All about Ovarian Cancer

According to Cancer Research UK, more than 7,000 women are diagnosed with ovarian cancer in the United Kingdom every year. Another staggering statistic from this same source is that more than 4,000 women die every year from this disease, which equates to 11 women each day.

Thankfully, 90% of women will survive if the cancer is caught at its earliest stage. In this article, we’ll tell you all about ovarian cancer, the causes, signs and symptoms and the treatments available.

What is ovarian cancer?

Ovarian cancer is cancer of the ovaries. Anyone who has ovaries could get ovarian cancer but it is most common in women over 50. The greatest age risk is from age 75 to 79.

What are ovaries?

Ovaries are a part of the female reproductive system that produces eggs. There are two ovaries, one on each side of the body. They are each about the size of an almond. Besides releasing eggs, they secrete the hormones progesterone and oestrogen that are needed for fertility and the menstrual cycle.

When cancer is in the ovaries, it involves the growth of abnormal cells that multiply rapidly, invading and destroying healthy tissue. These cells eventually form a tumour. If the disease is not caught early, the cancer cells will grow into surrounding tissues and spread to other parts of the body.

There are different types of ovarian cancer and this depends on which cell the cancer starts in.

What causes ovarian cancer?

Ultimately, cancer is the result of cells growing uncontrollably and not dying as they should. Normally, cells follow a path of growing, dividing and dying. This is a process called apoptosis or programmed cell death. When this process is disrupted somehow, cancer occurs.

Essentially, the DNA inside the cells has mutated and the ‘instructions’ of what the cell is supposed to do alters its behaviour and stops its usual function. These mutations occur by chance during cell division. One mutation doesn’t mean cancer. There are usually around six mutations before a healthy, normal cell becomes a cancer cell.

Different gene mutations in cell DNA cause different problems. A cell could start making too many of the proteins that trigger cell division, the proteins might be abnormal and work differently, or the cell might stop making the proteins responsible for sending a message to stop cell division.

Normally, the human body has just the right amount of each cell type. Our bodies have millions of cells, but cancer will begin in just one cell. Thus, it only takes one faulty cell out of hundreds of millions for cancer to begin.

In ovarian cancer, there is an error in the cells in the ovaries. The cells begin to grow and reproduce against the usual programme. These cancerous cells form a lump or tumour, which then invades and destroys healthy tissue and organs. When these cells break away from the original tumour site, the cancer spreads.

Signs of ovarian cancer

Ovarian cancer symptoms are hard to spot. This is because they are so similar to non-cancerous problems. For this reason, many ovarian cancers are diagnosed late.

Here are some of the most common symptoms of ovarian cancer:

• A swollen or bloated tummy that is long-lasting.
• Feeling full very quickly or quicker than normal when you eat a meal.
• Poor appetite.
• Pain in the lower abdomen.
• Back pain.
• Passing urine more frequently than usual.
• Having an urgent need to pee and feeling as though you can’t.

Other symptoms include:

• Unexplained weight loss.
• Extreme fatigue or unexplained tiredness.
• Post-menopausal vaginal bleeding.
• A change in bowel function (constipation or diarrhoea).

For women over 50 that suddenly develop symptoms of IBS, it’s recommended to have tests for ovarian cancer as this can be a sign. If women have had a full hysterectomy that includes removal of the ovaries, ovarian cancer is not possible. However, trans men or non-binary people who were assigned female at birth can still develop ovarian cancer.

How is ovarian cancer diagnosed?

If symptoms suggest a possibility of ovarian cancer, a GP will refer the patient to a gynaecologist for tests.

These tests will likely include:

• A physical examination – This will involve inserting fingers or instruments into the vagina to look for anything abnormal.
• Blood tests – These will check hormones and will look for ovarian cancer markers and gene mutations.
• Ultrasound tests – These will look inside the lower abdomen and examine the ovaries and surrounding areas to look for tumours.
• CT scans – These will look at the pelvis and abdomen to examine the ovaries in greater detail. It will show the shape, structure and size of the organs.
• Biopsies – Having a biopsy involves taking a small piece of the tissue and examining it underneath a microscope. Specialists check for characteristics of cancer and the type of cancer if it’s present. This is usually done with a needle.
• Laparoscopy – This involves looking at the ovaries through a camera inserted through a cut in the tummy.
• Surgery – This might be surgery to remove tissue for a biopsy or removal of the ovaries.
• MRI scan – This is usually done after a diagnosis to help diagnose the stage and size of the cancer.
• PET scan – This is also usually done post-diagnosis.
• Chest X-ray – This is done if it is suspected that the cancer has spread beyond the ovaries.

