The ovaries are two glands that are part of the female reproductive system. Their main functions are the production of eggs and the manufacture of female sex hormones. The term ovarian cancer refers to a group of tumors that can affect different tissues of this organ.

Ovarian cancer occurs when some cells in the ovary undergo a transformation that makes them cancerous. Under certain conditions, an abnormal cell can start to proliferate out of control and lead to the formation of a malignant ovarian tumor.

In 90% of cases, ovarian cancers are epithelial tumors, or adenocarcinoma. They develop from the superficial cells of the ovaries. Adenocarcinomas affect mostly postmenopausal women and their diagnosis is often late.

More rarely, ovarian cancers arise from cells involved in the production of eggs. These are then “germ cell” tumors. They generally concern premenopausal women.

According to the Centers for Disease Control and Prevention (CDC), in United States, ovarian cancer is considered rare, accounting for around 22,000 cases cases per year against 280,000 for breast cancer. However, ovarian cancer is much more deadly with nearly 14,000 annual deaths. Indeed, about 3 in 4 ovarian cancers are discovered at an advanced stage due to a lack of early symptoms.

Symptoms of ovarian cancer

In ovarian cancer, very non-specific symptoms such as bloating and digestive problems, abdominal pain, decreased appetite or more frequent urination usually occur. If these symptoms occur suddenly and do not disappear after a short time, or if they are not temporally related to normal menstrual bleeding or occur after menopause, they can be a possible warning sign for ovarian cancer.

Over time, other symptoms may be added, such as feeling of pressure in the upper abdomen, feeling full or nausea, as well as general fatigue and exhaustion. A heavy weight loss, which also leads to an increase in abdominal circumference, may also indicate ovarian cancer.

However, keep in mind that these symptoms are not specific to ovarian cancer, and may be due to other health conditions. But, the appearance of such symptoms for no apparent explanation and their persistence should lead to a consultation with your attending physician to complete a possible assessment that can guide the diagnosis.

Risk factors of ovarian cancer

Certain factors unique to the individual or caused by their environment can increase the likelihood of developing ovarian cancer. Having one or more risk factors for a disease does not necessarily mean that you will develop it, the opposite being true as well. For example, a non-smoker can develop lung cancer. However, smokers are 10 times more likely to develop lung cancer than an individual who does not smoke.

• Age

An older woman is more likely to have abnormal cells that progress to cancer than a younger woman. It is for this reason that the average age at diagnosis is 65.

• Genetics

It has been established that approximately 10 to 15% of epithelial tumors in the ovary are of genetic origin. In 9 out of 10 cases, the mutation affects the BCRA1 and BCRA2 genes which are also known to greatly increase the risk of breast cancer. A woman carrying mutated versions of BCRA1 and BCRA2 has a cumulative risk of developing breast and/or ovarian cancer estimated at 70% at age 70.

Genetic screening may be considered if the woman is related to the first degree (mother, child, sister) to a person who has been affected by this type of tumor, especially at a young age (40-50 years). If a genetic anomaly is detected, a close and individualized follow-up will be offered to the patient. A woman at risk will thus benefit from appropriate monitoring in order to detect any possible abnormalities at a very early stage.

• Hormonal factors

Data from studies of populations of women seem to show that a woman’s hormonal history influences the risk of ovarian cancer. Indeed, a large number of pregnancies, breastfeeding and the use of oral contraceptives (the pill) seem to reduce the risk of developing an ovarian tumor. While late menopause, taking hormone replacement therapy, or an early puberty appear to increase the risk of ovarian cancer.

• Smoking

In 2009, the International Agency for Research on Cancer (IARC) concluded that there was sufficient evidence for a causal link between active smoking and a specific type of epithelial ovarian cancer: mucinous tumors.

Recent studies have also shown that women who smoke are approximately 1.5 times more likely to develop a mucinous tumor than women who do not smoke. However, smoking does not seem to be a risk factor for ovarian cancer in general, it is even slightly protective for certain rare types of ovarian cancer.

• Exposure to asbestos

Since 2009, asbestos has been recognized as a definite carcinogen for the ovaries (IARC). Many states around the world have banned the use of asbestos. But even in these countries, the burden of asbestos-related pathologies is still increasing, due to the long latency periods between exposure and notification of these diseases. In addition, asbestos continues to be exploited in some countries in Asia, the Middle East, South America and the former Soviet Union.

