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Cancer > Overview

Ovarian Cancer: The Basics

Christopher Dolinsky, MSIV
The University of Pennsylvania Cancer Center
Posting Date: November 27, 2002
What is the ovary?
The ovaries are two small organs that only
women have. They are in a woman's pelvis, on
each side of her uterus (the organ where a baby
grows and develops when a woman is
pregnant). The ovaries are each about the size
of a peanut M&M, and they can often be felt by
your doctor during the bi-manual portion of a
pelvic examination. A woman's ovaries are
responsible for two important functions in her
body: they produce female hormones and they
produce eggs. Every month that a woman is
fertile and not pregnant, her ovaries release an
egg that travels into her uterus and has the
potential to become fertilized. The ovaries also
produce the important hormones, estrogen and
progesterone, which regulate a woman's
menstrual cycles, influence the development of
a woman's body during puberty, and keep a
woman fertile.

What is ovarian cancer?

Ovarian cancer develops when cells in the
ovaries begin to grow out of control and can
then invade nearby tissues or spread
throughout the body. Large collections of this
out of control tissue are called tumors.
However, some tumors are not really cancer
because they cannot spread or threaten
someone's life. These are called benign
tumors. The tumors that can spread throughout
the body or invade nearby tissues are
considered cancer and are called malignant
tumors. The distinction between benign and
malignant tumors is very important in ovarian
cancer because many ovarian tumors are
benign. Also, sometimes women (especially
young women) can get ovarian cysts, which are

collections of fluid in the ovaries that can

occasionally grow large or become painful.
However, ovarian cysts are not cancerous and
should not be confused with ovarian cancer.
Your doctor may suggest that you have an
ovarian cyst removed if it is becoming
bothersome.
Cancers are characterized by the cells that they
originally form from. The most common type of
ovarian cancer is called epithelial ovarian
cancer; it comes from cells that lie on the
surface of the ovary known as epithelial cells.
Epithelial ovarian cancer compromises about
90% of all ovarian cancers and usually occurs in
older women. About 5% of ovarian cancers are
called germ cell ovarian cancers and arise from
the ovarian cells that produce eggs. Germ cell
ovarian cancers are more likely to affect
younger women. Another 5% of ovarian
cancers are known as stromal ovarian cancers
and develop from the cells in the ovary that
hold the ovary together and produce hormones.
These tumors can create symptoms by
producing large amounts of excess female
hormones. Each of these three types of ovarian
cancer (epithelial, germ cell, stromal) contains
many different subtypes of cancer that are
distinguished based on how the cells look under
a microscope. Discuss the exact category of
ovarian cancer that you have with your
physician, so that you can get a sense of the
particulars of your case.

Am I at risk for ovarian cancer?

As women get older, their risk of developing
ovarian cancer increases. In the U.S., it is
expected that 23,300 women will develop
ovarian cancer in 2002; and 13,900 women will
die of ovarian cancer in 2002. This puts ovarian
cancer as the 6th most common cancer that
women develop, and the 5th most common
cause of cancer death for women in the U.S.
Unfortunately, the majority of cases of ovarian
cancer are found when it is somewhat advanced
because early stage ovarian cancers rarely

cause any symptoms.

Although there are several known risk factors
for getting ovarian cancer, no one knows exactly
why one woman gets it and another doesn't.
The most significant risk factor for developing
ovarian cancer is age; the older a woman
becomes, the higher her chances are of getting
it. The majority of ovarian cancers are
diagnosed in women after they have gone
through menopause, in their late fifties and
sixties. The average age for a woman to get a
sporadic ovarian cancer is 61 years, although
women with genetic or familial risk factors tend
to get ovarian cancer at a younger age (average
age of diagnosis is 54 years).
Other than age, the next most important risk
factor for ovarian cancer is a family history of
ovarian cancer, particularly if your family
members are affected at an early age. If your
mother, sister, or daughters have had ovarian
cancer, then you have an increased risk for
development of the disease. Scientists estimate
that 7% to 10% of all ovarian cancers are the
result of hereditary genetic syndromes. Genetic
mutations for ovarian cancer have become a hot
topic of research lately. Currently, there are
three syndromes that are recognized to increase
ovarian cancer risk: ovarian cancers associated
with colon and endometrial cancers (called
hereditary nonpolyposis colorectal cancer
syndrome - HNPCC), breastand ovarian cancer
syndrome (associated with mutations in either
the gene BRCA1 or the gene BRCA2), and sitespecific ovarian cancer syndrome (which
produces an increased risk for ovarian cancer
alone). Women can inherit these mutations from
their parents and it may be worth testing for
mutations if a woman has a particularly strong
family history of breast or ovarian cancer
(meaning multiple relatives affected, especially
if they are under 50 years old when they get the
disease). Having a mutation doesn't necessarily
mean a woman is going to get the disease, but
it does greatly increase her chances above the
general population. Family members may elect
to be tested to see if they carry mutations as
well. If a woman does have the mutation, she

