Ovarian Cancer

Original Editors - Trisha Counce & Brandy Hirsch from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Brandy Hirsch, Trisha Counce, Lucinda hampton, Aminat Abolade, Vidya Acharya, Elaine Lonnemann, WikiSysop, Kim Jackson, 127.0.0.1, Wendy Walker and Rishika Babburu  

Introduction

Ovarian cancer (OC) is one of the most common gynecologic cancers that has the highest mortality rate.

The term "ovarian cancer" encompasses several types of cancer that all arise from the cells of the ovaries in the female reproductive system. 

Ovarian cancer commonly manifests as three different types

1. Epithelial - derived from the cells on the surface of the ovary or fallopian tube, accounts for about 70% of all ovarian cancers, making it the most common type.

2. Germ cell - derived from the cells that produce eggs

3. Cord-stromal cell - derived from the connective tissue within the ovary

Stages

1. Stage I - Growth of the cancer is limited to the ovary or ovaries.
2. Stage II - Growth of the cancer involves one or both ovaries with pelvic extension.
3. Stage III - Growth of the cancer involves one or both ovaries, and one or both of the following are present: (1) the cancer has spread beyond the pelvis to the lining of the abdomen; and (2) the cancer has spread to lymph nodes. The tumor is limited to the true pelvis but with histologically proven malignant extension to the small bowel or omentum.
4. Stage IV - This is the most advanced stage of ovarian cancer. Growth of the cancer involves one or both ovaries and distant metastases (spread of cancer to organs located outside of the peritoneal cavity) have occurred. Finding ovarian cancer cells in pleural fluid (from the cavity which surrounds the lungs) is also evidence of stage IV disease.

Risk of Recurrence:

• Patients diagnosed in stage I have a 10 percent chance of recurrence.
• Patients diagnosed in stage II have a 30 percent chance of recurrence.
• Patients diagnosed in stage III have a 70 to 90 percent chance of recurrence.
• Patients diagnosed in stage IV have a 90 to 95 percent chance of recurrence.

Epidemiology

Risk Reality

• Lifetime risk: 1 in 90 women (1.1%)
• Annual US impact: 19,000+ new cases, 12,000+ deaths

Age & Ethnicity Patterns

• High-grade serous: Peaks at 60-65 years (most common in White women)
• Low-grade endometrioid: Peaks at 45-50 years (most common in White women)
• Clear cell: Peaks at 55-60 years (highest in Asian/Pacific Islander women)
• Lowest rates: Non-Hispanic Black women across all subtypes

The Survival Gap

Early detection = excellent outcomes:

• Early stage: 93% five-year survival, <10% recurrence
• Advanced stage: 31% five-year survival, 90% recurrence

The Challenge: Over half of patients already have metastasis at diagnosis

Clinical Takeaway

Your patients' prognosis and rehabilitation needs will vary dramatically based on:

• Stage at diagnosis (early vs. advanced)
• Cancer subtype
• Age at onset

Early-stage patients need fitness maintenance; advanced-stage patients need symptom management and quality-of-life focus.

Ovarian Cancer Spread & Origins: Key Points for Physiotherapists

How Cancer Spreads

Primary route: Lymphatic spread to abdominal lymph nodes (para-aortic, pelvic) Most common site: Peritoneum (abdominal lining) and omentum Advanced disease: Blood-borne spread becomes more significant

Cancer Origins - New Understanding

Many "ovarian" cancers actually start in the fallopian tubes, then spread to ovaries. This is why staging now includes ovarian, fallopian tube, and peritoneal cancers together.

Genetic Factors

Key mutations:

• BRCA1/BRCA2: Major hereditary risk factors
• TP53: Most common in aggressive serous cancers
• Lynch syndrome: Increases risk significantly

Risk Factors Your Patients May Have

Higher risk: No pregnancies, family history, BRCA mutations, previous breast/endometrial cancer Lower risk: Birth control use, breastfeeding, multiple pregnancies

Clinical Relevance. Understanding spread patterns helps explain:

• Why surgery is so extensive (multiple abdominal organs involved)
• Post-surgical lymphedema risk
• Why recovery affects core function significantly
• Genetic counseling importance for family members

Characteristics/Clinical Presentation

Epithelial ovarian cancer presents with a wide variety of vague and nonspecific symptoms.

Abdominal & Pelvic Signs

• Persistent bloating - abdomen feels swollen or full
• Pelvic/abdominal pain or discomfort
• Abdominal mass or distension
• Back pain

Digestive Changes

• Early satiety - feeling full quickly when eating
• Indigestion and acid reflux
• Bowel changes - constipation or diarrhea

Urogenital Symptoms

• Urinary urgency or painful urination
• Abnormal vaginal bleeding or discharge

Systemic Symptoms

• Unexplained weight loss
• Persistent fatigue and lack of energy
• Shortness of breath

Clinical Alert for Physiotherapists

These symptoms are vague and nonspecific - often mistaken for common conditions. Key red flags:

• Persistence of symptoms
• New onset in middle-aged/older women
• Combination of multiple symptoms
• Progressive worsening

Remember: Many patients seek physiotherapy for "back pain" or "core weakness" that could be early ovarian cancer signs. Maintain clinical suspicion for unexplained symptom clusters..

