The ovaries are a pair of female reproductive organs. The ovaries are the main source of female hormones (estrogen and progesterone). They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries have two functions: they produce eggs and female hormones. Each month, during the menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a fallopian tube to the uterus.

Like all other organs of the body, the ovaries are made up of many types of cells. Normally, cells divide to produce more cells only when the body needs them. This orderly process helps keep us healthy. If cells keep dividing when new cells are not needed, a mass of tissue forms. This mass of extra tissue, called a growth, or tumor, can be benign or malignant.

Benign tumors are not cancer. They can usually be removed and, in most cases, they do not come back. Most important, cells from benign tumors do not invade nearby tissues and do not spread to other parts of the body. Benign tumors are rarely life threatening.

In women under age 30, most ovarian growths are benign, fluid-filled sacs called cysts. Cysts may occur during a women's monthly cycle and often go away without any treatment. If a cyst does not go away, the doctor may suggest removing it, especially if it is causing problems or seems to be changing. In some cases, the doctor may decide to wait and watch for changes with ultrasonography or other tests.

Malignant tumors are cancer. Cancer cells can invade and damage tissues and organs near the tumor. Also, cancer cells can break away from a malignant tumor in the ovary and spread to other organs in the abdomen and form new tumors. Ovarian cancer spreads most often to the peritoneum (lining of the abdominal) as well as the colon, the stomach, and the diaphragm. The cancer cells also can enter the lymphatic system or the bloodstream and spread to other parts of the body. The spread of cancer is called metastasis.

There are several types of ovarian cancer. Ovarian tumors are the most histologically diverse group of tumors. At least 80% of malignant ovarian tumors arise from the lining of the ovary and are called epithelial carcinomas. The most common type is serous cyst adenocarcinoma, which accounts for 75% of cases of epithelial ovarian cancer. The remaining 20% of malignant ovarian tumors are germ cell and sex cord-stromal cell tumors, which are non-epithelial in origin and metastatic carcinoma to the ovary. Germ cell tumors, which arise from the primary germ cells of the ovary, occur in young women and are uncommon in women greater than 30 years old.

When cancer spreads, the new tumor has the same kind of abnormal cells and the same name as the original (primary) tumor. For example, ovarian cancer that spreads to the colon is metastastic ovarian cancer. It is not colon cancer, even though the new tumor is in the colon.

Ovarian cancer is difficult to detect at an early stage. Often there are no symptoms in the early stages and, in many cases, the cancer has spread by the time it is found. The cancer may grow for some time before it causes pressure, pain, or other problems. Even when symptoms appear, they may be so vague that they are ignored.

As the tumor grows, the woman may feel swollen or bloated, or may have general discomfort in the lower abdomen. The disease may cause a loss of appetite or a feeling of fullness, even after a light meal. Other symptoms may include gas, indigestion, nausea, and weight loss. A large tumor may press on nearby organs, such as the bowel or bladder, causing diarrhea or constipation, or frequent urination. Less often, bleeding from the vagina is a symptom of ovarian cancer.

Ovarian cancer may cause swelling due to a buildup of fluid in the abdomen (ascites). Fluid also may collect around the lungs, causing shortness of breath. These symptoms may be causes by cancer or by other, less serious conditions. Only a doctor can tell for sure.

To find the cause of any of these symptoms, the doctor asks about the woman's medical history and does a careful physical exam, including a pelvic exam. The doctor may also order other tests such as an ultrasonongraphy, CT scan (series of x-rays), or blood tests. Ultrasonography is the best diagnostic modality for determining the malignant (cancerous) potential of a mass in the pelvis. The only sure way to know if cancer is present is for a pathologist to analyze the tissue under the microscope after it is removed from the body. If cancer is found at this time, the surgeon proceeds with surgery.

Most health problems respond best to treatment when they are found early. Women who have regular pelvic exams may increase the chance that, if ovarian cancer occurs, it will be found before the disease causes symptoms. However, pelvic exams often cannot find ovarian cancer at an early stage. Scientists are trying to find better ways to detect ovarian cancer earlier, when treatment may be more successful. Often, the doctor orders a blood test to measure a substance in the blood called CA-125. This substance, called a tumor marker, can be produced by ovarian cancer cells. However, CA-125 is not always present in women with ovarian cancer, and it may be present in women who have benign ovarian conditions. Thus, this blood test cannot be used alone to diagnose cancer.

