Ovarian cancer

Symptoms Of Ovarian Cancer

The symptoms of ovarian cancer are usually missed at an early stage due to their resemblance with other medical conditions. Most of the following symptoms are recognizable at later stages of the condition: 

• Abnormal vaginal discharge

• Pain or pressure in the pelvic area

• Abdominal pain and fullness

• Nausea

• Indigestion

• Bloating

• Constipation

• Early satiety

• Urgency to urinate

• Increased frequency of urination

• Fatigue

• Back pain

• Loss of weight

• Persistent or recurrent genital pain that occurs just before, during or after sexual intercourse

• Menstrual abnormalities

• Vaginal bleeding

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Causes Of Ovarian Cancer

Before knowing about the exact cause of ovarian cancer, it is important to understand the structure and function of ovaries. 

What are ovaries?

Ovaries are the primary reproductive glands in females that produce eggs. Women have two ovaries located on each side of their uterus. The egg produced by the ovaries travels through the fallopian tube and fuses with the sperm. This fertilized egg travels further and settles in the uterus. The uterus nourishes the developing fetus prior to birth.

The ovaries also produce estrogen and progesterone – the two main reproductive hormones of the women. 

Ovaries comprises three kinds of cells which are:

• Epithelial cells: The outer surface of the ovaries consists of epithelial cells. 
• Germ cells: The cells that develop into eggs are germ cells. 
• Stromal cells: These cells make up the connective tissue throughout the ovary and surrounding follicles. These cells are also responsible for the production of hormones estrogen and progesterone. 

What is cancer?

Cancer is a disease in which some of the body's cells grow uncontrollably and spread to other parts of the body. Cells of any part of the body can become cancerous. 

What causes ovarian cancer?

The exact cause of ovarian cancer is not known. However, there are certain theories behind the pathogenesis of ovarian cancer:

• Incessant ovulation theory: The surface epithelial cells of the ovary experience physical injury during ovulation (process in which a mature egg is released from the ovary). The repetitive trauma to the epithelium can sometimes cause cellular DNA damage. This can turn the normal cells into cancerous cells.
• Fallopian tube theory: Some ovarian cancers originate from the epithelium of the fallopian tube which then spilled over the surface of the ovary.

Types Of Ovarian Cancer

Ovarian cancer are of four types based upon the cells from which they arises:

I. Epithelial cell carcinomas

They are the most commonly observed ovarian cancer accounting for 85 to 90% of all observed ovarian cancer. This cancer originates from the surface of the ovary and extends first to the lining of the pelvis. 

The cancer is then spread to the abdomen and other parts of the body. Nearly 70% of these types of cancers are usually diagnosed in advanced stages.

There are following types of epithelial ovarian cancer:

• High-grade serous ovarian carcinomas (HGSOC): These types of cancer spread at a faster rate and usually remain undiagnosed in the initial stages. 

• Endometrioid carcinoma: This type of cancer spreads to the endometrium (inner lining of the uterus) 

• Low-grade serous ovarian carcinoma (LGSOC): LGSOC spreads slowly and usually affects people at a younger age (between 45 and 57).

• Mucinous carcinoma: In this, tumor (mass of cells) is made up of cells coated in mucus. 

• Ovarian clear cell carcinoma (OCCC): This cancer is characterized by the presence of a pelvic mass which causes symptoms such as abdominal pain and bloating. 

• Primary squamous cell carcinoma (SCC) of the ovary: They typically develop from noncancerous) conditions and respond well to treatment. 

II. Germ cell ovarian carcinoma

This type of cancer originates from reproductive cells of the ovaries. This cancer is rarely observed and usually affects teenagers. 

III. Stromal cell ovarian cancer

These cancers arise from connective tissue cells of the ovaries. These represent about 1% of all ovarian cancers. This type of cancer is often found in the early stages. Vaginal bleeding is one of the most common symptoms of stromal cancer. 

IV. Small cell carcinoma

It is an extremely rare ovarian cancer whose exact origin is still not known.  It usually presents in younger females with features of hypercalcemia.

V. Stages of ovarian cancer

Ovarian cancer has four stages:

Stage 1: It is the earliest stage in which cancer is found in both the ovaries. 

Stage 2: In this, the cancer has spread to the pelvic region. 

Stage 3: It is the advanced stage in which cancer has spread to the areas of the abdomen. 

Stage 4: It is the most advanced stage in which cancer has spread beyond the abdomen to other parts of the body, such as the lungs.

Risk Factors For Ovarian Cancer

Various risk factors are associated with an increased chance of colon cancer: 

1. Genetic predisposition

Mutations (changes) in BRCA1 and BRCA2 genes significantly increase the risk of developing ovarian cancer. 

