Ovarian Cancer

Overview

Ovarian cancer is often called the "silent killer." Like pancreatic, liver and stomach cancer, ovarian cancer rarely announces itself in its early stages, which is why the overall five-year survival rate is just 47.4%. With early diagnosis, the five-year survival rate is 92% — but only 15% of women get diagnosed before the disease has spread.

In its report, "Cancer Facts & Figures 2020," the American Cancer Society estimated 21,750 women would be diagnosed with ovarian cancer, and approximately 13,940 women would die from the disease in 2020. This makes ovarian cancer the fifth-leading cause of cancer-related death in women. Overall, one in every 78 women in the United States will develop ovarian cancer in her lifetime.

The good news is that the number of women who develop ovarian cancer, and the number who die from the disease, has been falling since the 1980s, likely because of a greater use of oral contraceptives, which studies find can reduce the risk of ovarian cancer by 50% when used for five or more years.

There are three main types of ovarian cancer: epithelial, germ cell and sex cord stromal. Epithelial, which begins in the outer surface of the ovary, is most common, accounting for between 85% to 90% of ovarian cancers.

Symptoms

Symptoms of ovarian cancer are vague and can often be mistaken for other conditions, especially in the early stages of disease. They include:

• Bloating
• Pelvic or abdominal pain
• Feeling full quickly or having difficulty eating
• Urinary urgency or frequency
• Back pain
• Fatigue
• Pain during sex
• Constipation or upset stomach
• Changes in a woman's period

If you experience these symptoms more than 12 times a month, see your healthcare provider.

Risk Factors

The risk of developing ovarian cancer increases with age. Most women are diagnosed after menopause, with half of all ovarian cancers occurring in women 63 years of age or older.

An important risk factor for ovarian cancer is family history. If your mother, sister or daughter has (or has had) ovarian cancer, you have an increased risk. A family history of breast or colorectal cancer also can increase your risk due to mutations (changes) in the so-called "breast cancer genes," BRCA1 or BRCA2. Up to 25% of ovarian cancers result from gene mutations. These genes normally help prevent cancer by making a protein that prevents cells from rapidly multiplying. But defects in the gene allow cells to divide very rapidly, increasing the risk of "mistakes" that can lead to cancer.

Women may also have their tumors tested to see if any mismatch repair genes (MMR) or other gene changes are present. Mutations in the MMR gene are associated with increased risk of ovarian cancer. Changes in these genes are often seen in people with Lynch Syndrome.

The overall lifetime risk of ovarian cancer is 1.2%.

• Women with the BRCA1 mutation have a lifetime risk of ovarian cancer between 39% and 46% by age 70.
• Women with the BRCA2 mutation have a lifetime risk of ovarian cancer between 10% and 28% by age 70.

Other risk factors include having obesity; having had a late pregnancy, fertility treatment, or hormonal therapy after menopause; having a personal history of breast cancer; and smoking.

Screening

There are no specific recommendations for ovarian cancer screening. The United States Preventive Services Task Force has stated that populationwide screening can cause more harm than good. There are dangers associated with unnecessary surgeries, for instance, and no major studies have shown that large-scale screening reduces the risk of death from ovarian cancer, unlike with breast cancer.

However, women at high risk of ovarian cancer (those with a strong family history of the cancer and/or genetic mutations) should talk to their healthcare provider about getting screenings and pelvic exams; a blood test to check for levels of a protein called CA-125, which can be a marker for ovarian cancer; and a transvaginal ultrasound.

Diagnosis

If you have symptoms of ovarian cancer, your healthcare provider may perform a pelvic exam, along with other tests, including an abdominal or transvaginal ultrasound and CT scan. If cancer is suspected, you'll then receive a biopsy, where the surgeon uses ultrasound to guide a needle into the suspicious area and remove a tissue sample. The sample is then examined and used to confirm the diagnosis and determine the cancer stage. Other tests after diagnosis may include X-rays, PET scans and MRIs to see if the cancer has spread.

