Ovarian Cancer

OVARIAN CANCER

Cancer begins when cells in the body begin to grow out of control. Cells in nearly any part of the body can become cancer and can spread as well.

Ovarian cancers were previously believed to begin only in the ovaries, but recent evidence suggests that many ovarian cancers may actually start in the cells in the far end of the fallopian tubes.

The ovaries

Ovaries are reproductive glands found only in females. The ovaries produce ova (eggs) for reproduction. The eggs travel from the ovaries through the fallopian tubes into the uterus where the fertilized egg settles in and develops into a fetus. The ovaries are also the main source of the female hormones estrogen and progesterone. There is one ovary on each side of the uterus.

The ovaries are mainly made up of 3 kinds of cells, with each type of cell being able to develop into a different type of tumor:

• Stromal tumors begin from structural tissue cells that hold the ovary together and produce the female hormones estrogen and progesterone
• Epithelial tumors begins from the cells that cover the outer surface of the ovary. Most of ovarian tumors are epithelial cell tumors.
• Germ cell tumors begin from the cells that produce the eggs (ova).

Some of these tumors are benign (non-cancerous) and never spread beyond the ovary. However, malignant/cancerous or borderline/low malignant potential ovarian tumors can metastasize (spread) to other parts of the body and can be fatal sometimes.

Cancer Basics

Cancer develops when abnormal cells in a part of the body begin to grow uncontrollably (in this case, the ovaries). This abnormal cell growth is common among all cancer types.

Normally, the cells in the body divide and form new cells to replace worn out or dying cells, and to repair injuries. Because cancer cells continue to grow and divide, they are different from normal cells. Instead of dying, they outlive normal cells and continue to create new abnormal cells, forming a tumor. The formed tumors can put pressure on other organs near the ovaries.

Sometimes, cancer cells travel to other parts of the body, where they begin to grow and replace normal tissue. This is a process called metastasis, and it occurs as the cancer cells move into the bloodstream or lymph system of the body. Cancer cells that spread from other organ sites to the ovary are not considered ovarian cancer because cancer type is determined by the original site of the malignancy.

TYPES OF OVARIAN CANCER

Each ovarian cancer patient is different, and each deserves a treatment plan that is tailored to her needs and specific diagnosis. That begins with knowing the type of ovarian cancer the patient has. Although ovarian cancer is categorized into more than 30 different types, they are mostly identified based on the name of the cell in which the cancer originated. Cancerous ovarian tumors develop most commonly in the epithelial cells, which make up the outer layer of the ovary (the germ cells, which form eggs), or in the stromal cells, which produce and release hormones.

Epithelial ovarian carcinomas are often referred to by their subtype: (i.e. mucinous, endometrioid, clear cell and undifferentiated). They commonly spread to the lining and organs of the pelvis and abdomen first before spreading elsewhere, such as to the lungs and liver. They may also spread to the brain, bones and skin.

Germ cell tumors

Tumors may appear in the germ cells, which are the egg-producing cells, of the ovaries. Most of these tumors are benign. Teens and women in their 20s are more likely to have this type of ovarian cancer.

Ovarian germ cell tumors are divided into the following subtypes:

• Endodermal sinus tumor and choriocarcinoma tumors are extremely rare. Choriocarcinomas may begin in either the placenta during pregnancy, which are more common, or in the ovaries.
• Teratomas are germ cell tumors that are either mature (benign) or immature (cancerous). Immature Teratomas are quite rare. Their cells commonly contain different types of tissue, such as hair, muscle and bone.
• Dysgerminoma ovarian germ cell cancer is also rare, but it's still the most common germ cell ovarian cancer. Dysgerminomas don't typically grow or spread quickly. They may also occur in other parts of the body, such as the central nervous system.

Sex cord-stromal tumors

Also called sex cord tumors, sex cord-gonadal stromal tumors and ovarian stromal tumors, sex cord-stromal tumors are very rare, making up a tiny percentage of ovarian cancer cases. They develop from the stroma tissue cells that produce the female hormones estrogen and progesterone. It has been noted that because sex-cord stromal tumors make an overabundant supply of estrogen, they often cause abnormal vaginal

Less common types

Ovarian cancer accounts for only a paltry 3 percent of cancers among women. While the most common types of ovarian cancer are epithelial, germ cell and stromal tumors, some of the rarer types of ovarian cancer occur more than others.

