Ovarian Cancer
What are the ovaries?
The ovaries are a pair of female reproductive organs. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries have two functions: they produce eggs and female hormones. 
Each month, during the menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a fallopian tube to the uterus.
The ovaries are the main source of female hormones (estrogen and progesterone). These hormones control the development of female body characteristics, such as the breasts, body shape, and body hair. They also regulate the menstrual cycle and pregnancy.
What is cancer?
Cancer is a group of more than 100 different diseases. They all affect the body's basic unit, the cell. Cancer occurs when cells become abnormal and keep dividing and forming more cells without control or order.
Like all other organs of the body, the ovaries are made up of many types of cells. Normally, cells divide to produce more cells only when the body needs them. This orderly process helps keep us healthy.
If cells keep dividing when new cells are not needed, a mass of tissue forms. This mass of extra tissue, called a growth, or tumor, can be benign or malignant.
Benign tumors are not cancer. They can usually be removed and, in most cases, they do not come back. Most important, cells from benign tumors do not invade nearby tissues and do not spread to other parts of the body. Benign tumors are rarely life - threatening.
In women under age 30, most ovarian growths are benign, fluid- filled sacs called cysts. Cysts may occur during a woman's monthly cycle and often go away without any treatment. If a cyst does not go away, the doctor may suggest removing it, especially if it is causing problems or seems to be changing. In some cases, the doctor may decide to wait and watch for changes with ultrasonography or other tests.
Malignant tumors are cancer. Each year, more than 22,000 women in the United States learn they have ovarian cancer. Cancer cells can invade and damage tissues and organs near the tumor. Also, cancer cells can break away from a malignant tumor in the ovary and spread to other organs in the abdomen and form new tumors. Ovarian cancer spreads most often to the colon, the stomach, and the diaphragm. The cancer cells can also enter the lymphatic system or the bloodstream and spread to other parts of the body. The spread of cancer is called metastasis.
There are several types of ovarian cancer. Most ovarian cancers are epithelial carcinomas, which begin in the lining of the ovary. Other types of ovarian cancer are rare and will not be discussed.
When cancer spreads, the new tumor has the same kind of abnormal cells and the same name as the original (primary) tumor. For example, ovarian cancer that spreads to the colon is metastatic ovarian cancer. It is not colon cancer , even though the new tumor is in the colon.
What causes ovarian cancer?
About 1 in every 70 women in the United States will develop ovarian cancer during her lifetime. Most cases occur in women over the age of 50, but it can also affect younger women. The disease is more common in white women than in black women, but doctors do not know why.
Scientists do not know what causes ovarian cancer. It is clear, however, that this disease is not contagious; no one can "catch" ovarian cancer from another person.
By studying large numbers of women all over the world, researchers have found certain risk factors that increase a woman's chance of developing ovarian cancer. However, studies also show that most women with these risk factors do not get ovarian cancer, and many women who do contract the disease have none of the risk factors we know about.
The following are some of the known risk factors for ovarian cancer:
Family medical history - The risk of developing ovarian cancer increases for a woman whose close relative (mother, sister, daughter) has had the disease. The risk is especially high if two or more close relatives have had the disease. The risk is not quite as high for women with other relatives (grandmother, aunt, or cousin) who have had ovarian cancer.
Childbearing - Women who have never been pregnant are more likely to develop ovarian cancer than are women who have had children. In fact, the more times a woman has been pregnant, the less likely she is to develop ovarian cancer. Also, women who use oral contraceptives (birth control pills) are less likely to develop ovarian cancer than are women who do not. A possible reason is that the pill creates hormone levels in the body that are similar to those during pregnancy.
Recent research raises the question of whether infertile women who take fertility drugs and do not become pregnant may be at increased risk of developing ovarian cancer. But this possible link has not been proven. Further research is under way to determine whether ovarian cancer is related to infertility and/or to the use of fertility drugs.
Age - The risk of developing ovarian cancer increases as a woman gets older. Most ovarian cancers occur in women over the age of 50; the risk is especially high for women over 60.
Personal medical history - Women who have had breast cancer are twice as likely to develop ovarian cancer as are women who have not had breast cancer.