If you are diagnosed with ovarian cancer, you should seek treatment from a gynecologic oncologist, a surgeon with specialized training in cancers of the reproductive tract. You can find one through the Foundation for Women's Cancer.

There are four different stages of ovarian cancer, determined by what is found during surgery:

• Stage 1: Cancer is found in one or both of the ovaries but has not spread.
• Stage 2: Cancer is found in one or both ovaries and has spread to other areas within the pelvis.
• Stage 3: Cancer is found in one or both ovaries and has spread to the lymph nodes, other organs within the pelvis, the surface of the liver or the lining of the abdomen.
• Stage 4: This is the most advanced stage. Cancer is found in one or both ovaries and has spread outside the abdominal cavity to distant organs such as the lungs, the inside of the liver or the lymph nodes in the groin, or there are cancer cells in the fluid around the lungs.

Treatment

Surgery

Treatment for ovarian cancer depends on the cancer stage and the type of cancer.

Typically, surgery is the first step with the goal of removing as much of the tumor as possible, called debulking.

The type of surgery depends on the stage of the disease. If you have early-stage disease, the doctor may only have to remove one ovary and one fallopian tube. This is particularly important if you still want to have children.

Later-stage disease can require removing both ovaries and fallopian tubes, as well as the uterus, the fatty lining of the abdominal cavity and surrounding tissue. This procedure will affect your ability to become pregnant.

The surgeon will also check your lymph nodes (small organs that fight infection and disease) for signs of disease and may take tissue samples from other places in the abdominal cavity to check for cancer cells.

Chemotherapy

Because most women are diagnosed after the disease has spread, chemotherapy is typically used following surgery. Chemotherapy for ovarian cancer usually consists of a combination of two or more drugs given through an IV every three to four weeks. The standard of care for ovarian cancer is treatment with the platinum-based drugs paclitaxel and carboplatin, with or without bevacizumab. Bevacizumab is an anti-angiogenesis drug, meaning it prevents blood vessels from feeding the tumor, which keeps it from growing as quickly.

Some women with more advanced disease will undergo chemotherapy that is delivered directly into the abdomen (called intraperitoneal chemotherapy).

How often you receive treatment and how long treatment continues varies depending on your tumor, although chemotherapy is typically given for three to six cycles.

All chemotherapies have side effects, which can include varying degrees of hair loss, nausea, fatigue, diarrhea and muscle pain, among others. Some treatments used for ovarian cancer can affect your body's ability to make certain immune cells, putting you at risk for infection, or to make enough red blood cells, putting you at risk for anemia.

All side effects depend on which drugs are given, the dosage and your individual response. Luckily, side effects today are not as severe as they used to be because we have better drugs, improved treatment regimens, and medications to prevent side effects like nausea. If you receive chemotherapy, it's important to tell your healthcare provider about any reactions or side effects you have so they can adjust treatments to help you feel better.

After Chemotherapy

Ideally, chemotherapy puts you into remission, meaning there is no sign of the cancer. To maintain remission, your doctor may recommend regular infusions of bevacizumab or other types of treatment if you have a BRCA mutation.

After chemotherapy, there are four possible treatment responses.

• Complete remission means there are no signs of cancer remaining.
• Partial remission means there has been a reduction in tumor size, CA-125 levels or the extent of the cancer in your body.
• Stable disease means the cancer has not improved or worsened from the treatment.
• Progression means the cancer is continuing to spread throughout the body.

For women in complete or partial remission, drugs called PARP inhibitors can be used in combination with bevacizumab after the initial treatment with chemotherapy. These drugs can be used for women with or without a BRCA mutation.

Follow-Up Care

After your initial treatment ends, you'll need monitoring and regular visits to your cancer doctor. This typically involves regular blood tests — possibly including tests for tumor markers such as CA-125 — X-rays, ultrasound studies, symptom monitoring or, more rarely, a second-look surgery to make sure the cancer has not returned.

Because ovarian cancer is typically diagnosed in the later stages, only about 20% of patients remain disease-free after initial therapy. That means further treatment is required. Surgery is unlikely. It's more common to receive additional chemotherapy. The type of chemotherapy used at this point depends on whether your cancer still responds to the regimens you've had before.

