Ovarian Cancer

f all the cancers to which women are prey, this is the deadliest. By the time it's discovered in the majority of cases, odds of a cure have already dropped to little more than 1 in 10.

Fortunately, this kind of cancer is also quite rare. Your overall chances of developing it are 1 in 100—in contrast to a breast cancer rate of 1 in 9. Even if you're in the group at greatest risk—women in their 50s and 60s—the odds against you are still only 1 in 70. In a typical year, some 20,000 American women find out they have ovarian cancer, and more than 12,000 die from it.

Like all cancers, this one is most dangerous when discovered late. Hope of a cure in the most advanced stage is only 5 percent. On the other hand, there's much more reason for optimism if your doctor finds the disease early, when chances of a cure are 2 to 1 in your favor. The catch, however, is in finding it.

The Symptoms

One of the reasons ovarian cancer is so deadly is that it frequently doesn't have any symptoms in its earlier stages. To compound the problem, because the ovaries are located deep within the abdomen there's no way to do a self­examination on a regular basis, as you can with your breasts. And when the disease does produce symptoms, they can often be confusing, possible signaling many other conditions, or meaning nothing at all.

The most frequent symptoms are vague stomach discomfort, an expanded abdomen, or abnormal bleeding. But many women have these types of nonspecific symptoms throughout their lives and therefore don't bother telling their doctor. By the time you are troubled enough to see your doctor, or your doctor feels (palpates) an ovarian tumor during the course of a normal examination, the disease may have spread too far to stop.

Happily, even when your doctor does find an ovarian mass, it does not always mean cancer. In fact, the great majority of ovarian masses detected in premenopausal patients are benign and eventually disappear on their own. If you are over 50, an enlargement is considered potentially more serious—since the ovary shrinks during menopause, and ovarian cancer occurs more frequently in women in their 50s and 60s. Still, even masses found in postmenopausal women are often just benign cysts.

Who's at Greatest Risk

As with many cancers, doctors just don't know what exactly causes the growth of cancerous ovarian cells. Current theory is that a number of factors—some controllable, many not—may influence the development of ovarian cancer. One proposal suggests a link between the number of times a woman ovulates during her life and her risk of developing ovarian cancer: The more she has ovulated, the greater the risk.

Some researchers have noted that for 99.9 percent of the human history, women ovulated much less frequently than they do today, since so much time was spent in pregnancy and breast feeding. One expert has estimated that our remote ancestors might have had only about 50 menstrual cycles in an entire lifetime compared to more than 400 that the average American woman has today.

Whether this theory is true or not remains to be proven, but it may help explain why the following factors tend to increase the risk of ovarian cancer:

• Ovulation for more than 40 years
• Never being pregnant or having your first pregnancy after age 30
• Late menopause

The theory might also help explain why oral contraceptives, pregnancy, and breastfeeding appear to protect against ovarian cancer, since you don't ovulate when you are on the Pill, pregnant, or breastfeeding. In fact, one study showed that using oral contraceptives, even for just a few months, can markedly reduce the risk of ovarian cancer, with the protection lasting for years.

Other factors—unrelated to ovulation—that are thought to increase the risk of ovarian cancer include:

• A family history of ovarian or uterine cancer (especially mother or sister)
• Having had breast cancer or benign breast disease
• Having had colon or rectal cancer or polyps

A history of mumps infection before the start of menstruation and a diet high in animal fat may also play a role. Researchers have speculated that the use of talcum powder in the vaginal and anal area might increase the risk of ovarian cancer, perhaps because the powder can enter the reproductive tract and settle on the ovary, possibly causing irritation.

How the Disease is Diagnosed

If your doctor feels a mass that might indicate an enlarged ovary, he or she will usually send you for an ultrasound (sonogram) of the pelvic area. This is a painless diagnostic test that allows your doctor to see your internal reproductive organs by bouncing sound waves off of them. It is usually performed in the doctor's office. Generally, if a mass is small, and only one ovary is involved, the chances are very good that it is benign (non­cancerous). It may still require treatment (see chapter 9, “What You Need to Know About Ovarian Cysts”), but at least you will know it's not cancer.

