Ovarian Cancer

In the UK over 7,300 women are diagnosed with ovarian cancer every year and is the sixth most common cancer among women after breast cancer, bowel cancer, lung cancer, cancer of the uterus (womb) and melanoma skin cancer.

What is ovarian cancer?

Cancer of the ovary is most common in post -menopausal women, although it can affect women of any age.

There are many types of ovarian cancer, with epithelial ovarian cancer being by far the most common form. Germ cell and stromal ovarian cancers are much less common.

  • Epithelial ovarian cancer (epithelial ovarian tumours) – derived from cells on the surface of the ovary
  • Fallopian tube cancer; we now know that many ovarian cancers begin here.
  • Germ cell ovarian cancer (germ cell ovarian tumours) – derived from the egg-producing cells within the body of the ovary. This rare type of cancer more commonly affects teenagers.
  • Stromal ovarian cancer (sex cord stromal tumours) – develops within the cells that hold the ovaries together.
  • Cancers from other organs in the body can spread to the ovaries – metastatic cancers. A metastatic cancer is one that spreads from where it first arose as a primary tumour to other locations in the body.

How does it develop?

In ovarian cancer, cells in the ovary start to change and grow abnormally. If the cancer isn’t identified at an early stage, it can breach the ovary skin and spread to the abdomen and pelvis (peritoneal cavity).

Ovarian cancer symptoms - Key signs

If ovarian cancer symptoms are identified and the cancer diagnosed at an early stage, the outcome is more optimistic. However, because some of the symptoms of ovarian cancer are often the same as for other less serious conditions, such as irritable bowel syndrome (IBS) or pre-menstrual syndrome (PMS), it can be difficult to recognise the symptoms in the early stages – which is why most women are not diagnosed until the disease has spread.

However, there are four main ovarian cancer symptoms that are more prevalent in women diagnosed with the condition. They are:

  • increased abdominal size and persistent bloating (not bloating that comes and goes)
  • persistent pelvic and abdominal pain
  • unexplained change in bowel habits
  • difficulty eating and feeling full quickly, or feeling nauseous

Other symptoms, such as back pain, needing to pass urine more frequently than usual, and pain during sex may be present in some women with the disease; however, it is most likely that these are not symptoms of ovarian cancer but may be the result of other conditions in the pelvic area.

Risk Factors

We don’t know exactly what causes epithelial ovarian cancer. But some factors may increase the risk include;

Age
Your risk of getting cancer increases with age, with most cases occurring after the menopause. More than 8 out of 10 cases of ovarian cancer occur in women who are over 50 years of age.

Family history
If you have two or more close relatives (mother, sister or daughter) who developed ovarian cancer or breast cancer, your risk of also developing the condition may be increased.

If your relatives developed cancer before the age of 50, it’s more likely it was the result of an inherited faulty gene. BRCA1 and BRCA2 are faulty genes that are linked to ovarian cancer. They’re also known to increase the risk of breast cancer.

You may be at a high risk of having a faulty gene if you have:

  • One relative diagnosed with ovarian cancer at any age and at least two close relatives with breast cancer whose average age is under 60; or alternatively at least one close relative with breast cancer under the age of 50. All of these relatives should be on the same side of your family (either your mother’s OR father’s side)
  • Two relatives from the same side of the family diagnosed with ovarian cancer at any age.

If you’re at a higher risk of having a faulty gene, your GP can refer you for tests to check for faulty BRCA1 and BRCA2 genes.

Ovulation and fertility
Every time an egg is released, the surface of the ovary breaks to let it out. The surface of the ovary is damaged during this process and needs to be repaired. Each time this happens, there’s a greater chance of abnormal cell growth during the repair.

This may be why the risk of ovarian cancer decreases if you take the contraceptive pill, or have multiple pregnancies or periods of breastfeeding as eggs aren’t released during this time.

Primary Peritoneal
This is where a cancer develops in the peritoneal cavity , the area of the body from the pelvis up to the diaphragm. The cancer develops in the Mullerian tract, the “footprint “ of where the ovaries arise from deep in the pelvis to their final anatomical position higher up during embryonic development.

Endometriosis
This condition may also increase your risk of a rare sub- type of peritoneal cancer (a rare type of ovarian cancer). In endometriosis, the cells that usually line the womb grow elsewhere in the body.

How is ovarian cancer diagnosed?

In 2015, the National Institute for Health and Care Excellence (NICE) published guidelines to help GPs recognise the signs and symptoms of ovarian cancer and refer people for the right tests faster. Suspected Cancer: Recognition and Referral

Your GP will gently feel your tummy (abdomen) and ask you about your symptoms, general health and whether there’s a history of ovarian or breast cancer in your family.

Blood test (CA125)
You may have a blood test to look for a protein called CA125 in your blood. CA125 is an enzyme produced by irritation to tissues in the peritoneal cavity. A very high level of CA125 may indicate that you have ovarian cancer.

CA125 isn’t specific to ovarian cancer and it can be raised in conditions including endometriosis and pelvic inflammatory disease, so a raised CA125 level doesn’t necessarily mean you have ovarian cancer. Approximately half of all women with early stage ovarian cancer have a raised level of CA125 in their blood. If your CA125 level is raised, you’ll be referred for an ultrasound scan.

Ultrasound scan
An ultrasound scan uses high-frequency sound waves to create an image of your ovaries. You may have an internal ultrasound where the ultrasound probe is inserted into your vagina, or you may have an external ultrasound, where the probe touches (or is rolled over / strokes the skin of your abdomen).

The image produced can show the size and texture of your ovaries, plus any cysts or other abnormalities that are present.

Further tests
If you’ve been diagnosed with ovarian cancer, you will have further tests to see how large the cancer is and if it’s spread. This is called staging.

Other tests you may have include:

  • a CT scan +/-
  • a biopsy – small tissue samples taken from your peritoneal cavity under CT guidance for testing

The CT scan helps your doctors to decide on the best kind of ovarian cancer treatment for your condition. However, it’s important to remember that the stage of your ovarian cancer alone cannot predict how your condition will progress.

Ovarian Cancer Treatment

Most women with ovarian cancer will be treated by a combination of chemotherapy and surgery.

Your surgeon will discuss what will happen during surgery. It will probably involve removing:

  • both ovaries and the fallopian tubes (a bilateral salpingo-oophorectomy)
  • the womb (a total abdominal hysterectomy)

The surgeon may also remove the omentum (a fold of peritoneum connecting the stomach with other abdominal organ) and other tissues affected by disease. This may involve taking a segment of bowel, but this does not necessarily mean the need for a permanent colostomy.  This is known as “debulking surgery”.

Your oncologist will explain what happens during chemotherapy.

Chemotherapy is usually given either before surgery (known as neo -adjuvant) or afterwards (adjuvant) or, in most cases 3 doses (known as cycles) before surgery and 3 afterwards.

The type of chemotherapy and order of surgery is decided on an individual case basis by a multi – disciplinary team (MDT) comprised of surgeons, oncologists, cancer nurse specialists, histopathologists (microscope doctors), and radiologists.

They will work out the best order for your individual situation based on distribution of disease, symptoms and well-being.