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Cancer, ovarian

 

The ovaries are a pair of small organs in the female reproductive system that contain and release an egg once a month. This is known as ovulation. Cancer of he ovary can spread to other parts of the reproductive system and the surrounding areas, including the womb (uterus), vagina and abdomen.

How common is ovarian cancer?

Cancer of the ovary affects over 315 women in Ireland each year. It is 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 had the menopause (usually over the age of 55), but 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 pain in the pelvis and lower stomach, persistent bloating and difficulty eating.

Types of ovarian cancer

There are several types of ovarian cancer. They include:

  • epithelial ovarian cancer, which affects the surface layers of the ovary; it is by far the most common type 
  • germ cell tumours, which originate in the cells that make the eggs
  • stromal tumours, which develops within the cells that hold the ovaries together

Epithelial ovarian cancer is by far the most common type of ovarian cancer. This information concentrates on epithelial ovarian cancer.

The exact cause of ovarian cancer is unknown, although a number of possible factors are thought to be involved, such as the number of eggs the ovaries release, and whether someone in your family has had ovarian cancer in the past. However, only one in 10 cases of ovarian cancer has a genetic link.

Outlook

Treatment for ovarian cancer usually involves a combination of surgery and chemotherapy.

There are methods of screening for ovarian cancer but, at the moment, they are not yet fully tested. They are only available for women who are at high risk of developing the disease due to a strong family history or inheritance of a particular faulty gene. Clinical trials are currently assessing the effectiveness of screening in high-risk women and in the general population.

A cervical screening test (which used to be called a smear test) cannot detect ovarian cancer.

As with most types of cancer, the outlook depends largely on how far the cancer has advanced by the time it is diagnosed and your age at diagnosis. Ninety per cent of women diagnosed with early stage one ovarian cancer will be alive in five years time (the five-year survival rate).

Abdomen
The abdomen is the part of the body between the chest and the hips.
Chemotherapy
Chemotherapy is the treatment of an illness or disease with a chemical substance. It is used, for example, in the treatment of cancer.
Genetic
Genetic is a term that refers to genes, the characteristics inherited from a family member.
Ovaries
Ovaries are the pair of reproductive organs that produce eggs and sex hormones in females.
Uterus
The uterus (or womb) is a hollow, pear-shaped organ in a woman where a baby grows during pregnancy.

The symptoms of ovarian cancer can be difficult to recognise, particularly in the early stages of the disease. They are often the same as the symptoms of other, less serious, conditions, such as irritable bowel syndrome (IBS) or pre-menstrual syndrome (PMS). However, three main symptoms are more frequent in women who are diagnosed with ovarian cancer.

The three symptoms are:

  • persistent pelvic and abdominal pain
  • increased abdominal size/persistent bloating (not bloating that comes and goes)
  • difficulty eating and feeling full quickly, or feeling nauseous

Other symptoms, such as back pain and needing to pass urine more urgently and frequently than normal, may be the result of other conditions in the pelvic area. They are probably not ovarian cancer, but may be present in some women with the disease.

If you have any of these symptoms, keep a symptom diary to see how many of these symptoms you have over a longer period. Bear in mind that ovarian cancer is rare in women under 40 years old. If you regularly have any of these symptoms, talk to your GP. It's unlikely that they are being caused by a serious problem, but it's best to be checked.

If you've already seen your GP and the symptoms continue or get worse, it is important to go back and explain this, as you know your body better than anyone.

 

Our bodies are made up of billions of tiny cells. Normally, cells grow and multiply in an orderly way. New cells are only made when and where they're needed. In cancer, this orderly process goes wrong and cells begin to grow and multiply out of control.

In ovarian cancer, cells in the ovary start to change and grow abnormally. If the cancer is not identified at an early stage, it can spread to nearby parts of the body, including other parts of the female reproductive system.