A blood test called the CA­125 assay can also provide useful diagnostic information, especially in postmenopausal women. This test also measures a substance that can be associated with ovarian tumors. A higher level of this substance than is normal, coupled with an ultrasound that shows a significant mass, can lead your doctor to suggest that further exploration is needed. However, like many tests, the CA­125 assay can produce a false positive result, predicting that a cancer is present, when, in fact, the mass is benign.

If the ultrasound and blood tests suggest that a mass might be cancerous, your doctor will recommend a laparotomy (surgery done through the abdomen), in order to make a clear diagnosis.

Stages of Ovarian Cancer

If your doctor makes a diagnosis of ovarian cancer, he or she will categorize it as one of 4 stages of the disease. Stage I is the earliest stage in which only the ovaries are involved. About two­thirds of Stage I patients can look forward to a cure. In Stage II, the cancer will have spread from an ovary to other parts of the pelvis. As with most cancers, as the disease begins to spread, survival rates decrease. About half of those diagnosed with Stage II ovarian cancer will survive after treatment. The majority of cases are diagnosed at Stage III, at which point the disease involves the lymph nodes and/or other parts of the abdomen. About 13 percent of patients diagnosed with Stage III cancer are cured. The most advanced form is Stage IV which has a very low survival rate—only about 5 percent of those diagnosed with Stage IV ovarian cancer will survive for five years. The overall five­year survival of all patients with ovarian cancer, regardless of stage, is about 30 percent.

CANCER'S INSIDIOUS ATTACK ON THE OVARIES

Because ovarian cancer often develops without any troubling symptoms, your only warning could be discovery of an enlarged ovary during your annual physical exam. If your doctor does encounter a mass while checking your pelvic area, he or she will probably follow up with an ultrasound look at the internal organs, followed by a blood test for a tumor-related substance. Surgery may be needed if both tests suggest the possibility of cancer.

Kinds of Ovarian Tumors

Ovarian tumors tend to arise from three different kinds of ovarian tissue: About 85 percent grow from epithelial tissue, the kind of tissue that covers most internal and external surfaces of the body and its organs; about 10 percent from stromal cells, the cells that make up the connective tissue framework of an organ; and the remaining 5 percent come from germ cells (the egg cells and their precursors).

Tumors that grow from these kinds of cells can be benign, on the borderline between benign and malignant, or purely malignant. The ones that are malignant vary in their severity: Some spread quickly; others are easier to control.

Treatment Strategies

If you are diagnosed with ovarian cancer, your treatment will depend on the malignancy and stage of the tumor; in other words, what kind of tumor it is and how far it has spread.

Surgery

Surgery is almost always the first step in treating ovarian cancer because the cancerous tissue must be removed. If the cancer is confined to the ovary and has not spread to the lymph nodes or to other parts of the abdomen, your doctor will try to ensure that you'll still be able to have children, if you are of childbearing age. However, since ovarian cancer can spread rapidly, this is not always possible; your doctor's primary goal is to do what needs to be done to eradicate the cancer and prolong life. Even when an early stage cancer is confined to a single ovary, it is occasionally necessary to remove the other ovary and the uterus, if your doctor is concerned that the cancer will spread.

The primary operation for ovarian cancer is a laparotomy. This is considered major surgery in ovarian cancer patients, since the surgeon usually must make a vertical incision between the belly button and the pubic area in order to reach the cancerous tissue in the abdominal or pelvic area. A laparotomy should not be confused with a laparoscopy. The latter procedure requires only a small incision below the belly button, through which an instrument called a laparoscope is inserted. (For more on laparoscopy, see chapter 9.)

Since surgery for ovarian cancer is usually relatively extensive, you can expect to go under general anesthesia, in which you are completely unconscious, rather than get a regional or local anesthetic that would numb only the abdominal and pelvic areas.

