indiacancer.org - Ovarian Cancer

Ovarian Cancer

		What are the Ovaries?
		What is Ovarian Cancer?
		How does Ovarian Cancer present?
		How is Ovarian Cancer detected?
		What are staging and grading?
		How is Ovarian Cancer treated?
		What are the side effects of Ovarian Cancer treatment?
		What is the importance of follow up?
		What are the possible causes of Ovarian Cancer?

What are the Ovaries?

The ovaries are a pair of female reproductive organs, located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs and female hormones. During the menstrual cycle, an egg is released from one ovary which 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 in a female, like breasts, body shape and body hair. They also regulate the menstrual cycle and pregnancy.

The Ovaries

What is Ovarian Cancer?

The Uterus, Ovaries and the Fallopian Tubes (front and side view.)

Cancer occurs when cells become abnormal and keep dividing and forming more cells without control or order. 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 usually do not come back. Most importantly, 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 the age of 30 years, most ovarian growths are benign and consist of fluid-filled sacs called cysts. They may occur during a woman's monthly cycle and often go away without any treatment. If a cyst does not go away, it may be removed if it is causing problems or seems to be changing. In some cases, the doctor may wait and watch for changes with ultrasonography or other tests.

Malignant tumors are cancer. Cancer cells can invade and damage tissues and organs near the tumor. They may 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 alsoenter 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 cancer are epithelial carcinomas which begin in the lining of the ovary.

When cancer spreads, the new tumor has the same kind of abnormal cells as the original (primary) tumor. Though ovarian cancer spreads to the colon it is a metastatic ovarian cancer and not colon cancer.

How does Ovarian Cancer present?

	Ofen there are no symptoms in the early stages and, in many cases, the cancer has spread by the time it is diagnosed. The cancer may grow for sometime 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 women may
		Feel that her abdomen is swollen or bloated.
		Have general discomfort in the lower abdomen.
		Cause a loss of appetite.
		Have a feeling of fullness even after a light meal.
		Have indigestion and nausea.
		Have weight loss.
	A large tumor may press on nearby organs, such as the bowel or bladder, causing diarrhoea or constipation, or frequent urination. Less often bleeding from the vagina is a symptom of ovarian cancer. Ovarian cancer may cause swelling by collection of fluid in the abdomen (ascites). Fluid may collect around the lungs (effusion), causing shortness of breath. These symptoms may be caused by cancer or by other, less serious conditions. Only a doctor can tell for sure.

How is Ovarian Cancer detected?

	After taking the woman's medical history, the doctor does a physical examination, including a pelvic examination. The doctor feels the vagina, rectum and lower abdomen for masses or growths. The doctor may also order other tests:
		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, 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 urogram (IVU) is an x-ray of the kdineys and ureters, taken after the injection of a dye.
	Often, the doctor orders a blood test to measure a substance in the blood called CA 125. This substance, called a tumor marker, can be produced by ovarian cancer cells. 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. However, it is quite a sensitive marker for ovarian cancer, and if it is raised, then the clinician must look at the case with a high degree of suspicion. The only sure way to know if cancer is present is for a pathologist to examine a sample of biopsy tissue under the microscope. 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 further surgery.

What are staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is ; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive.

Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome.

Staging may require additional imaging tests such as CT Scan, MRI, Sonography, IVU, Bone scan or chest X-ray.

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.

How is Ovarian Cancer treated?

A lot depends on the patient's constitution, the grade of his disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach, which includes a gynaecologist, a surgical oncologist, a medical oncologist and a radiation oncologist.

Methods of Treatment

Ovarian cancer may be treated with surgery, chemotherapy, or radiation therapy. The doctor may use just one method or combine them.

Surgery for ovarian cancer usually involves removal of the ovaries, the uterus and the fallopian tubes. This operation is called total abdominal hysterectomy with bilateral salpingo-oopherectomy. (If a woman has a very early slow growing tumor and wants to have a child, the doctor may remove only the affected ovaary). 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.

Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the ovary is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy.

This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks).

Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after.

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.

The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It also affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced ovarian cancer.

Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after.

Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues, in this case inside the peritoneum. Patients may or may not require both modalities of radiation.

Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used.

What are the side effects of Ovarian Cancer treatment?

	Unfortunately treatments for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. 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 and to relieve pain. For a period of time after the surgery, some of the woman's normal activities are limited to let 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 women 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. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient. 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 in hearing. These problems may continue after treatment stops. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. It is also not uncommon to see impotence develop in those patients who are subjected to external radiation. This is usually temporary. Vaginal dryness is also known to occur in women, thus sexual intercourse during radiation therapy is discouraged. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such 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 commonly encountered with this therapy are as follows:
		Low grade fever.
		Rashes and bruises.
		Nausea and vomiting (usually mild).
	All these problems disappear on cessation of therapy.

What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit.

Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination ), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies (including CA-125)as indicated.

In some cases, doctors recommend second look surgery 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.

Depending on the drugs she has received, a woman treated for ovarian cancer with chemotheapy 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.

What are the possible causes of Ovarian Cancer?

	The following are some of the known risk factors for ovarian cancer:
		Family medical history. The risk of getting 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 (bith 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.
		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.