Several possible causes of ovarian cancer have been identified, along with risk factors that may make developing the condition more likely. Some of these risk factors cannot be changed, but there may be some that can. Although these factors may increase the risk of ovarian cancer, you can still get it even if none of them apply to you.

Possible causes and risk factors of ovarian cancer

Family history

If you have two or more close relatives (mother, sister or daughter) who developed ovarian cancer or breast cancer, you may be at higher risk of developing the condition.

If your relatives developed cancer before the age of 50, it may be the result of an inherited faulty gene. Faulty genes that have been linked to ovarian cancer include BRCA1 and BRCA2. They are also known to be linked to the development of breast cancer.

Having relatives with ovarian cancer does not mean you definitely have a faulty gene in the family: the cancer could have happened by chance. About one in 10 ovarian cancers are thought to be caused by a faulty gene.

You may be at high risk of having a faulty gene if you have:

  • One close relative (such as your mother, sister or daughter) diagnosed with ovarian cancer at any age, and at least two close relatives who have breast cancer. Your relatives with breast cancer should come from the same side of your family, and should have an average age of less than 50 years.
  • One close relative diagnosed with ovarian cancer at any age, and at least one close relative with breast cancer that was diagnosed under the age of 40. These relatives should come from the same side of your family.

If you are concerned that you may be at higher risk of ovarian cancer because of your family history, talk to your GP. If you are at high risk, your GP can refer you to a genetic counselling clinic. It is possible to test for the BRCA1 and BRCA2 genes.

Age

Your risk of ovarian cancer increases with age. Most cases of ovarian cancer occur after the menopause, in women who are over 65 years old.

Fertility and egg release

Every time an egg is released into the reproductive system, the surface of the ovary has to break to let it out. As the surface of your ovary is damaged during this process, it needs to be repaired. Every time this happens, there is a greater chance of abnormal cell growth during the repair.

This may be why the risk of ovarian cancer decreases if you take the contraceptive pill, or have multiple pregnancies or periods of breastfeeding, as during this time eggs will not be released. In contrast, some research has shown that there is an increased risk of ovarian cancer in women who have infertility treatment (as more eggs may be released because of the treatment). But other studies have found that this is not the case.

Hormone replacement therapy (HRT)

Women who take hormone replacement therapy (HRT) have been shown to have a small increased risk of ovarian cancer. However, if HRT is stopped, after five years the risk goes back down to the same risk as women who have never taken HRT.

Endometriosis

Endometriosis may increase your risk of ovarian cancer. Endometriosis is a condition where cells that usually line the womb grow elsewhere in the body. These endometrial cells behave as if they were in the womb, so the thickening and bleeding that usually happens during menstruation occurs in this other part of the body. But there is no way for this endometrial tissue to leave the body. It becomes trapped, leading to pain, swelling and bleeding in that area.

 

If you have any of the symptoms of ovarian cancer, it's important to see your GP as soon as possible.

Your GP will ask about your symptoms, your general health and whether there is a history of ovarian or breast cancer in your family. The GP may carry out a vaginal or internal examination to investigate your ovaries and womb. They may take some blood for testing.

Your GP may refer you to a specialist (a gynaecologist or gynaecological oncologist) at the hospital.

The specialist may carry out another internal examination. They will ask about your symptoms and general health. They may also do further tests to confirm the diagnosis of ovarian cancer, including a blood test and ultrasound.

Blood test (CA125)

You may have a blood test to look for a chemical called CA125 in the blood. This chemical is produced by some ovarian cancer cells and a raised level of CA125 in the blood may mean you have ovarian cancer.

However, a significant proportion of women with early stage ovarian cancers have a normal CA125 level. The chemical is also produced by other conditions and a raised level of CA125 does not definitely mean you have ovarian cancer.

Ultrasound

Ultrasound uses high frequency sound waves to produce an image of your ovaries. You may have an internal ultrasound (known as a transvaginal ultrasound), where the ultrasound probe is inserted into your vagina. Or you may have an external ultrasound, where the probe is put next to your stomach. The image produced can show the size and texture of your ovaries, as well as any cysts that may be present.

