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What is ovarian cancer?
Ovarian cancer is cancer that begins in the ovaries. Ovaries are reproductive glands found only in females (women). The ovaries produce eggs (ova) for reproduction. The eggs travel through the fallopian tubes into the uterus where the fertilized egg implants and develops into a fetus. The ovaries are also the main source of the female hormones estrogen and progesterone. One ovary is on each side of the uterus in the pelvis.
The ovaries are made up of 3 main kinds of cells:
Epithelial cells, which cover the ovary
Germ cells, which are found inside the ovary. These cells develop into the eggs (ova) that are released into the fallopian tubes every month during the reproductive years.
Stromal cells, which form the supporting or structural tissue holding the ovary together and which produce most of the female hormones estrogen and progesterone
Each of these types of cells can develop into a different type of tumor. There are 3 main types of ovarian tumors:
Epithelial tumors start from the cells that cover the outer surface of the ovary. Most ovarian tumors are epithelial cell tumors.
Germ cell tumors start from the cells that produce the eggs (ova).
Stromal tumors start from structural tissue cells that hold the ovary together and produce the female hormones estrogen and progesterone.
Most of these tumors are benign (non-cancerous) and never spread beyond the ovary. Benign tumors can be treated by removing either the ovary or the part of the ovary that contains the tumor.
Ovarian tumors that are not benign are malignant (cancerous) or low malignant potential tumors. These types can spread (metastasize) to other parts of the body and can be fatal. Their treatment is discussed later in this document.
Epithelial ovarian tumors
Benign epithelial ovarian tumors: Most epithelial ovarian tumors are benign, don’t spread, and usually don’t lead to serious illness. There are several types of benign epithelial tumors including serous cystadenomas, mucinous cystadenomas, and Brenner tumors.
Tumors of low malignant potential : When looked at under the microscope, some ovarian epithelial tumors don’t clearly appear to be cancerous. These are called tumors of low malignant potential (LMP tumors). They are also known as borderline epithelial ovarian cancer. These are different from typical ovarian cancers because they don’t grow into the supporting tissue of the ovary (called the ovarian stroma). Likewise, if they spread outside the ovary, for example, into the abdominal cavity (belly), they might grow on the lining of the abdomen but often don’t grow into it.
LMP tumors tend to affect younger women than the typical ovarian cancers. These tumors grow slowly and are less life-threatening than most ovarian cancers. LMP tumors can be fatal, but this isn’t common.
Malignant epithelial ovarian tumors : Cancerous epithelial tumors are called carcinomas. About 85% to 90% of ovarian cancers are epithelial ovarian carcinomas. When someone says that they had ovarian cancer, they usually mean that they had this type of cancer. When these tumors are looked at under the microscope, the cells have several features that can be used to classify epithelial ovarian carcinomas into different types. The serous type is by far the most common, but there are other types like mucinous, endometrioid, and clear cell.
Primary peritoneal carcinoma : Primary peritoneal carcinoma (PPC) is a rare cancer closely related to epithelial ovarian cancer. At surgery, it looks the same as an epithelial ovarian cancer that has spread through the abdomen. Under a microscope, PPC also looks just like epithelial ovarian cancer. Other names for this cancer include extra-ovarian (meaning outside the ovary)primary peritoneal carcinoma (EOPPC) and serous surface papillary carcinoma.
PPC seems to develop from cells in the lining of the pelvis and abdomen. This lining is called the peritoneum. These cells are very similar to the cells on the surface of the ovaries. Some experts believe that PPC may start in the cells lining the fallopian tubes.
Like ovarian cancer, PPC tends to spread along the surfaces of the pelvis and abdomen, so it is often difficult to tell exactly where the cancer first started. This type of cancer can occur in women who still have their ovaries, but it is of more concern for women who have had their ovaries removed to prevent ovarian cancer. This cancer does rarely occur in men.
Symptoms of PPC are similar to those of ovarian cancer, including abdominal pain or bloating, nausea, vomiting, indigestion, and a change in bowel habits. Also, like ovarian cancer, PPC may elevate the blood level of a tumor marker called CA-125.