What are the symptoms of ovarian cancer?
Ovarian cancer is hard to find early. Often there are no symptoms in the early stages and, in many cases, the cancer has spread by the time it is found. The cancer may grow for some time before it causes pressure, pain, or other problems. Even when symptoms appear, they may be so vague that they are ignored.
As the tumor grows, the woman may feel swollen or bloated, or may have general discomfort in the lower abdomen. The disease can cause a loss of appetite or a feeling of fullness, even after a light meal. Other symptoms may include gas, indigestion, nausea, and weight loss. A large tumor can press on nearby organs, such as the bowel or bladder, causing diarrhea or constipation , or frequent urination. Less often, bleeding from the vagina is a symptom of ovarian cancer.
Ovarian cancer can cause swelling due to a buildup of fluid in the abdomen (ascites). Fluid can also collect around the lungs, causing shortness of breath.
These symptoms may be caused by cancer or by other, less serious conditions. If a woman is experiencing symptoms, she should consult a doctor.
Early Detection
Most health problems respond best to treatment when they are found early. Women who have regular pelvic exams increase the chance that, if ovarian cancer occurs, it will be found before the disease causes symptoms. However, pelvic exams often cannot find ovarian cancer at an early stage. Scientists are trying to find better ways to detect ovarian cancer earlier, when treatment may be more successful. For example, they are exploring the usefulness of measuring the level of CA-125 in the blood. This substance, called a tumor marker, can be produced by ovarian cancer cells. Other ways of detecting the disease, such as new ultrasound techniques, also are under study.
Women over age 60 are taking part in a nationwide study of CA- 125 and transvaginal ultrasound. In this study, scientists are trying to learn whether these tests can detect early ovarian cancer (in women who have no symptoms of the disease) and reduce the number of deaths from this disease. The Cancer Information Service can provide information about this study.
How is ovarian cancer diagnosed?
To find the cause of any of these symptoms, the woman's medical history is taken and a thorough physical examination is conducted, including a pelvic exam. The doctor feels the vagina, rectum, and lower abdomen for masses or growths. A Pap smear (a common test for cancer of the cervix) is often part of the pelvic exam, but it is not a reliable way to find or diagnose ovarian cancer. One or more of the following tests may be ordered:
Ultrasonography is the use of high-frequency sound waves. These waves, which cannot be heard by humans, are aimed at the ovaries. The pattern of the echoes they produce creates a picture called a sonogram. Healthy tissues, fluid-filled cysts, and tumors produce different echoes.
CT (or CAT) scan is a series of x-rays put together by a computer.
A lower GI series, or barium enema , is a series of x-rays of the colon and rectum. The pictures are taken after the patient is given an enema with a white, chalky solution containing barium. The barium outlines the colon and rectum on the x-ray, which helps the doctor see tumors or other abnormal areas.
An intravenous pyelogram (IVP) is an x-ray of the kidneys and ureters, taken after the injection of a dye.
Often, a blood test to measure CA-125 is ordered. However, CA- 125 is not always present in women with ovarian cancer, and it may be present in women who have benign ovarian conditions. Thus, this blood test cannot be used alone to diagnose cancer.
The only sure way to know if cancer is present is for a pathologist to examine a sample of tissue under the microscope. Removing tissue from the body for this examination is called a biopsy. To obtain the tissue, the surgeon does an operation called a laparotomy. If cancer is suspected, the surgeon removes the entire ovary (oophorectomy). This is important because, if the problem is cancer, cutting through the outer layer of the ovary could allow cancer cells to escape and cause the disease to spread. If cancer is found at this time, the surgeon proceeds with surgery.
During surgery, the surgeon removes nearby lymph nodes, and takes samples of tissue from the diaphragm and other organs in the abdomen. The surgeon also collects fluid from the abdomen. All of these samples are examined by a pathologist to check for cancer cells. This process, called surgical staging, is needed to find out whether the cancer has spread. Staging is important in the planning of follow-up treatment.
How is ovarian cancer treated?
Treatment for ovarian cancer depends on a number of individual factors, including the stage of the disease and the woman's age and general health. Treatment for ovarian cancer is best planned by doctors who specialize in the diagnoses and treatment of the disease. The patient's doctor may refer her to a gynecologic oncologist, who specializes in treating cancer of the female reproductive organs.