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2. Age

The risk of ovarian cancer increases with advancing age. Approximately half of the women diagnosed with ovarian cancer are above 63 years. It is seen that the risk increases steeply from around 45 years. 

3. Race

The following races are more prone to ovarian cancer due to the higher prevalence of BRCA1 mutations:

• Eastern European
• Ashkenazi Jewish
• North American 
• Northern European

4. Family history

Ovarian cancer runs in families. It is considered as the strongest risk factor. A positive family history of breast, ovarian, and fallopian tube cancer increases the risk of ovarian cancer.

5. History of cancer

Individuals having a history of breast cancer, uterine cancer, and colorectal cancer have higher chances of contracting ovarian cancer too. The risk is higher in women diagnosed with breast cancer at a younger age.

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6. Early menarche

Women whose menstrual cycle starts early (age <12 years) are at a higher risk of developing ovarian cancer. This is due to the more number of ovulatory cycles. 

7. Late menopause

Women whose menopause hits late (age > 50 years) are also more likely to have ovarian cancer.  

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8. Endometriosis

It is a medical condition in which tissue from the lining of the uterus starts to grow outside. This condition slightly increases the risk of ovarian cancer. 

9. Nulliparity

Women who have never given birth to a child either by choice or due to some medical issues are more prone to ovarian cancer. 

10. Hormonal replacement therapy (HRT)

Women who take HRT, especially estrogen for a longer duration (10 or more years) have an increased risk of ovarian cancer. This risk is even more in postmenopausal women. 

Note: HRT is helpful for many women with menopausal symptoms. So, it is always advisable talking to your doctor about the risks and benefits of taking HRT.
 

11. Diabetes

Diabetes increases the risk of several cancers including ovarian cancer. Glucose allows tumors to grow larger and cancer cells to reproduce faster. Diabetics that are on insulin therapy are even more likely to develop ovarian cancer later in life. 

12. Obesity

Studies suggest that obesity in early adulthood increases the risk of ovarian cancer. 

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13. Genetic conditions

There are several genetic conditions that can cause ovarian/fallopian tube cancer, including:

• Lynch syndrome

• Peutz-Jeghers syndrome (PJS)

• Nevoid basal cell carcinoma syndrome (NBCCS)

• Li-Fraumeni syndrome and ataxia-telangiectasia
  
  

14. Smoking

Several studies also suggest the role of smoking in the development of ovarian cancer, especially epithelial cancers. The risk increases with the duration of smoking. 

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Diagnosis Of Ovarian Cancer

The tests that help detect ovarian cancer are: 

1. Rectovaginal pelvic exam

A rectovaginal exam examines and identifies abnormalities in the pelvic area, including the cervix, uterus, ovaries, fallopian tubes, anus, and rectum.

2. TVUS (transvaginal ultrasound)

In this, an ultrasound wand is put into the vagina to examine the uterus, fallopian tubes, and ovaries. It helps in the identification of any mass but cannot confirm its cancerous nature. 

3. Blood tests

• CA-125: This test measures the amount of a protein called CA-125 which is known to be elevated in ovarian cancer. The test does not confirm the presence of cancer due to its association with some other disease also. The test is, however, used to monitor the progress of treatment. 
• Human epididymis protein 4 (HE4): The level of HE4 in the blood is a more sensitive market to predict ovarian cancer. 

4. Laparoscopy

In this, the ovaries are examined through a thin tube inserted through a small cut in the abdomen. 

5. Biopsy

In biopsy, a small amount of tissue is studied under a microscope. The tissue is collected with the help of a needle from the ovaries or from a sheet of fatty tissue inside the abdomen called the omentum. 

Sometimes, a CT or ultrasound scan is used to guide where to put the needle. This is called an image guided biopsy. It helps in identifying the type, grade and stage of cancer. 

6. CT scan

This imaging test uses X rays to generate a detailed picture of the internal organs. CT scans of the abdomen, pelvis, and chest are done to check the spread of cancer.

Prevention Of Ovarian Cancer

There is no sure shot way to prevent ovarian cancer. However, there are certain factors that are known to reduce its risk. Although, these are not recommended for every woman as all have different risks and benefits.

1. Pregnancy

Studies suggest that women who have children are less likely to develop ovarian cancer. The more full-term pregnancies a woman has had, the lower their risk of ovarian/fallopian tube cancer.

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2. Contraceptive pills

It is seen that women who take oral contraceptives for at least 3 years have 30 to 50% lesser chances of developing ovarian cancer. This effect may last for 30 years after stopping pills. Intrauterine devices (IUDs) have also been linked to a decreased risk of ovarian cancer.