Women with PPC usually get the same treatment as those with widespread ovarian cancer. This could include surgery to remove as much of the cancer as possible (a process called debulking that is discussed in the section about surgery), followed by chemotherapy like that given for ovarian cancer. Its outlook is likely to be similar to widespread ovarian cancer.
Fallopian tube cancer : This is another rare cancer. It begins in the tube that carries an egg from the ovary to the uterus (the fallopian tube). Like PPC, fallopian tube cancer and ovarian cancer have similar symptoms. The treatment for fallopian tube cancer is much like that of ovarian cancer, but the outlook (prognosis) is slightly better.
Germ cell tumors : Germ cells are the cells that usually form the ova or eggs. Most germ cell tumors are benign, but some are cancerous and may be life threatening. Less than 2% of ovarian cancers are germ cell tumors. Overall, they have a good outlook, with more than 9 out of 10 patients surviving at least 5 years after diagnosis. There are several subtypes of germ cell tumors. The most common germ cell tumors are teratomas, dysgerminomas, endodermal sinus tumors, andchoriocarcinomas. Germ cell tumors can also be a mix of more than a single subtype.
Teratoma : Teratomas are germ cell tumors with areas that, when seen under the microscope, look like each of the 3 layers of a developing embryo: the endoderm (innermost layer), mesoderm (middle layer), and ectoderm (outer layer). This germ cell tumor has a benign form called mature teratoma and a cancerous form called immature teratoma.
The mature teratoma is by far the most common ovarian germ cell tumor. It is a benign tumor that usually affects women of reproductive age (teens through forties). It is often called a dermoid cyst because its lining looks like skin. These tumors or cysts can contain different kinds of benign tissues including, bone, hair, and teeth. The patient is cured by surgical removal of the cyst.
Immature teratomas are a type of cancer. They occur in girls and young women, usually younger than 18. These are rare cancers that contain cells that look like those from embryonic or fetal tissues such as connective tissue, respiratory passages, and brain. Tumors that are relatively more mature (called grade 1 immature teratoma) and haven’t spread beyond the ovary are treated by surgical removal of the ovary. When they have spread beyond the ovary and/or much of the tumor has a very immature appearance (grade 2 or 3 immature teratomas), chemotherapy is recommended in addition to surgery.
Dysgerminoma : This type of cancer is rare, but it is the most common ovarian germ cell cancer. It usually affects women in their teens and twenties. Dysgerminomas are considered malignant (cancerous), but most don’t grow or spread very rapidly. When they are limited to the ovary, more than 75% of patients are cured by surgically removing the ovary, without any further treatment. Even when the tumor has spread further (or if it comes back later), surgery, radiation therapy, and/or chemotherapy are effective in controlling or curing the disease in about 90% of patients.
Endodermal sinus tumor (yolk sac tumor) and choriocarcinoma : These very rare tumors typically affect girls and young women. They tend to grow and spread rapidly but are usually very sensitive to chemotherapy. Choriocarcinoma that starts in the placenta (during pregnancy) is more common than the kind that starts in the ovary. Placental choriocarcinomas usually respond better to chemotherapy than ovarian choriocarcinomas do.
Stromal tumors : About 1% of ovarian cancers are ovarian stromal cell tumors. More than half of stromal tumors are found in women older than 50, but about 5% of stromal tumors occur in young girls.
The most common symptom of these tumors is abnormal vaginal bleeding. This happens because many of these tumors produce female hormones (estrogen). These hormones can cause vaginal bleeding (like a period) to start again after menopause. In young girls, these tumors can also cause menstrual periods and breast development to occur before puberty.
Less often, stromal tumors make male hormones (like testosterone). If male hormones are produced, the tumors can cause normal menstrual periods to stop. They can also make facial and body hair grow.
Another symptom of stromal tumors can be sudden, severe, abdominal pain. This occurs if the tumor starts to bleed.
Types of malignant (cancerous) stromal tumors include granulosa cell tumors (the most common type), granulosa-theca tumors, and Sertoli-Leydig cell tumors, which are usually considered low-grade cancers. Thecomas andfibromas are benign stromal tumors. Cancerous stromal tumors are often found at an early stage and have a good outlook, with more than 75% of patients surviving long-term.
