Shana Wingo, MD, Gynecologic Oncologist Answers Your questions about ovarian cancer answered: from early symptoms to treatment
Your questions about ovarian cancer answered: from early symptoms to treatment
April 26, 2019
Young women have heard a lot about cervical cancer, mostly in the context of the the HPV vaccine. But you probably know less about ovarian cancer. It’s a disease not many younger women worry about since it typically affects women after menopause (i.e. over age 45), but the signs of ovarian cancer are still something every person with ovaries should know, no matter their age.
Ovarian cancer is the fifth most deadly cancer for women and one in 78 women will get it. While it’s fairly rare for young women to develop it, it does happen—as in the case of female college football player Toni Harris, who was diagnosed with ovarian cancer when she was only 18 years old.
The symptoms of ovarian cancer are particularly tricky since they are fairly common health issues that women often ignore. But getting an early diagnosis is critical to your survival, so we spoke with two gynecologic oncologists—Dr. Mitzie-Ann Davis of Piedmont Fayette Hospital and Dr. Shana Wingo of Arizona Oncology—to learn more about ovarian cancer.
What is ovarian cancer?
Dr. Davis: Ovarian cancer is cancer of the ovaries, which are an important part of the reproductive system that produces eggs and hormones.
What are the different grades and stages?
Dr. Davis: Grading means how the cells look under a microscope. Tumors can be high grade (aggressive) or low grade. There are epithelial ovarian tumors, which is the most common type of ovarian cancers; germ cell tumors, which are typically found in cases involving young people; and stromal cell tumors, which occur in the connective tissues that hold the ovary together.
Staging relates to how severe a person’s cancer is based on the size of a tumor and if the cancer has spread outside of the original location. Cancer stages are stage I through IV. For ovarian cancer, stage I is limited to the ovaries and there is a 90% chance of survival when treated with surgery. Stage IV is advanced metastatic disease, meaning it has spread to other organs. Most women diagnosed with Stage IV ovarian cancer have a five-year survival rate of approximately 17%.
What are the signs and symptoms of ovarian cancer?
Dr. Wingo: Early cancer of the ovaries tends to cause symptoms that are relatively vague, including:
• Abnormal swelling of the stomach
• Unusual vaginal bleeding
• Pelvic pressure
• Back pain
• Leg pain
• Digestive problems, such as gas, bloating, indigestion, or long-term stomach pain
• Trouble eating or feeling full quickly
• Having to urinate often or feeling like you have to “go” right away
In some instances, women also have urinary symptoms including bladder pressure, urinary frequency, and increased voiding at night. Women who experience any of these symptoms should consult their healthcare providers.
Why isn’t ovarian cancer always caught?
Dr. Davis: The signs and symptoms of ovarian cancer are often overlooked because they are very nonspecific. These general symptoms are some of the reasons why ovarian cancer is often not caught early. The other reason is that there is no good screening for ovarian cancer.
What are some common conditions that ovarian cancer can be misdiagnosed as?
Dr. Wingo: Ovarian cancer is often mistaken for gastroesophageal issues. These include, but are not limited to, gastroesophageal reflux disease (GERD), irritable bowel syndrome, gastritis/enteritis, and any other inflammatory condition of the G.I. tract.
How does ovarian cancer impact a person’s life?
Dr. Davis: When a patient is undergoing treatment, surgery and/or chemotherapy there can be nausea and vomiting, belly pain, and a potential loss of hair. If a person has advanced ovarian cancer, a cure is highly unlikely, but they can maintain with chemotherapy.
Dr. Wingo: Once a woman is diagnosed, her life changes forever. Typically, ovarian cancer treatment involves both surgery and chemotherapy. Once a woman has completed all her primary therapy, she has follow-ups four times a year for the first two years. I believe that anyone with cancer is impacted in their day-to-day lives, as any vague symptom is a concern for recurrence. I encourage my patients to try to maintain normal lives. The treatment can be very exhausting and certainly can impact a woman’s ability to work and do daily activities.
Do other health issues often accompany ovarian cancer (gynecologic or otherwise)?
Dr. Davis: No, but patients can have complications of treatment like nausea, vomiting, fatigue, neuropathy, anemia, and low white blood cell count.
Is ovarian cancer related to HPV?
Dr. Wingo: There is no risk for ovarian cancer with HPV. HPV, however, is a risk factor for cervical cancer and some vulvar and vaginal malignancies.
How about endometriosis or infertility?
Dr. Davis: There is a small risk for endometriosis. There may be a slightly increased risk with infertility but studies have not consistently shown a direct relationship.
Will I be able to have children if I’m diagnosed with ovarian cancer?
Dr. Wingo: The ability to have children after a diagnosis of ovarian cancer depends not only on the type of ovarian cancer but the stage at diagnosis. Women who have stage I cancer often undergo fertility-preserving procedures, where only the involved ovary is removed. Surgical staging is also performed at the same time to evaluate for spread of cancer. Some of these women go on to require chemotherapy. Nonetheless, many of these women are still able to conceive.
Who typically is diagnosed with ovarian cancer?
Dr. Davis: Ovarian cancer is typically found in patients that are post-menopausal and patients with a strong family history of the disease.
How is ovarian cancer diagnosed?
Dr. Wingo: Ovarian cancer, and all cancers, require a histologic diagnosis. Essentially that means the pathologist must evaluate cells from the tissue in order to establish the diagnosis. With ovarian cancer, this is often done with surgical removal of the involved organs. If the cancer is too extensive at diagnosis, a biopsy can be performed by the radiologist.
If a woman is suspected to have ovarian cancer, her health care provider may recommend additional testing including:
• Physical exam: Your doctor checks general signs of health. Your doctor may press on your abdomen to check for tumors or an abnormal buildup of fluid (ascites). A sample of fluid can be taken to look for ovarian cancer cells.
