What is Ovarian Cancer?
In Australia, ovarian cancer is a common gynaecological cancer with more than 1,500 women newly diagnosed every year.
Ovarian cancer is a malignant disease arising from the ovaries or the fallopian tubes. Normally, ovaries are small, almond-shaped pelvic organs that in healthy women produce the female hormones (oestrogen, progesterone, testosterone). In young women, the fallopian tubes carry the fertilised egg from the ovary to the uterus (womb). Cancer in the fallopian tubes is more common in women with BRCA1 or BRCA2 syndrome.
Rarely, cancer that resembles ovarian cancer can develop in women who had both ovaries and fallopian tubes removed previously. We call these cancers "peritoneal cancers" because they arise from the peritoneum, inner lining of the abdominal cavity, and lie on abdominal and pelvic organs.
Types of Ovarian Cancer
Epithelial ovarian cancer
Approximately 85% of all ovarian cancers are epithelial and originate from the outside layer of the ovary. Typically, epithelial ovarian cancer (EOC) is diagnosed in postmenopausal women. The two cornerstones of treatment of EOC are surgery combined with chemotherapy.
Non-epithelial ovarian cancer
These cancers account for approximately 10% of all ovarian cancers. Typically they develop in very young women and originate from the hormone-producing tissues inside the ovary. Surgery is essential but often only one ovary needs to be removed, and therefore fertility can be preserved. Sometimes chemotherapy is required. These cancers often carry a good prognosis and many of these young women will be able to have babies.
Borderline tumours
Borderline tumours are clusters of abnormal cells within ovarian tissue and have low malignant potential. If left untreated they have the possibility to become larger, spread and cause damage. They are treated by surgery and most patients can expect a very good prognosis which is usually a complete cure. Chemotherapy is not effective for borderline tumours. Sometimes young women are affected, and fertility can be preserved in the majority of young women by only removing the affected ovary. Postmenopausal women should have both ovaries removed to reduce the risk of a tumour recurrence.
Ovarian Cancer Symptoms
The symptoms of ovarian cancer are unspecific and can be mistaken for irritable bowel syndrome, an upset stomach or bladder infections.
Signs of ovarian cancer may include:
- Increase in abdominal size or bloating
- Difficulty eating or feeling full quickly after eating a small amount
- Frequent or urgent urination
- Back, abdominal or pelvic pain.
If you have one or more of these symptoms and they are persistent on most days over 2-4 weeks, then you should speak to a doctor as soon as possible. In hindsight, almost all ovarian cancer patients display some of those signs, but women who do not have ovarian cancer may experience them as well.
Causes of Ovarian Cancer
We don’t know exactly what causes ovarian cancer, however a number of factors can increase ovarian cancer risk. Risk factors include:
- Being over 50 years of age—the average age of women when they are diagnosed with ovarian cancer is 64 years.
- Family history of ovarian, breast or bowel cancer
- Being overweight or obese
- Changes in the genes BRCA1 or BRCA2
- Being of Ashkenazi Jewish descent due to a higher BRCA incidence
- Early onset of periods (before 12 years)
- Late menopause
- Women who have not had children
- Women who have their first full-term pregnancy after the age of 35
- Smoking, which may slightly increase mucinous ovarian cancer
- Using oestrogen-only hormone replacement therapy
- Fertility treatment.
Ovarian Cancer Diagnosis
First, your doctor will rule out other causes of your symptoms, perform a pelvic examination, and arrange for medical imaging scans (such as an internal ultrasound) and tumour marker blood tests (CA125, CA19.9, CEA, HE4).
Some women may even have a colonoscopy to rule out any bowel conditions that may present with similar symptoms. If there is still concern for ovarian cancer, surgical exploration will be initiated, where the surgeon takes a tissue sample (biopsy).
