Ovarian Cancer

Introduction

Ovarian cancer is the eighth most common cancer affecting women in Australia, and the sixth most common cause of death from cancer in women. The term ‘ovarian cancer’ is often used to describe cancers that arise from the ovaries, fallopian tubes, or peritoneum.

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Causes

Some factors may increase the risk of ovarian cancer, including:

• Age (the risk increases after the age of 50).

• Family history/genetic factors (particularly if there are changes in BRCA1 or BRCA2 genes, and where family background is Ashkenazi Jewish).

• Childbirth factors - not having had a child, or having first child after 30, or infertility.

• Early onset menstruation (before 12) or late menopause.

• Never having used oral contraception.

• Having taken oestrogen only hormone replacement therapy.

Symptoms

Unfortunately, ovarian cancer is often without obvious symptoms, which results in a delay in diagnosis or a more advanced stage of disease at diagnosis. Some of the following symptoms may be present:

• Pain – in the areas of the pelvis, abdomen or back, or during sexual intercourse.

• Bloating of the abdomen.

• Constipation / indigestion.

• Needing to urinate urgently or frequently.

• Feeling full more quickly when eating a meal.

• Irregular periods.

• Fatigue.

Diagnosis

There are no effective screening tests for ovarian cancer, despite a number of large clinical trials exploring tests such as ultrasound and blood tests. If a patient is suspected of having ovarian cancer, there are a number of examinations and tests that are used to confirm the diagnosis and establish how advanced it is. These can include:

• Physical examination (especially of the abdomen and an internal vaginal examination).

• Blood tests.

• Ultrasound tests, CT scans.

• Other tests depending on initial assessments, e.g. colonoscopy, PET scans.

These tests can establish if any abnormalities are present, and to assess the extent of abnormal areas. However, a tissue sample (biopsy) is the only way a diagnosis can be confirmed.

Ovarian Cancer Staging

The International Federation of Gynaecological Oncologists (FIGO) has established a system of classifying ovarian cancer depending on what stage it has reached. The following is a brief summary of these stages:

Stage I

The cancer is present in one or both ovaries or the fallopian tube(s), and has not spread to neighbouring tissues/organs.

Stage II

The cancer has spread to other tissue in the pelvic area e.g. implants on the uterus or other pelvic tissues

Stage III

The cancer has spread to the peritoneum outside the pelvis, or where cancer cells are present in lymph nodes in the abdomen.

Stage IV

The cancer has spread to tissue or organs outside the abdominal cavity or the pelvis. This may include the liver, the lungs, the spleen, inguinal (groin) lymph nodes, or other organs.

Treatment

Treatment of most women diagnosed with ovarian cancer involves both surgical resection and chemotherapy. The appropriate sequence and combination of treatments, will depend on the stage, and are individualised depending on each patient’s symptoms, general health, and pattern of disease spread.

Surgery

Surgery is an important component of treatment of ovarian cancer. A key goal is to remove as much of the cancer as possible, leaving little or no visible disease. Surgery may either be the first treatment provided, or performed after chemotherapy is given first to shrink the tumour, with the aim of improving the chance of removing all visible disease at the time of operation. Surgery is sometimes also performed when ovarian cancer recurs after initial treatment.

Chemotherapy

Chemotherapy is often recommended in most patients newly diagnosed with ovarian cancer. This is typically given in one of two scenarios:

Prior to surgery

This is often referred to as ‘neo-adjuvant’ chemotherapy. Typically given over a period of about 9 weeks prior to surgery, the aim of neoadjuvant chemotherapy is to shrink the tumour and improve the chances that subsequent surgery will remove most of the visible cancer. It may also make surgery easier and reduce the complication rates around surgery and allow a quicker recovery.

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After surgery

Referred to as ‘adjuvant’ chemotherapy, the aim of this treatment is to eliminate any remaining cancer not entirely removed at surgery, or small ‘microscopic’ disease that was not visible at surgery. The overall aim is to reduce the chance of the cancer recurring, or at least delay recurrence.

Targeted Therapies

These are new drugs that target specific genetic abnormalities or pathways that are driving cancers to grow and multiply. These drugs include biological therapies, such as antibodies that target blood-vessel formation, or oral tablets that target specific abnormalities in cancer genes such as BRCA1 and BRCA2.

Clinical Trials

Clinical trials are a type of research studies that may be testing new treatment approaches or new drugs. They are the best way to develop new treatments to treat cancer, and often are comparing a new approach to current standard treatments or testing a new treatment when there is no current beneficial treatment. They also are one way of getting the newest treatment for cancer, especially when treatment options are not effective or stop working.

Supportive Care

Other treatments may also be recommended to help prevent and/or control some of the symptoms of ovarian cancer and symptoms related to the treatments. These are referred to as Supportive Care.

Recurrent ovarian cancer

Unfortunately, and despite the best initial treatment, many patients with ovarian cancer will experience recurrence of their disease. When this occurs, treatment options are often still available and these can include further surgery or chemotherapy, novel drugs and therapies, or participation in clinical trials of novel anti-cancer drugs