The Farber Center: For Radiation Oncology

• Ovarian cancer happens when cells that are not normal grow in one or both of your ovaries. In most women with ovarian cancer, the cancer has already spread (metastasized) outside the pelvis by the time it is diagnosed.
• Advanced-stage cancer spreads most commonly to the lining of the abdominal cavity, the pelvic lymph nodes, and the fatty tissue around some of the abdominal organs.
• The exact cause of ovarian cancer is unknown.
• Some women are more likely than others to get this rare cancer. Women who are past menopause or who have never been pregnant are more likely to get ovarian cancer.
• There are three main types of ovarian cancer. The type is determined by the location in the ovary where the cancer develops.
• Epithelial cancer, which develops in the cells on the surface of the ovary. This is the most common form of ovarian cancer, accounting for about 90% of all ovarian cancers.
• Stromal cell cancer, which develops in the deeper supportive tissue of the ovary. Stromal cell cancer is present in 5% to 8% of all ovarian cancers.
• Germ cell cancer, which develops in an egg cell produced in the ovary. Germ cell cancer is present in less than 5% of all ovarian cancers and most typically occurs in girls and young women.

In many cases, ovarian cancer may not cause early symptoms. The most common symptoms of ovarian cancer include:

• Recent, frequent bloating.
• Pain in your belly or pelvis.
• Difficulty eating or feeling full quickly.
• Urinary problems, such as an urgent need to urinate or urinating more often than usual.

Other symptoms that affect some women with ovarian cancer include:

• Fatigue.
• Indigestion.
• Back pain.
• Pain with intercourse.
• Constipation.
• Menstrual cycle changes.

Risk Factors:

• Family history: Between 10% and 20% of women with ovarian cancer have a close female relative who had ovarian or breast cancer.
• BRCA1 or BRCA2 gene mutations are known to give an increased risk of developing ovarian cancer.
• Increasing age: Ovarian cancer most often affects postmenopausal women.
  
• Never having a baby.
• Starting menstrual cycles before age 12 and going through menopause at an older age. The more menstrual cycles you have, the more risk you have for ovarian cancer.
• Being unable to become pregnant (infertility). Women who do not use birth control and are sexually active but who are unable to become pregnant may have a higher chance for ovarian cancer.
• Use of estrogen or hormone replacement therapy.
• Women who are of Ashkenazi Jewish ancestry (Jews whose ancestors came from Eastern Europe) may have an increased risk because of changes to the BRCA1 or BRCA2 genes. Women with this ancestry have higher rates of these gene changes.
• Polycystic ovary syndrome (PCOS). Elevated levels of male hormones (androgens) commonly found in PCOS may increase your risk for ovarian cancer.
• History of breast cancer. Women with a personal history of breast cancer or a family history of breast cancer have a higher risk for ovarian cancer.

There are no reliable screening tests for ovarian cancer.

Early Detection

• For most women, the United States Preventive Services Task Force (USPSTF) does not recommend having a CA-125 blood test or a transvaginal ultrasound to find ovarian cancer early.
• There is no proof that having regular tests helps women live longer by finding ovarian cancer early.
• For women who are at a high-risk of developing ovarian cancer, like those who have inherited a BRCA gene mutation, they should be screened with a transvaginal ultrasound and a CA-125 blood test at least once a year.

If ovarian cancer is suspected, a doctor will get your history of symptoms and do a physical exam.

• A physical exam, including a pelvic exam and Pap test. An ovarian lump may be felt during a pelvic exam. A rectovaginal exam may also be done to feel the pelvic organs.
• Blood tests including a cancer antigen 125 (CA-125) level, to measure a protein found in ovarian cancer cells.
• A pelvic and transvaginal ultrasound, to look for an ovarian lump.

More tests may be done before surgery to determine if other areas of the body are involved. These tests include:

• A pelvic or abdominal CT scan or MRI to check for the spread of cancer.
• CT of the chest to look for the disease elsewhere in the body.

Surgery, usually a laparotomy, is done to confirm that cancer is present, to provide initial treatment, and to stage the cancer.

AJCC TNM and FIGO staging classification
Tumor extent (T)

TX. Primary tumor cannot be assessed.

T0. No primary tumor is seen.

T1 (Stage I). Ovarian cancer (carcinoma) is limited to one or both ovaries.

• T1a (Stage IA). Tumor is limited to one ovary. The ovarian capsule is intact and there is no tumor on the surface of the ovary. There are no cancer cells in the body fluid (peritoneal fluid) around the ovary.
• T1b (Stage IB). Tumor is limited to both ovaries. The ovarian capsule is intact and there is no tumor on the surface of the ovaries. There are no cancer cells in the body fluid (peritoneal fluid) around the ovaries.
• T1c (Stage IC). Tumor is limited to one or both ovaries AND the ovarian capsule is ruptured or there is tumor on the surface of the ovaries or there are cancer cells in the body fluid (peritoneal fluid) around the ovaries.

