About Ovarian Cancer Everything You Need To Know
Ovarian Cancer Overview
It's the fifth most common cancer among women after breast cancer, bowel cancer, lung cancer and cancer of the uterus (womb).
Ovarian cancer is most common in women who have been through the menopause (usually over the age of 50), although it can affect women of any age.
As the symptoms of ovarian cancer can be similar to those of other conditions, it can be difficult to recognise. However, there are early symptoms to look out for, such as persistent bloating, pain in the pelvis and lower stomach, and difficulty eating.
The ovaries are a pair of small organs in the female reproductive system that contains and release an egg once a month. This is known as ovulation.
Different types of ovarian cancer affect different parts of the ovaries. Epithelial ovarian cancer, which affects the surface layers of the ovary, is the most common type. This topic focuses on epithelial ovarian cancer.
Types Of Ovarian Cancer
Epithelial ovarian cancer
About 90 out of 100 tumours of the ovary (90%) are epithelial. Epithelial ovarian cancer means cancer started in the surface layer covering the ovary.
There are various types of epithelial cancers of the ovary:
- 1. Serious
- 2. Endometrioid
- 3. Clear cell
- 4. Mucinous
- 5. Undifferentiated or unclassifiable
Serous epithelial ovarian cancer is the most common type, making up about two-thirds of the cases diagnosed. Doctors now think that most high grade serous ovarian cancers actually start in cells at the far end of the fallopian tube, rather than the surface of the ovary. These early cancer cells then spread to the ovary and grow.
About 10 in 100 epithelial ovarian cancers (10%) are undifferentiated or unclassifiable. These tumours have cells that are very undeveloped, so it is not possible to tell which type of cell cancer started from.
Researchers are investigating in clinical trials whether the rarer types of epithelial ovarian cancer need to be treated any differently to the serious type. But at the moment, they are generally treated in the same way. The main treatments are surgery and chemotherapy.
A small number of ovarian cancers are a type called primary peritoneal carcinoma. Cancer develops from cells that form the membrane around abdominal organs. You can read more about primary peritoneal cancer.
Germ cell and other rare ovarian tumours
Around 1 or 2 out of 100 ovarian cancers (1 to 2%) are germ cell cancers. They start from the egg-making cells of the ovary. As well as these, there are also non-cancerous (benign) forms of germ cell tumour, which doctors sometimes call dermoid cysts or mature teratoma. You can read more about teratoma of the ovary.
Other rare types of cancer can affect the ovary, for example, stromal tumours and sarcomas. This section does not cover these rarer types of ovarian cancer.
Borderline ovarian tumours
Borderline ovarian tumours are different from ovarian cancer because they do not grow into the supportive tissue of the ovary (the stroma). They are also called tumours of low malignant potential. About 10 out of 100 epithelial ovarian tumours (10%) are borderline tumours.
Borderline ovarian tumours grow slowly and most are diagnosed at an early stage when the abnormal cells are still within the ovary. Abnormal cells can sometimes break away from a tumour and settle elsewhere in the body, usually the abdomen. These do not usually grow into the underlying tissue.
Borderline ovarian tumours are treated in a different way to ovarian cancers and are usually cured with surgery alone.
Signs & Symptoms To Look For
How to tell whether symptoms are ovarian cancer
Ovarian cancer symptoms are not always easy to spot as they can be vague. Some of the symptoms of ovarian cancer can also be symptoms of non-cancerous conditions.
There is more chance that symptoms are caused by cancer if they are new, quite severe, and don't come and go. If you have any of the symptoms below and they happen on most days for 3 weeks or more, particularly if you are over 50 or have a strong family history of breast or ovarian cancer, do go to your GP and get a checkup.
Remember the symptoms on this page can also be a sign of other illnesses that are not cancer. Most women with symptoms like these will not have cancer.
Symptoms of very early ovarian cancer
The stage of cancer describes how far it has grown and spread. Very early stage cancer means cancer that is completely inside the ovary and is also called stage 1.
Many women with a very early stage of ovarian cancer don't have any symptoms. If they do have symptoms, they may be vague and can include
- 1. Pain in the lower abdomen or side
- 2. Bloated, full feeling in the abdomen
- 3. Changes in appetite, often a loss of appetite or feeling full sooner
- 4. Changes in bowel movements.
- 5. Increased abdominal girth.
Symptoms if cancer has grown outside the ovary
Cancer that has grown outside the ovary includes stage 2 and stage 3 ovarian cancer.
