Ovarian cancer ranks third among gynecological cancers, after breast cancer and uterine cancer, accounting for only about 4 percent of cancers among women. Each year approximately 23,000 women are diagnosed with ovarian cancer and 14,000 women die of it. Ever since the comedian Gilda Radner died of ovarian cancer in 1989, this disease has received a lot of media attention. It is not its frequency but its mortality rate that makes ovarian cancer so threatening.

Generally, ovarian cancer is discovered late. While most uterine and cervical cancer is discovered while women have stage I disease, about 70 percent of ovarian cancers do not show up until the disease has reached stage III. Women who develop cancer of the cervix or uterus tend to bleed unexpectedly and women with breast cancer often feel a lump or see a change in their breast. Screening tests — Pap smears and mammograms — often pick up these diseases in their very early stages. With ovarian cancer, women seldom have unexpected vaginal bleeding and usually do not feel a mass in their abdomen. But if ovarian cancer is discovered early, while it is still localized in the ovary, the cure rate is about 95 percent.

What are the warning signs of ovarian cancer?

The symptoms that send women to seek help are usually the signs of extended disease. Most common is a sense of abdominal fullness or bloating, caused not by the size of the abdominal mass, but from fluid collecting in the abdomen. Most women regularly feel fullness or bloating at some time of the month, which makes it difficult to diagnose ovarian cancer. So if you are more than 30 years old and have vague digestive symptoms (stomach discomfort, gas, distension) that persist and cannot be explained by another cause, talk to your gynecologist about the need for an evaluation for ovarian cancer.

Who Is At Risk For Ovarian Cancer?

Genes And Cancer

Scientists believe that the BRCAi and BRCA2 (or Breast Cancer 1 and 2) genes are responsible for nearly all cases of “inherited” ovarian cancer and approximately half of all cases of “inherited” breast cancer. In addition to determining such things as height and eye color, genes instruct the body in building proteins, the chemical substances that keep it in working order. Sometimes an error in a gene causes it not to do its job properly, and this genetic defect can lead to disease.

Can you lower your risk for ovarian cancer?

The factors that reduce risk for cervical cancer — postponing your first intercourse, limiting the number of sexual partners, and using condoms for protection — unfortunately will not help prevent ovarian cancer. However, using birth control pills may offer significant protection. Women on the pill are about 50 percent less likely to get the disease than comparable women who are not. This protective effect seems to last for a considerable time after a woman has stopped taking oral contraceptives. If you are anxious about getting ovarian cancer, talk to your doctor about taking birth control pills.

Women who have never been pregnant are more at risk than women who have had at least one child, although of course avoiding ovarian cancer is not in itself a valid reason to have a child. Breast-feeding also reduces risk. Researchers believe that the ovarian changes that eventually lead to cancer come about because of ovulation; by reducing the number of times you ovulate, you reduce the number of times these ovarian changes can take place. Pregnancy, breast-feeding, and oral contraceptives all block ovulation.

Family History

The Gilda Radner Familial Ovarian Cancer Registry at the Roswell Park Cancer Institute in Buffalo, New York, is a data bank of familial histories. (The hotline and Web site are given in the Resources section at the back of this book.) The head of the registry is Dr. Steven Piver, whose job it is to supply any information you may need. When I called him about Erin, he concurred in our decision, believing strongly that she was at such high risk that she should have her ovaries removed even though she was still a young woman.

Do women without a strong family history of ovarian cancer get the disease?

Yes, familial cases make up only a small percentage, somewhere between 5 and 10 percent, of women who get ovarian cancer. Fortunately, if you have just one relative who has had ovarian cancer, perhaps your mother, you are not at greatly increased risk. Your mother — or your cousin or sister — might be one of the many nonfamilial, sporadic cases that turn up, so you are not genetically at risk. If, on the other hand, you have several relatives who have had ovarian cancer, then you probably are at increased genetic risk. Sad to say, you are not home free just because you do not have a relative who has had ovarian cancer.

Do fertility drugs increase the risk for ovarian cancer?

Considerable controversy has erupted over whether fertility drugs, for example Clomid and Pergonal, increase the risk of ovarian cancer. Large-scale studies suggest that it is not the Clomid or Pergonal that increases the risk, but the fact that women who have never been pregnant are at higher risk.

All the same, some connection may exist between fertility drugs and ovarian cancer, because women who get the disease are women who have ovulated often. Women who have many children have lower risk of ovarian cancer because they did not ovulate during their pregnancies. As we have seen, birth control pills also limit the incidence of ovarian cancer. Therefore it is reasonable to assume that a medication that increases ovulation may increase later ovarian problems.

