Who gets ovarian cancer?

The simple answer is anybody. More specifically, post-menopausal women (about 51 years of age in the U.S.), women who have never been pregnant, women who have never used birth control pills (yes, oral contraceptives are protective), women who have a first- or second-degree relative with ovarian cancer, and women who have a personal or family history of breast or colon cancers are prone to this disease.

The very strongest risk factor is family history, but only 5% or 1 in 20 women with a cancer of the ovary will have one of the genetic variants. This means that, for most patients, there is nothing in their family tree to alert concern.

Symptoms

For years, many believed that there were no symptoms associated with ovarian cancers in their early stages. The truth of the matter is that the symptoms are so vague and non-specific that oftentimes both patients and doctors attribute them to other causes. Heartburn and early satiety (fullness after eating) are blamed on the spicy foods they had for dinner.

An increase in abdominal girth is middle-age spread and too many rich meals. The pain in the lower abdomen is a muscle pull from moving the lawn. Or frequent urination is a fallen bladder. It is of little surprise then, that three-quarters of patients with ovarian cancer have a metastatic, advanced stage of the disease when they are diagnosed.

Diagnosis

Diagnosis is made at surgery for most patients. Usually there is evidence on an ultrasound or CT scan of abnormalities in the ovaries. Oftentimes, there is free fluid or ascites present in the abdomen. Many times, a woman's pelvic examination is abnormal. CA-125 is a blood test that is often elevated in women with advanced-stage epithelial ovarian cancer (80%), though only half of the women with cancer confined to the ovary will have an elevation of this test. In post-menopausal women with evidence of a mass on examination, ultrasound or CT scan, a CA-125 can predict, with great accuracy, whether there is a cancer present.

Advances in Research/ Screening/Genetic Testing

With such a devastating disease that presents in advanced stages so often, research efforts have focused on ways of diagnosing the disease early through screening. Unfortunately, there is no screening test or combination of tests that has proven of benefit for the average patient. In women considered to be high risk, recent evidence suggests that screening transvaginal ultrasound may be of benefit. But, even in this carefully screened and evaluated group of patients, cancers eluded the investigators and were diagnosed within a year of their evaluation. In women who come from families where cancers of the breast, ovary, endometrium, and colon cluster, genetic testing can sometimes be of benefit. Testing requires a blood or tissue sample from the woman with the cancer to determine if a variant of the BRCA 1 or 2 gene exists, and if so, what it is. When this information is available, then the blood of other family members can be tested to determine if they carry the same abnormal gene. A mother has a 50% chance of transmitting the gene to her children (both boys and girls) and a 25% risk of transmitting it to her grandchildren. In some families where the expression of the gene is strong, women who carry the abnormal gene have a 40% lifetime risk of developing ovarian cancer. Many would recommend that such a woman foregoes imperfect screening tests and simply have her ovaries removed when her childbearing is completed.

Surgical Treatment

Once a mass has been identified and examined radiographically, surgery is necessary to make a complete diagnosis. Surgery provides the opportunity to define the disease and resect (surgically remove) it. When cancer is ostensibly confined to the ovary, a systematic exploration of the abdomen and pelvis with biopsies of some 15-20 different sites is performed (a staging laparotomy).

When, as is so often the case, the disease is scattered widely throughout the abdominal cavity, a resection of as much cancer as possible is performed, occasionally requiring the removal of portions of the intestine. Ovarian cancer has a characteristic spread pattern it sprinkles and studs the inside of the abdominal cavity, a "salt and pepper" effect. It is important for the operating surgeon to be aggressive in his or her approach to the management of this disease, since many studies have shown a correlation between the amount of residual cancer and the chances of a patient responding to chemotherapy and living longer. Those patients with the smallest amount of residual disease have the very best prognosis.

Prognosis

Prognosis is clearly related to several key features of a woman s cancer, most importantly stage and grade. Stage defines the extent of disease. For the overwhelming majority of women with ovarian cancer, the disease is advanced. Survival for Stage III or IV disease is 15-20% at five years. When fortunate enough to find the disease when it s confined to the ovary, survival for Stage I disease is 80-85%. Grade describes the pattern of growth as seen under the microscope. Grade 1 cancers have a pattern of growth similar to that of normal tissues, and these cancers grow more slowly and are more likely to do well. Grade 2 and 3 cancers have a very disordered pattern of growth and consequently, are more unpredictable in their behavior. The woman who has Stage 1 Grade 1 disease is likely to be cured by surgery alone.