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OVARIAN CANCER
(1999)

• The ovaries - A vulnerable lifesource
• An elusive enemy
• Stages of ovarian cancer
• Ovarian cancer treatment
• Genetic risk factors
• Environmental and lifestyle factors

In her book, “It’s Always Something” (Avon 1990), comedienne Gilda Radner wrote a poem about her struggle with ovarian cancer that began: “My body turned a cold back on me, at less than forty-three/It started a war/whatever for/in the middle of the middle of my life.” Since Radner’s death in 1989, progress has been made in detecting and treating ovarian cancer, but it remains a deadly adversary.

If ovarian cancer is detected at an early stage, five-year survival rates approach 90 percent. Unfortunately, because the disease is so difficult to detect, only 24 percent of ovarian cancers are found before tumor growth has spread into tissues and organs beyond the ovaries.
The ovaries - A vulnerable lifesource
Women have two ovaries, each about the size of an almond. They are located about 4 or 5 inches below the waist, midway in the pelvic cavity, one on each side of the uterus. The ovaries produce eggs (ova) as well as the female sex hormones, estrogen and progesterone.

When ovarian cells grow in an uncontrolled, abnormal manner, tumors result. Although some tumors are benign, some are cancerous.
The majority of ovarian cancers develop in the epithelium, the thin layer of tissue that covers the ovaries. These are called epithelial tumors. Other types of ovarian cancer include germ cell tumors, which occur in egg-producing cells, and stromal tumors, which occur in the tissue that holds the ovary together and produces estrogen and progesterone.
Ovarian cancer affects about 25,000 women in the United States each year, and more than 14,000 women die of the disease annually. While most cases are diagnosed in women over age 50, it can affect younger women.
In its early stages, ovarian cancer produces few if any symptoms. As the tumor progresses and enlarges, it may exert pressure on the bowel, bladder and other organs in the abdominal cavity, producing vague symptoms that are easily confused with other conditions. The following symptoms, if persistent, may indicate ovarian cancer:
• Abdominal swelling
• Abdominal pain
• Bloating
• Indigestion, gas or nausea
• A feeling of pressure in the pelvis
• Unexplained changes in bowel habits
• Unexplained weight loss or gain
• A feeling of fullness, even after a small meal
An elusive enemy
Although there is currently no “gold standard” screening test that reliably detects ovarian cancer, some procedures may help identify the disease.
Pelvic exams, in which a physician examines the vagina, rectum and lower abdomen for masses or growths, may detect ovarian enlargement that may be associated with ovarian cancer.
The CA 125 blood test also can be helpful in detecting ovarian cancer. CA 125 is a protein antigen that is found at abnormally high levels in the blood serum of many people with cancer. Most healthy people have CA 125 levels below 35 U/ml (units per milliliter) of blood serum.
“The CA 125 test is helpful, but not perfect,” says Mary M. Gallenberg, M.D., a gynecologist at Mayo Clinic in Rochester, Minn. “A number of noncancerous conditions can cause elevated CA 125 levels, and some people with ovarian cancer never have an elevated CA 125.”
Stages of ovarian cancer
When the pelvic examination or tests suggest ovarian cancer, surgery is required to confirm the diagnosis. In a surgical procedure called a laparotomy, a surgeon explores the abdominal cavity to determine if cancer is present. If a cancer diagnosis is confirmed, the surgeon and a pathologist determine the type of tumor and whether the cancer has spread, which determines the stage of the disease.
Ovarian cancer is staged from I-IV (1-4), or earliest to most advanced disease:
• Stage I ovarian cancer is confined to one or both of the ovaries.
• Stage II ovarian cancer has spread to other locations in the pelvis, such as the uterus or fallopian tubes.
• Stage III ovarian cancer has spread to the lining of the abdomen (peritoneum) or to the lymph nodes.
• Stage IV ovarian cancer has spread to the liver, or to organs beyond the abdomen.
Ovarian cancer treatment
Ovarian cancer treatment usually involves a combination of surgery and chemotherapy. Occasionally, radiation is also used.
If cancer is diagnosed during the laparotomy, the surgeon will generally perform definitive surgical treatment at that time. Usually, this surgery will involve removing the ovaries, uterus, fallopian tubes, nearby lymph glands and a fold of fatty tissue called the omentum.
During this procedure, surgeons will also remove as much cancer as possible from the abdomen. Ideally, less than an inch (about 1 cm) total of tumor matter will remain in the abdominal cavity after surgery. This is called “optimal debulking,” and it is associated with superior response to chemotherapy treatment and improved overall survival rates.
After surgery, most women with ovarian cancer are treated with chemotherapy. New combinations of chemotherapy drugs have demonstrated improved survival rates in recent years. “For years, the standard treatment for ovarian cancer was a combination of two chemotherapy drugs, cisplatin and cyclophosphamide.
Genetic risk factors
About 7 percent of ovarian cancer cases are linked to a genetic predisposition for the disease. Researchers have identified certain genes that, when mutated, increase a woman’s risk for ovarian cancer. Women who have a BRCA1 (short for BReast CAncer 1) gene mutation have up to an 80 percent increased lifetime risk for breast cancer, and a 40 percent to 60 percent increased lifetime risk for ovarian cancer.
Tests are available to determine whether someone has a BRCA1 mutation. Current recommendations from the National Institutes of Health (NIH) for women with a BRCA1 gene mutation include regular CA 125 testing, pelvic exams, and pelvic ultrasounds until age 35 or until childbearing is completed. At that time, NIH recommends a procedure called a prophylactic oophorectomy, in which both ovaries are removed to reduce cancer risk.
Research indicates that prophylactic oophorectomy reduces, but doesn’t totally eliminate, ovarian cancer risk. The procedure is controversial, because it induces early menopause and may have a substantial negative impact on a woman’s quality of life.
Environmental and lifestyle factors
Only a small percentage of ovarian cancer cases are due to inherited gene mutations. Environmental causes likely play a role, but evidence about suspected risk factors is inconclusive. For example, a number of studies have reported a link between the use of fertility drugs and ovarian cancer, but results of recent, large-scale studies have disputed that evidence.
For years, use of talcum powder was thought to increase ovarian cancer risk. While a link between talcum powder and ovarian cancer has not been proven, the issue remains controversial.
A handful of factors, including the long-term use of oral contraceptives, having children, breast feeding, and undergoing a hysterectomy, have been proven to reduce the risk of ovarian cancer. However, the most important steps you can take to reduce your risk are to have yearly pelvic exams and Pap smears, and discuss any concerns or unusual symptoms with your physician.