Ovarian Cancer: Overview

Should You Get Screened?

No routine screening tests are recommended for women who are at average or low risk for ovarian cancer. And because symptoms can be subtle and hard to distinguish from everyday ailments like a stomach bug, SurvivorNet's medical experts say women need to know their family history, be vigilant for symptoms, and ask their doctor for testing if they have any unusual or persistent symptoms.

If you have a family history of breast or ovarian cancer, ask your doctor whether you should have genetic counseling and testing. Genetic testing for ovarian cancer can lead to life-saving actions, like tests for early detection. And when it comes to ovarian cancer, which has greater than a 90% survival rate when diagnosed in its earliest stages, genetic testing can be a valuable option.

Medical oncologist Dr. Derrick Haslem explains why women with a strong family history of ovarian cancer should talk to their doctor about genetic testing 

Screening is available for women with:

• A family history of ovarian cancer
• An inherited genetic condition like Lynch syndrome
• A mutation in a gene called BRCA1 or BRCA2
• A mutation in other genes associated with hereditary ovarian cancer
• Recurring symptoms of ovarian cancer

Doctors recommend testing women in these situations with a transvaginal ultrasound or CA-125 blood test.

For women at lower risk, the best chance of catching ovarian cancer early is to go to your doctor with any symptomssuch as bloating, abdominal pain, and changes in bowel habitsimmediately. It's important that women not be afraid to ask about their symptoms, because the sooner doctors can diagnose this cancer, the better the outlook will be.

Gynecologic oncologist Dr. Beth Karlan, on why it's important to push for a diagnosis if you have symptoms of ovarian cancer 

What are the Symptoms of Ovarian Cancer?

According to the medical oncologists SurvivorNet consulted, the symptoms of ovarian cancer can include:

• A feeling of bloating or fullness
• Pain in the pelvis or abdomen
• Nausea
• Vomiting
• Changes in bowel habits

Any of these can be similar to symptoms many women experience monthly with their menstrual cycle, which makes distinguishing this cancer so difficult.

Gynecologic oncologist Dr. Lisa Diver explains why ovarian cancer is called "the cancer that whispers," and why women need to advocate for themselves if they do have symptoms 

Additional ovarian cancer symptoms can include:

• Bleeding from the vagina (especially after menopause)
• Unusual discharge from the vagina
• Pain or pressure in the pelvis
• Belly or back pain
• Feeling full too quickly, or having difficulty eating
• A change in urinary or bowel habits, such as a more frequent or urgent need to urinate and/or constipation
• Extreme fatigue
• Pain during sex

If these symptoms are new for you, or they don't go away after a week or so, call your doctor and schedule an appointment.

Getting a Diagnosis

One thing that various types of ovarian cancer have in common: They're tricky to diagnose. Here's what you can expect to happen during your workup, according to SurvivorNet's specialists:

Medical history. Not only will your doctor ask you how long you've been experiencing these symptoms, but they will also want to know your family's medical history. Did any of your relatives have ovarian cancer or other types of cancer?  About 15% of ovarian cancer cases have a hereditary connection, mostly due to mutations in the BRCA1 or BRCA2 gene (which can also factor into breast cancers).

Physical exam. Once you're done talking, your doctor will examine you. Along with all the normal measurements — blood pressure, weight, etc. — they will most likely perform a pelvic exam. This should include a rectovaginal exam, so the doctor can feel the tissue behind the uterus where the ovaries are located.

Nurse navigator Cindy Cantril explains why it's important for women who are diagnosed with ovarian cancer to seek a second opinion

Imaging tests. In order for your doctor to get a better picture of what's happening, you may get a transvaginal ultrasound — an exam that uses ultrasound waves to help your doctor see your ovaries and other organs in your pelvis.

There's also a chance your doctor will want to do more in-depth imaging and send you for a computed tomography (CT) scan. This imaging test takes highly detailed cross-sectional pictures of your body, and it can show your doctor whether the cancer, if present, has spread to other organs or if lymph nodes are enlarged.

Blood test. Your doctor may also take a blood sample as part of the exam. The CA-125 blood test is a barometer for many ovarian cancers. If your doctor suspects you might have ovarian cancer, it can be very helpful. You should get it early in the course of your diagnosis, so your oncologist can monitor the progression of your disease and evaluate the impact any treatments have on it.

Getting diagnosed with ovarian cancer can be an anxiety-provoking experience. Physician's Assistant Marisa Gholson offers advice to help you manage your worries and be better equipped to handle your diagnosis.

