What every woman should know about ovarian cancer

 In 2011, approximately 21,990 patients are estimated to be diagnosed with ovarian cancer in the United States.  An estimated 15,460 will die of this disease.  Thus, it is the most deadly of the gynecological malignancies.  The average lifetime risk of ovarian malignancy is 1.7% in the USA.  African American women have a lower incidence of this tumor.  Women who have never had children are at higher risk.  Cancer risk is lower in those who have given birth, breastfed, have had tubal ligation, or took oral contraceptives.

Ovarian tumor is a silent disease.  Most patients have no symptoms until the malignancy spreads to the upper abdomen.  Common complaints include abdominal discomfort, bloating, and feeling full.  By this time, 70% of the patients already have advanced disease.  Yet, there is no reliable screening test for women of average risk.  Pelvic exams are important for cervical cancer screening, but are not reliable for the detection of ovarian cancer.  The tumor marker CA-125 is only elevated in the blood of only about half the women with early-stage ovarian cancer.  To complicate matters, CA-125 level can be abnormal in many benign conditions such as endometriosis, pregnancy, ovarian cyst, pelvic inflammatory disease, uterine fibroid, pancreatitis, abdominal infection, lung infection, and liver disease such as cirrhosis.  Unfortunately, ovarian cancer in general cannot be diagnosed by just a needle biopsy, because this method is not reliable for this disease.  A suspicious finding usually leads to invasive surgery in order to definitively tell whether the ovarian cyst or mass is cancer or not.

For women who have the hereditary BRCA gene mutation, the lifetime risk of ovarian cancer can be as high as 60%.  BRCA gene testing should be performed when there are multiple family members with ovarian cancer, bilateral or early onset breast cancer, both breast and ovarian tumor in the same person, or male breast cancer.  This gene can be passed on by either the male or female parent.  Patients with the hereditary nonpolyposis colorectal cancer (HNPCC) syndrome have a 3.5 fold increase in the risk of ovary tumors.  (Of note, their lifetime risk of uterine cancer can be as high as 60%).  Removal of both ovaries and fallopian tubes is the most effective method to prevent the malignant ovarian disease in hereditary cases.  Because ovarian cancer usually does not develop until middle age, it is generally safe to wait until after the woman has completed childbearing.  During this time, intensive monitoring with CA-125, pelvic exam, and transvaginal ultrasound is recommended.  An alternative to surgery is the use of oral contraceptives, which may decrease the ovarian tumor risk by 50%.

           The treatment for ovarian cancer usually starts with open abdomen surgery to remove as much tumor as possible.  Surgery also allows accurate staging, which then dictates whether or not the patient needs chemotherapy afterwards.  In certain cases, chemotherapy is given both in the vein as well as into the abdominal cavity (intraperitoneal infusion).  Sometimes, radiation is also administered.  When the tumor is confined to one or both ovaries (stage 1A and 1B), the five-year survival rate is 90% or better.  However, most patients have stage 3 or 4 disease at presentation.  At this point, the five-year survival rate is only 18-45%.