On the other hand, in order to become pregnant you do have to ovulate. Sometimes women tell me that they don’t want to take Clomid or Pergonal because they have heard that these drugs increase the risk of ovarian cancer; but they do want to get pregnant. They cannot have it both ways. They can take birth control pills, which reduce the risk of ovarian cancer but also reduce to nearly zero the chances of getting pregnant.

Are there ways to detect ovarian cancer early?

Are all ovarian tumors cancerous?

Definitely not. If your doctor says you have a mass on your ovary, chances are that it is not malignant. The overwhelming number of ovarian masses are benign, even in women as old as 60.

Are there different kinds of ovarian cancer?

Yes, there are almost forty different kinds, but a few predominate. The ovary is made up of three kinds of tissue: the epithelium, which is the capsule surrounding the ovary; the tissue of which the eggs themselves are composed; and the inner stromal tissue that supports the eggs.

About 85-90 percent of ovarian cancers are epithelial tumors, on the outside rim of the ovaries. The most common of these are called serous cyst adenocarcinomas. “Serous” means that the tumors contain fluid or serum. The “adeno” root indicates that the tumor arises in glandular tissue. Some cancerous tumors of the epithelium contain a jelly-like substance; these are called mucinous cyst adenocarcinomas. Both mucinous cyst adenocarcinomas and serous cyst adenocarcinomas can have solid material inside them.

Tumors of the inner structure of the ovary are called stromal tumors. These tumors can make hormones and may cause hormone-related problems. For example, tumors in the granulosa cells (that surround the eggs as they mature) produce estrogen. Women with such tumors may have vaginal bleeding, because they are producing very high levels of estrogen. Women who have a different type of stromal tumor that produces testosterone may notice problems of masculinization: excessive facial hair, acne, and aggressive behavior. These tumors are rare, but are occasionally seen in older women.

Tumors of the egg tissue itself are called germ cell tumors or egg tumors. The most common are cystic teratomas, also called dermoid cysts. They are very rarely cancerous and are most common in younger women. They can have almost any body tissue inside them, including hair, teeth, or cartilage. After all, the egg is a totipotent cell, able to make any kind of cell found in the body; it makes sense, therefore, that disordered egg cells can also make body tissues. Because the diseased egg cells are not fertilized, they are not “turned on” in the normal way. Indeed, scientists do not know what turns them on and makes them start dividing. These tumors used to be diagnosed by taking an x-ray and looking for teeth within the ovarian mass. Once I had a patient who had a whole palate in a cyst.

Can any tests determine without surgery whether an ovarian mass is cancerous?

Recently developed tests can differentiate fairly effectively between malignant and benign growths. The Doppler flow study measures the blood supply to the ovarian mass. If the mass has normal flow characteristics and no signs of increased blood flow (which indicates the presence of rapidly dividing cells), it almost always proves to be benign. The test sometimes shows false positives, whereby it indicates that an ovarian mass has increased blood flow, but the mass turns out not to be cancerous at all.

If a physician recommends ovarian surgery, is cancer the likely diagnosis?

While some physicians are beginning to rely more heavily on tests such as the Doppler, it is often difficult to tell with certainty whether a tumor is benign or malignant without resorting to surgery. The only absolutely sure diagnostic method is to remove the tumor or cyst and send it to a pathologist who can determine what is going on. If your doctor recommends surgery, there is still a very good chance that your condition is benign.

When one of my patients has to have ovarian surgery for diagnostic reasons, I do prepare her for the possibility of cancer, however. It is psychologically important to realize that the possibility exists, even though chances are that she does not have cancer.

The Stages of Ovarian Cancer

The stages of ovarian cancer are similar to those of uterine or cervical cancer. Stage I disease is confined to the ovaries. Stage II disease extends through the pelvis to the uterus and fallopian tubes. Stage III disease involves spread through the pelvis to more remote pelvic organs such as the omentum, the apron of fatty tissue that surrounds the intestines. Stage IV disease has spread beyond the pelvis to distant tissues, for example the lungs.

With endometrial or cervical cancer, the physician can often tell how far the cancer has advanced. Because the gynecologist has already done a D&C or taken a Pap smear, the extent of the disease may be fairly evident before any surgery. With ovarian cancer this is not the case. Not until the surgery is performed can the physician know the extent of the disease.

If your doctor recommends a bowel prep before surgery, does that mean she thinks you have cancer?

Because ovarian tumors can attach themselves to the intestines or other internal organs, I often recommend a bowel prep to clear out the bowel before diagnostic surgery. If someone’s tumor has adhered to her intestine, the surgeon may have to peel it off. For that reason it is advisable to have the bowel completely prepared. Very few people end up with a colostomy or removal of part of the intestine, even if they have ovarian cancer. Today for a bowel prep, most physicians recommend a liquid laxative such as citrate of magnesia or a preparation called Go Lightly. Occasionally a bowel prep will also include oral antibiotics.