Results usually take a few weeks to come back. Patients are given an appointment with a specialist to discuss their results with them.

Stages of ovarian cancer

At diagnosis or shortly after, patients are told what stage and grade their cancer is. There are four stages. The grade describes the degree of abnormality of the cancer cells under a microscope. Knowing the grade and stage helps specialists to decide on appropriate treatment.

Stage 1 Ovarian Cancer

With stage 1, the cancer is limited to the ovaries and the most common treatment is surgery. Some women have chemotherapy too.

• Stage 1a means only one ovary or fallopian tube is affected.
• Stage 1b means both ovaries or fallopian tubes are affected.
• Stage 1c means the cancer is in one or both ovaries or fallopian tubes and either the surrounding tissue has broken (cancer cells could be leaking into the pelvis), the cancer cells are on the ovary or fallopian tube surface or there are cancer cells found in the fluid in the pelvis or tummy.

Almost 95% of patients are still alive five years after diagnosis of stage 1 ovarian cancer.

Stage 2 Ovarian Cancer

With stage 2, the cancer has begun to grow outside of the ovaries but still remains inside the pelvis. Patients usually have both surgery and chemotherapy.

• Stage 2a means the cancer has spread from the ovaries/fallopian tubes to the womb.
• Stage 2b means the cancer has spread to other structures within the pelvis like the bowel or bladder.

Almost 70% of patients are still alive five years after diagnosis of stage 2 ovarian cancer.

Stage 3 Ovarian Cancer

With stage 3, the cancer has begun to spread outside of the pelvis and is present in either the abdominal cavity or the lymph nodes. Like stage 2, patients usually have surgery and chemotherapy.

• Stage 3a1 means the cancer is within the lymph nodes in the tummy.
• Stage 3a2 means small amounts of cancer are outside of the pelvis, e.g., on the peritoneum.
• Stage 3b means the cancer located outside of the pelvis or on the peritoneum is larger than 2 centimetres in diameter. The lymph nodes might also be affected as might the capsule that contains the spleen and liver (but not the organs themselves).

Over 25% of patients are still alive five years after a diagnosis of stage 3 ovarian cancer.

Stage 4 Ovarian Cancer

When stage 4 is reached, the cancer has metastasised and has spread to other organs further away from the ovaries, like the lungs or the liver. Treatments include surgery or chemotherapy but it’s generally incurable at this stage and treatments are palliative.

• Stage 4a means the cancer has caused a pleural effusion – fluid has built up inside the pleura, which is the lining of the lungs.
• Stage 4b means the cancer is within the spleen or liver or it has spread to other organs or lymph nodes like the lungs.

Almost 15% of patients are still alive five years ager a diagnosis of stage 4 ovarian cancer.

Grades of ovarian cancer

Ovarian cancer is either low grade, intermediate grade or high grade.

• Grade 1 is low-grade cancer. This means the cells look almost like normal cells and that they grow more slowly and won’t spread as quickly. Low-grade cancer is less common and is mostly treated with surgery and chemotherapy or hormone-blocking tablets. This type of cancer grows slowly.
• Grade 2 is intermediate grade. This means the cells grow faster and are more abnormal in appearance.
• Grade 3 is high-grade cancer. These cells will look very different to normal cells and will typically grow very quickly. The most common type of ovarian cancer is epithelial ovarian cancer and most of these are high grade.

What are the treatments for ovarian cancer?

The treatment received for ovarian cancer depends on a number of factors.

These include:

• Where the cancer is.
• The type and size of the cancer.
• If the cancer has spread.
• The patient’s general health.

The main treatments for ovarian cancer are surgery and chemotherapy, but some patients are given hormone treatment and other medicines.

Surgery

The surgery type will depend on the stage of ovarian cancer and whether or not it has spread. If it is found early, it is more treatable. Early-stage ovarian cancer might be treated with surgery to remove the ovaries as well as the fallopian tubes. This is called bilateral salpingo-oophorectomy. Some people might have surgery to remove their cervix and womb. This is called an abdominal hysterectomy.

When surgery has spread outside of the ovaries or reproductive system, there might be a need to remove other parts, including sections of the bowel.

Chemotherapy

Chemotherapy involves treatment with a cancer-killing medicine. This is sometimes given before surgery and after surgery but sometimes it’s given alone.