Ovarian cysts : An ovarian cyst is a collection of fluid inside an ovary. Most ovarian cysts occur as a normal part of the process of ovulation (egg release) -- these are called functional cysts. These cysts usually go away within a few months without any treatment. If you develop a cyst, your doctor may want to check it again after your next cycle (period) to see if it has gotten smaller.
An ovarian cyst can be more concerning in a female who isn't ovulating (like a woman after menopause or girl who hasn't started her periods), and the doctor may want to do more tests. The doctor may also order other tests if the cyst is large or if it does not go away in a few months. Even though most of these cysts are benign (not cancer), a small number of them could be cancer. Sometimes the only way to know for sure if the cyst is cancer is to take it out with surgery. Cysts that appear to be benign (based on how they look on imaging tests) can be observed (with repeated physical exams and imaging tests), or removed with surgery.
What are the risk factors for ovarian cancer?
A risk factor is anything that changes your chance of getting a disease like cancer. Different cancers have different risk factors. For example, unprotected exposure to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for a number of cancers.
But risk factors don't tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And many people who get the disease may not have had any known risk factors. Even if a person with ovarian cancer has a risk factor, it is very hard to know how much that risk factor may have contributed to the cancer. Researchers have discovered several specific factors that change a woman's likelihood of developing epithelialovarian cancer. These risk factors don’t apply to other less common types of ovarian cancer like germ cell tumors and stromal tumors.
Age : The risk of developing ovarian cancer gets higher with age. Ovarian cancer is rare in women younger than 40. Most ovarian cancers develop after menopause. Half of all ovarian cancers are found in women 63 years of age or older.
Obesity : Various studies have looked at the relationship of obesity and ovarian cancer. Overall, it seems that obese women (those with a body mass index of at least 30) have a higher risk of developing ovarian cancer.
Reproductive history : Women who have been pregnant and carried it to term have a lower risk of ovarian cancer than women who have not. The risk goes down with each full-term pregnancy. Breastfeeding may lower the risk even further.
Birth control : Women who have used oral contraceptives (also known as birth control pills or the pill) have a lower risk of ovarian cancer. The lower risk is seen after only 3 to 6 months of using the pill, and the risk is lower the longer the pills are used. This lower risk continues for many years after the pill is stopped.
Gynecologic surgery :Tubal ligation (having your tubes tied) may reduce the chance of developing ovarian cancer by up to two-thirds. A hysterectomy (removing the uterus without removing the ovaries) also seems to reduce the risk of getting ovarian cancer by about one-third.
Fertility drugs : In some studies, researchers have found that using the fertility drug clomiphene citrate (Clomid®) for longer than one year may increase the risk for developing ovarian tumors. The risk seemed to be highest in women who did not get pregnant while on this drug. Fertility drugs seem to increase the risk of the type of ovarian tumors known as "low malignant potential. If you are taking fertility drugs, you should discuss the potential risks with your doctor. However, women who are infertile may be at higher risk (compared to fertile women) even if they don’t use fertility drugs. This might be in part because they haven't given birth or used birth control pills (which are protective).
Androgens : Androgens are male hormones. Danazol, a drug that increases androgen levels, was linked to an increased risk of ovarian cancer in a small study. In a larger study, this link was not confirmed, but women who took androgens were found to have a higher risk of ovarian cancer. Further studies of the role of androgens in ovarian cancer are planned.
Estrogen therapy and hormone therapy : Some recent studies suggest women using estrogens after menopause have an increased risk of developing ovarian cancer. The risk seems to be higher in women taking estrogen alone (without progesterone) for many years (at least 5 or 10). The increased risk is less certain for women taking both estrogen and progesterone.
Family history of ovarian cancer, breast cancer, or colorectal cancer : Ovarian cancer can run in families. Your ovarian cancer risk is increased if your mother, sister, or daughter has (or has had) ovarian cancer. The risk also gets higher the more relatives you have with ovarian cancer. Increased risk for ovarian cancer does not have to come from your mother's side of the family -- it can also come from your father's side.