3. Breastfeeding

Women who breastfed for a year or more are less prone to ovarian cancer. The risk is reduced further with the increase in duration of breastfeeding. 

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4. Surgical procedures

Women who have had a hysterectomy (removal of uterus) may have a lower risk of developing ovarian/fallopian tube cancer.

Tubal ligation (tying of fallopian tubes) in order to avoid pregnancy also decreases the risk of ovarian cancer.

Specialist To Visit 

Cancer requires multispecialty comprehensive care. Doctors who take care of patients with ovarian cancer and help in diagnosing and formulating a treatment plan are:

• Gynecologist
• Gynecologic oncologist
• Surgeon
• Medical oncologist

Gynecologists specialize in diagnosing and treating diseases of the female reproductive system. They help in diagnosing ovarian cancer and refer to the superspeciality doctors.

Gynecologic oncologists are doctors who have been trained to treat cancers of a woman’s reproductive system. 

Surgeons help in operative procedures that are essential for almost all ovarian cancers. 

Medical oncologists help in managing ovarian cancer through drugs. 

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Treatment Of Ovarian Cancer

The treatment of ovarian cancer consists of surgery and medications. The cycles of medications and the type of surgery depend upon the stage of cancer. 

1. Debulking surgery

The major aim of debulking surgery is to remove the tumor.

The unilateral salpingo-oophorectomy (removal of one ovary along with the fallopian tube) is usually done in the early stage of ovarian cancer.

However, an advanced-stage ovarian cancer may require the removal of both ovaries and fallopian tube along with uterus (hysterectomy/bilateral salpingo-oophorectomy or BSO).

Sometimes, spleen, gallbladder, a part of the stomach, liver, pancreas, a part of the colon is also removed depending upon the spread of cancer. 

2. Radiation therapy

It uses high-energy X-rays to kill cancer cells. The procedure is painless and each session takes a few minutes. 

3. Chemotherapy

It involves the use of medications to kill cancer cells. Chemotherapy is mostly useful to kill small-sized tumors that have left even after surgery.
In most cases, a combination of drugs are used as it seems to work better for ovarian cancer.

These drugs are usually given as an IV (put into a vein) every 3 to 4 weeks. The duration of chemotherapy depends upon the stage and type of ovarian cancer.

The drugs used during chemotherapy are:

• Paclitaxel

• Altretamine 

• Capecitabine 

• Cyclophosphamide 

• Etoposide 

• Gemcitabine 

• Ifosfamide 

• Irinotecan 

• Melphalan

• Pemetrexed 

• Topotecan

• Vinorelbine

4. Hormonal therapy

It involves the use of hormones to treat cancer. It is mainly used to treat ovarian stromal tumors. The class of drugs used in hormonal therapy are:

• Luteinizing hormone-releasing hormone (LHRH) agonists: These drugs block the production of hormone estrogen by the ovaries. They are usually injected every 1 to 3 months. The common examples are goserelin and leuprolide. 

• Tamoxifen: The primary function of tamoxifen is to reduce the level of female sex hormone, estrogen. This restricts the growth of cancer cells. 

• Aromatase inhibitors: These drugs block an enzyme known as aromatase which converts other hormones into estrogen. The drugs that belong to this category are letrozole, anastrozole, and exemestane. 

5. Targeted drug therapy

Targeted therapy targets specific proteins that help in the growth, division, and spread of cancer cells. The examples include: 

• Bevacizumab

• Olaparib

• Rucaparib

6. Immunotherapy

In this, the immune system is modified to destroy cancer cells. This is done through following medications such as pembrolizumab.

Home-care For Ovarian Cancer

Cancer requires conventional medical care. However, some specific additions to the diet can aid in managing some associated symptoms of ovarian cancer and its treatment.
However, make sure to take consent from your doctor before starting any of these:

1. Shiitake mushrooms: This is also known as medicinal mushroom due to the presence of an active ingredient called lentinan. Lentinan inhibits the growth of certain types of cancer including ovarian cancer. 

Its extract can be prepared by boiling mushrooms in water which can later be consumed by straining. 

2. Soybean: Isoflavones present in soybean help in inhibiting the growth of ovarian tumor. They also help in curing the body from the harmful impacts of chemotherapy and other conventional cancer treatment.

3. Peppermint (pudina) tea: It helps in relieving abdominal pain which is the most characteristic symptom of ovarian cancer. It can be easily prepared by boiling around four or five torn peppermint leaves into the water. 

4. Ginger tea: It helps in relieving symptoms such as pain and cramping that is associated with ovarian cancer. Studies also suggest that ginger stopped the growth of ovarian cancer cells.