Radiotherapy

This uses radiation that kills cancer cells. Radiotherapy is often used for people with advanced ovarian cancer or to help deal with symptoms associated with ovarian cancer like pain and bleeding.

Targeted therapies

This involves different drugs to stop cancer from spreading by identifying the cancer-causing genetic changes in cells and blocking them. This halts the progression of the disease. Different targeted therapies exist for ovarian cancer.

Avastin

Avastin is a brand name of Bevacizumab, which is a drug that belongs to treatments called anti-angiogenics. These stop cancer from creating new blood vessels. As such, the cancer receives less oxygen and food and cannot grow. Currently, Avastin is only available to patients as a maintenance drug for advanced cancer. It aims to delay or prevent the cancer from returning.

PARP inhibitors

These are a new class of drug that are being used more and more in the treatment of ovarian cancer. They help prevent cancer from spreading by preventing PARP (a protein) from carrying out its usual role of aiding cells to repair damage. This drug prevents cancer cells from being repaired and so they weaken and die. Three different PARP inhibitors exist: olaparib, rucaparib and niraparib.

• Olaparib is a maintenance drug for women with high-grade ovarian cancer. It prevents growth, which means women can decrease the frequency of their rounds of chemotherapy. It comes in tablet form.
• Rucaparib, which is also called Rubraca, is a maintenance drug for relapsed patients. It is available to all women in England but only to those who don’t have a BRCA mutation in Scotland.
• Niraparib is also a maintenance treatment that prevents the progression of the disease. This is given to women whose cancer is platinum sensitive. It is given to women whose cancer has returned after chemotherapy. In Scotland, it’s only available to women who have a BRCA mutation but in England all women can access it.

Hormone therapy

Some cancers of the ovaries use the hormone oestrogen to grow. If a patient has this type of cancer, they might be given hormone treatments to block oestrogen production, which will stop the cancer from growing. However, it is rare to receive this treatment.

Who is at risk of ovarian cancer?

There are some things that increase a person’s risk of developing cancer of the ovaries. Having risk factors doesn’t mean you will get ovarian cancer.

Like most cancers, ovarian cancer is more common the older a person gets. From around 45 years of age the risk starts to increase steeply.

Another risk factor is a person’s genetics. Between 5% and 15% of ovarian cancers are caused by a woman inheriting a faulty gene. The genes involved are called BRCA1 and BRCA2. These are the genes that can also increase a woman’s risk of breast cancer if they’re faulty. If a person has a relative who develops ovarian cancer, it doesn’t mean that there is a faulty gene involved. However, if a person’s sister or mother has had ovarian cancer, there is a threefold risk compared to women who don’t have a family history.

Having had a previous cancer can also increase a person’s risk of developing ovarian cancer. This is particularly true for breast cancer, especially if this was diagnosed at a young age or if the cancer was oestrogen receptor negative breast cancer. This is usually linked to faulty BRCA1/2 genes.

HRT (hormone replacement therapy) can also increase a person’s risk of developing ovarian cancer. According to Cancer Research UK, around 4% of ovarian cancers are linked to HRT use. The risk, however, is still very small.

Smoking also puts women at risk of particular types of ovarian cancer e.g., mucinous ovarian cancer. The longer a person has smoked, the greater their risk will be.

Exposure to asbestos (a substance that was banned at the end of the 20^th century but was widely used in different industries) can also increase the likelihood of developing ovarian cancer.

Finally, medical conditions including diabetes, endometriosis or being overweight can increase a person’s risk.

Support for those with ovarian cancer

Getting a diagnosis of ovarian cancer can be a scary time for individuals as well as their family and friends. Usually, a member of the patient’s specialist team will be able to provide information about local support services.

There are lots of charities and organisations that help patients and their families.

These include:

• Ovacome – This is a UK-based charity providing support and information to anyone affected by ovarian cancer.
• Macmillan Cancer Support – This is a charity helping anyone affected by cancer, including ovarian cancer.
• Target Ovarian Cancer – This charity has a helpline and email address for anyone seeking support for ovarian cancer.
• Marie Curie – This charity supports anyone affected by terminal illness.

Final thoughts – prognosis

The outcome of a diagnosis of ovarian cancer depends on the stage the cancer was when it was diagnosed. The type of cancer and its grade will also affect survival. Another factor that affects things is how successful the surgery is for removal.

Patients with a better performance status (general  health and fitness) also have a better outlook, as do younger patients. Overall, considering all ovarian cancers at diagnosis, 35% of women survive for ten years or more.