Gynecologic Conditions

Ovarian Cancer

Ovarian cancer is uncommon, accounting for only 4% of all cancers in women. About 1 in 70 women develop ovarian cancer. There are approximately 25,000 new cases of ovarian cancer a year in the United States. Because there are no specific early warning symptoms and effective screening tests do not exist, 75% of all ovarian cancers are diagnosed after the disease has spread beyond the pelvis.

What causes ovarian cancer?
We do not know exactly what causes ovarian cancer, but we do know what increases or decreases ovarian cancer risk. Ovarian cancer can either be sporadic (random) or familial (hereditary). Ninety percent of all ovarian cancers are sporadic, occurring by chance. The following factors increase your risk of ovarian cancer.

Risk Factors for any Ovarian Cancer

  • Over 50 years of age
  • High fat diet
  • Never had children
  • Used fertility drugs
  • Started your period at a young age and went through menopause at an older age
  • Caucasian race
  • Ashkenazi Jewish descent
  • Family history of ovarian or breast cancer

Risk Factors for Familial Ovarian Cancer

Ten percent of all ovarian cancer is familial, meaning that it is passed through genes. People with familial ovarian cancer have mutations in the BRCA1 or BRCA2 gene (or both). Changes in these genes significantly increase the risk for developing ovarian cancer (and breast cancer).

  • Multiple relatives on either side of the family with a history of ovarian or breast cancer
  • Relatives with breast or ovarian cancer diagnosis before the age of 50
  • Multiple generations in the family with breast and/or ovarian cancers
  • Male relative with breast cancer
  • Ashkenazi Jewish descent

If these factors are present, you may consider genetic testing to determine if you carry the mutation of the BRCA1 or BRCA2 genes. With or without genetic testing, you should be actively screened for ovarian cancer with pelvic ultrasounds and blood tests every six months.

Factors that lower the risk of ovarian cancer

  • Using birth control pills for more than five years
  • Having multiple children
  • Breast feeding
  • Tubal ligation
  • Removing the ovaries

Warning Symptoms of Ovarian Cancer

It is very important for women to know the early warning signs of ovarian cancer and to see their healthcare provider if they experience the symptoms.

  • Vague abdominal and pelvic discomfort
  • Bloating
  • Unexplained gastrointestinal symptoms like excess gas, indigestion and back pain
  • A feeling of pressure in the pelvic area
  • Unexplained weight gain or loss
  • A feeling of fullness, even after a small meal
  • Fatigue
  • Pain during intercourse

If, after reviewing the risk factors and warning symptoms you feel you are at risk, you should be screened for ovarian cancer. If your gynecologist examines you and there is an indication that you have a suspicious ovarian mass, you should see a gynecologic oncologist for evaluation and possible surgery. Ovarian cancer cannot be diagnosed without tissue sampling; this happens at the time of surgery.

Treatment of Ovarian Cancer
The treatment of ovarian cancer includes surgery and chemotherapy (for patients with Stage IC and higher). There are several ways to approach surgery and chemotherapy for ovarian cancer.

Chemotherapy: Over the last several years, there has been a transition to weekly chemotherapy with Carboplatin and Taxol given into a vein (called IV chemotherapy). The weekly dose is low and well tolerated. Most patients have mild (if any) nausea, vomiting, fatigue, joint and muscle aches and lowered blood counts. For patients who are found to have an early cancer at the time of surgery, most will have 18 weeks of chemotherapy starting a few weeks after surgery. For patients who are found to have more advanced ovarian cancer, many will have 9 or 18 weeks of chemotherapy, a short break from chemotherapy for surgery, and then additional chemotherapy.

Some patients will be candidates for a different type of chemotherapy called IV/IP chemotherapy (sometimes referred to as a “belly wash” chemotherapy) using the same drugs. This way of giving chemo puts some of the chemotherapy into the veins and some of it directly into the abdomen where ovarian cancer cells grow. This type of chemotherapy has more significant side effects including nausea, vomiting, fatigue, lowered blood counts and hair loss. Chemo is given two days the first week, one day the second week and then off for a week. This pattern (called a cycle) is repeated for a total of 3 - 4 cycles. Some patients receive a combination of both IV and IV/IP chemotherapy.

After the first several months of chemo as just described, we often recommend maintenance chemotherapy (called consolidation). This kind of chemotherapy uses just one drug (Taxol) at a low dose given either once a month or every other week. For some people, adding maintenance chemotherapy keeps the cancer from ever returning. For others, adding maintenance chemo lengthens the time before the cancer returns and gives more time off chemotherapy.

