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  

Definition/Description

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.

Prevalence and Incidence 

Population growth, increased risk factors for cancer, decreased pregnancy and duration of lactation, and tube ligation, have led to an upward trend in the incidence of Ovarian Cancer around the world. 

• It is the fifth most common cause of death from cancer in women and is the most lethal of all gynaecological cancers.
• The lifetime risk of a woman developing ovarian cancer is 1 in 71, and 1 in 200 women will develop ovarian cancer between their 50th and 70th birthday.
• Ninety percent of all deaths from ovarian cancer are due to high-grade serous cancer, and this cancer sub-type accounts for 75% of all cases.
• Worldwide, 295,414 cases of ovarian cancer have been identified in 2018, accounting for 3.4% of all cancer cases in women.  

The incidence of epithelial ovarian cancers varies in different age and race groups. 

• Higher among transitioned countries 
• Approximately 30% of ovarian cancer cases occur in European countries 
• In 2012, the highest rates of ovarian cancer occurred in China (14.60% of all cases), India (11.33% of all cases), and the US (81.8% of all cases).
• In 2012 that year, 22,240 cases of ovarian cancer were detected in the US alone. 
• Among the Asian countries, Singapore, Kazakhstan, and Brunei have the highest standardized incidence rate of ovarian cancer

Considering the heavy burden of ovarian cancer on women's health, preventive measures, as well as health education and early detection in high-risk groups of women are highly recommended. Although some risk factors cannot be changed, a focus on preventable risk factors may reduce the risk of ovarian cancer.

Mortality

In 2018, 184,799 deaths occurred due to ovarian cancer, accounting for 4.4% of the entire cancer-related mortality among women.

• The incidence of cancer is higher among high Human Development Index (HDI) countries however the trend of mortality rate tends to be the reverse
• The highest mortality rate in Asia is seen in India, and the mortality rate has decreased in Europe and North America in recent years, especially among young people.
• The mortality-to-incidence ratio is high among African women, indicating their lack of access to suitable treatment.
• Two-thirds of ovarian cancer mortality is attributable to high-grade serous carcinoma.

Etiology/Risk Factors

General risk factors include:

• Nulliparity
• Middle-aged (50) or older 
• Early menopause
• Gonadal dysgenesis
• Family history: contributes to 24% of cases of epithelial ovarian cancer
  • BRCA1/BRCA2 mutations: particularly for serous types
  • Lynch syndrome-associated ovarian cancers most often have an endometrioid or serous type histology
• Smoking: especially for mucinous adenocarcinoma
• Previous history of breast, endometrial or colon cancer
• Certain ethnic groups
• Use of fertility drugs: There is mixed evidence with some studies finding associations between fertility drug use and cancer risks while others not. An old review of literature could not draw conclusion on the association between use of fertility drugs and risk of ovarian cancer due to insufficient data. However a cohort study (2017) found elevated risk of endometrial cancers in women exposed to clomiphene citrate (fertility drug).
• Protective factors:
  • Oral contraceptives
  • Breastfeeding (this is controversial)

Characteristics/Clinical Presentation

Epithelial ovarian cancer presents with a wide variety of vague and nonspecific symptoms. Ovarian cancer may cause one or more of these signs and symptoms--

•      Bloating, which is when the area below your stomach swells or feels full 
•      Vaginal bleeding or discharge (not normal for individual) 
•      Pain in the pelvic or abdominal area, abdominal distension or discomfort, abdominal mass 
•      Back pain 
•      Feeling full quickly while eating 
•      Painful urination or frequent urges, constipation, or diarrhea 
•      Indigestion and acid reflux 
•      Shortness of breath (SOB) 
•      Weight Loss
•      Persistent lack of energy 

Treatment

Ovarian cancer is the deadliest gynecologic malignancy in the United States.

• Evidence-based interventions for the prevention and early detection of ovarian cancer do not currently exist.
• Several treatment guidelines, including the receipt of treatment from a gynecologic oncologist, have been shown to result in improved survival from ovarian cancer.

Progress in the treatment of ovarian cancer has been exponential over the last decade, with a flurry of new experimental targeted agents and new drug approvals. With new opportunities come new challenges with regard to what agents to select, how best to evaluate those agents, and how best to identify optimal treatment regimens and improve patient outcomes.

Surgery, chemotherapy, and radiation may be used to treat ovarian cancer, depending on the disease’s stage

1. Surgery - This is usually the first step. How much surgery you have depends on how far the cancer has spread. In some cases, the ovaries, uterus, cervix, or fallopian tubes may need to be removed. Other tissue typically removed includes lymph nodes, the omentum (fatty apron covering the intestines) and all visible cancer.

2. Chemotherapy - usually receive through an IV. However, sometimes they work better for ovarian cancer if they’re injected into the abdomen.

3. Radiation - It can be used if cancer has come back after treatment or to help control symptoms like pain.

4. Targeted Therapy - These treatments use newer medications that find and attack cancer cells while doing little damage to surrounding normal cells. These meds all work in different ways, but they’re able to stop cancer cells from growing, dividing, or fixing themselves. The medications are either taken by mouth or given by IV.

5. Hormone Therapy - In some cases, doctors might suggest using hormones or hormone-blocking medications. According to the American Cancer Society, this therapy is most often used to treat ovarian stromal tumors, not epithelial ovarian cancer

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.