Ovarian cancer

Content

Introduction

Introduction

Ovarian or ovarian cancer is one of the most common types of cancer in women, in fact it represents about 30% of malignant tumors of the female genital system and occupies the tenth place among all cancers in women, with 3% of cases.

The ovaries are a pair of small symmetrical organs located on the sides of the uterus, in the lower part of the abdomen (pelvis). They perform the function of storing the quantity of eggs necessary for the entire fertile period of the woman.

Ovarian cancer occurs mainly after menopause; usually over the age of 50 but sometimes also in younger women. To date, the exact cause is not known but some factors are known that increase the risk of its occurrence. They can be hormonal, environmental and genetic-familial in nature. Ovarian cancer therapy consists in its surgical removal and in chemotherapy.

Symptoms

Symptoms

The most common disorders (symptoms) caused by ovarian cancer include:

  • constant feeling of bloating, especially the belly
  • discomfort in the lower abdomen and in the pelvic area
  • feeling of fullness during a meal or even loss of appetite
  • need to urinate more often than normal and with greater urgency

Often they are not easy and immediate to recognize because they are similar to those of the more common irritable bowel syndrome or pre-menstrual syndrome.

Other, less common, possible disorders are:

  • persistent indigestion or nausea
  • panic attacks during sexual activity
  • backache (low back pain)
  • vaginal discharge particularly after menopause
  • continuous feeling of tiredness
  • unintentional weight loss

It is important to see a doctor in the presence of risk factors such as "age over 50, family members with ovarian or breast cancer" (family history) or the appearance of one or more persistent complaints (symptoms).

However, it is advisable to undergo periodic checks. The attending physician will be able to prescribe simple analyzes that allow to exclude this type of carcinoma or, in any case, through a very early diagnosis, allow its treatment.

Causes

Causes

In ovarian cancer, cells in the ovary grow and multiply excessively, thus producing cancer. It is not known exactly how this happens, but some factors can increase the risk of developing ovarian cancer:

  • be over the age of 50, about 8 out of 10 cases are known (diagnosed) in women over the age of 50, mostly after menopause
  • have close family members, like a sister or mom, who are, or have been, people with breast or ovarian cancer. This could increase the risk of having inherited genes such as BRCA1 and / or BRCA2 which increase the risk of developing cancer; in this case, it is advisable to talk to your doctor who could propose genetic counseling to undergo predictive tests to search for any defective genes. It is important to know that only 1 in 10 cases of ovarian cancers have the mutated BRCA gene
  • take hormone replacement therapy, although the increased risk of developing cancer is very low and appears to decrease after ceasing treatment
  • suffer from endometriosis, a condition characterized by the presence of cells of the uterus also outside it, for example in the ovaries or other organs located in the belly. During the period of menstruation these cells behave as if they were still in the uterus and bleed. However, by being trapped in the organs and unable to escape, the blood can cause pain

Other factors that can increase the risk of ovarian cancer are:

  • overweight or obesity, losing weight through regular physical activity and a healthy diet can help lower your risk
  • smoke, quitting smoking can help reduce the risk of both ovarian cancer and other serious diseases
  • use of talc, some research has suggested that the use of talcum powder between the legs could increase the risk of ovarian cancer. This evidence, however, is not that strong and even if there is a potential risk it is certainly low.
  • exposure to asbestos
Diagnosis

Diagnosis

If you experience symptoms (symptoms) due to the presence of ovarian cancer, you must go to the doctor who will be able to:

  • ask to describe the annoyances and general health
  • lightly palpate the belly (abdomen and pelvis) to check for any swelling, blood clots or fluids
  • ask if in the family (family history) there have been cases of ovarian cancer or breast cancer
  • take a blood sample to be sent to the analytical laboratory to look for a substance called CA125

In some cases, he will prescribe further tests to be carried out directly in the hospital by a specialist, usually the gynecologist, without having to undergo a blood sample first.

Blood test (CA125 test)

If the doctor suspects that the symptoms (symptoms) may be due to ovarian cancer, he will order a blood test to check whether the levels of a substance, called CA125, are normal or not.

CA125 is produced by some ovarian cancer cells. A large amount in the blood could signal the presence of the tumor. However, an increase in CA125 could also be due to less serious reasons, such as endometriosis, fibrosis and even pregnancy.