Depending on medical imaging and blood tests I will recommend one of the following:
- Very low risk of malignancy (less than 1%): I recommend a repeat ultrasound (ideally transvaginally) and tumour marker test in 2 to 3 months
- Low to medium risk of malignancy: Surgical exploration may be useful to establish a diagnosis using a laparoscopic (keyhole) approach
- High risk of malignancy: Surgery is ideally performed through an open abdominal incision. A laparoscopic approach is reasonable if the tumour is advanced and if it needs to be determined whether surgery should be the first choice of treatment.
I discourage draining pelvic masses to establish a diagnosis because of the enormous risk of tumour cell dissemination during such a procedure (i.e. if it is cancer it could spread to other parts of the body).
Ovarian Cancer Treatment
The key to successful ovarian cancer treatment is the combination of surgery plus chemotherapy. The timing of the combination of the two approaches may depend on the patient's age, her general health and the extent of the disease.
I will recommend the following treatment options:
- Upfront surgery followed by chemotherapy, or
- Upfront induction chemotherapy, followed by surgery and completion chemotherapy.
Surgery
Ovarian cancer surgery is usually done through an abdominal incision and will typically remove the uterus, fallopian tubes and both the ovaries.
Commonly the omentum (fatty tissue that stitches over the intestines, liver and stomach) and lymph nodes will need to be removed also. Sometimes, patients will require a bowel resection (removal of part of the bowel).
Patients are required to fast at least 6 hours prior to surgery. Patients are advised to stop smoking before the operation as it makes your postoperative management much easier.
In most instances, a frozen section examination will be required during surgery. The frozen section is a diagnostic procedure where a biopsy is taken and examined under a microscope for cancerous cells.
Depending on the results of the frozen section, the operation is continued to either:
- Determine the extent of the disease (pelvic and/or aortic lymph node dissection, and omentectomy (removal of omentum)
- To remove as much cancer tissue as technically possible. If the diagnosis of ovarian cancer is confirmed and surgery is deemed the most promising approach, I will always aim to remove all cancer from the body.
Surgery for suspected advanced ovarian cancer should not be performed in regional hospitals. These patients benefit from surgery in a big (tertiary) centre because of the availability of specialised services (nursing) and medical specialities if required.
After surgery
When you wake up from general anaesthesia a drip will provide the necessary fluids and a urinary catheter will drain the urine from your bladder. An oxygen mask will supply oxygen to the respiratory system. A drain may collect body fluid from the inside of the abdomen. These will be removed once I am happy that the body functions have returned to normal, which is usually after a few hours or days.
Whenever possible we will mobilise patients (standing up) on the day or the day after surgery with the help of experienced physiotherapy staff.
Patients need to stay in hospital for 1 or 2 days if the procedure was done laparoscopically or 5 to 7 days if a laparotomy (opening of the abdomen) was necessary.
At discharge, I recommend to "take it easy" for 2 to 4 weeks. I recommend avoiding intercourse, vaginal tampons, full baths and other factors that could disrupt wound healing or facilitate an infection. All patients will receive painkillers upon leaving the hospital. It is critical that patients continue the pain medication beyond discharge from hospital for approximately 10 to 14 days.
The final histopathological report may take a few days. It forms the basis for the decision if any further treatment (e.g., chemotherapy) is required.
Surgical risks
Surgery always carries risks. I do everything possible to minimise these risks.
Risks may include:
- Laparoscopic surgery may need to be converted to open surgery through the opening of the abdomen. This risk of conversion is approximately 2% to 3%. The vast majority of all laparoscopic procedures proceed laparoscopically.
- A risk of injury to pelvic organs, such as the bowel, bladder, ureters, blood vessels and nerves. Should this occur, these injuries usually are repaired during surgery. However, in an exceedingly small proportion of patients these injuries can unfortunately not be recognised during surgery or injuries may even develop after surgery. If this should occur another operation is required to repair those injuries. Injury to large blood vessels may result in the need of a blood transfusion. Injury of nerves is common in patients who require removal of lymph nodes in the pelvis. In this case, patients will experience some numbness of the skin around the upper thigh.