It can be prepared by boiling a few slices of ginger with water. Lemon juice and honey can also be added to enhance flavor.

Complications Of Ovarian Cancer

Untreated ovarian cancer can lead to:

• Ascites (accumulation of fluid between the layer of abdomen and pelvis)

• Obstruction in the small or large intestine

• Pleural effusion (build-up of fluid between the tissues that line the lungs and the chest)

• Bladder obstruction (blockage in the urinary system)

• Nutritional disorders

Alternative Therapies For Ovarian Cancer

Ovarian cancer cannot be treated and managed without surgery and chemotherapy. However, certain therapies help in managing symptoms and help cope with the side effects of chemotherapy. They also aid in relieving stress and improve overall quality of life. 

1. Tai chi

It is a form of physical activity that helps in increasing mental concentration through breathing control. It helps in reducing stress. It also alleviates pain through improving flexibility, strength, and balance. 

2. Acupuncture 

It is a very ancient technique that is used in China and Japan. In this, fine metal needles are inserted into the skin at specific points. This helps in alleviating symptoms of ovarian cancer such as pain. It also helps in coping with the side effects of chemotherapy. 

Sometimes, needles are stimulated by electricity which is known as electro-acupuncture. 

3. Relaxation response

This technique is used to reduce stress. It involves methods such as quiet sitting, progressive muscle relaxation, repetition of a particular word during inhale and exhale.  Practicing for 10-20 minutes daily helps in providing emotional stability. 

4. Biofeedback

The technique records the responses of the individuals such as heart rate, muscle tension, brain activity etc after stimulation.  It helps in alleviating physical and emotional symptoms through analyzing the triggers. 

5. Guided imagery

In this, the practitioner hallucinates the person to create some pictures in the mind. These mental images calms down the person and helps in relieving stress.

Living With Ovarian Cancer

Whether you are a patient who has been diagnosed with ovarian cancer or care for someone who has the disease, it will have a large impact on their lives. Things that the caregiver and the patient should take into consideration include:

1. Keep hydrated

Hydration is very important to curb the most important symptoms of ovarian cancer such as diarrhea and constipation. This also helps in smooth digestion and helps in reducing gastrointestinal symptoms. 

2. Try massage therapy

Massage gives relaxation and helps in coping with the stress and pain associated with ovarian cancer. 

3. Managing physical effects

Every cancer therapy has numerous physical changes. It is important to discuss every little change happening in your body to your doctor. This helps doctors in modulating your treatment regimen to alleviate the symptoms. Continuous follow up even after the end of therapy is recommended to track long term effects and relapse of cancer. 

4. Managing the fear of side effects

Every cancer therapy has side effects which may vary depending on various factors. It is completely common to have a fear of side effects. However, there are various options available to manage the side effects effectively. These include: 

• Take an active role in your treatment plan. This helps you in knowing about possible side effects well in advance. 

• Talk about the side effects to your doctor that may help you in alleviating and preventing the side effects.

• Maintain a journal in which you can write about your experiences. 

• Talk about your fear to your loved ones. This will reduce your anxiety. 

5. Managing emotional and social effects

Diagnosis of cancer can have emotional and social effects on the patient. This includes stress, anxiety, depression, sadness, and a feeling of helplessness. Some of the easy steps that can be taken to manage your emotional health is to: 

• Engage yourself in activities you like such as crafting, painting, and singing. 

• Do regular exercise as it helps in reducing stress.

• Join any support group either online or offline.

• Ask help from a professional counselor.

• Meet someone who is undergoing the same type of treatment.

• Listen to a podcast related to survival stories of the patients with colon cancer

6. Managing the cost of cancer treatment

Cancer treatment can be very expensive and this can give anxiety and stress to the patient and his/her family. This can be managed through: 

• Understanding the cost of therapy well in advance. 

• Communicating any financial issues with the cancer team. This will help doctors to look for affordable alternatives.

• Finding financial support resources though oncology social workers, oncology nurses, doctors, or online. 

• Taking help through your health insurance partners.

7. Watching for recurrence

Follow-up care even after the completion of treatment is required to check relapse, managing long-term side effects and overall health. The first 5 years after treatment are very crucial for ovarian cancer. Follow-up care includes regular physical examinations, tests, and counseling. Cancer rehabilitation is also required to give: 

• Physical therapy

• Emotional counseling

• Managing the long-term pain

• Nutritional guidance
  
  

Cancer can drain a person physically and mentally. Gaining knowledge and awareness about cancer and the myths that surround it is necessary to enable timely diagnosis and treatment.
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