can get more rigorous screening or even

undergo prophylactic oophorectomies
(preventive removal of your ovaries) to
decrease her chances of contracting cancer.
The decision to get tested is a highly personal
one that should be discussed with a doctor who
is trained in counseling patients about genetic
testing.
The rest of the risk factors for ovarian cancer
are not as significant as age and family
history/genetic syndromes, but are mentioned
because some of them can be controlled. It
appears that the more menstrual cycles (and
thus ovulations) a woman has in her lifetime,
the more likely she is to develop ovarian
cancer. Thus women who started menstruating
early, go through menopause late, don't have
any children (or have children after age 30),
don't use a form of birth control that stops
menstruation/ovulation (like birth control pills),
and don't breastfeed are more likely to develop
ovarian cancer. It also appears that having a
tubal ligation (having your tubes tied) and/or
a hysterectomy (removal of your uterus)
decreases your risk of ovarian cancer.
Prolonged use of the infertility drug, clomiphene
citrate, without getting pregnant, slightly
increases a woman's risk for ovarian cancer.
Finally, it has been suggested that a diet high in
animal fats can increase your risk for ovarian
cancer. Remember that all risk factors are based
on probabilities, and even someone without any
risk factors can still get ovarian cancer. Talk to
your doctor about you risk factors for ovarian
cancer to understand his/her recommendations
for screening and prevention.

How can I prevent ovarian cancer?

Unfortunately, there aren't very good screening
methods for ovarian cancer, so preventing it is a
particularly important challenge. If you are a
woman without a family history/genetic
syndrome, then the best way to prevent ovarian
cancer is to alter whatever risk factors you have
control over. Consider using methods of birth
control (like OCPs oral contraceptive pills, or

depo-provera) that stop ovulation/menstruation

or think about tubal ligation/hysterectomy for
permanent sterilization when the time is right.
If you plan to get pregnant, try and do so
before age 30 and make sure and breastfeed.
Women who are carriers of one of the above
mentioned genetic syndromes face different
decisions. They generally need to have more
rigorous screening done for ovarian cancer, and
some of them may elect to have their ovaries
removed when they are still healthy (called a
prophylactic oophorectomy). This should only
be done when a woman is finished having
children, and it can drastically reduce a
woman's chances for developing ovarian cancer
(but not reduce the risk to zero). Before a
woman decides to do this, she should have
genetic testing and a significant amount of
counseling from a physician who has experience
with genetic diseases.
While a diet high in animal fats has been
implicated in ovarian cancer, a diet rich in fruits
and vegetables may have a small preventive
effect. It has been suggested that
supplementation with vitamins A, C, and E may
decrease your risk, but further studies need to
be performed before any nutritional
recommendations can be made regarding
ovarian cancer prevention.

What screening tests are available?

An ideal screening test for ovarian cancer could
save many lives. The vast majority of ovarian
cancers are found at advanced stages, because
early, small ovarian cancers are asymptomatic
and cannot usually be found by a physician.
Patients who are diagnosed with early ovarian
cancers tend to respond to treatment better
than patients with more advanced cancers.
There are not currently any effective
approaches to ovarian cancer screening. There
are a few tests that are being studied, but we
need further data before they become routine
for ovarian cancer screening.

