Although aggressive new therapies are being developed by the gynecologic cancer specialists at UCI Health, early detection and diagnosis remain a woman’s best opportunity to successfully treat ovarian cancer.

A high level of suspicion and a willingness to seek medical attention for non-specific symptoms are the first line of defense. Ovarian cancer is notorious for having very non-specific symptoms.

Women should consult a physician if they:

• Experience pressure or fullness in the pelvis
• Abdominal bloating
• Rapid weight gain
• Changes in bowel and bladder patterns that continue or worsen over a period of weeks or months

A diagnosis of ovarian cancer is suggested by the presence of symptoms, such as abdominal swelling or bloating, weight gain and bowel or urinary tract changes. A physician may also discover an ovarian or pelvic mass on routine pelvic exam.

Imaging tests

The most common tests used to evaluate a possible ovarian cancer diagnosis are imaging studies:

• A pelvic ultrasound

An ultrasound (or sonogram) of the pelvic area can evaluate the presence and characteristics of an ovarian mass or cyst.

• Computed tomography (CT)

CT scans are commonly used to evaluate the pelvic organs, the abdomen and even the chest. CT scanning gives a more comprehensive picture of the abdomen and pelvis than an ultrasound.

• Combination PET/CT scan 

In some cases, physicians may order a combined positron emission tomography (PET) and CT scan to evaluate the metabolic activity of any abnormalities (cancer cells have a higher metabolism than non-cancer cells).

Blood tests

Your physician also may order a blood test to further evaluate an ovarian mass. The most common tests the levels of the CA125 protein, which is a marker for ovarian cancer. An abnormal reading is considered higher than 35 u/ml. Generally, this test is useful only for women who have undergone menopause. Premenopausal women may have conditions that can cause a false positive CA125 test (endometriosis, fibroids, menstrual period, etc.).

The OVA1 blood test, which recently became commercially available, tests for five proteins that change in the presence of ovarian cancer. Although this test doesn't diagnose ovarian cancer earlier, an abnormal result can prompt referral to an appropriate cancer specialist (gynecologic oncologist) for treatment.

Staging

Ovarian cancer is staged according to the size, extent and location of the tumor(s). Accurate staging determines the appropriate treatment regimen following surgery as well as a woman's long-term prognosis.

The higher the stage level, the more extensive the cancer.

• Stage I: Ovarian cancer is confined to the ovaries. 
• Stage II: Ovarian cancer has spread beyond the ovaries to the pelvis. 
• Stage III: Ovarian cancer has spread to the abdomen and/or lymph nodes. 
• Stage IV: Ovarian cancer has spread beyond the abdomen or involves the liver.

Surgery is the mainstay for initial diagnosis and treatment of ovarian cancer. It is critical for women with suspected ovarian cancer to find an experienced gynecologic oncologist who is capable of performing the complete range of surgical procedures this disease can require.

The purpose of surgery is two-fold. First, tissue is obtained for the pathologist to study and establish a definitive diagnosis of ovarian cancer and the specific subtype of cancer. For women with ovarian cancer that has spread, the second purpose of surgery is to remove all or most of the disease through cytoreductive surgery.

Surgical approaches

Depending on the pre-operative imaging findings, the gynecologic surgeon may choose a robot-assisted or laparoscopic approach, or a traditional laparotomy, which involves a midline incision through the abdomen.

In most cases, ovarian cancer surgery includes:

• A total hysterectomy (removal of the uterus)
• A bilateral salpingo-oophorectomy (removal of both tubes and ovaries)
• Removal of the omentum (a fatty apron that hangs off the colon)
• Biopsies of lymph nodes and other peritoneal structures

Information from this staging surgery allows the assignment of the surgical stage of disease, which helps determine the prescription for any additional treatment, usually chemotherapy.

For young women with Stage I ovarian cancer who want to preserve their fertility, a more conservative operation may be appropriate. If there has been no evidence of spread beyond the primary ovary, surgery may involve only removal of the diseased ovary and staging biopsies, preserving the remaining ovary and the uterus.

For women with advanced ovarian cancer (Stage III or IV), the main determinant of survival is the surgeon’s ability to remove all or most of the metastatic cancer deposits through cytoreductive, or debulking, surgery. This can mean removal of part of the intestine or colon (which can almost always be reattached), as well as sections of the abdominal peritoneum, the spleen or a portion of the diaphragm.