Ovarian Cancer Management: Key Points for Physiotherapists

Treatment Timeline Your Patients Follow

• Early Detection Challenge: 90% cure rate for early-stage disease, but most patients diagnosed at advanced stages
• Standard Approach: Surgery first (staging + tumor removal), then chemotherapy
• Alternative Route: Some patients get chemotherapy first to shrink tumors before surgery

What Patients Experience

Surgery Phase

• Major abdominal surgery with extensive tissue removal
• Recovery impacts core strength and mobility
• Fertility-sparing options for younger patients

Chemotherapy Phase

• Carboplatin + paclitaxel (standard combination)
• Significant fatigue and functional decline
• May continue for months as maintenance therapy

Advanced Treatments

• PARP inhibitors: Newer targeted drugs with fewer side effects
• Bevacizumab: Anti-cancer drug that may cause fatigue
• Hormone therapy: For specific cancer types

Recurrence Reality

80% of advanced-stage patients experience cancer return, requiring additional treatment cycles.

Physiotherapy Implications

• Expect prolonged treatment timelines affecting fitness
• Post-surgical core weakness and scar tissue management
• Chemotherapy-related fatigue requiring modified exercise programs
• Potential for multiple treatment phases over years
• Focus on maintaining function during active treatment periods

Diagnostic Tests

There are currently no reliable screening tools available to diagnose ovarian cancer.

• One goal of all cancer therapy is to provide early screening and pre-emptive intervention to avoid the challenges presented by highly metastatic cancers. The stages of cancer have a huge influence on the outcome. Early diagnosis of cancer will fundamentally affect the management of these tumors.
• The current recommendations include an annual pelvic exam, transvaginal ultrasound, and CA-125 blood test. 
• These are the best options for screening but even in combination, results have been found to be unreliable.

Physical Therapy Management

Although there are no specific physical therapy protocols for ovarian cancer, evidence supports the benefits of physical therapy in improving daily function, quality of life, and health in patients with cancer.

• Each person’s exercise program should be based on what is safe and what works best for them. It should also be something they like doing.
• The exercise plan should take into account any exercise program already followed, what they can do now, and any physical problems or limits. 
• These therapeutic exercises aim to reduce fatigue and optimize physical function, safety and well-being.  

An exercises regimen could include:

• Range-of-motion training with 
• Light resistance exercises 
• Cardiovascular activity 
• Flexibility exercises 
• Strength training 

Exercise, even minimal physical exertion, increases heart rate and muscle flexion while boosting the body’s tolerance to chemotherapy and radiation treatments. Participating in daily exercise programs enables client to gain a sense of physical control over the condition, and provide an outlet for stress and anxiety. 

 Physical therapy also provides:

• Massage Therapy, which recent studies show can decrease stress, anxiety, depression, and pain, and increase alertness 
• Lymphedema Therapy eg MLD
• Self-Care Management to improve an individuals ability to return to their home

The American Cancer Society outlines the following for physical activity after cancer treatment. 

When you are recovering from cancer treatment

•  Many side effects get better within a few weeks after cancer treatment ends, but some can last much longer or even emerge later. Most people are able to slowly increase exercise time and intensity.
• What may be a low- or moderate-intensity activity for a healthy person may seem like a high-intensity activity for some cancer survivors.

When you are living disease-free or with stable disease

•  During this phase, physical activity is important to your overall health and quality of life. It may even help some people live longer. There’s some evidence that getting to and staying at a healthy weight, eating right, and being physically active may help reduce risk of second cancer as well as other serious chronic diseases. More research is needed to be sure about these possible benefits.

The American Cancer Society recommends that cancer survivors take these actions

• Take part in regular physical activity.
• Avoid inactivity and return to normal daily activities as soon as possible after diagnosis.
• Aim to exercise at least 150 minutes per week.
• Include strength training exercises at least 2 days per week.

A growing number of studies have looked at the impact of physical activity on cancer recurrence and long-term survival. Exercise has been shown to improve cardiovascular fitness, muscle strength, body composition, fatigue, anxiety, depression, self-esteem, happiness, and several quality of life factors in cancer survivors.
Living with advanced cancer

• Some level of physical activity can improve quality of life for people with certain types of cancer, even if the disease is advanced (has spread to many places and/or is no longer responding to treatment). But this varies by cancer type, physical ability, health problems related to the cancer or cancer treatment, and other illnesses. The situation can also change quickly for a person with advanced cancer, and physical activity should be based on the person’s goals, abilities, and preferences.