Ovarian Cancer Treatment Options

If your doctor diagnoses you with ovarian cancer, you might be referred to a gynecologic oncologist. The following treatments are available for ovarian cancer:

Surgery Then Chemotherapy, or Vice-Versa

Surgery and chemotherapy both factor into treatment for most women with ovarian cancer. The only variation is the sequence in which women get them, according to SurvivorNet's experts.

Several factors go into deciding what kind of treatment is best, depending on the type and stage of ovarian cancer, your age, and whether you are planning to have children in the future. Surgery is usually the first treatment recommended, with chemotherapy afterward to get rid of any cancer that may have been left behind. The other option is to have chemotherapy first, called neoadjuvant chemotherapy, to shrink the tumor so that it's easier to remove surgically.

Should you get surgery first, or chemotherapy? Gynecologic oncologist Dr. John Nakayama outlines your options.

If a doctor is confident that he or she can remove the ovarian tumor completely without initial cycles of chemotherapy, they will go ahead with a surgical procedure. Doctors who are not confident they can perform successful surgical tumor removal will go with chemotherapy initially, then proceed with surgery once tumors have shrunk.

Chemotherapy

Chemotherapy can shrink ovarian cancers. The standard chemotherapy regimen for ovarian cancer is made up of two drugs in combination:

• a platinum-based chemotherapy drug like carboplatin or cisplatin
• a taxane chemotherapy drug such as paclitaxel (Taxol) or docetaxel (Taxotere)

Women with ovarian cancer typically get these treatments through an IV every three to four weeks. The usual course of chemotherapy is made up of three to six treatment cycles, based on the cancer stage, but different drugs have different treatment cycles.

Gynecologic oncologist Dr. Adam ElNaggar, on what you can expect if you get chemotherapy for ovarian cancer

Maintenance Therapy

After the initial treatment with surgery and chemotherapy got rid of as much of the cancer as possible, the next goal is to extend the amount of time before the cancer comes back. Doctors call this maintenance therapy, and for ovarian cancer it can include two drugs:

• bevacizumab (Avastin)
• olaparib (Lynparza), which is a PARP inhibitor

PARP inhibitors work by preventing cancer cells from repairing their damaged DNA. They have shown great promise in keeping the cancer from returning. These drugs can also now be used in the initial treatment of ovarian cancer.

Dr. Ursula Matulonis, chief of gynecologic oncology at Dana-Farber Cancer Institute, discusses how doctors are using PARP inhibitors to treat their patients with ovarian cancer

Late-Stage Ovarian Cancer Treatment

With stage IV ovarian cancer, the cancer cells have spread beyond the abdominal cavity to other organs. There may be tumors inside the liver (not just on the surface), inside the spleen, in and around the lungs or other organs outside the abdomen and pelvic region, and possibly in the bones, say SurvivorNet's experts.

Stage IV ovarian cancer can be treated like stage III, with surgery to remove the tumor and debulk the cancer, followed by chemo (and possibly the targeted drug Avastin). Another option is to try chemo first. Then, if the tumors shrink from the chemo, surgery may be done, followed by more chemo.

Can women with stage IV ovarian cancer be treated with surgery? Mayo Clinic gynecologic oncologist, Dr. Amanika Kumar, explains how your cancer's stage might affect the type of surgery you get to treat it 

Palliative care, which is aimed at improving comfort (but not at fighting the cancer), is another option. It doesn't replace chemotherapy, surgery, and other active treatments. You get palliative care along with these treatments to make you more comfortable.

Palliative care is a whole-patient approach to care, according to gynecologic oncologist, Dr. Daniel Metzinger 

The chemo drug carboplatin puts most of the women who receive it into remission, according to the medical oncologists SurvivorNet consulted. However, during the next five years, 70 to 80 percent of women who've gone into remission may have a recurrence, when their cancer comes back.

That's why post-treatment living entails surveillance visits every three months or so for the first two years of remission. These visits can help your doctors and care team monitor your body for any early signs of recurrence.

Typically, a surveillance visit for ovarian cancer will include the following:

• A physical exam, during which a doctor checks your body for any signs of recurrence
• A conversation about symptoms, including changes in bowel habits or an increase in pain
• A CA-125 blood test, which can indicate recurrence in cases where a woman does not have symptoms

Many women will be able to push these visits to every six months after the two-year mark, and then once a year after the five-year mark.