Ovarian Cancer: The Basics

How is ovarian cancer diagnosed and staged?

The most common reason for a physician to suspect ovarian cancer is if he/she feels a mass during a pelvic examination. When a pelvic mass is found in either a postmenopausal woman, or a girl who has not yet begun menstruating, then they will need to undergo surgery to make the final diagnosis. Chances are very high that a pelvic mass in a young girl or teenager who hasn't begun menstruating is a cancer (usually a germ cell ovarian cancer). However, only 5% of masses felt on pelvic exam in menstruating women are malignancies, and certain characteristics of the mass make it more or less likely to be a cancer. For example, if the mass is solid, irregular or fixed, it is more likely to be a cancer. Often, if you are a menstruating woman, your physician will have the mass further characterized by transvaginal ultrasound. If the mass is small, has holes (is cystic), is in only one ovary, is freely movable, and has regular contours, then it is unlikely to be a cancer. Masses with these qualities can be followed by clinical exam because there is a good chance that they represent ovarian cysts and will disappear on their own. However, if these masses persist or enlarge, then they need to be surgically explored. Women with a pelvic mass and an increased CA-125 level will go straight to surgery, and women with a pelvic mass and other symptoms suggestive of cancer (like having fluid collect in their abdomen) may also go directly to surgery.

Ovarian cancer is a type of cancer that needs to be diagnosed and staged during a surgery. Often, the cancer is diagnosed and treated during the same procedure. Surgeries for ovarian cancer diagnosis and treatment should be done by a surgeon specialized in gynecologic malignancies. Surgery is done so that samples of the mass and surrounding tissue can be biopsied and analyzed. A biopsy is the only way to know for sure if you have cancer, because it allows your doctors to get cells that can be examined under a microscope. Once the tissue is removed, a doctor called a pathologist will review the specimen. The pathologist can tell if it is cancer or not; and if it is cancerous, the pathologist will characterize it by what type of tissue it arose from and what subtype of ovarian cancer it is, how abnormal it looks (called the grade), and whether or not it is invading surrounding tissues.

In order to guide treatment and offer some insight into prognosis, ovarian cancer is staged into four different groups at the time of the surgery. Surgeons who specialize in gynecologic malignancies go through a careful inspection and sampling of a woman's pelvis during this procedure, and biopsy specimens are sent to a pathologist for immediate examination while the surgeon is still working. The staging system used for ovarian cancer is the FIGO system (International Federation of Gynecologists and Obstetricians). The staging system is somewhat complex, but here is a simplified version of it:

Stage I ovarian cancer confined to the ovary or ovaries

Stage II ovarian cancer that has spread beyond the ovaries, but is confined to the pelvis (can be in the uterus, bladder or rectum)

Stage III ovarian cancer that has spread to the peritoneum (the lining of the abdomen) and/or lymph nodes

Stage IV ovarian cancer that has distant spread (metastasis) to other organs

Generally, the higher the stage, the more serious the cancer. Although surgery is required for staging, your physicians may want to order some other tests to better characterize the mass/masses and look for distant spread. Tests like CT scans or MRIs (like a CT scan but done with magnets) can examine the pelvis and localized lymph nodes. Some patients with bony pain are referred for a bone scan, which is a test using a radioactive tracer to look for metastasis to any of the bones. You may also undergo a colonoscopy, which uses a lighted scope to examine your rectum and colon, or a barium enema in which dye is inserted into your rectum and an x-ray is taken. These tests are to look for spread of the tumor to your colon. Each patient unique, so the specific tests people get will vary; but overall, your doctors want to know as much about your particular tumor as possible so that they can plan the best available treatments.

What are the treatments for ovarian cancer?

Surgery

Almost all women with ovarian cancer will have some type of surgery in the course of their treatment. The purpose of surgery is first to diagnose and stage the cancer, and then to remove as much of the cancer as possible. In early stage cancers (stage I and II), surgeons can often remove all of the visible cancer. Generally, women with ovarian cancer will have a hysterectomy (removal of the uterus) and bilateral salpingo-ooporectomy (removal of both ovaries and fallopian tubes) as part of their operation. This is because there is always a risk of microscopic disease in both of the ovaries and the uterus. The only circumstance in which a woman may not have this entire operation is if she has a very early stage cancer (IA) that looks favorable under the microscope (grade 1). This is often the case with germ cell ovarian tumors. If a woman's tumor has these characteristics and she desires to maintain the ability to have children, then the surgeons can remove only her diseased ovary and tube. Then after she is done having children, she will need to have her uterus and the other tube and ovary removed. With any other stage or grade of tumor, or in patients finished with childbearing, the entire operation should be performed in order to provide the best possible chance for a cure.

Women who have more advanced disease (stage III or IV) will often have debulking surgeries, which means that their surgeon will attempt to remove as much disease as possible. Data collected in many studies has demonstrated that the more tumor that it debulked, the better the long term outcome for the patient. Sometimes ovarian cancer is diffusely spread throughout the entire pelvis and abdomen, and it can take a surgeon quite some time to get it adequately debulked.