Pelvic Mass

Surgical evaluation of a pelvic mass is a common indication for a gynecologic operation. A pelvic mass may be benign or malignant and may originate from the ovary or from another organ. In addition to alleviating symptoms attributed to benign ovarian lesions, many of these operations are performed to determine the presence of a malignancy and to complete appropriate surgical treatment of an ovarian cancer, if present. Gynecologic oncologists are subspecialists trained to complete the operative management of malignant, potentially malignant or suspected malignant conditions of the female genital tract. Existing clinical data led to the recent National Institutes of Health consensus panel opinion suggesting that preoperative consultation with a gynecologic oncologist should be offered to all women with a suspected ovarian malignancy. Consultation or referral is clinically important as an optimal surgical effort exerts a favorable affect on overall response and survival.

Transvaginal and/or pelvic ultrasound is generally indicated in the evaluation of pelvic mass and is the most efficient, accurate and least expensive of the imaging tests. Young patients with suspicious masses should have laboratory evaluation of tumor markers as well. A CA-125 should also be obtained in patients with a suspicious pelvic mass, especially if they are perimenopausal or postmenopausal in age. While the CA-125 is useful, a normal test does not eliminate the possibility of the cancer, particularly in early stage disease.

A diagnosis can only be made by surgical removal of the mass and/or ovary. A pathologist must examine a sample of the tissue under the microscope to determine the diagnosis. To obtain the tissue, the surgeon does an operation by making an incision. This is called laparotomy. An alternative procedure is laparoscopy, which is surgery performed through small tubes where a camera is used to view the pelvis and abdomen. The advantage of this is that a large incision may be avoided. If cancer is suspected, the surgeon removes the entire ovary. The surgeon should be prepared to perform complete surgical staging if the malignancy appears to be confined to the ovary. A significant portion of these patients will have spread that is only recognized by obtaining multiple tissue samples and removing lymph nodes.

If there is obvious disease spread outside the ovary, it's important that the surgeon removes as much of the tumor as possible (tumor debulking). This may require a long and detailed surgery. However, evidence supports that patients will have a longer survival when treated with chemotherapy if the tumor debulking is deemed to be optimal.

Risk Factors

The risk of ovarian cancer increases with age and peaks at about 70 years old. Patients of low parity, decreased fertility and delayed childbearing appear to be a greater risk for ovarian cancer. Use of oral contraceptives appears to have a protective effect and decreases the risk of ovarian cancer by as high as 50%. Most cases of ovarian cancer are sporadic in nature, i.e. not inherited. There also appears to be an autosomal dominant inherited form of ovarian cancer which accounts for only 3 to 5% of all cases of ovarian cancer. They tend to occur at younger ages (approximately 10 years before noninheritable ovarian cancer). There are three recognized hereditary forms which include the following:

• site specific familial ovarian cancer

• breast-ovarian familial cancer syndrome

• Lynch II syndrome (nonpolyposis colon cancer, endometrial cancer, breast cancer, and ovarian cancer clusters in first and second degree relatives)

While the minority of cases of ovarian cancer are secondary to a hereditary cause, the possibility of this risk related to a person's family history may cause a great deal of anxiety and stress. New genetic tests may be helpful for stratifying a patient's risk, but interpretation of these tests may be complex and expert genetic counseling is required.

Ovarian cancer may be treated with surgery, chemotherapy, or radiation therapy. The doctor may use just one method or combine them.

Surgery is the initial treatment for almost every woman with ovarian cancer. Chemotherapy may be used following surgery as adjuvant therapy, to kill any cancer cells that may remain in the body. It may also be used at a later time if there are signs that the cancer has recurred. Radiation therapy may be used in a small number of patients to kill cancer cells that may remain in the pelvic area after surgery.

Surgery for ovarian cancer usually involves removal of the ovaries, the uterus, and the fallopian tubes. This operation is called hysterectomy with bilateral salpingo-oophorectomy.

