Dr. Bhavana Parikh

Ovarian Cancer

DIAGNOSIS, TREATMENTS, CAUSES

Ovarian cancer is more prevalent among women aged above 50. Having a positive family history is also considered a strong risk factor for ovarian cancers.

Overview

Ovarian cancer refers to the cancerous growth that starts in the ovaries. It is the third most common cancer among Indian women. However, it is one of the cancers that are detected in the later stages when they are relatively challenging to treat.

The risk of developing ovarian cancers increases with age. It is more prevalent among women who are above 50 and who have reached the menopausal stage. Having a positive family history is also considered a strong risk factor for ovarian cancers.

Symptoms

Ovarian cancer often goes undetected until it has spread within the pelvis and abdomen. At this late stage, both treatment and management of the disease become challenging. An early-stage ovarian cancer, on the other hand, is more likely to be treated with the best clinical outcomes as the disease is largely confined to that organ only. Ovaries are located in the lower abdomen region and their location makes the examination difficult too. This, along with vague symptoms, makes early detection of ovarian cancer a daunting task. Although vague, unlike symptoms of other less severe conditions, ovarian cancer symptoms persist and can worsen over time. Here are some of the main symptoms of ovarian cancer that women must keep an eye on:
  • Pain or pressure in the pelvis
  • Abnormal vaginal bleeding
  • Pain in the back or abdomen
  • Bloating
  • Feeling full with less food
  • Frequent urination
  • Unexplained weight gain or weight loss
  • Changes in bowel habits
  • Loss of appetite
  • Nausea and vomiting
Women must get in touch with their physician if any of these symptoms last for more than two weeks.

Types

Ovarian cancers are categorised into three types based on the types of cells they originate from:
  • 1. Epithelial tumours, which account for about 90% of ovarian cancers, arise from the thin layer of tissue that lines the outside of the ovaries.
  • 2. Stromal tumours account for about 7% of the ovarian cancers, and it begins in the ovarian tissues that carry the hormone-secreting cells. Unlike other ovarian tumours, stromal tumours are diagnosed at relatively earlier stages.
  • 3. Germ cell tumours are the rare type of ovarian cancers that are more prevalent among younger women. These tumours arise from the egg-producing cells.

Causes

Although the exact cause of this disease is yet to be completely known, the following are the factors that increase the risk of developing ovarian cancer among women:
  • Reproductive History: Women who have no history of pregnancy or have their full-term pregnancy after 35 are at a higher risk of developing ovarian cancer.
  • Family History: A woman’s risk of developing ovarian cancer is higher if she has a close relative with a history of ovarian or breast cancer.
  • Age: Ovarian cancer risk is reported to increase with age.
  • Having a Personal History of Certain Cancers: Those with a history of breast, uterine or colorectal cancers have a higher risk of getting diagnosed with ovarian cancer.
  • Endometriosis: Some rare types of ovarian cancer, like clear cell ovarian cancer, are found to be more common among women with endometriosis.
  • Genetic Mutations: Genetic mutations of genes associated with ovarian cancers, namely BRCA1 and BRCA2
  • Hormone Replacement Therapy: Women using estrogen alone or with progesterone after menopause have an increased risk of developing ovarian cancer compared to women who are not on them.
  • Fertility Medicines: In rare cases, the usage of fertility medicines is found to increase the risk of ‘borderline’ or ‘low malignant potential’ ovarian cancers.
  • Obesity: Obese women are found to be at a higher risk of developing ovarian cancer.

Diagnosis

Our specialists use multiple testing methods for the detection and diagnosis of ovarian cancers. From simpler blood tests to advanced imaging tests such as PET/CT scans are employed to arrive at an accurate diagnosis. Personalised treatment plans are devised based on the diagnostic information available.

a. Physical Examination: During the physical examination, the doctor enquires on the patient’s health condition, medical history and other aspects to determine the possible risk factors. Patients may also be asked about the symptoms that they have been experiencing. The doctor may also likely conduct a pelvic examination to look for signs of enlarged ovary or fluid in the abdomen (ascites).

b. Blood test (CA125): A blood test may be performed to look for a biomarker called CA125 in the blood. High CA125 levels in the blood may be an indicator of ovarian cancer development. However, this molecule is not exclusive to ovarian cancer, and the elevated levels of this biomarker can be caused due to other illnesses too.

If symptoms such as frequent bloating, feeling of fullness, reduced appetite, or pelvic or abdominal pain are frequently experienced, a CA125 blood test should be carried out as per the National Institute for Health and Care Excellence (NICE).

c. Imaging Tests: Imaging tests help in finding if ovarian cancer has spread to nearby organs. They may also provide other information, such as the size of the tumour, its exact location, stage and grade. Apart from this, the results from imaging tests may also aid in treatment planning and therapy monitoring.