If the test result indicates a high value of CA125, it will be necessary to undergo further tests to find out the possible causes.

Sometimes the amount of CA125 may be normal in the early stage of ovarian cancer development. If you have a normal test result but your symptoms do not improve, then you need to go back to your doctor for a visit and possibly retest.

Ultrasound examination

The doctor, if the blood test has suggested the possible presence of ovarian cancer, will prescribe an "ultrasound. This is a test that uses ultrasound to obtain an" image of the inside of the body.
There are two ways to do ovarian ultrasound:

  • abdominal, requires that a small device, called an ultrasound probe, is passed over the belly (abdomen) to obtain an "image of the ovaries
  • transvaginal, consists in inserting the ultrasound probe inside the vagina to obtain a clearer image of the ovaries

The ultrasound image can show any changes in the ovaries that may have been caused by the tumor or other problems such as endometriosis or fluid accumulation.

In case of anomalies, the doctor will ask for a specialist visit to carry out further investigations in order to confirm the cause.

Further tests

To confirm or rule out ovarian cancer, the specialist doctor may prescribe:

  • CT exam, involves taking many X-ray plates from different angles to get a detailed picture of the ovaries
  • radiography of the chest, allows you to check whether the cancer has spread to the lungs
  • needle biopsy, consists in inserting a needle into the ovaries, passing through the abdomen, to take a sample of cells (or the liquid that surrounds them) to be analyzed under a microscope to verify the presence, or not, of cancerous cells
  • laparoscopy, consists in inserting a thin tube, with a camera at the end, in a small cut made on the belly to examine the ovaries and take a piece of tissue to be analyzed

In the case of ovarian cancer, these tests (diagnostic tests) can be useful to know if, and how much, the cancer has spread.

Stages and degrees of ovarian cancer

In case of detection (diagnosis) of ovarian cancer, the so-called staging, namely the verification of the stage of development in which it is found:

  • stage 1, the tumor is confined to only one or both ovaries
  • stage 2, the tumor has spread to the pelvis or uterus
  • stage 3, the tumor has spread inside the belly, on the surface of the kidney or in the lymph glands of the pelvis or uterus
  • stage 4, the cancer has spread to other parts of the body, such as the liver or lungs

The tumor will also be assigned a degree which corresponds to the forecast of its speed of growth and diffusion. We go from grade 1, which corresponds to a slow growth, al grade 3 which identifies probable fast growth.

Therapy

Therapy

Ovarian cancer treatment (therapy) varies according to the stage of the cancer, the general health of the affected person and his age.

Most sufferers receive dual treatment: surgery and drug treatment, la chemotherapy.

If the cancer is too advanced to be treated, then the goal will be to improve the symptoms (symptoms) and limit their growth for as long as possible.

Patients are usually followed by a team of doctors who identify, on a case-by-case basis, the best therapy and guarantee support throughout the treatment process.

Surgery

The primary treatment of ovarian cancer is surgical. The aim is to eliminate all or as much of the tumor as possible.
Surgery usually removes:

  • both ovaries and fallopian tubes
  • uterus (hysterectomy)
  • layer of fat tissue in the belly (omentum)

If the tumor is present in only one or both ovaries, then it will be enough to remove them and leave the uterus intact. This means that you will still be able to have children.
The surgery is performed under general anesthesia. You will probably only have to stay in the hospital for a few days, but it may take several weeks for the body to fully recover.

Chemotherapy

Chemotherapy is a treatment, consisting of drugs, which aims to eliminate cancer cells. The majority of women with ovarian cancer undergo chemotherapy in addition to surgery.
It is used in the following cases:

  • after surgical removal of the ovaries, in order to eliminate any cancerous cells that may be left
  • before surgery, to reduce the size of the tumor and make it easier to eliminate
  • in case the ovarian cancer comes back (relapse) after initial treatment

The chemotherapy drug is usually injected into a vein in the arm in small drops; sometimes, it is given in tablets. To undergo the infusion into a vein it is necessary to go to the hospital but at the end of each session it is possible to go home.

The treatment is organized in cycles that provide for a period of drug administration alternating with a period of suspension, to ensure that the body rests.