Further tests

If you've been diagnosed with ovarian cancer, you may have further tests to see how large the cancer is and whether it has spread. This is called staging.

These other tests may include:

  • Chest X-ray- this can see if your ovarian cancer has spread to your lungs or if it has caused a build-up of fluid around the lungs (called a pleural effusion).
  • CT scanor MRI scan - these imaging techniques are used to look for signs of cancer elsewhere in your chest, abdomen and pelvis.
  • Abdominal fluid aspiration -  if there is a build-up of fluid in your abdomen and it looks swollen, it could mean your ovarian cancer has spread. To find out, a thin needle is passed into your abdomen to take a sample of fluid to be tested for cancer cells. 
  • Laparoscopy - this small operation may be performed if the gynaecologist wants to take a better look at the ovaries. A thin viewing tube with a camera on the end (a laparoscope) is inserted through a small cut in your lower abdomen (stomach) in order to examine your ovaries. A small sample of tissue may be taken from your ovaries for testing (this is known as a biopsy).

Staging helps your doctors to decide on the best kind of treatment for your condition. However, it is important to remember that the stage of your ovarian cancer alone cannot predict how your condition will progress.

Stages and grades of ovarian cancer

Staging

When your ovarian cancer is diagnosed, the doctors will give it a stage. This is often based on surgical findings. The stage describes the size of the cancer and how far it has spread. Ovarian cancer has four commonly used stages:

  • Stage 1: the cancer only affects one or both of the ovaries.
  • Stage 2: the cancer has spread out from the ovary and into the pelvis or uterus.
  • Stage 3: the cancer has spread to the lining of the abdomen, the surface of the bowel and the lymph nodes in the pelvis.
  • Stage 4: the cancer has spread to other parts of the body.

This is a simplified guide: each stage is divided into further categories called A, B and C. If you're not sure what stage you have, ask your doctor.

Grading

The grade of cancer refers to the appearance of the cells under a microscope.

  • Low grade: the cells though abnormal, appear to be slow-growing.
  • Moderate grade: the cells look more abnormal than low-grade cells.
  • High grade: the cells look very abnormal and are likely to be fast-growing.

 

Surgery

Nearly all women who have ovarian cancer will require surgery. Sometimes, it is not possible to confirm the stage of the cancer until the surgery.

Your doctor will discuss with you what will happen during the surgery. The surgery will probably involve removing:

  • both ovaries and the fallopian tubes (called a bilateral salpingo-oophorectomy)
  • the uterus (called a total abdominal hysterectomy)
  • the omentum, a fatty layer of tissue within the abdomen (called an omenectomy)

The surgeon may also remove the lymph nodes from the pelvis and abdomen. They may also take samples of nearby tissue and send it to the laboratory to see if the cancer has spread.

If the cancer has spread, the surgeon will try to remove as much of it as possible. This is known as debulking surgery.

If the cancer is confined to one or both ovaries, you may only need to have the ovary or ovaries removed, leaving your uterus (womb) intact. This means you may still be able to carry a pregnancy. For most women, however, pregnancy is not an issue and the normal procedure is to remove both ovaries and the uterus.

You will probably be ready to go home three to seven days after your operation, but it can take many weeks to fully recover. After your operation you will be encouraged to start moving about as soon as possible. This is very important. Even if you have to stay in bed you must keep doing regular leg movements to help your circulation and prevent blood clots. A physiotherapist will show you exercises to help prevent complications.

When you go home, you will need to exercise gently to build up your strength and fitness. Walking and swimming are good exercises that are suitable for most people after treatment for ovarian cancer. Discuss with your doctor or physiotherapist which types of exercise would be suitable for you.