  • Ultrasound: Ultrasound is one of the most commonly used imaging tests for ovarian cancer detection. It employs high-energy sound waves to detect abnormalities such as solid masses or fluid-filled cysts. A transvaginal ultrasound can reveal the size of the ovaries and any abnormalities in the structure of the ovaries and the nearby structures, namely vagina, uterus, bladder, or fallopian tubes.
  • PET/CT scan or MRI scan: PET/CT scan or MRI scan may be recommended to look for signs of ovarian cancer that may have spread to abdomen and pelvis.
  • Chest X-ray: Chest X-ray is recommended to check if ovarian cancer has spread to the lungs or caused a build-up of fluid around the lungs.

d. Abdominal fluid aspiration: It’s possible that ovarian cancer has spread if there’s a build-up of fluid in the abdomen and it appears enlarged. A tiny needle is inserted into the abdomen to collect a sample of fluid, which will be later examined for cancer cells.

e. Laparoscopy: This technique involves a doctor examiningthe ovaries and other pelvic organs and tissues using a thin, lit tube. The tube is insertedthrough a minor incision (cut) in the lower abdomen, and ittransmits images of the pelvis or abdomen to a video monitor. The results from laparoscopy may help in disease staging and treatment planning.

Treatment

Treatment planning for ovarian cancer is made based on numerous factors, namely the cancer type and stage, the potential side effects, the woman’s age and whether she’s planning to have children after the treatment. Surgery is often the first treatment recommended for ovarian cancer and may involve the removal of the ovaries and fallopian tubes, uterus, lymph nodes in the area and surrounding tissues and organs. Chemotherapy is usually recommended after surgery.

a. Surgery

Surgery can be done to confirm the diagnosis, determine the stage of cancer, and operate the tumour. There are multiple surgical approaches that are considered by specialists to manage ovarian cancers successfully.

  • Biopsy: Lymph node biopsy or the removal of all or part of a lymph node is performed to analyse the tumour.
  • Unilateral Salpingo-oophorectomy: This procedure involves the removal of one ovary and one fallopian tube.
  • Bilateral Salpingo-oophorectomy: This is the procedure where both ovaries and fallopian tubes are removed.
  • Omentectomy: This surgery involves the removal of the tissue in the peritoneum (called the omentum), which includes lymph nodes.
  • Hysterectomy: This is the procedure where the womb is completely removed. There are different subtypes of hysterectomy and the right procedure is employed based on the stage of the disease.
    • Partial hysterectomy removes the uterus
    • Total hysterectomy is performed to remove the uterus and cervix
    • Total hysterectomy with salpingo-oophorectomy removes the uterus, cervix and one ovary and fallopian tube (unilateral salpingo-oophorectomy) or both ovaries and fallopian tubes (bilateral salpingo-oophorectomy)
    • Radical hysterectomy removes all of the above, along with the nearby tissues.

b. Chemotherapy

Chemotherapy has been the accepted standard of care for ovarian cancers. Chemotherapy may also be administered following surgery, as adjuvant therapy, to treat any residual disease and bring down the risk of a relapse, particularly in advanced stages of ovarian cancer.

c. Targeted therapy

Targeted therapy uses drugs that can target specific protein particles present in cancer cells, particular genes and the tumour environment. Targeted therapy drugs are generally reserved to treat relapsed ovarian cancers or those that resist other treatments. Before administration, cancer cells will be tested to determine which targeted therapy is most likely to be effective.

d. Radiation therapy

Since important organs are in the radiation field, a large dose cannot be safely delivered in the case of ovarian cancers. Also, radiation therapy may not be useful for advanced-stage ovarian cancers. Radiation therapy is, therefore, frequently avoided because the important organs may be unable to endure the complications.

Treatment

There are various treatment options available for osteosarcoma. However, the doctor devises the treatment plan upon considering various factors, such as the location of the tumour, the size, stage of the disease, its grade, patient’s age, his/her overall health condition and preferences.

Surgery, chemotherapy, radiation therapy are the main treatment options available for osteosarcoma. However, those with osteosarcomas may also be treated with targeted therapy.

a. Surgery: The primary goal of surgery is to remove the cancer cells entirely, while also striving to reduce disability and keep the cancer-affected bone functional. Following are various surgical procedures available, and the doctor may recommend one of these depending on the severity of the disease.

  • Limb-sparing Surgery (Limb-salvage Surgery): Most osteosarcoma cases can be treated successfully through limb-sparing surgery. It is often combined with radiation therapy or chemotherapy. This surgery involves the removal of the tumour without removing the entire limb. A small amount of healthy tissue around the tumour may also be removed. The main goal of this surgery is to preserve the structure and functioning of the limb. In a few cases, where a large section of the bone is removed, reconstructive surgery may be performed, wherein metal prosthetics or bone grafts are used to reconstruct the bone and restore its functions.
  • Amputation: In rare cases, especially in the case of high-grade osteosarcomas, amputation may be recommended by the doctor. During this procedure, a part or the entire limb is removed in order to remove the tumour successfully. Today, we have tremendous advancements in the field of prosthetics and various ways to improve the quality of clinical outcomes for patients undergoing amputation and help them return to the best state of health possible.
  • Rotationplasty: Rotationplasty is usually recommended for osteosarcomas that form in the areas close to the knees. During this procedure, the lower portion of the thigh bone (femur), the knee and the upper tibia (upper shinbone) are removed. The lower portion of the leg is rotated by 180 degrees (rotationplasty) and attached to the thigh bone. The foot is now attached to the thighbone in the backwards direction and the ankle functions as the knee. With regular training, the patient will learn how to use the ankle as the knee.