Extensive scientific literature shows that women with ovarian cancer who are operated on by an experienced gynecologic oncologist who performs cytoreductive operations frequently have a long-term survival rate that is two to three times higher than women operated on by less experienced surgeons.

Neoadjuvant chemotherapy

For a minority of patients, cytoreduction may not be appropriate, either because their medical condition does not permit the surgery to be performed safely or because the location of the disease does not readily lend itself to surgical removal. In these instances, treatment starts with chemotherapy (usually three to four treatments or cycles) to allow the patient’s medical condition to improve or to reduce the extent of disease.

Cytoreductive surgery is then performed three to four months after starting chemotherapy and is usually followed by another three to four months of chemotherapy.

Chemotherapy

With the exception of those patients with very early Stage I disease, most women with ovarian cancer receive some type of chemotherapy to either treat visible disease or eradicate tumor cells that cannot be seen with the naked eye.

Standard chemotherapy for the most common types of ovarian cancer consists of two drugs, carboplatin and paclitaxel, administered intravenously every three weeks for three to six cycles as an outpatient (a cycle is a 21-day treatment period).

These drugs work by interfering with the cancer cells’ ability to divide and reproduce, but they also can damage healthy, noncancerous cells, resulting in temporary hair loss, fatigue, nausea and suppression of the bone marrow and blood cells.

New approaches

For selected patients with Stage III ovarian cancer, chemotherapy agents may be administered directly into the abdominal (or peritoneal) cavity immediately after cytoreductive surgery in a procedure known as intraperitoneal chemotherapy. Scientific studies show that for appropriately selected patients, intraperitoneal chemotherapy can substantially improve the chances of long-term survival.

At UCI Health, our ovarian cancer specialists may perform hyperthermic intraperitoneal chemotherapy (HIPEC), in which a heated solution of high-dose chemotherapy is pumped into the abdominal cavity and massaged so that it circulates throughout the pelvic area where any malignant cells may remain.

Researchers also are testing angiogenesis inhibitors in the treatment of ovarian cancer. These drugs block the growth of new blood vessels and interfere with the proteins and enzymes that ovarian cancer needs to grow. Avastin is the most widely studied angiogenesis inhibitor for ovarian cancer. It also appears to enhance the effectiveness of standard chemotherapy with carboplatin and paclitaxel.

Managing recurrence

Unfortunately, many women with ovarian cancer eventually experience a recurrence of their disease. A typical follow-up program will include checking the CA125 level combined with a physical exam every three months for the first few years. CT scans are usually performed at six- to 12-month intervals. Follow-ups decrease in frequency because the risk of recurrence diminishes with time.

Effective management of recurrent ovarian cancer requires an individualized approach. Usually, this starts with repeat imaging, either CT scanning or combined PET/CT scanning to determine the location and extent of disease. About 40 percent of patients who experience a recurrence are candidates for a repeat attempt at cytoreductive surgery to remove all visible tumor before beginning re-treatment with chemotherapy.

Patients most likely to benefit from a second debulking surgery are those who completed their initial chemotherapy at least 12 months earlier, who have no more than three sites of recurrence and are in good physical condition to withstand another major operation. The decision to proceed with secondary cytoreductive surgery should be made by an experienced gynecologic oncologist.

Radiation therapy is infrequently used to treat ovarian cancer, mostly because the disease tends to be metastatic at the time of diagnosis, and would require radiation of a very large area. However, for patients with isolated ovarian cancer recurrence, radiation therapy can be a very effective treatment either alone or in combination with standard chemotherapy.

Chemotherapy treatment for recurrent disease depends on prior treatments, the time between completion of initial therapy and recurrence and the patient’s experience with toxicity in the previous treatments. For certain patients, tissue may be obtained and sent for a commercially available chemotherapy sensitivity/resistance assay to help direct the choice of treatments.

Questions? Please call us at 714-456-8000.

The incidence of ovarian cancer increases with age. In fact, half of all cases are detected in women older than 65. Most are diagnosed after age 60.

The presence of an ovarian mass or cyst in a post-menopausal woman should generally be evaluated with surgery, especially if her serum CA125 level is abnormal.