 

Chemotherapy

Chemotherapy involves using anti-cancer (cytotoxic) drugs to kill cancer cells. It is often given after surgery for ovarian cancer. In some cases, it can be given before surgery as it may help to shrink the tumour and make it easier to remove. This is called neo-adjuvant chemotherapy.

Several different drugs can be used in chemotherapy. Often, a combination is given. The choice of drug and how and when it is given depends on the stage of your cancer and how much it has spread. The most common treatment for ovarian cancer is a platinum-containing drug (carboplatin), which is used alone or in combination with another drug, paclitaxel.

Chemotherapy is usually given as an injection into the vein, but is sometimes given as tablets. Some studies have looked at giving chemotherapy directly into the abdomen, called intraperitoneal chemotherapy. This is not established routine practice in the UK at the moment, but it is being assessed in clinical trials.

Most often, you will have chemotherapy as an outpatient but sometimes you may need a short stay in hospital. It is usually given in cycles, with a period of treatment followed by a period of rest to allow the body to recover. Most women have six cycles of chemotherapy.

How will I know if the chemotherapy is working?

Over the course of your chemotherapy, you will have tests in order to monitor how the ovarian cancer is responding to treatment. The various ways in which this may be done are outlined below.

  • If you had higher than normal levels of the cancer chemical CA125 in your blood when you were diagnosed, you may have a series of blood tests to see whether the levels are falling.
  • If you had a tumour that was visible on a CT or ultrasound scan when you were diagnosed, you may have repeated scans to see whether it has shrunk.
  • You may have another small operation, known as 'second-look surgery', which is carried out in the same way as a laparoscopy (for more information, see ovarian cancer - diagnosis).

If, after your chemotherapy treatment, all of your tests are clear of cancer, you will be in remission. This means that the cancer is under control.

Side effects of chemotherapy

The main side effects of chemotherapy are caused by its influence on normal, healthy cells, such as immune cells. Side effects include:

  • infections
  • loss of appetite
  • nausea and vomiting
  • tiredness
  • hair loss
  • sore mouth

Many side effects can be prevented or controlled with medicines that your doctor can prescribe.

Chemotherapy for cancer that has come back

Ovarian cancer can come back (relapse) after treatment. If that happens, you may have another course of chemotherapy. This may be the same drugs again or a different combination of chemotherapy drugs. This is called second-line treatment. The choice of drugs will take into account what drugs were used in previous treatments, and the side effects and benefits of the drugs. Your doctor will discuss this with you.

 

Radiotherapy

Radiotherapy uses high energy X-rays. Like chemotherapy, it works by targeting rapidly growing cancer cells. Radiotherapy is not often used to treat ovarian cancer. But occasionally, the multidisciplinary team may recommend it for ovarian cancer treatment under very specific circumstances, such as treating pain and bleeding from a localised tumour mass.

 

Clinical trials

A great deal of progress has been made in ovarian cancer treatment. More women are living longer and having fewer side effects. These advances were discovered through clinical trials in which new drugs and combinations are compared with standard treatment.

All cancer trials in this country are subject to careful oversight to ensure that the trial is worthwhile and safely conducted. Indeed, participants in clinical trials often do better overall than in routine care.

If you are approached about taking part in a trial, you will be offered an information sheet. If you wish to take part, you will be asked to sign your consent. You are always free to refuse or withdraw from a clinical trial without it affecting your care.

 

Factors which may help to prevent ovarian cancer

Stopping ovulation and the contraceptive pill

Each time you ovulate, your ovaries are damaged by an egg breaking through and being released into your reproductive system. The cells that make up the surface of your ovaries divide and multiply rapidly in order to repair the damage caused by the egg. It is this rapid cell growth that can occasionally go wrong and result in ovarian cancer.

Therefore, anything that stops the process of ovulation can help to minimise your chances of developing ovarian cancer. Factors that stop ovulation temporarily or altogether include:

 

Diet and lifestyle

Research into ovarian cancer has found that the condition may be linked to being overweight or obese. Losing weight through exercise, and having a balanced diet, may help to lower your risk of ovarian cancer. Aside from this, it is known that 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 is no method of screening for ovarian cancer that is reliable enough to be used by all women. Clinical trials into this are continuing.

