What is Ovarian Cancer?
Ovarian cancer is a malignant disease arising from one or both ovaries. Ovaries are almond-shaped pelvic organs that in healthy women produce the female hormones (oestrogen, progesterone, testosterone).
Sometimes, "ovarian" cancer can arise in the Fallopian tubes instead. In young women, the Fallopian tubes carry the fertilised egg from the ovary to the uterus (womb). Especially in women with BRCA1 or BRCA2 cancerous transformation within the Fallopian tube is frequently the case.
Rarely, cancer that resembles ovarian cancer can develop in women who had both ovaries and fallopian tubes removed previously. We call these cancers "peritoneal cancers" because they arise from the peritoneum, which is the inner skin of the abdomen.
In Australia, ovarian cancer is a common gynaecological cancer with more than 1700 women newly diagnosed every year. We distinguish several types:
- Epithelial ovarian cancer (EOC): Approx 85% of all ovarian cancers are epithelial and originate from the most oputside layer of the ovary. Typically EOC is a disease of postmenopausal women. These cancers require surgery and most patients will require chemotherapy postoperatively. Approx 16 to 18% of these cancers are hereditary.
- Non-epithelial ovarian cancer: These cancers account for approx 5% of all ovarian cancers. Typically they develop in very young women and originate from the hormone-producing tissues inside the ovary. Surgery is essential but often only one ovary needs to be removed and fertility can be preserved. Sometimes chemotherapy is required and these cancers carry a very good prognosis.
- Borderline tumours are tumours characterised somewhere between malignant and benign. Most patients can expect a very good prognosis but surgery is required. Chemotherapy is not effective. Sometimes young women are affected and fertility can be preserved in the majority of women. Borderline tumours are not inherited.
Signs and Symptoms of ovarian cancer
The symptoms of ovarian cancer are unspecific and can be mistaken for irritable bowel syndrome, an upset stomach or bladder infections. In hindsight, almost all ovarian cancer patients display some of those signs, but men and women who do not have ovarian cancer may experience them as well. Therefore signs of ovarian cancer are unspecific and include urinary symptoms (frequency), changes in bowel habits or an increase in abdominal circumference. Ovarian cancer symptoms may also include persistent pelvic discomfort.
Diagnosis of ovarian cancer
In contrast to most malignant tumours a diagnosis of ovarian cancer (or the absence of ovarian cancer) will require surgical exploration. Patients who display signs and symptoms of ovarian cancer and in who medical imaging suggests ovarian cancer will require further investigations to confirm or exclude the presence of ovarian cancer. I discourage radiologists to drain pelvic masses for the aim to establish a diagnosis because of the enormous risk of tumour cell dissemination during such a procedure. Therefore surgery not only aims to treat the condition but also needs to establish a diagnosis before a treatment can commence.
Certain tools are available to estimate the risk of malignancy, and these tools include medical imaging (CT scan and ultrasound) and tumour markers (CA125, CA19.9, CEA, HE4). Depending on this risk assessment I will recommend one of the following:
- Very low risk of malignancy (less than 1%): I recommend a repeat ultrasound (ideally transvaginally) and tumour marker test in 2 to 3 months;
- Low to medium risk of malignancy: Surgical exploration may be useful to establish a diagnosis. I prefer a laparoscopic (key hole) approach;
- High risk of malignancy: Surgery is ideally performed through an open abdominal incision. A laparoscopic approach is reasonable if the tumour is advanced and if it needs to be determined whether surgery should be the first choice of treatment.
The key to successful ovarian cancer treatment is the combination of surgery plus chemotherapy. The timing of the combination of the two approaches may depend on patient's age, general health and extent of disease. I will either recommend upfront surgery or upfront induction chemotherapy, followed by surgery and completion chemotherapy. The aim is to render a patient disease free after primary treatment.
Surgery for ovarian cancer will typically remove the uterus (if still present), tubes and the ovaries. In most instances, a frozen section examination will be required while the patient is under general anaesthesia. Sometimes the frozen section approach is inconclusive because only a limited number of sections can be taken and examined by the pathologist in the short time available. Depending on the pathologist’s preliminary report, the operation is continued to either i. Determine the extent of the disease (pelvic and/or aortic lymph node dissection, omentectomy (fatty pad arising from the outer line of the stomach) or ii. To remove as much cancer tissue as technically possible. If the diagnosis of ovarian cancer is confirmed and surgery is deemed the most promising approach, I will always aim to remove all cancer from the body.
Almost all patients will require chemotherapy postoperatively. Patients who had tumour limited to one ovary only (all lymph nodes and omentum are cancer free; no free floating cancer cells in the abdomen) and who had negative tumour markers prior to surgery do not benefit from chemotherapy. Their prognosis is so good – it cannot be improved further by any other means.
Chemotherapy will be given through a drip every 1 or 3 weeks. I do not administer chemotherapy myself but I will refer my patients to a perfectly qualified medical oncologist in your area who I work with and who is experienced in ovarian cancer treatment. Chemotherapy typically starts two or three weeks after discharge from hospital.
In some cases where patients are unable to tolerate surgery for medical reasons, chemotherapy needs to be considered as an alternative to surgery. In such cases, I will refer you to a medical oncologist who will give you 2 or 3 cycles of neoadjuvant chemotherapy and then we will re-evaluate if the patient is fit for surgery then. Ideally, the patient should be tumour-free at least once (either after upfront surgery or after surgery between chemotherapy cycles).