The surgery is considered both diagnostic and therapeutic. In other words, your doctor will be looking to see how far the cancer has spread, and then will remove all signs of it. This is very important because the tumor that your doctor may have felt on the ovary or seen on the sonogram may have spread from the ovary to other parts of the body such as the uterus, the fallopian tubes, the intestines, and the lymph nodes.

After surgery, you will be brought to a recovery room, and then a hospital room. Not surprisingly, you can expect considerable pain during the following few days, but you will be given painkilling medication to control it. You can also expect to remain hooked up to an intravenous (IV) line for several days until your digestive system recovers enough for you to eat and properly digest solid food. If any part of the digestive system was removed, you will probably be on IV feeding for a longer period.

As with all surgery, the first few days afterward are the most critical. You will probably be monitored carefully for infection, blood clots, and internal bleeding, all of which tend to occur earlier rather than later in the postoperative period. You should expect to be in the hospital for about a week, if there are no complications, and to convalesce at home for several weeks. Once you are home, be sure to call your doctor if you have fever, persistent bleeding, pain that is not relieved by medication, or any other unexpected symptoms.

Chemotherapy and Radiation

Whether you receive chemotherapy and radiation depends on the stage and malignancy of the cancer and how your individual case is being managed. These forms of treatment are generally used after surgery to destroy any cancerous tissue that was too small to have been detected during the operation.

You are less likely to get chemotherapy or radiation if you have a Stage I cancer (limited to one or both ovaries). More advanced cancers are often treated by chemotherapy, radiotherapy, or both, after the initial surgery is finished.

Radiation treatment can be administered either by an external machine or by putting a solution containing a radioactive substance into the abdomen.

Chemotherapy—the use of potent anti­cancer drugs that are selectively toxic to malignant cells and tissue—is usually started 2 to 4 weeks after surgery. There are many different kinds of drugs, and they can be given individually or in various combinations. How you get chemotherapy will depend on which drugs your doctor decides to use, but usually treatment is given for 1 to 3 days at a time and repeated every 3 to 4 weeks. The entire treatment period may last several months.

Chemotherapy is usually given intravenously, but the medications are sometimes instilled (poured drop by drop) directly into the abdomen. This method of administration is thought to maximize contact between the drug and the cancerous tissue, although intravenous drugs seem to work just as well. Also, because drugs delivered directly to the abdomen don't enter your circulation first, which would affect the entire body, they may have fewer side effects than they do when they are taken orally or intravenously.

The most effective medications studied so far include cisplatin (Platinol), carboplatin (Paraplatin), doxorubicin (Adriamycin, Rubex), cyclophosphamide (Cytoxan, Neosar), melphalan (Alkeran), chlorambucil (Leukeran), and hexamethylmelamine. Chemotherapy drugs are very powerful and can have side effects ranging from severe nausea and fatigue to actually causing other kinds of cancer such as leukemia. If you need to undergo chemotherapy (for ovarian or any other type of cancer), talk with your doctor and be sure to obtain comprehensive counseling about what to expect and how to deal with it.

Second­Look Procedures

Although you will be monitored constantly during both chemotherapy and radiation, sometimes it is very difficult to tell if the surgery and follow­up treatment have eradicated all the cancer. As a result, you may undergo what is known as a “second­look laparotomy so that your doctor can see first­hand whether any cancer has slipped past the treatments. A negative (no apparent cancer) second­look operation is a good sign. Unfortunately, it is not a guarantee. The best judge of cure in ovarian cancer is time.

Beating the Odds

Because ovarian cancer gives so few warning signs, and because there's no way you can check for it yourself, your annual checkup is your best—and possibly your only—hope of discovering the disease while it's still easily curable. Make sure you get a thorough pelvic exam every year, complete with palpation of the ovaries. If you feel you have any reason for concern, don't hesitate to ask your doctor about a sonogram and the CA­125 assay. If you're lucky, you'll find they weren't needed at all.

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