Possible side effects (side effects) of chemotherapy are:

  • tiredness
  • general malaise
  • loss of appetite
  • hair loss
  • diarrhea
  • increased risk of infections

Most unwanted effects can, however, be alleviated with the use of medications recommended by the doctor. Once the treatment is complete, the side effects usually disappear.

Radiotherapy

Radiation therapy is based on the use of beams of radiation directed precisely at cancerous cells to eliminate them. It is not used very often in the treatment of ovarian cancer, but it is possible to apply it:

  • after surgical removal of ovarian cancer in its initial stage, in order to eliminate any remaining cancer cells
  • to shrink the tumor, and the disorders (symptoms) it causes, if it is already widespread and can no longer be treated with the aim of healing it

The most common side effects (side effects) of radiation therapy are irritated skin, tiredness and loss of hair or hair in the affected area. These effects should pass once the treatment is finished.

Clinical trials

The objective of the current research is to discover new and better treatments for ovarian cancer and to confirm their effectiveness through studies called clinical trial (s). Recent results have shown the possibility of identifying new therapeutic targets (new molecules) for ovarian cancer, which will be available in the coming years and will help make cancer treatments more targeted and effective (therapeutic target means a determining factor for development a disease, such as a mutated gene, against which a specific drug can be used).

In particular, the data relating to three studies published in December 2019 by the prestigious New England Journal of Medicine, demonstrated the efficacy of the group of drugs, inhibitors of the PARP (poly [adenosine diphosphate-ribose] polymerase) family of proteins, in the significantly lengthen disease-free survival in women with high-grade serous ovarian cancer, both associated with the BRCA gene mutation and in the presence of a normal BRCA.

It will be the group of treating doctors to suggest the possible possibility of participating in a trial clinical if the necessary admission (inclusion) criteria are met and there is no effective treatment among those already tested.

Prevention

Prevention

In people with early stage ovarian cancer, with cancer limited to the pelvis, radical surgery is curative in 70% of cases. Unfortunately, due to the delay with which ovarian cancer symptoms are usually recognized, about 75-80% of people have advanced cancer by the time the disease is ascertained.

The first prevention, therefore, is not to underestimate any disorder that could be associated with ovarian cancer especially in the presence of risks considered higher than others such as, for example, being over 50 years old, being in menopause or having family members already affected by ovarian or breast cancer It should be emphasized that 80-85% of ovarian cancers are isolated cases, called sporadic, while those of hereditary type are a minority (10-15%).

In the presence of two or more cases of ovarian or breast cancer in the family, both on the part of mother and father, it is advisable, especially if this generates concern, to speak to the doctor. They will be able to provide more information about the level of risk and arrange for a consultation with a medical geneticist to decide whether or not to undergo a predictive genetic test. The test will highlight the possible presence of alterations in the BRCA1 or BRCA2 genes that could increase the risk of developing ovarian or breast cancer in the future.

Another way to prevent the disease is to follow a healthy lifestyle:

  • maintain a healthy weight or, if you are overweight, lose weight by engaging in "regular physical activity and a balanced diet (diabetes also appears to be associated with an increased risk)
  • stop smoking (smoking can increase the risk of some types of ovarian cancer)
  • pay attention to some environmental agents such as the use of talcum powder between the legs and exposure to asbestos

A small increase in risk is caused by hormone replacement therapy, during menopause, and by the use of the combined contraceptive pill, in childbearing age. People who use it should consult with their doctor to assess how much, in their case, the benefits are important over the risks.

Natural factors that protect against ovarian cancer are pregnancy and breastfeeding. In both cases, in fact, the ovaries remain at rest and do not ovulate during the entire period. Women who have their tubes tied because they chose not to have more children (sterilization) also have a lower risk of developing cancer. The removal of the uterus, on the other hand, does not seem to reduce the risk. If, in addition to the uterus, the ovaries are also removed, the risk of cancer is reduced, but the consequences deriving from their absence must be evaluated with the doctor.

Ovarian cysts are very common in women, especially during the childbearing age, because they are linked to ovulation. Most often, a cyst forms and then disappears without the woman noticing. This type of cyst does not increase the risk of developing ovarian cancer. In postmenopausal women, the presence of a cyst should be investigated with transvaginal ultrasound and with the blood test of CA125.