Surgery for suspected advanced ovarian cancer should not be performed in regional hospitals. These patients benefit from surgery in a big centre because of the availability of specialised services (nursing) and medical specialities if required. For patients with suspected advanced ovarian cancer, bowel preparation is required. Patients are require to fast at least 6 hours prior to surgery. Please stop smoking before the operation as it makes your postoperative management much easier. Before surgery, I will make arrangements for your admission to the intensive care unit (ICU) for monitoring.
When you wake up from general anaesthesia there will be some lines running in and out for support. A drip will provide the necessary fluids and a catheter will drain the urine from your bladder. An oxygen mask will supply oxygen to the respiratory system. A drain may collect body fluid from the inside of the abdomen. These lines will be removed once I am happy that the body functions have returned to normal, which is usually after a few hours or days.
The final histopathological report may take a few days. It forms the basis for the decision if any further treatment (e.g., chemotherapy) is required. If chemotherapy is required I will bring you in contact with a qualified medical oncologist.
Surgery always carries risks. Before surgery, I do everything to minimise these risks. I give antibiotics before the skin incision in order to avoid skin and other infections. Commencing prior to surgery I give calf compression stockings in order to prevent the formation of blood clots in the legs. At surgery sterile handling of instruments further reduces the risk of infectious complications. However, there are some immanent risks of surgery for uterine cancer:
- Laparoscopic surgery may need to be converted to open surgery through the opening of the abdomen. This risk of conversion is approximately 2%. The vast majority of all laparoscopic procedures proceed laparoscopically.
- Medical and anaesthetic risks associated with general anaesthetic, with epidural analgesia or with postoperative pain control do exist. In patients with pre-existing medical conditions these risks are slightly higher.
- There is a risk of injury to pelvic organs, such as the bowel, the bladder, the ureters, blood vessels and nerves. These injuries usually get repaired during surgery. However, in an exceedingly small proportion of patients these injuries can unfortunately not be recognised during surgery or injuries may even develop after surgery. Then another operation is required to repair those defects. Injury to big blood vessels may result in the need of blood transfusion. Injury of nerves is common in patients who require removal of lymph nodes in the pelvis. In that case, patients will experience some numbness of the skin around the upper thigh.
- Lymph oedema: Lymphatic fluid usually drains from the legs via the lymph glands in the pelvis and the aorta back into the blood circulation. When lymph glands have to be removed, some fluid may accumulate in the legs (lymph oedema). The risk of lymph oedema is around 20% in patients who had to have a lymph node dissection. Patients with lymphoedema require lymph drainage.
Other possible complications include ...
- Infections to the bladder, the abdominal wound, the lungs with resulting temperatures and septicaemia
- Thromboembolic complications (formation of blood clots) in the legs that can even travel to the lungs and cause life-threatening emboli. This risk is very small because of our efforts to minimise them.
- A vaginal discharge that can even be blood-stained is very common for up to 6 weeks.
- Shoulder tip pain is common after laparoscopic surgery. It is caused by the CO2 gas that s needed for the surgery. It normally lasts only for a day but painkillers are not effective.
- Changes in bowel habits are not uncommon for a couple of months post surgery. I recommend regulation of the bowels with natural substances such as yoghurt, prune juice and natural fibre.
Patients need to stay in hospital for one or two days if the procedure was done laparoscopically or 6 to 10 days if a laparotomy (opening of the abdomen) was necessary. I recommend you have a good break after surgery for 2 to 4 weeks. Especially I recommend avoiding intercourse, vaginal tampons and full baths and other factors that could disrupt wound healing or facilitate an infection.
Please notify me immediately if your condition becomes worse after you have been discharged from hospital.
Recovery from ovarian cancer surgery
Pain after surgery: All patients will receive pain killers upon leaving the hospital. It is critical that patients continue the pain medication beyond discharge from hospital for approximately 10 to 14 days. Otherwise pain will catch up and you will worry.
Exercise after surgery: Whenever possible we will mobilise patients on the day or the day after a hysterectomy with the help of experienced physiotherapy staff. At discharge, I recommend to "take it easy" for a couple of weeks. Gentle exercise is possible as is light homeduties. Competitive training should be avoided for a few weeks.
After surgery, you should be seen regularly for follow-up for 5 years. These examinations will always include pelvic examinations and tumour marker (blood) tests. I recommend PET/CT scans only if needed. After five years, the risk of a recurrence becomes very low. Should you experience any bleeding or pain, please do not hesitate and contact my office straight away.
Cancers of all types and stages may recur. Recurrence may be local or in the pelvis or at distant sites (abdomen, lungs). Treatment of recurrent ovarian cancer depends on the type of cancer (epithelial, non-epithelial, borderline), the time interval between the first diagnosis of cancer and the recurrence (the longer the better) and the distribution of disease (how many spots of cancer and their localisation).
Survival rates for Epithelial Ovarian cancer depends on its stage. Survival for stage 1 ranges between 75% and 95% at five years. Survival for stage 3 or 4 ovarian cancer depends on how successful surgery has been and how much tumour had to be left behind after surgery but also depends on the response of the cancer to chemotherapy. Unfortunately we have no means to predict if an individual patient will respond to chemotherapy or not.
Survival of patients with non-epithelial ovarian cancer is generally excellent. Most of these tumours require only the removal of one ovary, which allows us to preserve fertility in these very young women. While chemotherapy may be required, periods will return.
Survival of patients with borderline tumours is above 90% in patients with stage 1 disease. Patients with elevated CA125 tumour markers will need to attend to a strict follow up regimen. Patients with stage 1 borderline tumours and low CA125 will only need to be seen if problems develop down the track.