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Contents
What is Cancer of
the Ovary?
Epithelial
Ovarian Cancer
Staging
Side Effects of
Treatment
Surgery
Chemotherapy
Nutrition for
Cancer Patients
Follow-up Care
Introduction The ovaries are a pair of female reproductive organs that are located in the pelvis. They sit either side of the uterus (womb), at the ends of the fallopian tubes and are usually about the size of an almond. The ovaries have two functions: one is to produce eggs and the other is to make female hormones. Each month during the menstrual cycle an egg matures in a cyst on one of the ovaries. This egg is released (ovulation) about 14 days before the next menstrual period is due. The egg is picked up by the end of one of the fallopian tubes and is carried to the uterus. If fertilisation occurs it happens in the tube. When the egg reaches the uterus and if it has been fertilised it will implant into the lining (endometrium) of the uterus. The ovaries are the main source of the female hormones oestrogen and progesterone. These hormones control the development of female body characteristics, such as breasts, body shape, body hair etc. They are also important in regulating and controlling the menstrual cycle. What is Cancer of the Ovary?Cancer of the ovary is a disease in which some of the cells of the ovary undergo changes and develop into cancer. The type of cancer depends on the cells from which the cancer arises. The most common type of ovarian cancer is that which arises from the surface cells of the ovary and which is called an epithelial ovarian cancer. The other ovarian cancers are as follows:
Epithelial Ovarian Cancer Most cases occur in women after the menopause, usually in their 60's or 70's. Unfortunately, the vast majority (70%) of women with ovarian epithelial cancer are diagnosed with advanced (stage III or stage IV) disease. In almost all cases early ovarian cancer is picked up as an incidental finding in someone who is having treatment for an unrelated problem. Cancer of the ovary tends not to produce many symptoms until the disease is advanced. When it does produce symptoms they are very non-specific and usually do not make the doctor think of ovarian cancer. Cancer of the ovary spreads over the surface of other organs in the pelvis and abdomen. Because it does not invade very deeply it continues to grow without producing symptoms. Eventually, because of irritation to the peritoneum, (the sac inside the abdomen which holds the intestines, uterus and ovaries), fluid accumulates called ascites. This causes swelling of the abdomen. If the pressure from the ascites pressing on the diaphragm is too great the person my feel short of breath. Fluid may also build up in the chest and make the shortness of breath worse. The risk of developing ovarian cancer is about 1% in a lifetime. Some women are at increased risk because they have relative(s) who have had this cancer. A woman with one affected close relative (mother, sister or daughter) has about a 5% lifetime risk of developing ovarian cancer. There are no accepted population screening tests for ovarian cancer. However, women who are at increased risk may be able to be assessed with respect to their risk by a gynaecological oncologist. Once cancer of the ovary is strongly suspected the patient should be referred to a Certified Gynaecological Oncologist. After some further tests an operation called a laparotomy will be performed in most cases. At this operation the surgeon will assess the spread of the cancer and will attempt to remove as much, if not all of the cancer. What is removed is sent to a pathologist for testing. The results will allow the doctor to stage the disease and plan any further treatment. The following stages are used for ovarian cancer: Stage I Cancer is limited to one or both ovaries. Stage II Cancer is found in one or both ovaries and/or has spread to other organs in the pelvis. Stage III Cancer is found in one or both ovaries and has spread outside the pelvis to other organs in the abdomen or to lymph nodes in the abdomen. Stage IV Cancer is found in one or both ovaries and has spread outside the abdomen or has spread to the inside of the liver. Recurrent Recurrent cancer is cancer that has come back (recurred) after it
was treated. Recurrent cancer is never re-staged. A patient
who originally had Stage I cancer who develops a recurrence, say in the lungs
some time later, does NOT then have Stage IV cancer; they have recurrent
metastatic Stage I cancer. How is Ovarian Cancer Treated? All cases of ovarian cancer can be treated. The following sets out the principle approaches to treatment.