Most people with cancer want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. The doctor is the best person to answer their questions. When talking about treatment choices, the patient may want to ask the doctor about taking part in a research study. Such studies, called clinical trials, are designed to improve cancer treatment.
When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult to think of every question to ask the doctor. Also, patients may find it hard to remember everything the doctor says. But they do not need to ask all their questions or remember all the answers at one time. They will have other chances for the doctor to explain things that are not clear and to ask for more information.
Often, it helps to make a list of questions to ask the doctor. Also, to help remember what the doctor says, patients may take notes or ask the doctor whether they can use a tape recorder. Some patients also want to have a family member or friend with them, to take part in the discussion, to take notes, or just to listen.
Methods Of Treatment
Ovarian cancer can be treated with surgery, chemotherapy , or radiation therapy. One method or a combination of them may be used.
Surgery is the initial treatment for almost every woman with ovarian cancer.
Chemotherapy may be used following surgery as adjuvant therapy, to kill any cancer cells that may remain in the body. It can also be used at a later time if there are signs that the cancer has recurred.
Radiation therapy may be used in a small number of patients to kill cancer cells that may remain in the pelvic area after surgery.
Surgery for ovarian cancer usually involves removal of the ovaries, the uterus, and the fallopian tubes. This operation is called a hysterectomy with bilateral salpingo-oophorectomy. (If a woman has a very early, slow-growing tumor and wants to remain able to have a child, the doctor may remove only the affected ovary.) If the cancer has spread, the surgeon removes as much of the cancer as possible in a procedure called tumor debulking. Tumor debulking reduces the amount of cancer to be treated with chemotherapy or radiation therapy.
Chemotherapy for ovarian cancer often involves a combination of drugs. Anticancer drugs are usually given by injection into a vein or by mouth. Either way, chemotherapy is called systemic therapy because the drugs travel all through the body in the bloodstream.
Chemotherapy is usually given in cycles; a treatment period followed by a recovery period, then another treatment period, and so on. A woman may receive chemotherapy as an outpatient at the hospital, at the doctor's office, or at home. Depending on which drugs are used, how they are given, and her general health, a woman may need to stay in the hospital while receiving chemotherapy.
Doctors are studying another way of giving anticancer drugs called intraperitoneal chemotherapy. In this approach, the drugs are put directly into the abdomen through a catheter. In this way, drugs reach the cancer directly. This treatment is given in the hospital.
Radiation therapy (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. Radiation may come from a machine (external radiation) or from radioactive material placed into or near the tumor (internal radiation). Like surgery, radiation therapy is local therapy; it affects cancer cells only in the treated area.
For external radiation therapy, the patient goes to the hospital or clinic each day. Usually, the treatments are given 5 days a week for about 5 weeks.
Some women receive a type of internal radiation called intraperitoneal irradiation. Radioactive liquid is placed into the abdomen through a catheter. A short hospital stay may be necessary for this treatment.
Clinical Trials
Many patients with ovarian cancer are treated in clinical trials (treatment studies). Doctors conduct clinical trails to find out whether a new treatment is both safe and effective and to answer scientific questions. Patients who take part in these studies may be among the first to receive treatments that have shown promise in laboratory research.
Some patients may receive the new treatment while others receive a standard approach. In this way, doctors can compare different therapies. Patients who take part in a trial make an important contribution to medical science and may have the first chance to benefit from improved treatment methods.
Various trials for ovarian cancer patients are under way. Doctors are studying new drugs, new drug combinations, and different treatment schedules. They also are exploring drugs designed to make radiation therapy more effective, and other ways of combining different types of treatment. Biological therapy , the use of substances that boost the immune system's response to cancer or protect the body from some of the side effects of treatment, is under study in patients with recurrent or advanced ovarian cancer.
A woman with ovarian cancer who is interested in participating in a trial should talk with her doctor. The National Cancer Institute booklet What are Clinical Trials All About? explains the possible benefits and risks of treatment studies.