Right now, the only screening that is

recommended for the general population
(women without hereditary cancer syndromes)
is an annual pelvic examination. Your physician
can usually feel your ovaries during the bimanual portion of the exam, and if any
abnormalities are felt, you can be referred for
further tests. The major limitation to this
method is that early ovarian cancers aren't
usually appreciated on examination, and are
often missed.
There are a few other tests that are currently
being studied for ovarian cancer screening. One
is a blood test that looks for a protein named
CA-125. CA-125 is a protein that is shed from
damaged ovary cells, and is often elevated in
ovarian cancer. The major problem with CA-125
is that is elevated in many other diseases
besides ovarian cancer, and even completely
healthy women can have elevated CA-125
levels. Another problem with CA-125 is that its
levels normally fluctuate during a woman's
menstrual cycle. One possible way to use CA125 for ovarian cancer screening is to check it
and then re-check it 6 months later. If it has a
drastic increase over time, then there is more
suggestion that a woman has ovarian cancer.
The major problem with CA-125 screening is
that many patients without ovarian cancer will
have elevated CA-125 levels and need further
workup (which often means going for surgery).
It is dangerous to send lots of women for
surgery unnecessarily, so we need a test that is
more specific for ovarian cancer before it can be
recommended for screening the general
population.
Another investigational method for ovarian
cancer screening is transvaginal
ultrasonography. Ultrasound is an imaging
technique that uses sound waves that bounce
off of tissues and provide a picture of whatever
is being investigated. By inserting an
ultrasound probe into a woman's vagina,
doctors can get a pretty good look at her
ovaries. If the ovaries look suspicious, then
further tests can be done. The biggest problem
with using transvaginal ultrasound for ovarian

cancer screening is the same problem as using

CA-125: both of these tests cause too many
healthy women to go for unnecessary
procedures because they aren't specific enough
for ovarian cancer. Doctors hope that perhaps a
combination of CA-125 and transvaginal
ultrasound will be an effective method for
ovarian cancer screening, and large studies are
currently underway examining the feasibility
and usefulness of this approach.
Currently, the general population should only be
screened for ovarian cancer with a pelvic
examination. However, women with a strong
family history or who have a proven hereditary
cancer syndrome may need to get more
rigorous screening with serial CA-125 tests
and/or transvaginal ultrasounds. Talk to your
doctor about your ovarian cancer risk, and what
the best way to go about screening is in your
particular case.

What are the signs of ovarian cancer?

Unfortunately, the early stages of ovarian
cancer usually do not cause any symptoms.
Even when it does produce symptoms, they are
often very non-specific and don't point towards
a diagnosis of ovarian cancer. As the tumor
grows in size, it can produce a variety of
problems including:

abdominal swelling or abdominal pain

vaginal bleeding between periods or after
menopause
bloating, gas, indigestion or cramps
pelvic pain
loss of appetite
feeling full after a small meal, or feeling
full very easily
changes in bowel or bladder habits
weight loss or weight gain

All of these symptoms are non-specific, and

could represent a variety of different conditions;
however, your doctor needs to see you if you
develop any of these problems.

How is ovarian cancer diagnosed and

staged?
The most common reason for a physician to
suspect ovarian cancer is if he/she feels a mass
during a pelvic examination. When a pelvic
mass is found in either a postmenopausal
woman, or a girl or teenager than hasn't yet
begun menstruating, then they will need to
undergo surgery to make the final diagnosis.
Chances are very high that a pelvic mass in a
young girl or teenager that hasn't begun
menstruating is a cancer (usually a germ cell
ovarian cancer). However, only 5% of masses
felt on pelvic exam in menstruating women are
malignancies, and certain characteristics of the
mass make it more or less likely to be a cancer.
If the mass is solid, irregular or fixed, it is more
likely to be a cancer. Often, if you are a
menstruating woman, your physician will have
the mass further characterized by transvaginal
ultrasound. If the mass is small, has holes (is
cystic), is in only one ovary, is freely movable,
and has regular contours, then it is unlikely to
be a cancer. Masses with these qualities can be
followed by clinical exam because there is a
good chance that they represent ovarian cysts
and will disappear on their own. However, if
these masses persist or enlarge, then they need
to be surgically explored. Women with a pelvic
mass and an increased CA-125 level will go
straight to surgery, and women with a pelvic
mass and other symptoms suggestive of cancer
(like having fluid collect in their abdomen) may
also go directly to surgery.
Ovarian cancer is a type of cancer that needs to
be diagnosed and staged during a surgery.
Often, the cancer is diagnosed and treated
during the same procedure. Surgeries for
ovarian cancer diagnosis and treatment should
be done by a surgeon specialized in gynecologic
malignancies. Surgery is done so that samples
of the mass and surrounding tissue can be
biopsied and analyzed. A biopsy is the only way
to know for sure if you have cancer, because it
allows your doctors to get cells that can be
examined under a microscope. Once the tissue

