Each year, more than 300 women with endometrial, cervical, ovarian and other cancers of the female reproductive system receive treatment from Cleveland Clinic gynecologic oncologists, who collaborate closely with Clinic gynecologic pathologists, medical and radiation oncologists, and radiologists. Membership in the Gynecologic Oncology Group offers patients access to investigational treatments through more than 40 ongoing clinical trials. Additional studies offer patients access to the latest treatments under investigation.
What is Ovarian Cancer?
Ovarian cancer is expected to affect more than 20,000 new women in the United States in 2006 alone. This number has decreased slightly in recent years. However, we continue to see nearly 15,000 women die each year from this disease. The most common type of ovarian cancer starts on the surface of the ovaries and is called epithelial ovarian cancer. It accounts for approximately 80% of cases. Risk factors for the development of ovarian cancer include older age, women who have never had children, Caucasian race, infertility, early age for first menstrual period or late age for last menstrual period, and family history of breast or ovarian cancer. A few things seem to be protective from ovarian cancer including multiple pregnancies, oral contraceptive use, tubal ligation, and hysterectomy.
What are the symptoms?
Signs and symptoms for ovarian cancer are often times "whispers" that occur. Unfortunately there are no symptoms of early ovarian cancer. Women typically seek medical care when they notice abdominal swelling due to the fluid that accumulates in the abdomen from ovarian cancer. Women may also notice urinary changes such as increased frequency or discomfort with urination. Many women with ovarian cancer also complain of abdominal bloating, gas, heartburn, or intolerance to certain foods prior to the diagnosis. When these symptoms occur the tumor has often already spread outside of the ovary. The absence of symptoms with early ovarian cancer is the main reason that more than 70% of women are diagnosed with advanced stage disease. Additionally, there is no reliable screening test for ovarian cancer.
How is it diagnosed?
Although we do not have a screening test designed for the general population there are women who are considered high-risk based on their family history. These women have either had a breast cancer themselves, have two or more close blood relatives with breast or ovarian cancer, have one close relative with breast or ovarian cancer and are of Ashkenazi Jewish origin, or carry a mutation in one of the breast-ovarian cancer susceptibility genes: BRCA1 or BRCA2. These genes are more common in women of Ashkenazi Jewish origin where carrier rates are up to 2%. Being a carrier of one of these genes gives these women a lifetime risk of ovarian cancer of 25-60%. This is much higher than the 1.5% lifetime risk in the general population. For this reason women with the above risk factors are offered genetic counseling, genetic testing, elective preventive removal of the fallopian tubes and ovaries (prophylactic bilateral salpingo-oophorectomy), or close surveillance. Screening for these women consists of twice yearly pelvic exams, twice yearly blood testing for Cancer Antigen-125 (CA-125), and once a year transvaginal ultrasounds. Unfortunately, these tests are not available for women without a strong family history of breast or ovarian cancer because of the low prevalence of the disease in the general population and because the tests cannot accurately predict who actually has a cancer rather than a benign finding. We are currently enrolling high-risk women into clinical trials involving prophylactic surgery or surveillance and are always looking to identify new tests that may be used to screen the general population.
What are the treatment options?
The options for the treatment of ovarian cancer mainly involve surgery and or chemotherapy. Most women suspected of having ovarian cancer are found to have a mass on examination, ultrasound, or CT scan. Any woman with a new mass should then undergo a pre-operative workup including a CA-125 and many times a CT scan if one was not done previously.
The optimal management for women suspected of having ovarian cancer is to undergo surgical removal of the mass with pathologic evaluation of the mass during surgery. If a cancer is identified by the pathologist a complete staging procedure should take place and all visible tumor should be removed. Complete staging includes: removal of the uterus (hysterectomy), fallopian tubes and ovaries (bilateral salpingo-oophorectomy, pelvic and para-aortic lymph nodes), omentum (a fatty apron attached to the large intestines), and biopsies of the lining of the abdominal cavity. If the tumor has spread inside the abdominal cavity, women sometimes require removal of part of the intestines, the spleen, or bladder to remove as much of the visible tumor as possible. The ability to perform comprehensive staging and removal of the largest bulk of tumor has been shown to be best performed by a gynecologic oncologist, surgeons specially trained to treat gynecologic cancers.
Stages of Ovarian cancer
- Stage I Tumor limited to one or both ovaries
- Stage II Tumor limited to ovaries and other pelvic structures
- Stage III Spread to upper abdomen, pelvic or abdominal lymph nodes
- Stage IV Spread to the liver, lungs, or outside of the abdominal cavity
Occasionally, patients will have a hysterectomy or an ovary removed at another hospital and will not have complete surgery or staging. In these cases, we offer repeat surgery to complete the staging since up to one-third of women will be found to have more advanced disease when the proper surgery is completed. Occasionally we see ovarian cancers in young women who have not completed their childbearing. For these patients, comprehensive surgical staging would include removing only the fallopian tube and ovary, the lymph nodes, omentum, and biopsies. The other fallopian tube, ovary, and uterus are left in place to preserve fertility in the future.
Following surgery for ovarian cancer, chemotherapy is used to treat small cells left behind at surgery and microscopic cells that may be elsewhere in the body. Most women with ovarian cancer will have chemotherapy following surgery unless they have cancer only within the ovary and the cells do not look aggressive under the microscope (ie: a low grade tumor). Typically two to three drugs are given in combination at set intervals. The most common approach is to give carboplatinum and paclitaxel intravenously every three weeks for six to eight treatments. More recently, attention has been given to delivering chemotherapy directly into the peritoneal cavity where the tumor resides (Intraperitoneal chemotherapy). Although this approach has significantly more toxicity, it may provide women with a better survival rate or longer time to recurrence. More research regarding this mode of chemotherapy is underway both locally and nationally. Both routes (intravenous and intraperitoneal) are available to patients here at The Cleveland Clinic.
How is it followed after treatment?
Once treatment is completed, patients are started on a surveillance program to identify women who develop recurrence of their ovarian cancer. Currently we expect as many as 60% of women with advanced ovarian cancer to have a recurrence of their disease. Women are typically seen every three months for the first two years, every four months for the third year, every six months during their fourth and fifth years, and then annually. Follow-up usually consists of a review of the history, a physical examination, and measurement of CA-125. CT scans are performed when indicated based on exams and CA-125 levels.