There are around 300 cases of new ovarian cancers diagnosed in NZ yearly. There is no evidence at present that screening for ovarian cancer helps to prevent the disease or increase survival rates.
There are several types:
- Epithelial ovarian cancer (EOC): About 85% of all ovarian cancers are epithelial which originate from the outer layer of the ovary. EOC is mostly a disease of postmenopausal women. The majority of ovarian cancers are already at an advanced stage when diagnosed, with significant tumour in the abdomen and surrounding tissue. Up to 16% of these cancers are hereditary
- Non-epithelial ovarian cancer: Germ cell tumors -these cancers account for around 5% of all ovarian cancers. Typically, they develop in very young women and originate from the hormone-producing tissues inside the ovary.
The information below relates to Epithelial ovarian cancer
Most women will have symptoms such as bloating which is persistent, feeling full quickly and difficulty eating, abdominal and pelvic pain and urinary symptoms. However, because they can be non-specific it is not uncommon that women do not seek medical advice until later.
A thorough investigation, using a combination of medical history and physical examination, blood tests (Ca125, CEA, Ca19-9) and imaging (ultrasound, CT scans) is done to enable accurate assessment of the patient’s condition and consideration of the best treatment options.
A thorough diagnostic ‘work-up’ is particularly important for women with the above symptoms that persist for longer than a month, and especially if they are over 40 years old or have a family history of ovarian or breast cancer.
All cancers cases are reviewed weekly in a multidisciplinary review meeting to plan management and ensure the highest possible standards of care are maintained. Better outcomes are achieved if management of women with ovarian cancer go through the multidisciplinary meetings.
Note: Not all lumps and cysts in the ovaries are cancerous – some may be benign (not cancerous).
Frozen Section – what is it?
If there is any concern regarding the nature (cancer or benign) of any ovarian mass, Dr. Tan will arrange a frozen section. This is a special assessment by a pathologist performed while you are asleep during the procedure on the abnormal tissue and the result is telephoned through to theatre. This enables a tailor made procedure to be performed immediately (all in the one procedure) pending the intraoperative pathology result and in your preoperative counselling with Dr. Tan, you would have agreed upon that you wish to have done depending on results: benign versus cancer. You also need to understand that this is accurate in 80% of cases.
The key to successful ovarian cancer treatment is the combination of surgery and chemotherapy. The timing of the combination of the two approaches may depend on patient’s age, general health and extent of disease. Options include upfront surgery followed by chemotherapy or upfront chemotherapy sandwiched with surgery and completion chemotherapy.
There will be different treatment options depending on whether the cancer is only inside the ovaries (in 10% to 15% of cases) or has spread to other areas of the abdomen (in 85% of cases). A decision on whether a surgical approach is best will be made following careful consideration of your pre-existing medical conditions as well as discussion at our Multidisciplinary Team Meeting by a panel of experts (pathologist, radiologist, gynaecological oncologist, medical oncologist and radiation oncologist)
In cases that do not appear to have spread a full Staging procedure is undertaken to check in all the usual places these tumor cells can be (e.g. lymph nodes). Fertility sparing procedures for appropriate tumours may be possible and will be discussed fully preoperatively.
If the tumour has spread, then the goal will be to remove all signs of visible disease, through a procedure known as a debulking operation. In addition to removing the ovaries and uterus, this procedure will also include extensive examination of all the usual places that tumour cells may hide, such as in the lymph nodes, liver, bowel, diaphragm, and other abdominal organs.
The gold standard is to achieve ‘optimal debulking’, which is when no disease is visible at the conclusion of the surgery. A certified gynaecological oncologist has the expertise and extensive experience necessary to ensure that there is a high chance of reaching this goal and will also discuss any available procedures that can help to preserve fertility, if appropriate, prior to surgery.
In most cases, chemotherapy is a vital part of the treatment for ovarian cancer. Chemotherapy is usually delivered intravenously (into the bloodstream) by a medical oncologist every 1 or 3 weeks. Chemotherapy typically starts a couple of weeks after discharge from hospital.
Chemotherapy can usually be arranged for closer to home for most patients who come from outside of Auckland.
In certain cases, depending on the distribution of the tumour, it may be considered more effective for the patient to undergo a course of chemotherapy before an operation in order to reduce the size of tumour so that surgery has a better chance of successfully eliminating all visible disease. Thus, a patient may be given three to four cycles of chemotherapy followed by a less extensive debulking operation, which is then followed by another three to four cycles of chemotherapy. This is known as ‘neoadjuvant chemotherapy with interval debulking’. This has been shown to achieve similar results and rates of survival compared to initial surgery followed by chemotherapy.
After the cancer is treated, Dr. Tan will discuss the best follow-up regime that is tailored to suit each individual patient. There are normally reviews every four to six months for the first two years, extending to 12-monthly reviews for the next three years. For patients living outside Auckland, arrangements can be made for on-going follow-up with their GP or Gynaecologist.
There is no evidence that regular blood tests and reviews improve outcome. However, it may be reassuring to have on-going follow-up for five years after diagnosis.
If the patient has had chemotherapy after surgery, follow-up may be shared Dr. Tan and the medical oncologist.
More important than planned follow-ups, should the patient develop any new symptoms or problems, she should contact us so a review by can be arranged.
Cancers of all types and stages may recur. Recurrence may be local in the pelvis or at distant sites (abdomen, lungs). Treatment of recurrent ovarian cancer depends on the type of cancer, the time interval between the first diagnosis of cancer and the recurrence (the longer the better) and the distribution of disease.
Survival rates for Epithelial Ovarian cancer depends on its stage. Survival for stage 1 ranges between 75% and 95% at five years. Survival for stage 3 or 4 ovarian cancer depends on how successful surgery has been and how much tumour had to be left behind after surgery but also depends on the response of the cancer to chemotherapy. There is no means way of predicting if an individual patient will respond to chemotherapy or not
Peritoneal Cancer starts in the lining of the abdominal cavity the ‘peritoneum’ which is like the plastic bag liner in which all your abdominal organs are contained. It should be regarded as a variety of ovarian cancer and is treated in an identical fashion and has identical outcomes. It is often only possible to establish the diagnosis of peritoneal cancer versus ovarian cancer once all the surgical pathology specimens have been processed