Ovarian cancer is one of the most aggressive tumors and the second most frequently occurring gynecological cancer. The great danger with this type of cancer is that it is usually discovered very late, because many women do not have symptoms or the initial symptoms are very vague and nonspecific. Therefore, the majority of women have advanced-stage disease by the time the diagnosis is made.
However, there are also a number of factors that can reduce the risk: These include a younger age at the time of first pregnancy or having had several pregnancies. It is not uncommon for malignant tumors located in the ovaries to have originated from other tissue than that of the ovary (so-called primary tumor), but rather originated through colonization (metastases) from cancer of other organs. So your doctor might want to examine additional organs as well.
The incidence of ovarian cancer is directly related to the increase of age. In more than two thirds of the cases, the disease is discovered only at a very late stage because there are no symptoms for a long time. Significant complaints often appear in an advanced disease stage. At this point, more prominent symptoms such as, abdominal distention (swelling), nausea, or significant loss of appetite appear. It occurs most frequently in women between the age of 50 and 65, with a median age of onset of 63. But it can occur in younger or older women as well, with a lifetime risk of developing ovarian cancer of approximately 1.4 percent.
Due to their similarity in tumor development and biological behavior, ovarian cancer, fallopian tube cancer and peritoneum cancer are treated as one and the same identity in relation to therapeutic treatment options.
The only way to diagnose ovarian cancer with certainty is through surgery. In some cases, however, if surgery is not possible or a woman is a candidate for chemotherapy prior to surgery (neo-adjuvant therapy), a non-surgical procedure may be done instead. This involves tissue or fluid removal from the abdomen or chest with a needle (called, biopsy, paracentesis or thoracentesis) for testing. However, some examinations can be carried out if there is any suspicion on ovarian cancer:
- Anamnesis and physical examination with tactile examination.
- Ultrasound examinations (transvaginal and abdominal sonography).
- X-ray of the chest.
- Blood analysis.
Sonography (transvaginal ultrasound). The ultrasound examination of the internal genital organs is carried out with the help of an ultrasound probe that is inserted into the vagina (transvaginal sonography). The transvaginal ultrasound examination is not always carried out if ovarian cancer is suspected. It is painless and can be repeated any number of times since it does not expose the patient to radiation.
Sonography (abdominal ultrasound). The ultrasound examination of the abdomen provides an insight of the internal organs such as the liver, kidneys, spleen and intestine. It explores whether the tumor has already spread to one of these nearby organs (metastasis). With ultrasound examination the presence of abnormal fluid can also be detected either accumulated in the abdominal cavity (ascites) or in the chest between the pleura and the lungs (pleural effusion).
Blood tests. These provide information about the general condition of the patient. The test results are important with regard to an upcoming treatment. Some types of cancer occasionally produce tumor markers that can then be detected in the blood, for example CA-125. However, these tumor markers are not elevated in all patients and can also be above the normal range in healthy people. Tumor markers are particularly of interest for monitoring the course of the disease during chemotherapy and in the event of a relapse. In aftercare, tumor markers can be used as indicator of relapse. Tumor markers usually play an insignificant role in routine clinical practice except for clinical trials.
The key treatments for ovarian cancer are:
- Radical surgery with the aim of removing all the tissue affected by the tumor,
- Antibody therapy
- In case of relapse
Surgery. A longitudinal abdominal incision is made during the operation. In order to confirm the diagnosis, the affected ovary is first removed and send to pathology for examination. The pathologist examines the tissue during the operation and reports whether it is actually ovarian cancer. Only after confirmation of the diagnosis, the surgery will be continued and carried out preferably according to the ESGO surgical guidelines.
As the aim of the operation is to completely remove the tumor, it usually involves removing both the ovaries, as well as the fallopian tubes, the uterus, the large abdominal network and parts of the peritoneum.The extent of the operation depends on the extent of invasion of the tumor and the tumor type. Sometimes, parts of the intestine or appendix have to be removed to completely eliminate the tumor. If only one ovary is affected and the tumor is very limited and not very aggressive, fertility-preserving surgery can be considered. In that case the uterus and the remaining ovary are left intact. Since this is a very extensive operation, it is mostly carried out at a specialized center with sufficient experiences. This increases the chances that the complete tumor can be eradicated. Along with tumor stage, complete eradication is the most important factor in terms of prognosis and survival.
Chemotherapy. Based on the histological findings after the operation, the adjuvant chemotherapy of choice will be discussed with you. Only ovarian tumors at a very early stage of discovery can be treated without chemotherapy. Chemotherapy uses powerful chemicals to kill fast-growing cells throughout the body by inhibiting cell growth, aiming specifically for rapidly growing cells, like tumor cells. Which chemotherapy comes into question depends on your physical condition and any accompanying illnesses. The standard therapy for ovarian cancer consists of a combination therapy with two drugs (carboplatin and paclitaxel), which are given six times three weeks apart.In advanced stages, the antibody bevacizumab or a parp inhibitor can also be administered in accordance with the current guidelines in order to extend the time until relapse.
What are the side effects of chemotherapy?
Treatment with chemotherapy also affects normal tissues that renew themselves relatively quickly. This primarily affects the mucous membranes of the stomach and intestines, the hematopoietic system in the bone marrow and the hair roots. Most of the side effects can be alleviated well with medication and usually disappear again when chemotherapy is no longer administered.
Antibody therapy. Current studies demonstrate that adding the anti-angiogenesis antibody Bevacizumab to the above-mentioned chemotherapy can considerably extend the time to relapse. Treatment with Bevacizumab is a so-called "targeted therapy". By sticking to its target protein, Bevacizumab prevents the new formation of blood vessels, thereby reducing the blood supply to the tumor. The additional costs of Bevacizumab therapy are being reimbursed by health care insurance companies for the treatment of advanced ovarian cancer in Switzerland.
In case of a relapse. Despite initial surgery and chemotherapy success, the disease usually returns (relapse). If the disease, after relapse, can no longer be cured, the therapy focuses on preventing the tumor from growing as long as possible, relieving symptoms and expanding life time. Depending on how fast and in what form the relapse occurs, surgery can be repeated and a subsequent (new) combination of chemotherapy regimen applied. Surgery will be the therapy of choice if there is still a good chance of completely removing the tumor again and the patient´s general health allows it.
If relapse occurs within half a year after surgery and completion of the first chemotherapy, the tumor does not seem to have responded sufficiently to the applied chemotherapy. Therefore, the chemical substance will be replaced typically by pegylated liposomal Doxorubicin, Topotecan or Paclitaxel. If no Bevacizumab was administered during the initial therapy, it can be added to the chemotherapy.
In addition, it is important to ask about the opportunities to participate in a clinical trial. As participation in a clinical trial can have an impact on your quality of life during treatment as well as on your prognosis.
Making decisions about your care:
The choice of therapy is an individual decision depending in particular on the location and size of the tumor(s), your age and general health status. It is important that you talk to your doctor in detail about the findings and the chances of recovery (prognosis) of your illness. Get a detailed explanation of the various therapy options and find out the possibilities of participating in a clinical trial. Well-designed, well-conducted clinical trials are the only way to determine the actual effectiveness of a promising new drug or intervention that is being studied.
The tremendous advances in the treatment of childhood cancer are a direct result of their participation in clinical trials. As more than 60 percent of children with cancer participate in clinical trials, whereas only 3% of adults with cancer do. The success of cancer therapy in children relates directly to this participation rate. For this reason, we recommend, if possible, participation in a clinical trial.
Should participation in clinical trials be the NEW standard of care for women with ovarian cancer?