Up to 10% of ovarian cancers result from an inherited tendency to develop the disease. A family history of some other types of cancer caused by an inherited mutation (change) in certain genes can increase the risk of ovarian cancer. For example, mutations in the genes BRCA1 and BRCA2 increase the risk of breast cancer -- so having a family member with breast cancer can increase your risk of ovarian cancer. Another set of genes increase the risk of colon cancer, so women who have colon cancer in their families may have a higher risk of developing ovarian cancer. Many cases of familial epithelial ovarian cancer are caused by inherited gene mutations that can be identified by genetic testing.
Women with ovarian cancers caused by some of these inherited gene mutations may have a better outcome than patients who don’t have any family history of ovarian cancer. (See the section on causes of ovarian cancer for information on these gene mutations.)
Genetic counseling, genetic testing, and strategies for preventing ovarian cancer in women with an increased familial risk are discussed in the prevention section of this document.
Personal history of breast cancer : If you have had breast cancer, you may also have an increased risk of developing ovarian cancer. There are several reasons for this. Some of the reproductive risk factors for ovarian cancer may also affect breast cancer risk. The risk of ovarian cancer after breast cancer is highest in those women with a family history of breast cancer. A strong family history of breast cancer may be caused by an inherited mutation in the BRCA1 or BRCA2 genes. These mutations can also cause ovarian cancer.
Diet : A study of women who followed a low-fat diet for at least 4 years showed a lower risk of ovarian cancer. Some studies have shown a reduced rate of ovarian cancer in women who ate a diet high in vegetables, but other studies disagree. The American Cancer Society recommends eating a variety of healthful foods, with an emphasis on plant sources. Eat at least 2 ½ cups of fruits and vegetables every day, as well as several servings of whole grain foods from plant sources such as breads, cereals, grain products, rice, pasta, or beans. Limit the amount of red meat and processed meats you eat. Even though the effect of these dietary recommendations on ovarian cancer risk remains uncertain, following them can help prevent several other diseases, including some other types of cancer.
Analgesics : In some studies, both aspirin and acetaminophen have been shown to reduce the risk of ovarian cancer. However, the information isn’t consistent. Women who don’t already take these medicines regularly for other health conditions should not start doing so to try to prevent ovarian cancer. More research is needed on this issue.
Do we know what causes ovarian cancer?
We don’t yet know exactly what causes most ovarian cancers. As discussed in the previous section, we do know some factors that make a woman more likely to develop epithelial ovarian cancer. Much less is known about risk factors for germ cell and stromal tumors of the ovaries.
There are many theories about the causes of ovarian cancer. Some of them came from looking at the things that change the risk of ovarian cancer. For example, pregnancy and taking birth control pills both lower the risk of ovarian cancer. Since both of these things reduce the number of times the ovary releases an egg (ovulation), some researchers think that there may be some relationship between ovulation and the risk of developing ovarian cancer.
Also, we know that tubal ligation and hysterectomy lower the risk of ovarian cancer. One theory to explain this is that some cancer-causing substances may enter the body through the vagina and pass through the uterus and fallopian tubes to reach the ovaries. This would explain how removing the uterus or blocking the fallopian tubes affects ovarian cancer risk. Another theory is that male hormones (androgens) can cause ovarian cancer.
Researchers have made great progress in understanding how certain mutations (changes) in DNA can cause normal cells to become cancerous. DNA is the chemical that carries the instructions for nearly everything our cells do. We usually look like our parents because they are the source of our DNA. However, DNA affects more than the way we look. Some genes (parts of our DNA) contain instructions for controlling when our cells grow and divide. Certain genes that promote cell division are called oncogenes. Others that slow down cell division, cause cells to die at the right time, or help repair DNA damage are called tumor suppressor genes. We know that DNA mutations (defects) that turn on oncogenes or turn off tumor suppressor genes can cause cancer.
Inherited genetic syndromes : Scientists have learned a lot about how certain genes you inherit from your parents can greatly increase your ovarian cancer risk. These include the BRCA1 and BRCA2 genes and several genes related to hereditary nonpolyposis colon cancer (see next section).
BRCA1 and BRCA2 genes : Inherited mutations in these genes were first found in women with breast cancer, and they are also responsible for most inherited ovarian cancers. When these genes are normal, they act as tumor suppressors -- they help prevent cancer by making proteins that keep cells from growing abnormally. But if you have inherited a mutation (defect) of one of these genes from either parent, this cancer-preventing protein is less effective, and your chances of developing breast and/or ovarian cancer increase. Mutations in BRCA1 and BRCA2 are about 10 times more common in those who are Ashkenazi Jewish than those in the general U.S. population.