Diagnosis

If you visit your gynecologists’ (gynecologist) with these or similar ailments, in addition to a detailed conversation about your medical history (anamnesis), he or she will perform speculum and a touch examination of the vagina, uterus and ovaries as a first step to determine any changes.

An ultrasound examination of the internal genital organs is also one of the first diagnostic steps. With the help of a special ultrasound probe inserted into the vagina (transvaginal ultrasound), the doctor can check the ovaries for irregularities and determine whether they are enlarged or whether there are indications of a pathological change.

If, after these examinations, there is a suspicion of a tumor disease of the ovaries, your doctor will take further steps to take a closer look at the ovaries and abdominal cavity. If a tumor is present, it is important to determine its exact location, size and extent. In addition, the entire abdominal cavity must be examined to determine whether other organs also show changes that indicate cancer. Therefore, a CT (computed tomography), an MRI (magnetic resonance imaging) or a PET (position emission tomography) CT of the abdominal cavity is used for further clarification. All these studies allow sectional images of individual body regions and are usually not associated with any inconvenience. In addition or alternatively, the abdominal cavity and the lymph nodes can in some cases also be assessed by ultrasound examination.

If these examinations identify pathological changes to individual organs, your doctor will decide individually whether further organ-specific examinations are necessary.

In addition to the imaging methods mentioned, a blood test is one of the necessary diagnostic steps. In this process, so-called tumor markers are usually determined. Tumor markers are molecules that are often formed by tumors themselves or whose concentration in the blood is related to tumor diseases. With regular determination, they can provide information about the course of the disease during therapy or help to detect a recurrence at an early stage.

All of these steps are used to estimate the probability of malignant disease and to get an overview of the possible spread. They can corroborate the suspected diagnosis, but they cannot give 100% certainty as to whether it is actually ovarian cancer. Ultimately, this can only be determined by a fine-tissue (histological) examination of the tumor, i.e. the cells of the tumor must be examined under the microscope. For this it is necessary to take a tissue sample (biopsy) of the tumor. This is usually done as part of a operation, which is also the first therapeutic step.

What happens during the surgery?

If, after all the tests mentioned above, there is an urgent suspicion of ovarian cancer, surgical intervention is necessary to ensure both diagnosis and therapy. As a rule, a so-called laparotomy (abdominal section) is performed and first the entire abdominal cavity is examined for tumor sieves. A tissue sample is then taken from all conspicuous sites and immediately sent to the laboratory for fine-tissue examination.

After that, the goal of the operation is the complete removal of the tumor. In order to provide the best possible chances of a complete cure, the entire tumor tissue must be removed from the abdominal cavity. In most cases, a very extensive surgical procedure is chosen to ensure that no cancer cells remain in the body – even those that may already be scattered but not yet visible. The standard method is the removal of both ovaries and fallopian tubes, the uterus, the large abdominal mesh, parts of the peritoneum and usually also the adjacent lymph nodes. Depending on the tumor spread, the appendix or other parts of the intestine may also be removed.

In some cases, a less extensive operation may be performed. If the tumor is limited to only one ovary and shows little growth, the second ovary and the uterus can be left in the body if necessary. Whether this is possible depends primarily on the stage of the disease, in addition to the type of tumor.

Stages of ovarian cancer

The findings of the preliminary examinations are supplemented or confirmed by the exact inspection of the entire abdominal cavity and the taking of individual tissue samples during the operation. In this way, it can be determined how far the tumor has spread in the abdominal cavity and whether there are settlements in other organs. This will allow your doctor to determine the stage of the disease you are at. Roughly, the individual stages can be summarized as follows:

• Stage I: The tumor is limited to one or both ovaries.
• Stage II: The tumor has spread in the pelvis (e.g. on the opium tubes).
• Stage III: The tumor has spread outside the pelvis in the abdominal cavity (e.g. on the peritoneum). Even if nearby lymph nodes are affected, it is called stage III.
• Stage IV: Also outside the abdominal cavity, daughter tumors (metastases) are found in other organs (e.g. in the liver).