For women with advanced ovarian cancer that has returned after earlier treatment, PARP inhibitors may be used.

Another option for recurrent ovarian cancer is radiation therapy. While radiation is not typically used as a first-line treatment and it won't cure the cancer, it can shrink the tumors and make you more comfortable.

Your doctor may recommend joining a clinical trial. There are numerous clinical trials offering new treatments for ovarian cancer or new combinations of existing treatments. Talk to your doctor about finding a clinical trial you qualify for. Your doctor may also recommend genetic counseling to discuss changes in genes and how those changes can run in families.

Risk Reduction

Ovarian cancer can't be prevented, but there are ways to reduce the risk. They include:

• Having both ovaries removed. This procedure, called an oophorectomy, is typically only used in women with genetic mutations like the BRCA1 or BRCA2. While it greatly reduces the risk of cancer, it doesn't entirely eliminate it. There is still a slight risk of primary peritoneal cancer, which occurs in the tissue that lines the abdomen and comes from the same cells that lead to ovarian cancer.
• Using oral contraceptives. Studies have found long-term use can reduce the risk by 30% to 50%.
• Having one or more children and breastfeeding. The more children you've had and the longer you've breastfed, the lower your risk. It is believed that this is because both reduce the number of times you ovulate (the release of eggs from your ovary), which reduces your exposure to estrogen.
• Having your tubes tied (called a tubal ligation). This is when your fallopian tubes are surgically tied to prevent pregnancy or are removed. This surgery reduces the risk of epithelial ovarian cancer, but doesn't entirely eliminate it, nor does it affect the risk of other less common types of ovarian cancer. One analysis found it reduced the risk by about one-third. This decision should be discussed with your healthcare provider.
• Avoiding the use of talcum powders in the genital area. Current research suggests a slight increased risk of ovarian cancer with use.

There is little evidence that a hysterectomy reduces your risk of ovarian cancer.

Questions to Ask

Review the following questions to ask about ovarian cancer so you're prepared to discuss this important health issue with your healthcare professional.

1. What are the symptoms of ovarian cancer?
2. If my family member has/had ovarian cancer, can I get any type of screening to determine my risk?
3. If my family member has/had breast cancer, am I at increased risk of ovarian cancer?

If you've been diagnosed with ovarian cancer:

1. What is the stage of my cancer and what does it mean?
2. What treatments do you recommend and why?
3. What risks are associated with those treatments?
4. Will I be able to work or will I need to be resting at home? For how long?
5. What should I do about diet and exercise while I'm getting treatments?
6. Will I be able to have children after my treatment?
7. If I go through all the treatments as you prescribe, what are the chances that the cancer will come back?
8. If the cancer returns, what do we do then?

Organizations and Support

For information and support on coping with Ovarian Cancer, please see the recommended organizations, books and Spanish-language resources listed below.

American Cancer Society (ACS)
Website: https://www.cancer.org
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
Phone: 404-315-1123

American College of Obstetricians and Gynecologists (ACOG)
Website: https://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Institute for Cancer Research
Website: https://www.aicr.org
Address: 1759 R Street, NW
Washington, DC 20009
Hotline: 1-800-843-8114
Phone: 202-328-7744
Email: aicrweb@aicr.org

Blanton-Davis Ovarian Cancer Research Program
Website: https://www.mdanderson.org/research/departments-labs-institutes/programs-centers/ovarian-cancer-research-program.html
Address: 1515 Holcombe Blvd.
Houston, TX 77030
Hotline: 1-800-392-1611
Phone: 713-792-6161

Cancer Care, Inc.
Website: https://www.cancercare.org
Address: 275 Seventh Ave., Floor 22
New York, NY 10001
Hotline: 1-800-813-HOPE (1-800-813-4673)
Phone: 212-712-8400
Email: info@cancercare.org