The lifetime ovarian cancer risk for women with a BRCA1 mutation is estimated to be between 35% and 70%. This means that if 100 women had a BRCA1 mutation, between 35 and 70 of them would get ovarian cancer. For women with BRCA2 mutations the risk has been estimated to be between 10% and 30% by age 70. These mutations also increase the risks for primary peritoneal carcinoma and fallopian tube carcinoma.
In comparison, the ovarian cancer lifetime risk for the women in the general population is about 1.5%.
Hereditary nonpolyposis colon cancer : Women with this syndrome have a very high risk of colon cancer and also have an increased risk of developing cancer of the uterus (endometrial cancer) and ovarian cancer. Many different genes can cause this syndrome. They includeMLH1, MLH3, MSH2, MSH6, TGFBR2, PMS1, and PMS2. An abnormal copy of any one of these genes reduces the body's ability to repair damage to its DNA. The lifetime risk of ovarian cancer in women with hereditary nonpolyposis colon cancer (HNPCC) is about 10%. This syndrome causes up to 1% of all ovarian epithelial cancers. An older name for HNPCC is Lynch syndrome.
Peutz-Jeghers syndrome : People with this rare genetic syndrome develop polyps in the stomach and intestine while they are teenagers. They also have a high risk of cancer, particularly cancers of the digestive tract (esophagus, stomach, small intestine, colon). Women with this syndrome have an increased risk of ovarian cancer, including both epithelial ovarian cancer and a type of stromal tumor called sex cord tumor with annular tubules (SCTAT). This syndrome is caused by mutations in the gene STK11.
MUTYH-associated polyposis : People with this syndrome develop polyps in the colon and small intestine and have a high risk of colon cancer. They are also more likely to develop other cancers, including cancers of the ovary and bladder. This syndrome is caused by mutations in the gene MUTYH.
Acquired genetic changes : Most DNA mutations related to ovarian cancer are not inherited but instead occur during a woman's life. In some cancers, acquired mutations of oncogenes and/or tumor suppressor genes may result from radiation or cancer-causing chemicals, but there is no evidence for this in ovarian cancer. So far, studies haven’t been able to specifically link any single chemical in the environment or in our diets to mutations that cause ovarian cancer. The cause of most acquired mutations remains unknown.
Most ovarian cancers have several acquired gene mutations. Research has suggested that tests to identify acquired changes of certain genes in ovarian cancers, like the p53 tumor suppressor gene or the HER2 oncogene, may help predict a woman's prognosis. The role of these tests is still not certain, and more research is needed.
Can ovarian cancer be prevented?
Most women have one or more risk factors for ovarian cancer. But most of the common factors only slightly increase your risk, so they only partly explain the frequency of the disease. So far, what is known about risk factors has not translated into practical ways to prevent most cases of ovarian cancer.
There are several ways you can reduce your risk of developing epithelial ovarian cancer. Much less is known about ways to lower the risk of developing germ cell and stromal tumors of the ovaries. The remainder of this section refers to epithelial ovarian cancer only. It is important to realize that some of these strategies reduce the risk only slightly, while others decrease it much more. Some strategies are easily followed, and others require surgery. If you are concerned about your risk of ovarian cancer, you may want to discuss this information with your health care professionals. They can help you consider these ideas as they apply to your own situation.
Oral contraceptives : Using oral contraceptives (birth control pills) decreases the risk of developing ovarian cancer, especially among women who use them for several years. Women who used oral contraceptives for 5 or more years have about a 50% lower risk of developing ovarian cancer compared with women who never used oral contraceptives. Still, birth control pills do have some serious risks and side effects. Women considering taking these drugs for any reason should first discuss the possible risks and benefits with their doctor.
Gynecologic surgery :Both tubal ligation and hysterectomy may reduce the chance of developing ovarian cancer, but experts agree that these operations should only be done for valid medical reasons -- not for their effect on ovarian cancer risk.