The mainstay for successful treatment of early stage ovarian cancer, which represents approximately 20-30% of ovarian malignancies includes comprehensive surgical staging followed by appropriate adjuvant chemotherapy. Surgical staging is completed as recommended by FIGO when a gynecologic oncologist is involved. Accurate surgical staging in patients with apparent early stage disease may avoid or limit the use of chemotherapy in patients with an excellent or good prognosis. Limited or conservative surgery with the goal of preservation of fertility may be appropriate in patients with certain types of ovarian cancer.

In patients with advanced stage disease, efforts at optimal surgical cytoreduction (tumor debulking) should routinely precede chemotherapy. Gynecologic oncologists are the only subspecialists whose training encompasses all aspects of ovarian cancer treatment including specific training in surgical staging and cytoreductive techniques as well as specific surgical procedures for treatment of complications, selection, administration and mangement of chemotherapy and its complications; appropriate selection of patients for further operative medical, radiation or palliative management. Gynecologic oncologists are also well trained to counsel or refer patients for genetic counseling regarding family/genetic cancer syndromes and individual cancer risks. By virtue of their comprehensive training gynecologic oncologists are the appropriate health care providers uniquely suited to provide primary longitudinal care for ovarian cancer patients and to head disease management teams involved in the care of these patients.

Chemotherapy for ovarian cancer often involves a combination of drugs. Anticancer drugs are usually given by injection into a vein or by mouth. Either way, chemotherapy is called systemic therapy because the drugs travel all through the body in the bloodstream.

A number of advances in the chemotherapeutic treatment of ovarian cancer have occurred in the last two decades. This has lead to a longer survival and longer disease-free survival for patients with the disease. The standard chemotherapy regimen usually includes paclitaxol and a platinum agent. Doctors are studying another way of giving anti-cancer drugs called intraperitoneal chemotherapy. In this approach, the drugs are put directly into the abdomen through a catheter. In this way, drugs reach the cancer directly. The treatment is usually given in the hospital.

Chemotherapy is usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. A woman may receive chemotherapy as an outpatient at the hospital, at the doctor's office, or at home. Depending on which drugs are used, how they are given, and her general health, a woman may need to stay in the hospital while receiving chemotherapy.

Radiation therapy is generally not used in the treatment of ovarian cancer except in selected individualized situations. Radiation therapy (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. Radiation may come from a machine (external radiation) or from radioactive material placed into or near the tumor (internal radiation). Like surgery, radiation therapy is local therapy, it affects cancer cells only in the treated area.

Our James Care for Life Gynecologic Oncology Patient Education notebook has a special section for recording of symptoms, salutation and care diary, and a listing of questions for the physician.Here are some questions a woman may want to ask her doctor before treatment begins:

•  What is the stage of the disease?

•  What is the stage of the disease?

•  What are my treatment choices? Which do you recommend for me? Why?

•  Do I need comprehensive surgical staging?

•  Is it likely that aggressive debulking surgery will be required?

•  Am I an individual that may require chemotherapy prior to my definitive surgery (this is called neoadjuvant chemotherapy)?

•  Would a clinical trial be appropriate for me?

•  What are the expected benefits of each kind of treatment?

•  What are the risks and possible side effects of each treatment?

The Gynecologic Cancer Support Group is facilitated by caring health care professionals with specific expertise in working with women's cancers. Participants find comfort and assurance as they candidly and confidentially discuss the impact of cancer on their lives.

Generally Asked Questions About Ovarian Cancer

1. What is ovarian cancer?

There are several types of ovarian cancer. Ovarian tumors are the most histologically diverse group of tumors. At least 80% of malignant ovarian tumors arise from the lining of the ovary and are called epithelial carcinomas. The most common type is serous cyst adenocarcinoma, which accounts for 75% of cases of epithelial ovarian cancer. The remaining 20% of malignant ovarian tumors are germ cell and sex cord-stromal cell tumors, which are non-epithelial in origin and metastatic carcinoma to the ovary. Germ cell tumors, which arise from the primary germ cells of the ovary, occur in young women and are uncommon in women greater than 30 years old.2. What are the causes and risk factors for ovarian cancer?

