancer/what-is-ovarian-cancer

https://www.webmd.com/ovarian-cancer/default.html

https://www.cancerresearchuk.org/about-cancer/ovarian-cancer

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