For the lower leg, a prosthesis may be used. After this procedure, the patient will be able to get back to their normal life and take part in physical activities, sports, etc., in three to six months.

b. Chemotherapy: Chemotherapy uses powerful anticancer drugs to stop the cancer cells from growing and dividing. Chemotherapy may be given before the surgery to shrink the tumour and/or after the surgery to destroy the residual cancers and reduce the risk of a relapse.

Chemotherapy may be administered orally or intravenously, or both.

c. Radiation Therapy: In a few cases, radiation therapy may also be recommended for osteosarcoma, especially if surgery is not feasible. Radiation therapy uses high-energy radiation beams, which could either be X-rays or proton beams, to kill the cancer cells. Radiation therapy could either be delivered externally or internally.

d. Targeted Therapy: Targeted therapy involves the usage of medications that block specific proteins that are vital for the growth of cancer cells. Unlike radiation therapy and chemotherapy, targeted therapy only attacks the cancer cells and thereby reduces damage to the healthy cells and causes fewer treatment-related complications.

e. Cryotherapy: During cryotherapy, liquid nitrogen is used to freeze the tumour cells and kill them.

FAQs

If ovarian cancer is detected early enough, it can be treated. In a few cases, even advanced-stage ovarian cancers can be treated with positive clinical outcomes.

There are multiple treatment options available for ovarian cancers today that not only support successful health outcomes but also a better quality of life among patients.

More often than not, the symptoms of ovarian cancer can be confused with those of many less severe health conditions. Following are some of the other health conditions that have similar symptoms to that of ovarian cancer:
  • Premenstrual Syndrome
  • Periods
  • Ovarian Cysts
  • Endometriosis
  • Uterine Fibroids
  • Irritable Bowel Syndrome
  • Pelvic Infection
However, this does not imply that one can ignore any symptom assuming that it could be of a less serious health condition that will gradually go away. Any symptom that persists for more than two weeks should be brought to the attention of the physician.

Ovarian cysts are pockets of regular cells, and these are usually filled with fluid. Ovarian tumours, on the other hand, are abnormal masses made of uncontrollably dividing tumour cells.

Although ovarian cysts present themselves with cancer-like symptoms, namely pelvic pain, difficulty in emptying the bladder, abdominal bloating, feeling of pressure in the abdominal area, etc., ovarian cysts are non-cancerous.

The majority of ovarian cysts show up and disappear with each menstrual cycle, and there is nothing alarming about it. Although most ovarian cysts are benign, following menopause, the presence of ovarian cysts only increases the risk of ovarian cancer.

The side effects experienced by each patient may depend on the treatment plan recommended. Possible side effects may include hair loss, bowel problems, joint and muscle pain, nausea and vomiting, changed bowel habits, increased risk of infections, diarrhoea, frequent urination, burning sensation while urinating (cystitis), and a little burn on the skin near the treatment area (for radiation therapy).

Among women who have not gone through menopause, removal of ovaries may lead to surgically-induced menopause as they can no longer make enough estrogen. In addition to normal menopause symptoms like hot flushes and vaginal dryness, low estrogen levels may also induce bone loss and cardiovascular disease.

Fatigue and neuropathy, a tingling, numbing sensation in the hands and feet are other possible side effects associated with ovarian cancer treatment.

A few side effects usually wear off over time and may not need any medical intervention. However, there are a few side effects that may affect the treatment response and quality of life among patients and may need medical intervention.

If ovaries are removed, hormone replacement therapy may help patients in restoring their estrogen levels. Dietary adjustments and other nutrition assistance, pain management, and psycho-oncology counselling and other interventions may help in the management of side effects among ovarian cancer patients.

If your treatment plan involves the removal of both ovaries and fallopian tubes, along with the uterus (womb), you will not be able to conceive naturally.

However, you still have other means through which you can conceive. If you wish to conceive after the treatment, talk to your gynae-oncologist about fertility preservation alternatives like ovarian cortex cryopreservation, which entails freezing the ovarian tissue before treatment. Other options available include IVF, surrogacy and adoption.

Other Types of Cancer

Rectal cancer develops when the cells that line the rectum start to divide and multiply uncontrollably. The last six inches of the large intestine forms the rectum and carries faeces until it is expelled.

Ewing sarcoma is a rare type of cancer that affects the bones or the soft tissue that surrounds them. This condition is more common among teenagers and young adults.

Tobacco use is the biggest risk factor for head & neck cancer. About 85% of head & neck cancers are linked to tobacco use. Quitting tobacco and regular screening can reduce head & neck cancer risk.

Every Patient Deserves

Best Care and Treatment

Dr. Bhavna Parikh DNB (Oncosurgery)