Surgery: The goal of surgery in ovarian cancer is to remove the organs and tissues where the cancer usually spreads to see if there is cancer present (called staging) and to remove as much cancer as possible (called debulking). For many patients, surgery can be done robotically with a few small incisions and a quick return to normal activity.

Staging removes tissue where ovarian cancer is often found but might be too small to be seen with just the eye at surgery. Staging includes removing the uterus, fallopian tubes, ovaries and appendix (if it has not already been removed). The omentum, an apron of fat tissue that hangs down from the colon (large intestine) and drapes over the small intestine, is also be removed. Everyone has this apron of fat, and ovarian cancer often spreads there. Lastly, your physician checks the lymph nodes in the pelvis and sometimes higher up toward the heart (in the para-aortic region).

Lymph nodes are found throughout the body as part of the filtration system. They “catch” cancer cells that break off from the original tumor. Finding cancer cells in the lymph nodes tells us that the cancer has begun to spread. Even if we cannot see or feel any other cancer, the lymph nodes may have cancer cells inside them. The pathologist looks at all tissues we remove to see if the cancer has spread. This tells us the stage of the cancer and whether chemotherapy is needed.

If cancer has spread beyond the ovaries, further surgery, called debulking, may be necessary. The goal of debulking is to remove all visible tumor or to remove as much tumor as possible. (“Optimal debulking” means removing all visible tumor or leaving tumor that is less than 1.5 centimeters in diameter.) The most common debulking procedures are to remove parts of the small or large intestine since those areas are often involved with ovarian cancer. The pre-operative bowel prep enables the surgeon to safely reattach the intestines. Rarely, you may need a colostomy or ileostomy which is done only if absolutely necessary. Other rare procedures involve the liver, spleen, and bladder.

For any additional procedure, your surgeon performs only what is in your best interest. Your physician considers the benefits and risks of the procedure. Only if the benefits for the patient outweigh the risks will the procedure be done. If the risks and benefits seem equal or if the risks outweigh the benefits, the procedure is not performed.

Stages of Ovarian Cancer
All gynecologic cancers, including ovarian cancer, are staged. Staging is a way of talking about how far a cancer has spread from where it started and helps guide our recommendations for treatment.  If ovarian cancer is diagnosed, your physician can inform you of the stage of your disease.

Stage I The cancer is contained in the ovaries.

  • IA: The cancer is completely contained in one ovary,
    and there are no cancer cells in the washing of the abdomen and pelvis.
  • IB: The cancer is completely contained in both ovaries, and there are no
    cancer cells in the washing of the abdomen and pelvis.
  • IC: The cancer is present in one or both ovaries and on the surface of the
    ovaries. Washing of the abdomen and pelvis show cancer cells present.

Stage II The cancer has spread to other organs in the pelvis.

  • IIA: The cancer has spread to the uterus, fallopian tubes, or both.
    The washings of the abdomen do not show cancer cells.
  • IIB: The cancer has spread to the organs in IIA and other nearby organs
    (bladder, sigmoid colon, or rectum). The washings of the abdomen do not
    show cancer cells.
  • IIC: The cancer has spread to the organs listed in IIA and IIB and involves
    the outer surface of the ovaries. Cancer cells are found in the abdominal washings.

Stage III
The cancer has spread beyond the pelvis and is present in the lining of the abdomen or lymph nodes.

  • IIIA: During surgery there was no visible sign of involvement in the abdomen or
    lymph nodes. However, biopsies show microscopic disease in the lower abdomen.
  • IIIB: The cancer has spread to the abdomen and is up to 2 cm (3/4") across.
    However, it has not spread to the lymph nodes.
  • IIIC: The cancer has spread to the lymph nodes and/or abdominal growths are greater than 2 cm (3/4").

Stage IV This is the most advanced stage and the cancer has spread (metastasized) to other organs outside the peritoneal cavity, usually the space outside the lung.

  • Has performed over 4000 robotic surgeries.
  • Papers accepted at the annual Society of Gynecological Oncologists and peer review journals.
  • Facilitates advanced courses and training in robotics for gynecologic oncologists around the country including peer observation of his cases and hands on instruction.
  • Ivy League educated and trained.
  • Presented results of multiple research studies on gynecologic cancers at national meetings, and published in several peer-reviewed journals.
  • Received multiple honors and special appointments throughout training.
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