These may cause symptoms from a tumour growing anywhere in the area between the hip bones (the pelvis) such as
- 1. Irregular periods or vaginal bleeding after menopause
- 2. Lower tummy (abdominal) pain
- 3. Back pain
- 4. Passing urine more often than usual
- 5. Constipation
- 6. Pain during sex
- 7. A swollen abdomen
- 8. The feeling of fullness or loss of appetite
Symptoms of ovarian cancer that has spread
Doctors call cancer that has spread to a distant body organ, such as the lungs, stage 4 ovarian cancer. Symptoms may include
- 1. Loss of appetite or a feeling of fullness in the abdomen
- 2. Feeling or being sick
- 3. Constipation
- 4. Tiredness
- 5. Shortness of breath
- 6. Noticeable swelling of the abdomen
Stages Of Ovarian Cancer
Staging ovarian cancer
The stage of cancer tells the doctor how far it has grown and if it has spread. The tests and scans you have to diagnose your cancer will give some information about the stage. It is important because your specialist will decide on your treatment according to the stage of your cancer.
Doctors use a simple 1 to 4 staging system for ovarian cancer. It is called the FIGO system after its authors - the International Federation of Gynaecological Oncologists.
Stage 1 ovarian cancer means the cancer is only in the ovaries. It is divided into 3 groups
- Stage 1a - the cancer is completely inside one ovary
- Stage 1b - the cancer is completely inside both ovaries
- Stage 1c - as well as cancer in one or both ovaries, there is some cancer on the surface of an ovary or there are cancer cells in fluid taken from inside your abdomen during surgery or the ovary ruptures (bursts) before or during surgery
Stage 2 means cancer has grown outside the ovary or ovaries and is growing within the area circled by your hip bones (the pelvis). There may also be cancer cells in the abdomen.
So stage 2 cancer can be:
- 2a - cancer has grown into the fallopian tubes or the womb
- 2b - cancer has grown into other tissues in the pelvis, for example, the bladder or rectum
2c - cancer has grown into other tissues in the pelvis and there are cancer cells in fluid taken from inside your abdomen.
Stage 3 cancer of the ovary means cancer has spread outside the pelvis into the abdominal cavity. Your cancer is also stage 3 if cancer is found in the lymph nodes in your upper abdomen, groin or behind the womb.
So stage 3 cancer can be:
- 3a - using a microscope, cancer growths can be seen in tissue taken from the lining of the abdomen
- 3b - there are visible tumour growths on the lining of the abdomen that are 2cm across or smaller
- 3c - there are tumour growths larger than 2cm on the lining of the abdomen, or cancer in lymph nodes in the upper abdomen, groin or behind the womb, or both
Stage 4 ovarian cancer means cancer has spread to other body organs some distance from the ovaries, such as the liver or lungs.
Stage 4 cancer can be:
- Stage 4a - cancer has caused a build-up of fluid in the lining of the lungs (called the pleura). This is called a pleural effusion.
- Stage 4b - cancer has spread to the inside of the liver or spleen, to the lymph nodes in the groin or outside the abdomen and/or to other organs such as the lungs.
What Increases The Risk Of Developing Ovarian Cancer?
The two most important aspects affecting a woman’s risk of developing ovarian cancer during her lifetime are age and family history.
- The risk of ovarian cancer does increase with age, and particularly after the menopause. Over eight in ten cases will occur in women who have gone through the menopause.
- Most cases of ovarian cancer are ‘sporadic’ or one-offs. This means that close female relatives of someone with ovarian cancer do not necessarily face an increased risk of developing the disease themselves. However, in around one in every ten cases, a family link can be identified.
- If a woman has two or more close family relatives with a history of ovarian cancer, or ovarian cancer and/or breast cancer then she should discuss her family history with her doctor. Both sides of a woman’s family (mother and father) should be considered.
Facts About Ovarian Cancer
83% of women survive cervical cancer for at least one year, and this is predicted to fall to 67% surviving for five years or more, as shown by age-standardised net survival for patients diagnosed with cervical cancer during 2010-2011 in England and Wales.
There were 7,378 new cases of ovarian cancer in the UK in 2014, this is 2% of all cancer cases, the peak age of women getting ovarian cancer is between 75-79
Ovarian cancer cases have gone up by 17% since the 1970's.There were 4,128 deaths in 2014, this is 5% of cancer deaths in women, the peak age of ovarian cancer in women is 85-89
Ovarian deaths have fallen by 17% since the 1970's
Ovarian cancer mortality rates are projected to fall by 37% in the UK between 2014 and 2035, to 10 deaths per 100,000 females by 2035
Treatment For Most Ovarian Cancers
The main treatments for ovarian cancer are surgery and chemotherapy.