Treatment usually starts with surgery. An operation aimed at giving adequate and complete surgical removal of as much of the cancer a possible. This allows accurate diagnosis and staging as well as preparing the patient/cancer for the next form of treatment. Such an operation generally involves a total hysterectomy (removal of the uterus and cervix), bilateral salpingo-oophorectomy (removal of both fallopian tubes and ovaries), omentectomy (removal of a fatty apron that hangs off part of the bowel) and sometimes removal of part of the bowel. The surgery is best performed by a Certified Gynaecological Oncologist (CGO), who is a gynaecologist who has had specialised training in managing gynaecological cancers. Following surgery most patients are then treated with chemotherapy. This is the use of drugs that can kill ovarian cancer cells. The first lot (cycle) of chemotherapy is usually given within a week of the surgery. The drug(s) are generally repeated every 3-4 weeks for six cycles. The drugs most commonly used are given by injection into a vein where they can travel through the body and kill cancer cells outside the ovaries. Chemotherapy can also be given directly into the abdomen or peritoneal cavity. The side effects of cancer treatment vary, depending on the type of treatment. Also, each woman reacts differently and recovers at a different rate. Doctors try to minimise the side effects of the treatment they give but sometimes problems may occur. SurgerySurgery for ovarian cancer is a major operation. The patient will generally be in hospital for anywhere from 7 to 14 days depending on how fast they recover from the surgery and whether or not they receive their first cycle of chemotherapy on that admission. Pain relief after surgery is usually very good. Most patients will have both an epidural and a general anaesthetic for their surgery. This means that they wake up more quickly and recover more easily. The epidural can be left in for 3 days during which time it will continue to provide pain relief. When it is removed other drugs may be given for pain relief but by then the worst of the pain is past. For a period of time after the surgery the woman's normal activities are limited to let healing take place. In younger women, when the ovaries are removed, the body's natural source of oestrogen is lost and the menopause starts. Hormone replacement therapy can be given and a past history of ovarian cancer is not a contraindication to hormone replacement therapy. Peritonectomy This is a new surgical procedure devised for the surgical treatment of peritoneal carcinomatoses. It is well known that the outcome, in terms of survival, is inversely related to the amount of tumour left at the end of surgery. Ovarian cancer tends to spread over the surface of the peritoneum and removal of the peritoneum, or peritonectomy, significantly contributes to the reduction of tumour and leads to many more patients leaving the operating theatre with no visible or palpable cancer present at the end of their surgery. However this is a very radical and major operation which is only being carried out in a handful of centres around the world and not all patients are eligible for this operation. On average the operation takes some 8 to 14 hours and towards the end of surgery often involves the instillation of hyperthermic (heated) chemotherapy into the abdomen at the end of the operation, so called hyperthermic intraPeritneal chemotherapy or HIPC. Patients will spend some days in the Intensive Care Unit and up to two to three weeks on the ward before discharge. At the present time I am the only gynaecological cancer surgeon in Australia performing this procedure. A detailed section on peritonectomy is currently being developed and will be added to this web site in the near future. ChemotherapyThe side effects of chemotherapy depend on the drugs(s) that are used. Furthermore, they vary from patient to patient. Basically chemotherapy drugs (cytotoxics) affect rapidly dividing cells. This includes the bone marrow and regular blood tests will be done to check on the patient's blood count. Patient's are more prone to infection and should within reason avoid coming in contact with someone ho is known to have an infective illness. Cells in the hair roots also divide rapidly and most women will lose some or all of their hair during their chemotherapy. Certain drugs used in the treatment of ovarian cancer can cause kidney damage. To help protect the kidneys while taking these drugs, patients are given large amounts of fluid. These drugs may also cause tingling in the fingers and toes, ringing in the ears, or difficulty hearing. These problems may continue after treatment stops. Nutrition for Cancer PatientsSome patients find it hard to eat well while they are undergoing treatment. In addition to loss of appetite, common side effects of therapy, such as nausea or vomiting can make eating difficult. Some patients say that food has a different taste. Eating well means getting enough calories and protein to help prevent weight loss and regain strength. Patients who eat well during cancer treatment often feel better and have more energy. In addition they may be better able to cope with and handle the side effects of treatment. Follow-up CareWhen treatment is over, regular follow-up check ups are instituted. The frequency of these visits is determined by the doctor, however, the following would be a common follow-up pattern: For the first two years: every three months For the next three years: every six months From five years onwards: every year. At these check ups there will generally be a physical examination and a laboratory blood test called a CA125 assay. Often the CA125 level in patients blood is high before treatment and falls following surgery and chemotherapy. If the CA125 level begins to rise again it may mean that the cancer is growing again, however, there are other reasons for the CA125 to rise, which are not due to cancer. Women should carefully follow their doctor's advice on health care and check ups and report any problems to the doctor as soon as it appears.
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