Other risk factors include:

Genetic predisposition

Women with a strong family history of ovarian cancer or breast cancer before age 50 have an increased risk of Breast and Ovarian Cancer Family Syndrome. Having a first-degree relative (mother, daughter or sister) with the disease increases the risk of ovarian cancer threefold. The more relatives who have had the disease, the greater the risk.

Experts attribute the majority of familial ovarian cancer to genetic mutations in the BRCA1 and BRCA2 genes, which normally help protect against both breast and ovarian cancer.

Women who inherit mutations in BRCA1 have a 40 percent to 50 percent lifetime risk of developing ovarian cancer, and an almost 80 percent chance of developing breast cancer.

A mutation in the BRCA2 gene results in a 20 percent lifetime risk of ovarian cancer. Less commonly, a mutation in the HNPCC gene that normally protects against a type of colon cancer called hereditary nonpolyposis colon cancer also raises the risk of ovarian cancer, but to a lesser degree than mutations in BRCA1 and BRCA2.

Families that carry these genes can come from any background. The mutation rate is highest among people of Asheknazi Jewish descent (whose ancestors came from eastern and central Europe), with two percent of the population carrying mutations in either BRCA1 or BRCA2.

Genetic testing is available to determine if a woman is at increased genetic risk of developing ovarian cancer. Women who are known to be at high risk for ovarian cancer may be good candidates for prophylactic (preventative) removal of their fallopian tubes and ovaries. Prophylactic surgery almost always can be performed using a minimally invasive approach.

Race/ethnicity

The incidence of ovarian cancer is highest among white women in Europe and North America. It is lowest among black women, regardless of their geographic location. Incidence also is low among Asian women.

Diet

Ovarian cancer rates are highest in affluent societies where diets are high in fat content. Saturated fats (the kind found in red meats, whole milk and cheese) are most often linked to ovarian cancer, although a causal relationship has been difficult to establish.

Reproductive factors

Women who have never been pregnant or have had problems with fertility are at an increased risk of ovarian cancer. Although fertility drugs, such as clomiphene citrate and pergonal have been implicated in causing ovarian cancer, more recent research suggests that use of these drugs happens to be associated with both infertility and ovarian cancer, but are not a cause of ovarian cancer.

Ovarian cancer also is more common in women who begin menstruating before age 12 or who reach menopause after age 50. Women who take birth control pills are at lower risk for ovarian cancer. The longer a woman is on the pill, the lower the risk. Five years of birth control pill use reduces the risk of ovarian cancer by about 50 percent. Tubal ligation has a similar protective effect against ovarian cancer, although the mechanism for this isn't known.

In general, women diagnosed with ovarian cancer before it has spread beyond the ovary have five-year survival rates of more than 90 percent. But only 15 percent of ovarian cancers are found at this early stage, according to the National Cancer Institute.

Improving survival

For women with advanced-stage cancer of the ovary, fallopian tube or peritoneum, one of the strongest determinants of survival is how much of the cancer is removed at the initial surgery. Research studies have shown that women who have all or most of the cancer removed at the time of diagnosis have a long-term survival rate that is two to three times greater than women who are not able to have cytoreductive surgery.

The expected survival time for women with Stage III ovarian cancer is now more than five years, provided that all visible cancer can be removed before beginning chemotherapy.

Experience counts

Where a woman undergoes surgery for advanced-stage ovarian cancer also is of critical importance. Gynecologic oncologists are surgical specialists trained to safely perform the often extensive operations required for ovarian cancer. An experienced gynecologic oncologist is significantly more likely to perform a surgery that removes all or most of the disease compared to other surgical specialists (for example, general obstetrician/gynecologists and general surgeons), with a resulting improvement in survival outcome.

In addition, medical centers that perform a high volume of ovarian cancer surgeries have the necessary resources to ensure the surgery is performed both safely and effectively. Ideally, this type of surgery should be performed by a qualified and experienced gynecologic oncologist in a tertiary medical center that treats more than 20 ovarian cancer surgery cases a year.

Our UCI Health gynecological oncologists, working at Orange County's only university medical center, are experienced in all facets of ovarian cancer treatment, including complex debulking procedures. They also are skilled in minimally invasive laparascopic and robot-assisted procedures, and are active in numerous clinical trials.

For more information, call 714-456-8000.