If you are going to have a hysterectomy for a valid medical reason and you have a strong family history of ovarian or breast cancer, you may want to consider having both ovaries and fallopian tubes removed (called a bilateral salpingo-oophorectomy) as part of that procedure.
Even if you don’t have an increased risk of ovarian cancer, some doctors recommend that the ovaries be removed with the uterus if a woman has already gone through menopause or is close to menopause. If you are older than 40 and you are going to have a hysterectomy, you should discuss having your ovaries removed with your doctor.
Prevention strategies for women with a family history of ovarian cancer, including cancer due to BRCA mutation
Genetic counseling can predict whether you are likely to have one of the gene mutations associated with an increased ovarian cancer risk. If your family history suggests that you might have one of these gene mutations, you might consider genetic testing.
Before having genetic tests, you should discuss their benefits and potential drawbacks with the counselor. Genetic testing can help determine if you or members of your family carry certain gene mutations that cause a high risk of ovarian cancer. Still, the results are not always clear cut, and a genetic counselor can help you sort out what the results mean to you.
For some women with a strong family history of ovarian cancer, knowing they do not have a mutation that increases their ovarian cancer risk can be a great relief for them and their children. Knowing that you do have such a mutation can be stressful, but many women find this information very helpful in making important decisions about certain prevention strategies for them and their children.
Using oral contraceptives is one way that many women can reduce their risk of developing ovarian cancer. Oral contraceptives also seem to reduce the risk for women with BRCA1 and BRCA2 mutations. But birth control pills can increase breast cancer risk in women without these mutations. This increased risk continues for some time after these pills are stopped. Studies that have looked at this issue in women with BRCA mutations haven’t agreed about what effect birth control pills have on breast cancer risk. Some studies have shown an increased risk of breast cancer, while some have not. Research is continuing to find out more about the risks and benefits of oral contraceptives for women at high ovarian and breast cancer risk.
It isn’t clear if tubal ligation effectively reduces the risk of ovarian cancer in women who have BRCA1 or BRCA2mutations. Studies that have looked at this issue haven’t agreed about this. Researchers do agree that removing both ovaries and fallopian tubes (salpingo-oophorectomy) protects women with BRCA1 or BRCA2 mutations against ovarian (and fallopian tube) cancer.
Sometimes a woman has this surgery to reduce her risk of ovarian cancer before cancer is even suspected. If the ovaries are removed to prevent ovarian cancer, the surgery is called "risk-reducing" or "prophylactic." Generally, salpingo-oophorectomy is recommended only for very high-risk patients after they have finished having children. This operation lowers ovarian cancer risk a great deal but does not entirely eliminate it. That’s because some women who have a high risk of ovarian cancer already have a cancer at the time of surgery. These cancers can be so small that they are only found when the ovaries and fallopian tubes are looked at under the microscope (after they are removed). Also, women with BRCA1 or BRCA2 gene mutations have an increased risk of primary peritoneal carcinoma (PPC). Although the risk is low, this cancer can still develop after the ovaries are removed.
The risk of fallopian tube cancer is also increased in women with mutations in BRCA1 or BRCA2. In fact, sometimes early fallopian tube cancers are found unexpectedly when the fallopian tubes are removed as a part of a risk-reducing surgery. That is why experts recommend that women at high risk of ovarian cancer who are having their ovaries removed should have their fallopian tubes completely removed as well (salpingo-oophorectomy).
Research has shown that premenopausal women who have BRCA gene mutations and have had their ovaries removed reduce their risk of breast cancer as well as their risk of ovarian cancer. The risk of ovarian cancer is reduced by 85% to 95%, and the risk of breast cancer cut by 50% to 60%.
How is ovarian cancer diagnosed?
Signs and symptoms of ovarian cancer
Ovarian cancer may cause several signs and symptoms. Women are more likely to have symptoms if the disease has spread beyond the ovaries, but even early stage ovarian cancer can cause them. The most common symptoms include:
Pelvic or abdominal pain
Trouble eating or feeling full quickly
Urinary symptoms such as urgency (always feeling like you have to go) or frequency (having to go often)
These symptoms are also commonly caused by benign (non-cancerous) diseases and by cancers of other organs. When they are caused by ovarian cancer, they tend to be persistent and represent a change from normal − for example, they occur more often or are more severe. If a woman has these symptoms almost daily for more than a few weeks, she should see her doctor, preferably a gynecologist.