One way to learn about clinical trials is through PDQ, a computerized cancer information resource developed by the National Cancer Institute. PDQ contains information about cancer treatment and about clinical trials in progress all over the country. The Cancer Information Service can provide information from PDQ to doctors, patients, and the public.
What are the side effects of treatment for ovarian cancer?
It is hard to limit the effects of therapy so that only cancer cells are destroyed. Because treatment often damages healthy cells and tissues, it can cause unpleasant side effects.
The side effects of cancer treatment vary, depending on the type of treatment. Also, each woman reacts differently. Doctors try to keep side effects to a minimum, but problems may occur.
Patients who eat well during cancer treatment often feel better and have more energy. In addition, they may be better able to handle the side effects of treatment. Eating well means getting enough calories and protein to help prevent weight loss and regain strength.
Surgery
Surgery for ovarian cancer is a major operation. For several days after surgery, the patient may have difficulty emptying her bladder and having normal bowel movements. Drugs may be given to relieve pain and to prevent or treat infection. For a period of time after the surgery, some of the woman's normal activities are limited to allow healing take place.
In younger women, when the ovaries are removed, the body's natural source of estrogen is lost and menopause starts. Symptoms of menopause are likely to appear soon after the surgery. Hormone replacement therapy is commonly used to ease such symptoms as hot flashes and vaginal dryness in menopausal women. However, the use of hormone replacement therapy has not been studied in woman who have had ovarian cancer. Deciding whether to use it is an individual matter; ovarian cancer patients should discuss the possible risks and benefits of hormone replacement therapy with their doctor.
Chemotherapy
The side effects of chemotherapy depend mainly on which drugs the patient receives. In addition, side effects vary from patient to patient. In general, anticancer drugs affect rapidly dividing cells. These include blood cells, which fight infection, cause the blood to clot, and carry oxygen to all parts of the body. When blood cells are affected by anticancer drugs, women are more likely to develop infections, bruise or bleed easily, and have less energy. Cells in hair roots and cells that line the digestive trace also divide rapidly. As a result, women may lose their hair and may have other side effects, such as nausea, vomiting, or mouth sores. Usually, diet changes or medications can ease these problems. Most side effects of chemotherapy gradually go away during the recovery period or after treatment stops.
Certain drugs used in the treatment of ovarian cancer can cause kidney damage. To help protect the kidneys while taking these drugs, patients are given large amounts of fluid. These drugs also may cause tingling in the fingers or toes, ringing in the ears, or difficulty hearing. These problems may continue after treatment stops.
Radiation Therapy
Patients are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can. It is also common for the skin in the treated area to become red, dry, tender, and itchy. There may be permanent darkening or "bronzing" of the skin in the treated area. This area should be exposed to the air as much as possible, but protected from sunlight. Patients should avoid wearing clothes that rub the treated area. The radiation therapist or nurse will give advice about keeping the skin clean. Patients should not use any lotion or cream on their skin without checking with the doctor or nurse.
Radiation treatment to the lower abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. Usually, dietary changes or medicines can ease these problems.
Radiation therapy for ovarian cancer also can cause vaginal dryness and interfere with intercourse. Women may be advised not to have intercourse during treatment. However, most women are able to resume sexual activity a few weeks after radiation treatment ends.
Biological Therapy
The side effects caused by biological therapy vary with the type of treatment. Often, these treatments cause flu-like symptoms, such as chills, fever, muscle aches, weakness, nausea, vomiting, and diarrhea. Sometimes patients develop a rash , and they may bleed or bruise easily or have bone pain. These problems can be severe, and patients may need to stay in the hospital during treatment.
What happens after treatment for ovarian cancer?
In some cases, "second-look" surgery is recommended after chemotherapy is complete. This allows the doctor to examine the abdomen directly and take fluid and tissue samples to see whether the treatment has been successful. If cancer is found, additional treatment is needed.
When treatment is over, regular checkups generally include a physical exam, as well as a pelvic exam and Pap smear. Sometimes, doctors also order chest x-rays, a CT scan of the abdomen, and laboratory tests such as urinalysis , a complete blood count , and the CA-125 assay. Often, the CA-125 level in a patient's blood is high before surgery and returns to normal within several weeks after the tumor has been removed. If the CA-125 level begins to rise again, it may mean the cancer has come back.
