Ovarian Cancer

Ovarian cancer is an uncontrolled proliferation of cancerous cells in the ovaries (which are part of female reproductive organs producing eggs and secreting female hormones situated under the fallopian tubes on both sides). The main treatments for ovarian cancer are surgery, followed by chemotherapy.

Symptoms

At the early stage, ovarian cancer is asymptomatic or causes mild, non-specific symptoms indistinguishable from other common health problems. Symptoms include:

• Palpable lower abdominal mass
• Bloating
• Lower abdominal pain or pelvic discomfort
• Weight loss
• Loss of appetite
• Fatigue
• Back pain
• Change of bowel habits such as constipation or diarrhea
• Frequent urination with unknown cause

When to see doctor
Seek medical care if the symptoms worsen or you feel concerned.

Causes

The cause of ovarian cancer is not entirely clear. However, it originates from a mutated ovarian cell that rapidly proliferates and grows into a malignant tumor of the ovary.

Type of ovarian cancers

The degree of malignancy varies with the cell type and stage of cancer, which can be classified as follows:

• Epithelial ovarian tumors are the most common, with several subtypes, such as serous and mucinous carcinoma.
• Germ cell tumors are rare but more common in young people.
• Stromal tumors are the rarest but can be diagnosed in an early stage.

Risk factors

• Age: The risk of ovarian cancer increases with age. It is more common in older women.
• Heredity: Genes such as BRCA1 and BRCA2 increase the risk of ovarian and breast cancers.
• Women with Lynch syndrome harboring the BRIP1, RAD51C, and RAD51D genes are also prone to have ovarian cancer.
• Family history: If ovarian or other cancers such as breast cancer, colon cancer, and endometrial cancers run in your family, your risk of ovarian cancer is higher.
• Hormone replacement therapy: Oral contraceptives can help lower the risk of ovarian cancer. However, other hormones may instead stimulate cancer. Always consult your doctor before taking them.
• Endometriosis: If left untreated, it can lead to ovarian cancer.
• Menarche or menopause: Women whose menstruation starts earlier or stops later than average are at increased risk.

Prevention

There are no specific preventive measures for ovarian cancer. However, the following could lessen the risk of ovarian cancer.

• Oral contraceptives: Taking birth control pills for more than five years can lower the risk of ovarian cancer by 50%. Consult your doctor regarding the risks and benefits of oral contraceptives before use.
• Reduce other risk factors: If someone in your family has ovarian or breast cancer, you should see your doctor for genetic testing. If you have inherited cancer risk, prophylactic removal of ovaries may be an option. Always consult your gynecologist before deciding.

Screening

There are no reliable screening tests for ovarian cancer yet.

• You can have regular pelvic ultrasounds. Testing for CA-125 should be limited to women with a genetic mutation linked to ovarian cancer.       

Diagnosis

• Pelvic exam: Your gynecologist wears gloves and performs bimanual palpation between the vaginal and abdominal fingers to assess the size of your uterus and ovaries.
• Medical imaging: Pelvic ultrasound (transvaginal or lower abdominal ultrasound) to determine ovaries' size, shape, and structure, and in some cases, a CT scan or MRI to evaluate the tumor mass and the spread of cancer.
• Blood testing and organ function tests to evaluate your overall health: Tumor markers determination of CA125 (cancer antigen 125), CA19-9 CEA, and HE4 (Human epididymal protein 4) increase the accuracy of diagnosis. These are proteins on the cell membrane of ovarian cancer cells.
• Biopsy provides the definitive diagnosis: Your ovary will be removed for pathologic diagnosis and staging of cancer, ranging from 1-4 (cancer is confined to the ovaries in the early stage and spreads to other organs in the late stage.)
• Genetic testing: To identify mutated genes if the information gleaned from the test can guide the most appropriate treatment plan. If you have gene mutation, you should inform your family members because they may be at risk of developing ovarian cancer.

Treatment

Surgery is the mainstay of ovarian cancer treatment. Chemotherapy is usually given in conjunction with surgery based on the stage and type of ovarian cancer.

Surgery

Surgeries for ovarian cancer include:

• Unilateral salpingo-oophorectomy removing the cancerous ovary, fallopian tube, regional lymph nodes, and the omental fatty apron draping over the abdominal organs. These are the basic operating protocol to treat and stage ovarian cancer.
• Bilateral salpingo-oophorectomy if both ovaries are affected. Total hysterectomy added in advanced cancer, no future pregnancy desired, or you are postmenopausal.
• For late-stage cancer, cytoreductive surgery may be advised to remove as much cancerous tissue as possible.

Chemotherapy

After surgery, chemotherapeutic agents given intravenously or orally are used to kill residual cancer cells. It is called adjuvant chemotherapy. In some situations, they may be given before surgery, called neoadjuvant chemotherapy, to decrease the size of the tumor and make surgical resection possible. In advanced stage 4 cancer, when the cancer is beyond surgery, chemotherapy is the primary treatment. Another approach for ovarian cancer treatment is "hyperthermic intraperitoneal chemotherapy."   Pre-heated chemotherapeutic agents are instilled directly into the abdomen immediately after surgery to bathe and kill remaining cancerous cells for an interval before being drained and washed off.

Targeted therapy

Make use of small molecules or monoclonal antibodies capable of targeting specific proteins that drive the growth of cancer cells. The side effects are much milder than traditional chemotherapy. Your doctor will have your cancer cells tested to confirm that targeted therapy is right for you. It can be prescribed together with or after chemotherapy.

Hormonal therapy

Block the effects of estrogen on cancer cells. Estrogen can drive the growth and proliferation of some cancers. Hormonal therapy is also a treatment option for slow-growing and recurrent cancers.

Immunotherapy

This cancer treatment enables the immune system to fight cancer. Cancer cells make proteins that shield and hide themselves from the immune system. Immunotherapy is to disrupt the process.

Palliative care

Team-based care by doctors, nurses, and healthcare professional specialists, collaborating to provide supportive care for cancer patients and their families to provide pain relief, coordinating with patients, their families, and doctors, so all treatments are aligned. Palliative care helps to uplift the spirit of cancer patients and enables extended survival.

How to cope with ovarian cancer and get support

The diagnosis of ovarian cancer can be overwhelming and hard to accept. Below are some tips which can make you feel better.

• Talk to someone: Talk to someone you trust, such as your friend or family member, or join a support group
• Ask for help: The long treatment can be exhausting and discouraging, do not hesitate to ask for a helping hand if needed.
• Set your goal: Setting a target can help you feel like you have an aim and purpose in life and are in control. However, try to set an achievable target.
• Make yourself a priority: Taking care of yourself is very important. Eating well and setting aside adequate resting time or sleep can help you unwind and handle the fatigue of the disease.

How to prepare before the appointment

If you are diagnosed with ovarian cancer, you will be referred to a gynecologic oncologist.

Prior to your appointment

• Take note of your symptoms, including those which may not be related to ovarian cancer.
• Prepare your treatment history, including other health problems.
• Take note of your personal information, including major life changes.
• List the medications, vitamins, and dietary or herbal supplements you are taking.

What you can expect from the doctor’s visit

• General physical examination, including a pelvic exam.
• Abdominal and pelvic ultrasound or other additional indicated tests.
• Blood testing is to find if there are any abnormalities, including ovarian cancer tumor markers.