is removed, a doctor known as a pathologist will

review the specimen. The pathologist can tell if
it is cancer or not; and if it is cancerous, then
the pathologist will characterize it by what type
of tissue it arose from and what subtype of
ovarian cancer it is, how abnormal it looks
(known as the grade), whether or not it is
invading surrounding tissues.
In order to guide treatment and offer some
insight into prognosis, ovarian cancer is staged
into four different groups at the time of the
surgery. Surgeons who specialize in
gynecologic malignancies go through a careful
inspection and sampling of a woman's pelvis
during this procedure, and biopsy specimens are
sent to a pathologist while the surgeon is still
working. The staging system used for ovarian
cancer is the FIGO system (International
Federation of Gynecologists and Obstetricians).
The staging system is somewhat complex, but
here is a simplified version of it:
Stage I ovarian cancer confined to the ovary
or ovaries
Stage II ovarian cancer that has spread
beyond the ovaries, but is confined to the pelvis
(can be in the uterus, bladder or rectum)
Stage III ovarian cancer that has spread to the
peritoneum (the lining of the abdomen) and/or
lymph nodes
Stage IV ovarian cancer that has distant
spread (metastasis) to other organs
Generally, the higher the stage, the more
serious the cancer. Although surgery is required
for staging, your physicians may want to order
some other tests to better characterize the
mass/masses and look for distant spread. Tests
like CT scans (a 3-D x-ray) or MRIs (like a CT
scan but done with magnets) can examine the
pelvis and localized lymph nodes. Some
patients with bony pain are referred for a bone
scan, which is a test using a radioactive tracer
to look for metastasis to any of your bones. You

may get also get a colonoscopy, which uses a

lighted scope to examine your rectum and
colon, or a barium enema in which dye is
inserted into your rectum and an x-ray is
taken. These tests are to look for spread of the
tumor to your colon. Each patient is an
individual so the specific tests people get will
vary; but overall, your doctors want to know as
much about your particular tumor as possible so
that they can plan the best available
treatments.

What are the treatments for ovarian

cancer?
Surgery
Almost all women with ovarian cancer will have
some type of surgery in the course of their
treatment. The purpose of surgery is first to
diagnose and stage the cancer, and then to
remove as much of the cancer as possible. In
early stage cancers (stage I and II), surgeons
can often remove all of the visible cancer.
Generally, women with ovarian cancer will have
a hysterectomy (removal of the uterus) and
bilateral salpingo-ooporectomy (removal of both
ovaries and fallopian tubes) as part of their
operation. This is because there is always a risk
of microscopic disease in both of the ovaries
and the uterus. The only circumstance in which
a woman may not have this entire operation is if
she has a very early stage cancer (IA) that
looks favorable under the microscope (grade
1). This is often the case with germ cell ovarian
tumors. If a woman's tumor has these
characteristics and she desires to maintain the
ability to have children, then the surgeons can
remove only her diseased ovary and tube. Then
after she is done having children, she will need
to have her uterus and the other tube and ovary
removed. With any other stage or grade of
tumor, or in patients finished with childbearing,
the entire operation should be performed in
order to provide the best possible chance for a
cure.
Women who have more advanced disease

(stage III or IV) will often have debulking

surgeries, which means that their surgeon will
attempt to remove as much disease as
possible. Data collected in many studies has
demonstrated that the more tumor that it
debulked, the better the long term outcome for
the patient. Sometimes ovarian cancer is
diffusely spread throughout the entire pelvis
and abdomen, and it can take a surgeon quite
some time to get it adequately debulked.
Operations for ovarian cancer should be
performed by surgeons who are trained in
dealing with gynecologic malignancies because
there are special skills and techniques necessary
to deal with these tumors. Sometimes, a
patient will have debulking surgery and then
later her cancer will come back. It may be
useful to debulk such a patient a second time,
particularly if she has had at least a year
between her initial surgery and the recurrence.
In patients with very advanced ovarian cancer,
surgery may be used for palliation meaning
that patients are operated on with the intent of
easing their pain or symptoms, rather than
trying to cure their disease.
Another way that surgery is occasionally used in
ovarian cancer is to closely monitor a patient for
signs of recurrent disease. This is a called a
second look surgery, and can be done with an
abdominal incision (a laparotomy) or using
fiberoptic scopes and long, narrow tools which
allow surgeons to operate less invasively
(laparoscopically). This used to be a more
common procedure in the past, because current
data has failed to show a strong benefit from
performing second look surgeries. However, it
may be useful in some cases, particularly in
patients with no other indication of a recurrence
during follow-up imaging and laboratory
testing. If a second-look procedure shows
recurrent tumor, then further surgery can be
performed or other treatment modalities may
be added or changed. Talk to your surgeons
about exactly which type of operation you are
going to undergo.