Women may be eligible for screening if they are at high risk of developing the disease because of a strong family history or they have inherited a particular abnormal gene.

If you are at high risk, your GP can refer you to your local genetics service or family cancer clinic. You may be screened for ovarian cancer once you are over the age of 35, or once you are five years away from the age at which your youngest relative was diagnosed with the condition. From this point, you will be screened again once a year.

The screening tests for ovarian cancer are the same as those that are routinely used to diagnose it. The tests are:

  • a blood test for higher-than-normal levels of CA125 (a chemical produced by cancer cells)
  • a transvaginal ultrasound, in which the ultrasound probe is inserted into your vagina to show the size and texture of your ovaries, as well as any cysts that may be present

The tests are used together in order to produce results that are as accurate as possible. However, as these screening methods are still in the process of being tested, they cannot guarantee that they will identify every case of ovarian cancer.

A cervical screening test (smear test) cannot detect ovarian cancer.

Recovery and follow up

Recovering from treatment

Many women with ovarian cancer have a hysterectomy. This is a major operation, and it takes around six to 12 weeks to recover from it. During this time you will have to avoid lifting things (e.g. children, heavy shopping bags) and doing heavy housework. You will not be able to drive for three to eight weeks after the operation. Most women need four to 12 weeks off work after a hysterectomy. The recovery time will depend on the type of surgery, whether or not post-operative problems developed, and what type of work you will return to.

If your ovaries have been removed and you have not already had the menopause, you will enter menopause after your treatment. You may decide to take hormone replacement therapy (HRT) to control your symptoms. There is no reason why you cannot take HRT after your ovarian cancer treatment. Your GP will be able to help you decide what's best for you.

Some of the treatments for ovarian cancer, particularly chemotherapy, can make you very tired. You may need to take a break from some of your normal activities for a while. Do not be afraid to ask for practical help from family and friends if you need it.

Practical help may be available from your local authority. Ask your doctor or nurse who to contact.

Follow-up after treatment

After your course of treatment has finished you will be invited for regular check-ups, usually every two to three months to begin with. At the check-up your doctor will examine you. They may do blood tests or scans to see how your cancer is responding to treatment.

Sex and relationships

Relationships with friends and family

Having cancer is not always easy to talk about, either for you or for your family and friends. You may sense that some people avoid you or feel awkward around you. Being open about how you feel and what your family and friends can do to help you may put them at ease. But don't feel shy about telling them you need some time to yourself, if you need it.

Your sex life

Ovarian cancer and its treatment can affect your sex life. This can happen in several ways:

  • Early menopause - if you have not already been through the menopause, removing the ovaries means you will have an early menopause. You are likely to have symptoms of the menopause, which can include vaginal dryness and loss of sexual desire. 
  • Not feeling like sex - it is common for women to lose interest in sex after treatment for ovarian cancer. Your treatment may leave you feeling very tired. You may feel shocked, confused or depressed about being diagnosed with cancer. You may also feel grief about the loss of your fertility. It is understandable that you may not feel like having sex while coping with all this. Try to share your feelings with your partner. If your sex problems are not getting better with time, speak to a counsellor or sex therapist.

Talk to others

If you have questions, your GP or nurse may be able to reassure you. Or you may find it helpful to talk to a trained counsellor, psychologist or specialist telephone helpline operator. Your GP surgery will have information on these. Some people find it helpful to talk to other people with ovarian cancer at a local support group or through an internet chatroom.

Dealing with dying

If you are told that nothing more can be done to treat your ovarian cancer, your care will focus on controlling your symptoms and helping you feel as comfortable as possible. This is called palliative care. Palliative care also includes psychological, social and spiritual support for you and your family or carers.


Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.