The classification of the disease into stages is important so that your doctor can determine the best possible therapy for you individually. In addition, tumors of the ovary are also assessed on the basis of the histological findings. In the healthy ovary there are various cell types from which a tumor can develop; based on this, a distinction is made between histologically different types of tumors. The so-called degree of differentiation of the tumor tissue is also determined, i.e. how much the cells resemble the healthy ovarian cells. These characteristics can provide clues for the further course of the disease and determine the subsequent therapeutic procedure.

Treatment of ovarian cancer

The extent of the operation and what treatment options are specifically available for you depend on the stage of the disease, the type of tumor and your general health condition.

Several physicians from different disciplines (e.g. gynecology, surgery, oncology) are usually involved in the planning of the individual therapy strategy. This collaboration between different experts is called a tumor board. The aim is to ensure that all important factors are taken into account and that the optimal treatment options are found for you individually.

In most cases, ovarian cancer is followed by chemotherapy (adjuvant chemotherapy) after surgery. The aim is to destroy cancer cells that may be left behind in the body, thus reducing the risk of recurrence of the tumor or the formation of metastases. This can improve the chances of a long-term cure. Drugs used for chemotherapy (so-called cytostatics) are administered in several cycles and attack mainly those cells that divide particularly quickly – primarily damaging the tumor tissue. However, rapidly growing healthy cells are also attacked, often causing undesirable side effects. Ask your doctor what side effects are likely to happen and discuss with him the ways to alleviate them.

A relatively new, additional treatment option for ovarian cancer in advanced stages is the use of so-called targeted therapies. Active substances of this group specifically attack certain structures in cancer cells, which are responsible for the formation and growth of a tumor. Healthy cells are largely spared. The active substance used to treat ovarian cancer is directed against the ability of cancer cells to develop new blood vessels. If the blood supply of the tumor is suppressed, it can no longer divide and continue to grow. In this way, the propagation of cancer cells can be stopped and the progression of the disease can be stopped. This form of therapy can improve the success of chemotherapy – but it is not free of side effects either. Your doctor will inform you whether this particular type of therapy is appropriate for you will educate you about the individual benefits and possible side effects.

The effects of ovarian cancer treatment

In most cases, surgery, in particular, brings about lasting changes. In the majority of patients, both ovaries and fallopian tubes as well as the uterus are removed, which makes pregnancy no longer possible after treatment. Especially for young women with a desire to have children, this is often a great burden at first – but it is the necessary step to achieve the best possible chances for a long-term cure. Only in the case of very small tumors at an early stage of the disease can the unaffected ovary and uterus be left in the body, thus preserving fertility. Talk to your doctor about whether this is an option for you. He or she will also help you to weigh up the pros and cons of this method and make the right decision for you.

Surgical removal of the uterus and ovaries also leads to a sudden loss of ovarian hormones. Menstruation is absent and young women go early into menopause, which can lead to the occurrence of typical menopause symptoms, such as hot flashes, mood swings or sleep disturbances. This, too, can be very stressful, especially for young women. Ask your doctor about ways to alleviate any discomfort. He or she will help you as much as possible to maintain a good quality of life even after the operation.

What further consequences you may have after the surgery depends primarily on the necessary extent of the procedure. Depending on how far the disease has progressed, it may sometimes be necessary to surgically remove other organs or parts of organs. Your doctor will inform you about the immediate or long-term consequences of the operation in your particular case. It can also help you get the right support for the post-surgery period.

In conclusion

If you have been diagnosed with ovarian cancer, you will have some important decisions to make. Often, the benefits and risks of individual therapies have to be weighed against each other. You have the right to let all the information go through your mind in peace. Also talk to your doctor openly about your concerns and ask any questions that seem important to you. he or she will help you make the best decision.

The earlier you were diagnosed with the disease, the better the chances of a long-term cure. In addition, there are now good ways to stop the progression of the disease and to maintain a good quality of life.

In any case, cancer means a serious cut in life. It’s not easy to cope with such a burden – don’t forget that you don’t have to be on your own. Experts from the field of psycho-oncology, psychology or other affected women can accompany you through this time, search for solutions together with you and help you to look positively into the future.