Cancer Information and Counseling Line (CICL)
Address: AMC Cancer Research Center
1600 Pierce Street
Denver, CO 80214
Hotline: 1-800-525-3777
Email: contactus@amc.org

Corporate Angel Network
Website: https://www.corpangelnetwork.org
Address: Westchester County Airport
One Loop Road
White Plains, NY 10604
Hotline: 1-866-328-1313
Phone: 914-328-1313
Email: info@corpangelnetwork.org

Foundation for Women's Cancer
Website: https://www.foundationforwomenscancer.org/
Address: 230 W. Monroe, Suite 710
Chicago, IL 60606
Phone: 312-578-1439
Email: FWCinfo@sgo.org

National Cancer Institute (NCI)
Website: https://www.nci.nih.gov
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-4-CANCER (1-800-422-6237)
Phone: TTY: 1-800-332-8615

National Coalition for Cancer Survivorship (NCCS)
Website: https://canceradvocacy.org/
Address: 1010 Wayne Ave., Suite 770
Silver Spring, MD 20910
Hotline: 1-877-NCCS-YES (1-877-622-7937)
Phone: 301-650-9127
Email: info@canceradvocacy.org

National Ovarian Cancer Coalition (NOCC)
Website: https://www.ovarian.org
Address: 2501 Oak Lawn Avenue Suite 435
Dallas, TX 75219
Hotline: 1-888-OVARIAN (1-888-682-7426)
Phone: 214-273-4200
Email: nocc@ovarian.org

Ovarian Cancer Research Alliance
Website: https://ocrahope.org/
Address: 14 Pennsylvania Plaza, Suite 1400
New York, NY 10122
Phone: 212-268-1002

Prevent Cancer Foundation
Website: https://www.preventcancer.org
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
Hotline: 1-800-227-2732
Phone: 703-836-4412

Roswell Park Familial Ovarian Cancer Registry
Website: https://www.roswellpark.org
Address: Roswell Park Cancer Institute
Elm and Carlton Streets
Buffalo, NY 14263
Hotline: 1-800-ROSWELL (1-800-767-9355)
Email: https://www.roswellpark.org/contact

SHARE - Self-Help for Women with Breast or Ovarian Cancer
Website: https://www.sharecancersupport.org
Address: 1501 Broadway, Suite 704A
New York, NY 10036
Hotline: 1-866-891-2392
Phone: 212-719-0364

Support Connection - Breast and Ovarian Cancer Support
Website: https://www.supportconnection.org
Address: 360 Underhill Ave., 2nd Floor
Yorktown, NY 10598
Hotline: 1-800-532-4290
Phone: 914-962-6402
Email: info@supportconnection.org

Women's Cancer Resource Center
Website: https://www.wcrc.org
Address: 5741 Telegraph Avenue
Oakland, CA 94609
Hotline: 1-888-421-7900
Phone: 510-420-7900
Email: info@wcrc.org

Books

A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health
by William H. Parker and Rachel L. Parker

Cancer Schmancer
by Fran Drescher

Coming Out of Cancer: Writings from the Lesbian Cancer Epidemic
by Victoria A. Brownworth

Feather in My Wig - Ovarian Cancer: Cured Twelve Years & Still Going Strong!
by Barbara R. Van Billiard and Theodore C. Barton

February Light: A Love Letter to the Seasons During a Year of Cancer and Recovery
by Heather Remoff

Gilda's Disease: Sharing Personal Experiences and a Medical Perspective On Ovarian Cancer
by M. Steven Piver, M.D. and Gene Wilder

Intimacy After Cancer: A Woman's Guide
by Dr. Sally Kydd and Dana Rowett

No Time to Die: Living with Ovarian Cancer
by Liz Tilberis

Ovarian Cancer: Your Guide to Taking Control
by Sara Meeks

Spanish-language resources

Medline Plus: Ovarian Cancer
Website: https://www.nlm.nih.gov/medlineplus/spanish/ovariancancer.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

National Cancer Institute
Website: https://www.cancer.gov/espanol/tipos/ovario
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-422-6237 / (1-800-4-CANCER)