Others symptoms of ovarian cancer can include:
Fatigue, Upset stomach, Back pain, Pain during sex, Constipation, Menstrual changes, Abdominal swelling with weight loss
However, these symptoms are more likely to be caused by other conditions, and most of them occur just about as often in women who don’t have ovarian cancer.
Physical exam : Your doctor will first take your history and do a physical exam to look for signs of ovarian cancer. These include finding an enlarged ovary (on a pelvic exam) and signs of fluid in the abdomen (which is called ascites).
If there is reason to suspect you have ovarian cancer based on your symptoms and/or physical exam, your doctor will order some tests to check further.
Consultation with a specialist : If your pelvic exam or other tests suggest that you have ovarian cancer, you will need a doctor or surgeon who specializes in treating women with this type of cancer. A gynecologic oncologist is an obstetrician/gynecologist who is specially trained in treating cancers of the female reproductive system. Treatment by a gynecologic oncologist helps ensure that you get the best kind of surgery for your cancer. It has also has been shown to help patients with ovarian cancer live longer. Anyone suspected of having ovarian cancer should see this type of specialist prior to surgery.
Imaging studies : Imaging tests like computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and ultrasound studies can confirm whether a pelvic mass is present. These studies cannot confirm that the mass is a cancer, but they may be useful if your doctor is looking for spread of ovarian cancer to other tissues and organs.
Ultrasound : Ultrasound (ultrasonography) is the use of sound waves to create an image on a video screen. Sound waves are released from a small probe placed in the woman's vagina or on the surface of her abdomen. The sound waves create echoes as they enter the ovaries and other organs. The same probe detects the echoes that bounce back, and a computer translates the pattern of echoes into a picture.
This is often the first test done if a problem with the ovaries is suspected. Ultrasound can be useful finding an ovarian tumor and seeing if it is a solid mass (tumor) or a fluid-filled cyst. It can also be used to better look at the ovary to see how big it is and how it looks inside (the internal appearance or complexity). These factors help the doctor decide which masses or cysts are more worrisome.
Computed tomography (CT) scans : The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of multiple slices of the part of your body that is being studied.
A CT scanner has been described as a large donut, with a narrow table in the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken.
CT scans do not show small ovarian tumors well, but they can see larger tumors, and may be able to see if the tumor is growing into nearby structures. A CT scan may also find enlarged lymph nodes, signs of cancer spread to liver or other organs, or signs that an ovarian tumor is affecting your kidneys or bladder.
You may be asked to drink 1 to 2 pints of a liquid before the CT scan called oral contrast. You may also receive an IV (intravenous) line through which a different kind of contrast dye is injected. Contrast dyes help better outline structures in your body.
The injection can cause some flushing (redness and warm feeling that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for imaging tests.
CT scans are not usually used to biopsy (see biopsy in the section "Other tests") an ovarian tumor, but they can be used to biopsy a suspected metastasis. For this procedure, called a CT-guided needle biopsy, the patient stays on the CT scanning table, while a radiologist moves a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than 1/8 inch in diameter) is removed and examined under a microscope.
Barium enema x-ray : This is a test to see if the cancer has invaded the colon (large intestine) or rectum (it is also used to look for colorectal cancer). After taking laxatives the day before, the radiology technician puts barium sulfate, a chalky substance, into the rectum and colon. Because barium is impermeable to x-rays (impossible for x-rays to go through), it outlines the colon and rectum on x-rays of the abdomen. This test is rarely used now in women with ovarian cancer. Colonoscopy may be done instead.
Magnetic resonance imaging (MRI) scans : MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross-sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of the body. A contrast material might be injected into a vein (same as with a CT scan). MRI scans are not used often to look for ovarian cancer.
MRI scans are particularly helpful to examine the brain and spinal cord. MRI scans take longer than CT scans, -- often up to 30 minutes or more. Also, you have to be placed inside a tube, which is confining and can upset people with claustrophobia (fear of enclosed spaces). The machine also makes a thumping noise that you may find disturbing. Some places will provide headphones with music to block the sound.
