OVARIAN CANCER

Ovaries are organs which generate the female seed- which is essential for reproduction- and produce female hormones (estrogen). These organs are present in every female since birth but they come functionally active only when a girl attains puberty. Ovaries are active throughout the woman’s reproductive career and stop functioning at menopause.
Normally ovaries are not felt by physical examination of the abdomen. Ovaries are located down in the pelvis next to the uterus and do not cause symptoms even with small tumours. They can be felt only once they have grown to a substantial size. This is a reason why ovarian cancer often presents in an advanced stage (III-IV). Once cancerous process sets in, it can involve the surrounding area and the uterus owing to its proximity to these structures. Ovaries have a rich blood supply and this makes it easy for cancer cells to move from ovaries to other parts of the body.
The exact cause of ovarian cancer remains largely unknown. A few hormonal factors have been suggested as possible causes. Early menarche (beginning of menses), late menopause and using hormone-replacement-therapy after menopause are some of the risk factors associated with ovarian cancer.
The symptoms of ovarian cancer can be non-specific. Early satiety, heaviness in lower abdomen, bloating sensation, increased frequency of urination, constipation and obvious distension of the abdomen are some of the symptoms. These symptoms may result from other illnesses too and hence patients often receive various treatments before evaluating themselves for the possibility of cancer. In very advanced stages, patients may present with poor appetite, vomiting, constipation, dull aching pain in abdomen, breathlessness or jaundice.
A CT scan of the abdomen and pelvis is the most vital investigation for ovarian cancer. Not only does it give an accurate picture of the ovaries but it also gives information about possible areas of spread (other pelvic organs, abdominal organs, areas behind the intestines and liver). An abdominal ultrasonography may also give a clue about ovarian cancers but the technique itself has limitations which prevent us from knowing other important and relevant details. Nevertheless, ultrasonography is easily available, takes less time, is easy to perform and hence can be a useful tool in suspecting ovarian cancer.
Cancer Antigen-125 (CA 125) is a tumour marker whose level is raised in most (but not all!) ovarian cancers. The CA 125 level is usually very high at diagnosis (sometimes in thousands) and it reduces gradually after surgery and/or chemotherapy. The level usually returns to normal at the end of treatment. Patients are followed up periodically and the rise in CA 125 often heralds a recurrence of the disease.
Biopsy (removing a small piece of the cancer affected part) is commonly performed as a rule for all cancers to establish a diagnosis. Early stage ovarian cancer (disease limited to the ovary)is an exception to this rule. , getting a diagnosis may need a major surgery (laparotomy) with facilities to perform a frozen sectionanalysis.
Surgical removal of the affected organ (ovary), surrounding structures (uterus) and structures where the cancer can spread is a complete and optimal surgery for ovarian cancer. Unfortunately it may not be possible in all patients due to the advanced nature of their disease. These patients are offered chemotherapy to reduce the size and extent of disease- this is called neoadjuvant chemotherapy. Giving chemotherapy does not necessarily ensure reduction of the cancer in all patients and in some patients; the cancer may actually increase in size.
Patients who undergo surgery need to receive chemotherapy to prevent recurrence. This is required even in patients with a stage I disease. Chemotherapy is started after ensuring that the surgical wound has healed and the patient is fit enough to tolerate it. Most patients receive 6 courses of chemotherapy. Recently, a lot of interest has been generated in giving chemotherapy inside the abdominal cavity- intraperitoneal chemotherapy. This approach- though has been shown to be very successful in some parts of the world- is yet to be taken up in a big way in India primarily because of its associated toxicity.
Patients completing their planned course of surgery and chemotherapy are followed up periodically with CA 125 levels and imaging (Ultrasound/CT scans).
The prognosis in ovarian cancer has improved significantly in the past few years. Several drug combinations are available to treat recurrences.
Screening for ovarian cancer has not been shown to be useful. The best defence against ovarian cancer remains vigilance; minor abdominal symptoms need to be evaluated on time and treated aggressively.

- Oncologist in Pune | Cancer Specialist | Dr. Chetan Deshmukh