- Medical and anaesthetic risks associated with general anaesthetic may occur.
Possible complications after surgery
- Shoulder tip pain is common after laparoscopic surgery. It is caused by the CO2 gas that is needed for the surgery. It normally lasts only for a day, but painkillers are unfortunately not effective.
- Infections to the bladder, the abdominal wound, the lungs with resulting temperatures and septicaemia. I prescribe antibiotics before the skin incision in order to avoid skin and other infections.
- Thromboembolic complications (formation of blood clots) in the legs that can even travel to the lungs and cause life-threatening emboli. This risk is very small because of our efforts to minimise them. Prior to and after surgery patients are asked to wear calf compression stockings in order to prevent the formation of blood clots in the legs.
- Lymphoedema following survey is the accumulation of excessive amounts of fluid resulting in swelling, most commonly in the arms or legs, but can also occur in other parts of the body.
- A vaginal discharge that can be blood-stained is common for up to 6 weeks.
- Changes in bowel habits are not uncommon for a couple of months after surgery. I recommend regulation of the bowels with natural substances such as yoghurt, prune juice and natural fibre.
Chemotherapy
Almost all patients with ovarian cancer will require chemotherapy postoperatively.
Only patients who meet all the following criteria do NOT benefit from chemotherapy:
- Tumour limited to one ovary only
- All lymph nodes and omentum are cancer free
- No free-floating cancer cells in the abdomen
- Had negative tumour markers prior to surgery.
Their prognosis is so good that it cannot be further improved by chemotherapy.
For those who require chemotherapy it will be given through a drip every 1 or 3 weeks. I do not administer chemotherapy but I will refer my patients to a medical oncologist who is experienced in ovarian cancer treatment.
Chemotherapy typically starts two or three weeks after discharge from surgery in hospital.
In some cases where patients are unable to tolerate surgery for medical reasons, chemotherapy needs to be given upfront before surgery. In such cases, I will refer you to a medical oncologist who will give you 2 or 3 cycles of neoadjuvant chemotherapy and then we will re-evaluate if the patient is then fit for surgery.
Ideally, the patient should be tumour-free at least once (either after upfront surgery or after surgery between chemotherapy cycles).
Follow-Up
After surgery, you should be seen regularly for follow-up for 5 years. These examinations will include pelvic examinations and tumour marker (blood) tests. I recommend PET/CT scans only if needed.
Should you experience any bleeding or pain after surgery, please do not hesitate and contact my office straight away.
Ovarian Cancer Outcomes
Cancers of all types and stages may recur. Recurrence may be local or in the pelvis or at distant sites (such as the abdomen or lungs).
Treatment of recurrent ovarian cancer depends on:
- The type of cancer (epithelial, non-epithelial, borderline)
- The time interval between the first diagnosis of cancer, and
- The recurrence (the longer the better) and the distribution of disease (how many spots of cancer and their localisation).
After five years, the risk of a recurrence becomes much lower.
Ovarian Cancer Survival Rates
Epithelial survival rates
Survival rates for epithelial ovarian cancer depends on its stage.
Survival for stage 1, localised cancer is between 85% and 90% at five years.
Survival for stage 3 or 4 ovarian cancer depends on how much tumour had to be left behind after surgery but also depends on the response of the cancer to chemotherapy. Unfortunately we have no means to predict if an individual patient will respond to chemotherapy or not.
Non-epithelial survival rates
Survival of patients with non-epithelial ovarian cancer is generally excellent.
Most of these tumours require only the removal of one ovary, which allows us to preserve fertility in young women. While chemotherapy may be required, periods will return.
Borderline tumour survival rates
Survival of patients with borderline tumours is above 95% in patients with stage 1, localised disease. Patients with elevated CA125 tumour markers will need to attend to a strict follow up regimen.
Patients with stage 1 borderline tumours and low CA125 will only need to be seen for regular follow-up if problems or symptoms develop down the track.