Polycystic ovary syndrome does not appear to cause an increased risk of ovarian cancer.

Irritable bowel syndrome causes disorders (symptoms) very similar to those of ovarian cancer but very rarely appears for the first time after the age of 50. A woman of this age, therefore, will need to undergo appropriate tests for ovarian cancer if she experiences any complaints.

Living with

Living with

Living with cancer can affect your days during and after treatment.
Surgical removal of the tumor is an operation that can take up to three months for complete recovery. In the first two weeks it is recommended to face the difficulties with greater patience, to rest as much as possible and not to stand too much upright. In the following weeks you can gradually return to normal activities. Already during hospitalization, the difficulties that could occur and the behaviors to follow when returning home will be explained to favor a complete recovery:

  • need for a period of absence from work
  • difficulty driving in the first month
  • ban on lifting weights and carry out heavy physical exercise in the first three months

The help of a physiotherapist, and specific exercises, could be useful for promoting physical recovery.

If both ovaries have been removed in childbearing age, you will enter menopause. In this case, the doctor, after appropriate evaluation, may suggest hormone replacement therapy to reduce the related disorders until the natural age of menopause (45-55 years) is reached.

Appointments for the Follow-up

Once the treatment is over, regular checks will be necessary to follow the progress of the disease. Initially, they will be carried out every two to three months but over time, and on a case-by-case basis, they will become less frequent.

Appointments with the treating doctor are a good opportunity to talk about problems that have arisen or doubts that need to be clarified. In the presence of disorders that reappear after treatment, however, it will not be necessary to wait for the next appointment to talk to the doctor but it will be necessary to inform him immediately.

It is quite common, in fact, for ovarian cancer to return (relapse) within a few years from the end of treatment, therefore, regularly undergoing the necessary blood tests and / or radiographs is essential to immediately discover any relapses.

Help and support

Finding out that you have cancer can be a huge challenge for the person affected, for their friends and family, both practically and emotionally.
It may help to express your feelings or fears and talk about them:

  • with the doctors following the therapy and with your doctor. They might suggest a professional for psychological help
  • with friends, or with family members, telling them about their feelings and moods and explaining what they could do to help. If you want to have time for yourself, don't be afraid to say it clearly
  • contact a group, many organizations have a toll-free number, an online forum, mutual aid groups where you can meet other people who live in the same situation

Sex and fertility

Cancer can affect sexual life in many ways.
After the operation it will be necessary to avoid sexual activity until the wound has healed well. Even after that, it may be more difficult to have sex. Many women take a long time to feel ready. This could depend on the state of menopause induced by the operation or even the fatigue and emotional stress resulting from the diagnosis and treatment. It is advisable to tell your partner how you feel and not force yourself to have sex if you are not ready.

Fertility and pregnancy

In some women, ovarian cancer therapy could cause premature menopause and therefore the inability to have children. It is advisable to discuss this with the treating doctor because in the case of early stage cancer it is possible to receive treatment that preserves fertility.

On the other hand, if you have lost fertility, it is normal to feel a feeling of loss or pain. It is helpful to discuss these feelings with your partner, friend, relative, or doctor.

If your treatment includes chemotherapy while you are still able to have children, you will be advised to avoid becoming pregnant in the first two years after treatment.

Costs and benefits

People who due to illness are forced to reduce working hours or no longer be able to work, could have financial problems. They should talk to the hospital social worker who follows them to find out about their rights regarding benefits at work and to receive all useful information. They can also contact their primary care physician to be informed about the drug, testing and testing exemptions that you are entitled to for the type of disease. Care may also include psychological, social and spiritual help for sick people, family members or the person caring for them.

Bibliography

Bibliography

Italian Association of Medical Oncology (AIOM). Ovarian Cancer Guidelines 2018

NHS Choices. Ovarian cancer (English)

Target Ovarian Cancer. Ovarian cancer information and support (English)

Dan Longo L, M.D. Personalized Medicine for Primary Treatment of Serous Ovarian Cancer. New Englamd Journal of Medicine. 2019; 381: 2471-4

In-depth link

In-depth link

Italian Association of Medical Oncology (AIOM)

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