June 2021
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Ovarian Cancer
Ovarian cancer is a cancer that develops in the ovary. It results in abnormal cells that invade adjacent structures or spread to other parts of the body. Ovarian cancer is the sixth most common cancer (age standardized incidence rate: 6.6/100,000) and the seventh leading cause of cancer deaths (age standardized mortality rate: 4.0/100,000) among women worldwide. In most of the population-based cancer registries in India, ovarian cancer is the third leading site of cancer among women, trailing behind cervix and breast cancer. The age-adjusted incidence rates of ovarian cancer vary between 5.4 and 8.0 per 100,000 population in different parts of the country. Ovarian cancer has the worst prognosis among all gynecological malignancies.

The most typical symptoms of ovarian cancer include bloating, abdominal or pelvic pain or discomfort, back pain, irregular menstruation or postmenopausal vaginal bleeding, loss of appetite, fatigue, diarrhea, indigestion, heartburn, constipation, nausea, feeling full, and possibly urinary symptoms (including frequent urination and urgent urination). Symptoms can be caused by a mass pressing on the other abdominopelvic organs or from distant spread.

Ovarian cancer is related to the amount of time spent ovulating. A longer period of ovulation caused by early first menstruation and late menopause is also a risk factor. Both obesity and hormone replacement therapy also raise the risk. The risk of developing ovarian cancer is less for women who have fewer menstrual cycles, no menstrual cycles, breast feeding, take oral contraceptives, have multiple pregnancies, and have a pregnancy at an early age. Postmenopausal hormone replacement therapy (HRT) with estrogen likely increases the risk of ovarian cancer. A family history of ovarian cancer is a risk factor for ovarian cancer. People with hereditary nonpolyposis colon cancer (Lynch syndrome), and those with BRCA-1 and BRCA-2 genetic abnormalities are at increased risk, which includes 10% of the cases. Mutations in BRCA1 have a lifetime risk of developing ovarian cancer of 15–45%. Mutations in BRCA2 are less risky than those with BRCA1, with a lifetime risk of 10% (lowest risk cited) to 40%. A strong family history of endometrial cancer, colon cancer, or other gastrointestinal cancers may indicate the presence of a syndrome known as hereditary nonpolyposis colorectal cancer (also known as Lynch syndrome), which confers a higher risk for developing a number of cancers, including ovarian cancer. Use of perineal talc, pesticides, smoking and herbicides increase the risk of ovarian cancer. Suppression of ovulation, which would otherwise cause damage to the ovarian epithelium and, consequently, inflammation, is generally protective. This effect can be achieved by having children, taking combined oral contraceptives, and breast feeding, all of which are protective factors.

Diagnosis of ovarian cancer starts with a physical examination (including a pelvic examination), a blood test (for CA-125), CT scan of the abdomen, image guided biopsy/ascitic fluid cytology, surgical procedure for diagnosis (laparoscopy, laparotomy). Surface epithelial-stromal tumour, also known as ovarian epithelial carcinoma, is the most common type of ovarian cancer, representing approximately 90% of ovarian cancers. Ovarian cancer is staged using the FIGO staging system and uses information obtained after surgery, into 4 stages. Stage I tumor is early stage ovarian cancer, confined to the ovaries. Stage IV disease involves advanced cancer with spread of tumor to distant parts of the body. Most common stage of presentation is stage III, where the disease spreads into the generalized abdominal cavity.

Treatment usually involves surgery and chemotherapy. Surgery done for ovarian cancer is termed staging laparotomy. It involves surgical removal of both ovaries including the tumor, uterus, lymph nodes draining the ovaries, omentum. It may involve stripping of cancer involved peritoneal lining, bowel resection, and HIPEC. Chemotherapy is used after surgery to treat any residual disease, if appropriate. In some cases, there may be reason to perform chemotherapy first, followed by surgery. Carboplatin is typically given in combination with either paclitaxel or docetaxel; the typical combination is carboplatin with paclitaxel. Generally, 6 cycles chemotherapy is delivered. HIPEC is hyperthermic intraperitoneal chemotherapy, delivered during surgery for stage III ovarian cancer. In this technique chemotherapy is delivered at temperature 40 to 42°C directly into the abdominal cavity. This technique reduces the chance of recurrence and improves survival. Expertise and technique caliber is available only in select cancer centers including KIMSHEALTH Cancer Centre.

Ovarian cancer is characterized by high chance of recurrence, hence the need for diligent follow up. Generally, the patients are followed up every three months for the first three years and then six monthly in the fourth and fifth year. Scans to look for recurrence is done every year along with appropriate blood investigations. Recurrent disease is treated with chemotherapy and if possible, surgery.

Ovarian cancer usually has a relatively poor prognosis. It is disproportionately deadly because it lacks any clear early detection or screening test, meaning most cases are not diagnosed until they have reached advanced stages. More than 60% of women presenting with ovarian cancer have stage-III or stage-IV cancer, when it has already spread beyond the ovaries. The five-year survival rate for all stages of ovarian cancer is 46%.

World Ovarian Cancer Day (WOCD) is observed on May 8. It aims to create a community where those living with ovarian cancer, survivors and their families and friends unite, share their experiences and help educate the public about this deadly disease.

Consultant Surgical Oncologist
KIMSHEALTH Cancer Centre
KIMS Health, Trivandrum

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