T2 (Stage II). Tumor involves one or both ovaries and extends into the pelvis or has implanted into the uterus.

• T2a (Stage IIA). Tumor has extended or implanted into the uterus or fallopian tube but there are no cancer cells in the body fluid (peritoneal fluid) around the ovaries.
• T2b (Stage IIB). Tumor has extended or implanted into other pelvic tissues but there are no cancer cells in the body fluid (peritoneal fluid) around the ovaries.
• T2c (Stage IIC). Tumor has extended or implanted into other pelvic tissues (T2a or T2b) AND there are cancer cells in the body fluid (peritoneal fluid) around the ovaries.

T3 (Stage III). Tumor involves one or both ovaries and there are cancer cells outside the pelvis (peritoneal metastasis).

• T3a (Stage IIIA). Cancer cells are identified microscopically outside the pelvis (peritoneal metastasis) or on abdominal peritoneal surfaces.
• T3b (Stage IIIB). Tumor involves one or both ovaries and implants on abdominal peritoneal surfaces measure 2cm or less in size.
• T3c (Stage IIIC). Tumor implants on abdominal peritoneal surfaces measure larger than 2cm in size and/or cancer involves lymph nodes in the abdominal area.

Lymph node spread (N)
NX. Lymph nodes near the primary tumor cannot be evaluated.
N0. Cancer has not spread to lymph nodes near the primary tumor.
N1. Cancer has spread to lymph nodes near the primary tumor.

Distant spread (M)
MX. Distant metastasis cannot be assessed.
M0. No distant metastasis is found.
M1. Metastasis to another part of the body has occurred.

Grade

• The grade of ovarian cancer refers to how the cancer cells look under a microscope.
• Most descriptions of ovarian cancer cells describe them as well-differentiated, moderately differentiated, or poorly differentiated. Differentiation is a term used to describe how clearly the cancer cells can be distinguished from the surrounding healthy tissues and how normal or abnormal the cells look.
• Well-differentiated cancers have very clear boundaries and cells that look relatively normal. They usually do not grow or spread rapidly.
• Poorly differentiated cancers have less clearly defined boundaries and cells that look very abnormal. They often grow and spread rapidly.
• Ovarian tumors are evaluated in the following grades:
  • GX: Grade cannot be assessed.
  • GB: Borderline cancer (malignant)
  • G1: Well-differentiated cancer
  • G2: Moderately differentiated cancer
  • G3–G4: Poorly differentiated or undifferentiated cancer

GENERAL

• Surgery is done to confirm and treat cancer.
• Removal of all cancerous tissue and taking biopsies to check for the spread of cancer (surgical staging) is important for diagnosis and treatment.
• The amount of cancer remaining (residual cancer) after the initial surgery may affect your outcome.
• Chemotherapy, which uses medicines to kill cancer cells, is recommended after surgery for most stages of ovarian cancer. Chemotherapy that is given after a surgery is called adjuvant therapy.

INITIAL TREATMENT
The goal of initial surgery is to remove all visible cancer. The type of surgery depends on the stage of cancer and whether or not you may still want to become pregant. Included in the surgery may be:

• A hysterectomy, which removes your uterus, and a salpingo-oophorectomy, which removes your ovaries and fallopian tubes OR removal of the obvious cancer and a biopsy of the other ovary
• Biopsies of other tissues and peritoneal fluids (peritoneal washings) from the belly to look for cancer cells.
• Removal of pelvic and aortic lymph nodes (lymph node dissection).
• Removal of fatty tissue (omentum).
• Removal of as much cancerous tissue as possible.
• Chemotherapy is recommended after surgery for most women.
• Paclitaxel (Taxol) and carboplatin or cisplatin are commonly used.
• The number of treatment cycles you have will depend on the stage of your disease.
• Chemotherapy may be given into a vein (intravenous, or IV). Or it may be given into your belly (intraperitoneal, or IP).

RECURRENT DISEASE

• Even with no sign of cancer after treatment, many women who are treated for ovarian cancer have cancer return within 5 years.
• If the cancer comes back, other chemotherapy agents may be recommended for further treatment. Second-look surgery is a possibility. Radiation therapy is a possibility.

Possible Treatment Side Effects
Dr. Farber, Dr. Spierer, and their staff at The Farber Center for Radiation Oncology will discuss potential side effects with you before, during, and after treatment, and ensure that your experience is personalized.