Almost all women with ovarian cancer will need surgery. The amount and type of surgery you have will depend on your stage and type of cancer. The information in this section is about treating epithelial ovarian cancer. For some women with very early stage ovarian cancer, surgery is the only treatment you need.
Most women with ovarian cancer are diagnosed with advanced disease and have a combination of both surgery and chemotherapy. You may have chemotherapy after surgery or both before and after surgery.
You may find that other women you meet with ovarian cancer are having different treatment from you. This may be because they have a different type of ovarian cancer. Or it may be that their cancer is a different stage.
Don't be afraid to ask your doctor or nurse any questions you may have about your treatment. It often helps to write down a list of questions you want to ask. You could also take a close friend or relative with you when you go to see the doctor - they can help you remember what was said.
You are most likely to be treated by a team of specialist doctors working together, known as a gynaecology oncology team. This will include a surgeon who specialises in treating women's cancers (a gynaecological oncologist) and a medical cancer specialist (an oncologist). It should also include a gynaecological cancer specialist nurse, who can give you information about treatment and any support you may need.
National guidelines recommend that women with ovarian cancer have their treatment in a specialist gynaecology cancer centre, where these specialist gynaecology oncology teams are usually based. So you may not be able to go to your local hospital and might need to travel to your nearest cancer centre for your treatment.
If you have only seen a surgeon, you should ask to see a cancer specialist (oncologist) before your treatment plan is finalised.
The team looking after you will plan your treatment according to a number of factors, including
- 1. The type of ovarian cancer you have
- 2. Whether cancer has spread (the stage)
- 3. What the cells look like under the microscope (the grade)
- 4. Your general health
Your doctor may not be able to tell you exactly what type or stage your cancer is until after your surgery. During the operation, your surgeon will examine the inside of your abdomen. They will take tissue samples (biopsies...see below about biopsies) to check whether cancer has spread.
Very early ovarian cancer
If you have a borderline ovarian tumour or a very early cancer (stage 1a) that is low grade, you may only need to have the affected ovary and fallopian tube removed. As the unaffected ovary and your womb are left behind, you may still be able to have children in the future. Your surgeon will take biopsies from several areas within your abdomen and pelvis during surgery to fully stage your cancer. If there are cancer cells in any of these samples, you may need another operation to remove the rest of cancer.
If you have had your menopause, or do not want to have any more children, your surgeon may advise that you have both ovaries and your womb took out. Women with a borderline tumour or very early cancer may not need any other treatment after surgery.
Early stage ovarian cancer
The aim of surgery for early-stage ovarian cancer (stage 1) is to remove cancer and fully stage the disease. Knowing the stage helps your doctor decide if you need treatment after surgery.
For most women with stage 1 ovarian cancer, you will have surgery to remove your:
- 1. Ovaries
- 2. Fallopian tubes
- 3. Womb (including the cervix)
After surgery, your doctor may suggest you have chemotherapy if there is a high risk of cancer coming back. For example, if you have stage 1c or a high grade (grade 3) cancer. This is known as adjuvant chemotherapy.
Advanced ovarian cancer
Stage 2, 3 and 4 ovarian cancers are classed as advanced. This means cancer has spread away from the ovary.
Some advanced cancers may be cured with surgery and chemotherapy. If your cancer can't be cured, the aim of treatment is to control cancer for as long as possible.
You may have surgery as the first treatment for your cancer. The surgeon removes as much of cancer as possible. This is called debulking. Whether you have surgery or not will depend on a number of factors, including:
- 1. Where cancer has spread to
- 2. Your general health
- 3. How quickly the cancer is growing
After you have recovered from surgery, you will have chemotherapy. If the surgeon was able to remove all your cancer, the aim of chemotherapy is to reduce the risk of cancer coming back. If the surgeon couldn't take out all cancer, then the aim of chemotherapy is to shrink cancer that has been left behind. Some women may then have further surgery.
From looking at the scans you had at diagnosis, your surgeon may decide in advance that it would not be possible to remove all cancer. In this case, you may have chemotherapy before surgery. This is to shrink cancer and make it easier to remove. Chemotherapy before surgery is called neoadjuvant (pronounced nee-oh-ad-joo-vent) or primary chemotherapy.
Scans during chemotherapy
With primary chemotherapy, you have a scan halfway through the course. If the cancer is shrinking, you will then have surgery. You may hear your surgeon call this interval debulking surgery or IDS. After the surgery, you have the rest of the course of chemotherapy.
For some advanced cancers, you may have a type of biological therapy called bevacizumab with chemotherapy. Women with gene changes called BRCA1 or BRCA2 may have a drug called olaparib if chemotherapy is no longer controlling their cancer.