Operations for ovarian cancer should be performed by surgeons who are trained in dealing with gynecologic malignancies because there are special skills and techniques necessary to deal with these tumors. Studies have shown better outcomes and survival for patients operated on by a certified gynecologic oncologist. Sometimes, a patient will have debulking surgery and then later the cancer will come back. It may be useful to debulk the tumor a second time, particularly if it has been at least a year between the initial surgery and the recurrence. In patients with very advanced ovarian cancer, surgery may be used for palliation, meaning that patients are operated on with the intent of easing their pain or symptoms, rather than trying to cure their disease.

Another way that surgery is occasionally used in ovarian cancer is to closely monitor a patient for signs of recurrent disease. This is called a second look surgery, and can be done with an abdominal incision (a laparotomy) or using fiberoptic scopes and long, narrow tools which allow surgeons to operate less invasively (laparoscopically). This used to be a very common procedure, but studies failed to show a strong benefit from performing second look surgeries. Therefore, this procedure should only be done in the context of a clinical trial.

Chemotherapy

Despite the fact that the tumors are removed during surgery, there is always a risk of recurrence because there may be microscopic cancer cells left that the surgeon cannot remove. In order to decrease a patient's risk of recurrence, they are offered chemotherapy. Chemotherapy is the use of anti-cancer drugs that go throughout the entire body. The vast majority of patients with ovarian cancer should be offered chemotherapy after their surgery. The higher the stage of cancer you have, the more important it is that you receive chemotherapy. Generally, only very early stage cancers (early stage I) that look favorable under the microscope (grade 1 or 2) can be treated with surgery alone. Any woman with a more advanced stage or grade cancer should be offered chemotherapy.

There are many different chemotherapy drugs available, and treatments often combine several drugs to create a regimen. For the treatment of ovarian cancers, chemotherapy is typically given intravenously (into a vein) or directly into the abdomen (intraperitoneal) and is given in a clinic or hospital. The most common combination currently used for epithelial ovarian cancer is paclitaxel plus either cisplatin or carboplatin (platinum containing drugs), given intravenously. There are other drugs that can be used, like gemcitabine and doxorubicin, and sometimes new combinations are tried if there isn't a response to the original combination. There are advantages and disadvantages to each of the different regimens that your medical oncologist will discuss with you. Based on your own health, your personal values and wishes, and side effects you may wish to avoid, you can work with your doctors to come up with the best regimen for your cancer and your lifestyle.

Another way to administer chemotherapy for ovarian cancer is to give it directly into the abdomen, allow it to remain in the abdomen for several hours, and then drain the fluid from the abdomen. This method is called intraperitoneal chemotherapy and is becoming more common given the positive results seen in studies. Several large studies have shown significant survival advantages for women with good surgical debulking followed by intraperitoneal chemotherapy given with or without intravenous chemotherapy. Concerns over quality of life, technical difficulty of the procedure and lack of reimbursement for the procedure have limited the widespread use of IP therapy.

Radiotherapy

Ovarian cancer does not commonly receive radiation therapy in the United States. Radiation therapy uses high energy rays (similar to x-rays) to kill cancer cells. It comes from an external source, and it requires patients to come in 5 days a week for up to 6-8 weeks to a radiation therapy treatment center. The treatment takes just a few minutes, and it is painless. Radiation therapy is occasionally combined with surgery in patients with stage II tumors with low bulk disease. Radiation can also be used to ease the pain of metastases and/or to stop tumors from bleeding. Generally, doctors try to limit the amount of radiation that your vital organs receive, and don't like to treat large portions of the bowel and pelvis. This makes radiation less useful in ovarian cancer, where disease is often diffusely spread throughout the abdomen and pelvis. A radiation oncologist can answer questions about the utility, process, and side effects of radiation therapy in your particular case.

Follow-up testing

Once a patient has been treated for ovarian cancer, they need to be closely followed for a recurrence. At first, you will have follow-up visits fairly often. The longer you are free of disease, the less often you will have to go for checkups. Your doctor will tell you when he or she wants follow-up visits, CA-125 levels, pelvic ultrasounds and/or CT scans depending on your case. Your doctors will also perform pelvic examinations during each of your office visits. It is very important that you let your doctor know about any symptoms you are experiencing and that you keep all of your follow-up appointments.

Clinical trials are extremely important in furthering our knowledge of this disease. It is though clinical trials that we know what we do today and many exciting new therapies are currently being tested. Some of the areas being studied include new screening tests, vaccine therapies derived from a patient's tumor cells and new chemotherapy and biologic therapies. Talk to your doctor about participating in clinical trials in your area or visit OncoLink's clinical trials matching system to learn about current trials.

This article is meant to give you a better understanding of ovarian cancer. Use this knowledge when meeting with your physician, making treatment decisions, and continuing your search for information. You can learn more about ovarian cancer on OncoLink through the related links to the left.

New patients may find our New Patient Guide helpful. Also, visit the National Comprehensive Cancer Network for an interactive guide to standards of care for all types of cancer.

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