• Pelvic exam: Your doctor feels the ovaries and nearby organs for lumps or other changes in their shape or size. A Pap test is part of a normal pelvic exam, but it is not used to collect ovarian cells. The Pap test detects cervical cancer. The Pap test is not used to diagnose ovarian cancer.
• Blood tests: Your doctor may order blood tests. The lab may check the level of several substances, including CA-125. CA-125 is a substance found on the surface of ovarian cancer cells and on some normal tissues. A high CA-125 level could be a sign of cancer or other conditions. The CA-125 test is not used alone to diagnose ovarian cancer. This test is approved by the Food and Drug Administration for monitoring a woman’s response to ovarian cancer treatment and for detecting its return after treatment.
• Ultrasound: The ultrasound device uses sound waves that people cannot hear. The device aims sound waves at organs inside the pelvis. The waves bounce off the organs. A computer creates a picture from the echoes. The picture may show an ovarian tumor. For a better view of the ovaries, the device may be inserted into the vagina (transvaginal ultrasound).
• Biopsy: A biopsy is the removal of tissue or fluid to look for cancer cells. Based on the results of the blood tests and ultrasound, your doctor may suggest surgery (a laparotomy) to remove tissue and fluid from the pelvis and abdomen. Surgery is usually needed to diagnose ovarian cancer.
How can genetic testing help diagnose ovarian cancer?
Dr. Wingo: Genetic counseling is an important piece of my gynecologic oncology program. Ovarian cancers are sometimes associated with inherited gene changes—called mutations—that increase the risk for types of cancer. Most well-known is the association between ovarian cancer and mutations in genes BRCA1 and BRCA2, which also increase the risk for breast, prostate, and other cancers. Finding a mutation in one of these genes may not only explain your current cancer but may guide your ovarian cancer treatment and allow your health care provider to tailor screening or preventive recommendations for you and for your family members.
If you or a family member have any of the following “red flags” for hereditary breast and ovarian cancer syndrome, you may want to consult a genetics counselor for genetic counseling and possibly testing:
• Breast cancer before age 45
• Triple-negative breast cancer before age 60
• Ovarian cancer at any age
• Male breast cancer at any age
• Metastatic prostate cancer at any age
• Pancreatic cancer at any age
• Three or more relatives with breast, ovarian, pancreatic and/or aggressive prostate cancer on the same side of the family
• Ashkenazi Jewish ancestry with a personal or family history of breast, ovarian, aggressive prostate, or pancreatic cancer
• Prior negative BRCA1 or BRCA2 testing
Do we know what causes ovarian cancer and is there a way to prevent it?
Dr. Davis: Ovarian cancer starts in the fallopian tube and falls to the ovary. There are no good screening tools, so it is hard to catch it early. Some risk factors for ovarian cancer are age, genetics/family history, and, in some studies, links to asbestos. Breastfeeding is protective, taking birth control is protective, and it can be prevented by the removal of one’s ovaries or tubal ligation.
Dr. Wingo: We do know that genetics play a large role in ovarian cancer, but the majority of cases still are sporadic. The more menstrual cycles a woman has, the greater the risk for cancer. As such, birth control pills and pregnancy are protective against ovarian cancer.
What are some questions I should ask my medical professional if I’m worried I may have it?
Dr. Davis: If you have a history of ovarian cancer in your family, let your doctor know so you can get genetic testing. That will allow you to know if it is something to look out for in your future. If you have a pelvic mass detected, a CA-125 test can measure the amount of the cancer antigen 125 is in your blood. Although this is not a screening tool and having this test performed when not indicated can lead to unnecessary surgery.
Dr. Wingo: Open dialogue with a physician you trust is always a good first step. I believe that many health care professionals recognize the signs and symptoms of ovarian cancer and are much quicker to order a pelvic ultrasound and further work if indicated.
If you present symptoms that your provider does not feel are consistent with ovarian cancer, questions to consider are:
• Should I be concerned about a gynecologic cause of my symptoms?
• At what point do we pursue a gynecologic source?
• Should I see a gynecologist?
• When should I return if the symptoms don’t resolve?
What are some common ways that ovarian cancer is treated?
Dr. Wingo: Women with ovarian cancer are commonly treated with surgery and/or chemotherapy.
Surgery treats the cancer by removing the cancerous tissue. The type of surgery required depends on the stage of the cancer and where a woman is in her reproductive life. Often ovarian cancer is treated by removing the uterus, both ovaries, and fallopian tubes. Sometimes, in younger women who may wish to become pregnant, only the affected ovary is removed. Often, a layer of fatty tissue called the omentum and lymph nodes in the pelvis area are removed as well.
Radiation therapy is the use of high-energy rays to kill cancer cells in the treated area. It can be administered externally from a machine outside the body, or internally through thin tubes placed in the vagina. It is rarely used in the treatment of ovarian cancer.
Chemotherapy is the use of drugs to kill cancer cells. Because the drugs enter the bloodstream, they travel throughout the body reaching cancer cells that may have spread beyond the point of origin.
What are some misconceptions about ovarian cancer?
Dr. Davis: Ovarian cancer is not a death sentence. There are new treatment agents, such as PARP inhibitors, and other forms of immunotherapy and targeted therapy. There are a lot more options than before.
Dr. Wingo: I think it is a standard belief that all women who get ovarian cancer die from their disease. Not only are there different sub-types of ovarian cancer with differing prognoses, but patients are also diagnosed at different stages. Further, the science continues to advance, and we are finding more ways to help women live longer, sometimes by providing them maintenance treatment to help slow the recurrence of their cancer. There are also new drug therapies emerging that are allowing women to live longer.
These interviews have been edited and condensed