What Is The Usual Surgery For Ovarian Cancer If A Woman Has Completed Her Family?

What is the surgical routine if a woman has not completed her childbearing?

Each woman must discuss her situation at length with her gynecologist. If at all possible, the surgeon will take out only the cancerous ovary, removing only what is absolutely necessary to cure the disease. If the patient has completed her childbearing, her options depend on the type of tumor. The gynecologist may recommend removing the remaining ovary and possibly the uterus and fallopian tubes, since her previous ovarian cancer places her in a higher risk category.

Sadly, there are times when the ovaries cannot be saved because the tumor has spread. All doctors who treat cancer would recommend removal of the cancerous tissue at the expense of childbearing.

Jane had a worrisome 10-cm ovarian mass, roughly the size of a large orange. Because there was no chance of saving the ovary that had been invaded by the tumor, the surgeon removed the ovary as well as the tumor. The tumor turned out to be not cancer but a cyst of endometriosis, which would have had to be removed in any case.

Unfortunately, Jane’s other ovary was missing. Although she was cured of her disease, she went on to sue the surgeon for making her infertile, though chances are that the large endometrial cyst kept the ovary from functioning and, considering the size of the cyst, there was no way to save the ovary. Jane testified under oath that she would rather have kept a cancerous ovary than be infertile. Despite the unrealistic nature of her allegation, the jury awarded her $375,000.

If the physician recommends chemotherapy, does it mean that he could not remove all the cancerous cells?

Many physicians recommend chemotherapy as a preventive step, even though they are quite certain that they got all the cancer and there is no evidence that the cancer has spread. In some cases the surgeon is unable to remove all the cancer. Chemotherapy may well be recommended in such a situation. It is worth knowing that chemotherapy often dissolves the remaining tumor and that there are recently developed chemotherapies to which ovarian cancer is extremely responsive. One of the reasons for ovarian cancer’s bad reputation is that in the past none of the available therapies worked.

Chemotherapy can still be difficult to endure and can have significant side effects. There is no way to prevent hair loss, although lost hair invariably grows back. The agents for chemotherapy are changing all the time, and there have been significant breakthroughs in nausea medications. A wonderful (and expensive) drug called ondansetron almost always prevents nausea in chemotherapy patients. Many health maintenance organizations will pay for its use.

What kind of follow-up is done after chemotherapy?

After several rounds of chemotherapy, perhaps six months to a year after the original operation, the physician may want a second look at the interior of the pelvis, to see whether the disease has completely cleared up.

There are two possibilities. Some physicians recommend a laparoscopy, the kind of procedure that is used when someone’s tubes are tied with the aid of a laparoscope. The physician makes a small incision, inserts a long tube with a light into the pelvic cavity, and looks around to see what is going on. The older standard procedure was a second-look laparotomy. The physician reopens the old incision and looks at the organs in the pelvis, taking biopsies to see whether any evidence of cancer remains. Even if the second-look operation does not reveal any cancer, the physician occasionally recommends several more rounds of chemotherapy to make sure that all the cancer is truly gone.

If the cancer is still present at the time of the second-look operation, then the physician will recommend more cycles of chemotherapy and perhaps a third-look operation. This may seem like heavy-duty therapy, but the reason for the second-look operation is that ovarian cancer is obscure and hard to track. The doctor wants to be certain that the disease is no longer present.

The surgery for a second look is apt to be much less intense than the original operation. With a hysterectomy, women should allow at least six weeks for recuperation; after a second-look procedure, women seem to be pursuing their normal activities in three or four weeks.

What kind of doctor should perform the pelvic surgery for women who have not finished their childbearing?

Over the past two decades, attitudes toward surgery and ovarian cancer have changed. Twenty years ago the standard recommendation was that if a woman had ovarian cancer, her ovaries, fallopian tubes, and uterus were removed — no exceptions. Physicians have become more open-minded and try to adapt their recommendations to the specific circumstances. If a woman wants to have children, often the surgery can be restricted to the diseased ovary with a very careful follow-up.

Many women who have had ovarian cancer do subsequently have children, even women who have had chemotherapy.

For this reason younger women should be particularly careful about who operates on a pelvic mass. The surgery is probably best performed by a gynecologist, not a general surgeon. In some parts of the United States general surgeons routinely do these operations, but they may not be as knowledgeable about the latest thinking on conserving ovarian function as gynecologists, who are specialists in this field.

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