Depending on the drugs she has received, a woman treated for ovarian cancer with chemotherapy may have an increased risk of developing leukemia later in life. However, it is important to keep in mind that the benefits of receiving treatment for ovarian cancer far outweigh the risks of future disease.
Women should carefully follow their doctor's advice on health care and checkups and should report any problem to the doctor as soon as it appears.
Living with a serious disease is not easy. Cancer patients and those who care about them face many problems and challenges. Coping with these difficulties is easier when people have helpful information and support services. Several useful booklets, including Taking Time: Support for People with Cancer and the People Who Care About Them are available from the Cancer Information Service.
Cancer patients may worry about holding their job, caring for their family, or keeping up with daily activities. Concerns about tests, treatments, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a nurse, social worker, counselor, or a member of the clergy can be helpful to patients who want to talk about their feelings or discuss their concerns about the future or about personal relationships.
Friends and relatives can be very supportive. Also, many patients find it helps to discuss their concerns with others who have cancer. Cancer patients often get together in support groups, where they can share what they have learned about coping with cancer and the effects of treatment. It is important to keep in mind, however, that each patient is different. Treatments and ways of dealing with cancer that work for one person may not be right for another, even if they both have the same kind of cancer. It is a good idea to discuss the advice of friends and family members with the doctor.
Often, a social worker at the hospital or clinic can suggest groups that can help with rehabilitation, emotional support, financial aid, transportation, or home care. For example, the American Cancer Society has many services for patients and their families. Local offices of the American Cancer Society are listed in the white pages of the telephone directory.
Information about other programs and services is available through the Cancer Information Service. The toll-free number is 1-800-4- CANCER.
What does the future hold for ovarian cancer patients?
Patients and their families are naturally concerned about what the future holds. Sometimes they use statistics to try to figure out whether the patient will be cured or how long she will live. It is important to remember, however, that statistics are averages based on large numbers of patients. They cannot be used to predict what will happen to a particular patient because no two cancer patients are alike; treatments and responses vary greatly. Patients should talk with the doctor about their chance of recovery (prognosis). When doctors talk about surviving cancer, they may use the term remission rather than cure. Even though ovarian cancer can be cured, doctors use these terms because the disease can return. (The return of cancer is called a recurrence).
Scientists at hospitals and medical centers all across the country are studying ovarian cancer. They are trying to learn more about what causes this disease and how to prevent it. They are also looking for ways to detect it earlier and to treat it more effectively.
What resources are available to patients with ovarian cancer?
Information about cancer is available from many sources, including the ones listed below. You may wish to check for additional information at your local library or bookstore and from support groups in your community.
CANCER INFORMATION SERVICE (CIS) 1-800-4-CANCER
The Cancer Information Service, a program of the National Cancer Institute, is a nationwide telephone service for cancer patients, their families and friends, the public, and health care professionals. The staff can answer questions in English and Spanish and can send booklets about cancer. They also know about local resources and services. One toll-free number, 1-800-4- CANCER (1-800-422-6237), connects callers with the office that serves their area.
AMERICAN CANCER SOCIETY (ACS)
1599 Clifton Road, N.E.
Atlanta, GA 30329
1-800-ACS-2345
The American Cancer Society is a voluntary organization with a national office and local units all over the country. It supports research, conducts educational programs, and offers many services to patients and their families. To obtain free booklets about services and activities in local areas, call the Society's toll-free number, 1-800-ACS-2345 (1-800-227-2345), or the number listed under "American Cancer Society" in the white pages of the telephone book.
Ovarian Cancer At A Glance - Most ovarian growths in women under age 30 are benign, fluid-filled cysts.
- There are several types of ovarian cancer.
- Factors that increase the chance of developing ovarian cancer have been identified.
- The symptoms of ovarian cancer can be vague.
- Detection of ovarian cancer involves physical examination (including pelvic exam), ultrasound, X-rays, the CA-125 blood test and biopsy of the ovary.
- The treatment of ovarian cancer depends on the stage of the disease and the age and health of the woman.
The above article was produced, in part, from information supplied with the kind permission of the National Institutes of Health.
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