These include:

• Ovarian sarcoma: Unlike their carcinoma counterparts, ovarian sarcoma tumors develop in the connective tissues of ovarian cells.
• Krukenberg tumors: A Krukenberg tumor is cancer that spreads to the ovaries from other organs, often times from the gastrointestinal tract.
• Ovarian cysts: Ovarian cysts are fluid-filled sacs that develop inside the ovary. They're common during ovulation and often go away on their own without treatment. Though most ovarian cysts are benign, some actually develop into cancer.

Recurrent ovarian cancer

Recurrent ovarian cancer occurs when malignant cells reappear after cancer treatments have been completed for a period of time. Recurrent ovarian cancer may return at its original location, or it may be found somewhere else in the body. When ovarian cancer recurs, it is not re-staged.

Ovarian cancer typically resurfaces when a small number of cancer cells survive the treatment process because they are not detected during tests. After treatment, these cancer cells may grow into tumors.

The signs of recurrent ovarian cancer may vary from patient to patient. Because a lot of times, ovarian cancer recurs in the abdomen and pelvis, near the bladder and the intestines. The development gives rise to gastrointestinal and urinary symptoms typically.

Signs and symptoms of ovarian cancer recurrence may include:

• Frequent urination
• Elevated levels of the protein CA-125
• Continuous abdominal bloating, indigestion or nausea
• Loss of appetite or feeling full sooner
• Pressure in the pelvis or lower back
• Changes in bowel movements
• Increased abdominal size
• Fatigue, lethargy or a general lack of energy

CAUSES

The causes of ovarian cancer is not yet known, but doctors have identified factors that can increase the risk of the disease.

In general, cancer begins when a cell develops errors (mutations) in its DNA. The mutations tell the cell to grow and multiply quickly, creating a mass (tumor) of abnormal cells. The abnormal cells continue living when healthy cells would die. They can invade nearby tissues and break off from an initial tumor to spread elsewhere in the body.

SYMPTOMS OF OVARIAN CANCER

It's all too easy to overlook the early symptoms of ovarian cancer because they're similar to other common illnesses, and then the symptoms tend to vary.

The early symptoms include:

• A strong urge to urinate
• Abdominal bloating, pressure, and pain
• An increase in urination
• An abnormal fullness after eating
• Difficulty in eating

Ovarian cancer can also cause other symptoms, such as:

• Menstrual irregularities
• Back pain
• Fatigue
• Indigestion
• Heartburn
• Constipation
• Painful intercourse
• Dermatomyositis (a rare inflammatory disease that can cause skin rash, muscle weakness, and inflamed muscles)

These symptoms may occur for other reasons. They may not necessarily be due to ovarian cancer. Many women have some of these problems at one time or another.

These types of symptoms are often temporary and in most cases respond to simple treatments.

The symptoms will however persist if they're due to ovarian cancer. Symptoms usually become more severe as the tumor grows. By this time, the cancer has usually spread outside of the ovaries, making it much harder to treat effectively.

RISK FACTORS

All women are at risk. Symptoms exist - they can be vague, but usually get more intense over time. Early detection increases survival rate. A Pap test DOES NOT detect ovarian cancer.

Risk factors for ovarian cancer include:

• Age
• Genetic predisposition
• Personal or family history of breast, ovarian, or colon cancer
• Infertility

While the presence of one or more risk factors may increase a woman's chance of developing ovarian cancer, it does not necessarily mean that she will get the disease.

A woman that has one or more risk factors should be extra vigilant in watching for early symptoms.

Recommendations for women at risk

Current recommendations for management of women at high risk for ovarian cancer are summarized below:

• Women who do not wish to maintain their fertility, or who have completed their family, may undergo prophylactic bilateral salpingo-oophorectomy. These women should be counseled that this operation does not offer absolute protection because peritoneal carcinomas occasionally can occur after bilateral oophorectomy.
• Oral contraceptives should be recommended to young women before they embark on planning a family.
• Women who appear to be at high risk for ovarian cancer should undergo genetic counseling and, if the risk appears to be substantial, they may be offered genetic testing for BRCA1 and BRCA2.
• Women with HNPCC Syndrome, also known as Lynch Syndrome, should ensure to undergo periodic screening mammography, colonoscopy, and endometrial biopsy.
• Women who wish to preserve their reproductive capacity can undergo screening by transvaginal ultrasonography every six months, although the efficacy of this approach has not been clearly established.
• It has been established that BRCA1 and BRCA2 gene mutations increase the risk of developing breast cancer, therefore annual mammography screening is suggested, beginning from age 25.