Chemotherapy
Despite the fact that the tumors are removed
during surgery, there is always a risk of
recurrence because there may be microscopic
cancer cells left that the surgeon cannot
remove. In order to decrease a patient's risk of
recurrence, they are offered chemotherapy.
Chemotherapy is the use of anti-cancer drugs
that go throughout the entire body. The vast
majority of patients with ovarian cancer should
be offered chemotherapy after their surgery.
The higher the stage of cancer you have, the
more important it is that you receive
chemotherapy. Generally, only very early stage
cancers (early stage I) that look favorable under
the microscope (grade 1 or 2) can be treated
with surgery alone. Any woman with a more
advanced stage or grade cancer should be
offered chemotherapy.
There are many different chemotherapy drugs,
and they are often given in combinations.
Patients will usually have to go to a clinic to get
the chemotherapy because many of the drugs
have to be given through a vein. Different
chemotherapy regimens are used for different
purposes. The most common combination
currently used for epithelial ovarian cancer is
Paclitaxel plus either Cisplatin or Carboplatin
(platinum containing drugs). There are other
drugs that can be used, like Gemcitabine and
Doxorubicin, and sometimes new combinations
are tried if there isn't a response to the original
combination. There are advantages and
disadvantages to each of the different regimens
that your medical oncologist will discuss with
you. Based on your own health, your personal
values and wishes, and side effects you may
wish to avoid, you can work with your doctors to
come up with the best regimen for your cancer
and your lifestyle.

Radiotherapy
Ovarian cancer does not commonly receive
radiation therapy in the United States.
Radiation therapy uses high energy rays (similar

to x-rays) to kill cancer cells. It comes from an

external source, and it requires patients to
come in 5 days a week for up to 6-8 weeks to a
radiation therapy treatment center. The
treatment takes just a few minutes, and it is
painless. Radiation therapy is occasionally
combined with surgery in low disease bulk
patients with stage II tumors. Radiation can
also be used to ease the pain of metastases and
stop tumors from bleeding. Generally, doctors
try to limit the amount of radiation that your
vital organs receive, and don't like to treat large
portions of the bowel and pelvis. This makes
radiation less useful in ovarian cancer, where
disease if often diffusely spread throughout the
abdomen and pelvis. A radiation oncologist can
answer questions about the utility, process, and
side effects of radiation therapy in your
particular case.

Follow-up testing
Once a patient has been treated for ovarian
cancer, they need to be closely followed for a
recurrence. At first, you will have follow-up
visits fairly often. The longer you are free of
disease, the less often you will have to go for
checkups. Your doctor will tell you when he or
she wants follow-up visits, CA-125 levels, pelvic
ultrasounds and/or CT scans depending on your
case. Your doctors will also perform pelvic
examinations during each of your office visits.
It is very important that you let your doctor
know about any symptoms you are experiencing
and that you keep all of your follow-up
appointments. Depending on your case, there
may be some utility in performing a second look
surgery to monitor any possibility of recurrent
disease or treatment failure. Talk to your team
about their feelings on performing a secondlook surgery in your case.
Clinical trials are extremely important in
furthering our knowledge of this disease. It is
though clinical trials that we know what we do
today, and many exciting new therapies are
currently being tested. Talk to your doctor

about participating in clinical trials in your area.

This article is meant to give you a better
understanding of ovarian cancer. Use this
knowledge when meeting with your physician,
making treatment decisions, and continuing
your search for information. You can learn
more about ovarian cancer on OncoLink through
the related links to the left.

References
The American Cancer Society All About Ovarian
Cancer Overview http://www.cancer.org/.
Hensler, M. (2002) Epithelial Ovarian Cancer.
Current Treatment Options in Oncology.
3(2):131-41
Jemal, A. et. al (2002). Cancer Statistics, 2002.
Ca: a Cancer Journal for Clinicians 52 (1):23-47
National Cancer Institute. What You Need To
Know About Ovarian Cancer.
http://www.cancer.gov/.
Partridge E. and Barnes M. (1999) Epithelial
Ovarian Cancer:Prevention, Diagnosis and
Treatment. Ca: a Cancer Journal for Clinicians
49 (5):297-320
Rubin, P. and Williams, J.P., (Eds): Clinical
Oncology: A Multidisciplinary Approach for
Physicians and Students 8th ed. (2001). W.B.
Saunders Company, Philadelphia, Pennsylvania.