Chest x-ray : This procedure may be done to determine whether ovarian cancer has spread (metastasized) to the lungs. This spread may cause one or more tumors in the lungs and more often causes fluid to collect around the lungs. This fluid, called a pleural effusion, can be seen with chest x-rays as well as other types of scans.
Positron emission tomography (PET) scan : In this test, radioactive glucose (sugar) is given to look for the cancer. Because cancers use glucose (sugar) at a higher rate than normal tissues, the radioactivity will tend to concentrate in the cancer. A scanner can spot the radioactive deposits. This test can be helpful in spotting small collections of cancer cells. In some instances this test has proved useful in finding ovarian cancer that has spread. It is even more valuable when combined with a CT scan (PET/CT scan). PET scans can help find cancer when it has spread, but they are expensive and are not always covered by insurance when they are used to look for ovarian cancer.
Laparoscopy : This procedure uses a thin, lighted tube through which a doctor can look at the ovaries and other pelvic organs and tissues in the area. The tube is inserted through a small incision (cut) in the lower abdomen and sends the images of the pelvis or abdomen to a video monitor. Laparoscopy provides a view of organs that can help plan surgery or other treatments and can help doctors confirm the stage (how far the tumor has spread) of the cancer. Also, doctors can manipulate small instruments through the laparascopic incision(s) to perform biopsies.
Colonoscopy : A colonoscopy is a way to examine the inside of the large intestine (colon). After the large intestine has been cleaned with laxatives, the doctor inserts a fiberoptic tube into the rectum and passes it through the entire colon. The images are sent to a video monitor. This lets the doctor see the inside and detect any abnormalities. Colonoscopy can be uncomfortable, so the patient is sedated before the procedure. This procedure is more commonly used to look for colorectal cancer.
Biopsy : The only way to determine for certain if a growth is cancer is to remove a sample of the growth from the suspicious area and examine it under a microscope. This procedure is called a biopsy. For ovarian cancer, the biopsy is most commonly done by removing the tumor.
Blood tests : Your doctor will order blood count tests to make sure you have enough red blood cells, white blood cells and platelets (cells that help stop bleeding). There will also be tests to measure your kidney and liver function as well as your general health status. Finally the doctor will order a CA-125 test. Patients who have a high CA-125 level are often referred to a gynecologic oncologist, but any woman with suspected ovarian cancer should see a gynecologic oncologist, as well.
Some germ cell cancers can cause elevated blood levels of the tumor markers human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and/or lactate dehydrogenase (LDH). These may be checked if your doctor suspects that your ovarian tumor could be a germ cell tumor.
Some ovarian stromal tumors cause the blood levels of a substance called inhibin and hormones such as estrogen and testosterone to go up. These levels may be checked if your doctor suspects that you have this type of tumor.
How is ovarian cancer staged?
Staging is the process of finding out how widespread a cancer is. Most ovarian cancers that are not obviously widespread are staged at surgery. One of the goals of surgery for ovarian cancer is to take tissue samples for diagnosis and staging. To stage the cancer, samples of tissues are taken from different parts of the pelvis and abdomen and examined under the microscope.
Staging is very important because ovarian cancers have different prognoses at different stages and are treated differently. The accuracy of the staging may determine whether or not a patient will be cured. If the cancer isn’t accurately staged, then cancer that has spread outside the ovary might be missed and not treated. Once a stage has been given it does not change, even when the cancer comes back or spreads to new locations in the body.
Ask your cancer care team to explain the staging procedure. After surgery, ask what your cancer's stage is. In this way, you will be able to make informed decisions about your treatment. One of the reasons it is important to be operated on by a gynecologic oncologist is that you are more likely to be staged accurately.
Ovarian cancer can be staged according to the AJCC/TNM System. This describes the extent of the primary tumor (T), the absence or presence of metastasis to nearby lymph nodes (N), and the absence or presence of distant metastasis (M). This closely resembles the system that is actually used by most gynecologic oncologists, called theFIGO system. Both rely on the results of surgery for the actual stages. Fallopian tube cancer is staged like ovarian cancer, but with different T categories. Primary peritoneal cancer (PPC) is staged like ovarian cancer, with all cases being either stage III or IV depending on whether the cancer has spread to distant sites.