DIAGNOSIS

Tests and procedures used to diagnose ovarian cancer include:

Blood tests. Blood tests might include organ function tests that can help determine the patient's overall health. The doctor might also test the blood for tumor markers that may indicate ovarian cancer. A cancer antigen (CA) 125 test for example can detect a protein that's often found on the surface of ovarian cancer cells.

Pelvic exam. During a pelvic exam, the doctor inserts gloved fingers into the vagina and simultaneously presses a hand on the abdomen in order to feel (palpate) the pelvic organs. The doctor will also visually examine the external genitalia, vagina and cervix.

Imaging tests. Tests (e.g. ultrasound or CT scans) of the abdomen and pelvis, may help determine the size, shape and structure of the ovaries.

Surgery. Sometimes the doctor might not be certain of the diagnosis until the patient undergoes surgery to remove an ovary and have it tested for signs of cancer.

Once ovarian cancer is confirmed, the doctor will use information from the tests and procedures to assign the cancer a stage.

STAGES

If a doctor diagnoses ovarian cancer, they will need to determine the stage and grade in order to decide on a treatment plan.

The stage refers to how far the cancer has spread. For example:

Localized: The cancer cells have affected only the ovaries or fallopian tubes and have not spread elsewhere.

Regional: The cancer has spread to nearby organs, such as the uterus.

Distant: The cancer is present elsewhere in the body. It now affects other organs, such as the lungs or liver.

The grade, meanwhile, refers to how abnormal the cancer cells appear.

Getting an early diagnosis usually means that treatment can be more effective. However, other factors such as the person's age and overall health and especially the type or grade of the cancer cell can affect this because some types are more aggressive than others.

TREATMENT

Treatment will depend on many factors, including:

• The individual's age and overall health
• The type, stage, and grade of the cancer
• Accessibility and affordability of treatment
• Personal preferences

Options tend to include:

Surgery: The choice will depend on the type of cancer and how far it has spread. Surgical options include the removal of one or both ovaries (a hysterectomy), and removing affected lymph nodes.

Chemotherapy: These drugs aim to kill cancer cells. If a person takes chemotherapy drugs by mouth or as an injection or infusion, they will affect the whole body. Another option is Intraperitoneal chemotherapy. In this case, a tube delivers the drug directly to the body area affected by cancer. Chemotherapy can have widespread adverse effects, especially if it affects the whole body.

Targeted therapy: Some treatments target specific cells that help promote cancer growth. Examples include monoclonal antibody therapy and angiogenesis inhibitors. This therapy aims to limit the adverse effects by targeting specific functions.

Radiation therapy: This technique uses X-rays to kills cancer cells. One way to do this is by introducing a radioactive liquid into the peritoneum. This may be more helpful to people with advanced ovarian cancer.

Immunotherapy (biotherapy): This aims to boost the immune system's ability to defend the body against cancer. Vaccine therapy involves injecting substances that will find and kill a tumor. It may help people with advanced ovarian cancer.

PREVENTION

There are no proven ways to totally eliminate a person's risk of developing ovarian cancer. However, there are steps that can be taken to lower the risk.

Factors that have been shown to lower the risk of developing ovarian cancer include:

• Pregnancy
• Taking oral birth control pills
• Breastfeeding
• Surgical procedures on the reproductive organs (like a tubal ligation or hysterectomy)

LIVING AS AN OVARIAN CANCER SURVIVOR

Completing treatment can be both stressful and exciting. For some people with ovarian cancer, treatment may remove or destroy the cancer. One will be relieved to finish treatment, yet it is difficult not to worry about the cancer's return.

Learning to live with cancer that does not go away can be difficult and very stressful. Because for some other people, ovarian cancer never goes away completely. Some women may be treated with chemotherapy on and off for years.

Follow up care

Talk with a doctor about developing a survivorship care plan.

This plan might include:

• A suggested schedule for follow-up exams and tests
• A schedule for other tests that might be needed in the future, such as early screening tests for other types of cancer, or tests to look for long-term health effects from the cancer or its treatment
• A list of possible late- or long-term side effects from the treatment, including what

Follow-up schedules after ovarian cancer

After the completion of the treatment, the patient will likely have follow-up visits with the doctor for many years. It is very important to attend to all of the follow-up appointments. During these visits, the doctors will ask questions about any problems one may be having, and may possibly do more exams, lab tests or x-rays and scans to look for signs of cancer or treatment side effects.

Some cancer treatment side effects may last a long time or might not even show up until years after has finished treatment.