If surgery isn't possible
If you have a very advanced cancer, it may not be possible for a surgeon to remove it. You may also not be well enough for a big operation. You can have chemotherapy to shrink cancer as much as possible and to slow it down. You may have radiotherapy to relieve symptoms, depending on where in the body cancer has spread.
Your doctor may suggest having treatment as part of a clinical trial. You can read about taking part in trials and how to find a clinical trial in our trials and research section.
Making decisions about treatment
You will need time to think about your options for treatment, and you will need support from your family as well as your doctor in making your decision.
Getting a second opinion
Some people feel they would like to get an opinion from a second doctor before they decide about their treatment. If a surgeon who specialises in women's cancer (gynaecological oncologist) is treating you, you should also get an opinion from a cancer specialist (oncologist) about whether you need chemotherapy. Most doctors are happy to refer you to another NHS specialist for a second opinion if you would find this helpful.
Note: A second opinion means just that. It does not mean that the second doctor will take over your care. Your treatment will usually still be managed by your original specialist. And if you want a second surgical opinion, you need to make sure that it is from someone who specialises in ovarian cancer surgery, and not a general gynaecologist.
Ovarian Cancer Prevention
Preventing ovarian cancer
There's currently no reliable screening test for ovarian cancer. However, there are a number of things that may help to prevent ovarian cancer.
Stopping ovulation and the contraceptive pill
Each time you ovulate, your ovaries are damaged by the egg as it breaks through the surface of the ovary and is released into your reproductive system.
The cells that make up the surface of your ovaries divide and multiply rapidly to repair the damage caused by the egg. It's this rapid cell growth that can occasionally go wrong and result in ovarian cancer.
Anything that stops the process of ovulation can help to minimise your chances of developing ovarian cancer. This includes:
- 1. Pregnancy and breastfeeding
- 2. Contraceptive pill
- 3. Hysterectomy surgery (removal of the ovaries)
Diet and lifestyle
Research into ovarian cancer has found that the condition may be linked to being overweight or obese. Losing weight through regular exercise and a healthy, balanced diet may help lower your risk of getting ovarian cancer. Aside from this, regular exercise and a healthy, low-fat diet are extremely beneficial to your overall health and can help to prevent all forms of cancer and heart disease.
Screening for ovarian cancer
At present, there's no screening method for ovarian cancer that is reliable enough to be used by all women in the UK. Clinical trials into this are continuing.
You may be eligible for screening if you're at high risk of developing the condition due to a strong family history, or if you've inherited a specific abnormal gene.
If you're at high risk, your GP can refer you to your local genetics service or family cancer clinic. You may be screened for ovarian cancer when you're over the age of 35, or when you're five years away from the age at which your youngest relative was diagnosed with the condition. From this point, you'll be screened again once a year.
The screening tests for ovarian cancer are the same as those routinely used to diagnose it. The tests are:
- 1. Blood test for higher-than-normal levels of CA125 (a protein produced by cancer cells)
- 2. Transvaginal ultrasound – where an ultrasound probe is inserted into your vagina so that the size and texture of your ovaries can be seen, as well as any ovarian cysts that may be present
The tests are used together to produce results that are as accurate as possible. However, as these screening methods are still in the process of being tested, there's no guarantee they'll identify every case of ovarian cancer.
A cervical screening test, previously known as a smear test, can't detect ovarian cancer.
What Is A Biopsy
A biopsy is a sample of tissue taken from the body in order to examine it more closely. A doctor should recommend a biopsy when an initial test suggests an area of tissue in the body isn't normal.
Doctors may call an area of abnormal tissue a lesion, a tumour, or a mass. These are general words used to emphasise the unknown nature of the tissue. The suspicious area may be noticed during a physical examination or internally on an imaging test.
Why Are Biopsies Done?
Biopsies are most often done to look for cancer. But biopsies can help identify many other conditions.
A biopsy might be recommended whenever there is an important medical question the biopsy could help answer. Here are just a few examples:
- A mammogram shows a lump or mass, indicating the possibility of breast cancer.
- A mole on the skin has changed shape recently and melanoma is possible.
- A person has chronic hepatitis and it's important to know if cirrhosis is present.
In some cases, a biopsy of normal-appearing tissue may be done. This can help check for cancer spread or rejection of a transplanted organ.
In most cases, a biopsy is done to diagnose a problem or to help determine the best therapy option.
Types of Biopsies
There are many different kinds of biopsies. Nearly all of them involve using a sharp tool to remove a small amount of tissue. If the biopsy will be on the skin or other sensitive areas, numbing medicine is applied first.
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