Less often, bleeding from the vagina is a symptom of ovarian cancer.

Most of these may also be caused by benign (noncancerous) diseases of the ovaries and by cancers of other organs. It is important to see your doctor.

4. How will my doctor know if I have ovarian cancer?

Women who have regular pelvic exams increase the chance that, if ovarian cancer occurs, it will be found before the disease causes symptoms. However, pelvic exams often cannot find ovarian cancer at an early stage. Often, the doctor orders a blood test to measure a substance in the blood called CA-125. This substance, called a tumor marker, can be produced by ovarian cancer. However, CA-125 is not always present in women with ovarian cancer, and it may be present in women who have benign ovarian conditions. Thus, this blood test cannot be used alone to diagnose cancer.

A diagnosis can only be made by surgical removal of the mass and/or ovary. Once the mass is removed, a pathologist must examine a sample of the tissue under the microscope to determine the diagnosis. To obtain the tissue, the surgeon does an operation by making an incision. This is called laparotomy. An alternative procedure is laparoscopy, which is surgery performed through small tubes where a camera is used to view the pelvis and abdomen. If cancer is suspected, the surgeon removes the entire ovary. The surgeon should be prepared to perform complete surgical staging if the malignancy appears to be confined to the ovary. A large portion of these patients will have spread that is only recognized by obtaining multiple tissue samples and removing lymph nodes.

5. What about treatment, what should I ask?

It is hard to limit the effects of therapy so that only cancer cells are destroyed. Because treatment often damages healthy cells and tissues, it can cause unpleasant side effects.

The side effects of cancer treatment vary, depending on the type of treatment. Also, each woman reacts differently. Doctors try to keep side effects to a minimum, but problems may occur.

Surgery for ovarian cancer is a major operation. For several days after surgery, a woman may have difficulty emptying her bladder or having normal bowel movements. Doctors or nurses can administer medicine to relieve pain and/or prevent infection associated with ovarian cancer surgery. For a period of time after surgery, some normal activities are limited to encourage healing. Young women whose ovaries are removed begin experiencing the side effects of menopause because their body’s natural source of estrogen has been removed. Hormone replacement therapy is commonly used to lessen these side effects.

With chemotherapy, side effects depend on which drugs the patient receives, as well as personal variance from patient to patient. In general, chemotherapy drugs affect rapidly dividing cells. The drugs kill cancer cells, but also affect other cells in the body, like cells in hair roots and cells that line the digestive tract. As a result, chemotherapy can cause hair loss, nausea, vomiting, or mouth sores. Doctors can suggest diet changes or medication to ease these problems, and most side effects of chemotherapy gradually disappear during the recovery period or after treatment stops.

Radiation therapy mainly causes fatigue, especially in the later weeks of treatment. Though resting is important, doctors usually advise patients to stay as active as possible. Skin in the treated area may become red, dry, tender and itchy, and there may be permanent darkening or "bronzing" in the treated area. Radiation therapy in the lower abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. Doctors can usually suggest diet changes or medicines to ease these problems. Radiation therapy for ovarian cancer can also cause vaginal dryness and interfere with intercourse. Women may be advised not to have intercourse during treatment. However, most women are able to resume sexual activity a few weeks after radiation therapy ends.

Each cancer survivor’s recovery is different, and a person’s adjustment after cancer treatment depends on a number of factors. Ovarian cancer can cause major life changes in its survivors. If a woman undergoes removal of the ovaries and/or uterus, she will be unable to become pregnant. Women will also begin menopause if they have not already if they receive this treatment. Chemotherapy may also cause premature menopause or infertility.

It is important for women to seek support during and after cancer treatment. In fact, behavioral scientists have found that women who took advantage of a social support system, such as a cancer support group, survived with a better quality of life. Maintain an open dialogue with your cancer care team to address any concerns you have.

The Gynecologic Cancer Support Group at The James is facilitated by caring health care professionals with specific expertise in working with women's cancers. Participants find comfort and assurance as they candidly and confidentially discuss the impact of cancer on their lives.

8. Are there clinical trials available for ovarian cancer?