In the United States, there will be 22,440 women diagnosed with ovarian cancer in 2017 and over half of those cases will be fatal, according to the American Cancer Society. For women, ovarian cancer is the fifth leading cause of cancer deaths. And a woman’s risk of developing ovarian cancer in her lifetime is about 1 in 75.
With these staggering numbers it is imperative that primary care providers (PCPs) educate themselves on the disease, risk factors, prevention, detection, diagnosis, treatment and prognosis.
Knowing when to refer patients and which patients to refer for further screening is very important because we all know that early detection and diagnosis is key.
Ovarian cancer is hard to detect because the ovaries are small and embedded deep within a woman’s abdominal cavity. Being able to recognize symptoms such as bleeding after menopause, nausea, unexplained weight loss or gain, fatigue or a constant feeling of fullness to detect this type of cancer are very important.
Dr. Peter Dottino, director of gynecologic oncology at the Mount Sinai Health System said, in addition to the symptoms mentioned above, any woman who experiences unexplained bloating, upset stomach, urgency to urinate or abdominal pain for a few weeks should seek the expertise of their PCP.
Unfortunate dismissal by primary doctors
Dr. Dottino said too often women with these symptoms are dismissed by their PCPs or told they are just normal signs of aging, which strips them of valuable time they could have been seeking treatment.
Most recently, the U.S. Preventive Services Task Force issued a draft recommending against ovarian cancer screening in women without signs or symptoms of ovarian cancer, except in instances of genetic mutations, like the BRCA1 and BRCA2 mutations.
Causes, risk factors, and prevention
- Most ovarian cancers occur in women after menopause
- Half of all ovarian cancers are found in women who are over 62 years old
- Obese women have a higher risk of developing ovarian cancer
- Women who have had a child before the age of 26 are less likely to develop ovarian cancer than those who have not
- Women who have their first child after the age of 35 or have never birthed a child have a higher risk of ovarian cancer
- Women who have used birth control pills have a lower risk of ovarian cancer and the lower risk continues the longer the pills are used
- Women who have received depot medroxyprogesterone acetate (DMPA or Depo-Provera CI®) have a lower risk of ovarian cancer
- Researchers have found that using the fertility drug clomiphene citrate (Clomid®) for longer than one year may increase the risk for developing ovarian tumors and there is a higher risk if the woman did not get pregnant on the drug
- Women using estrogen only during and after menopause have an increased risk of developing ovarian cancer
- Ovarian cancer risk is increased if a patient’s mother, sister, or daughter has or has had ovarian cancer
- The risk gets higher with the more relatives you have with ovarian cancer
- If a patient has a family history of ovarian cancer and they have gone through genetic testing, they may consider prophylactic surgery to remove her ovaries
Detection and diagnosis
PCPs should encourage women to have a yearly gynecologic visit. During those visits a routine pelvic examination should be completed. The size, shape and consistency of a patient's ovaries and uterus are palpated and explored. Small tumors can be difficult to detect but a skilled provider will be able to feel inconsistencies.
Currently, there is not one specific screening test for ovarian cancer. If a patient is experiencing symptoms there are two tests that can detect abnormalities. A transvaginal ultrasound (TVUS) can detect abnormal masses in the uterus, fallopian tubes and ovaries. However, a TVUS cannot tell if a tumor is benign or malignant.
The other test is the CA-125 blood test. This should go along with the TVUS if an abnormality is found. The CA-125 measures a protein in the blood which is usually elevated in patients with ovarian cancer.
The TVUS and CA-125 can lead to further testing and sometimes surgery but they have not lowered the number of deaths caused by ovarian cancer. Because they have not reduced the number of deaths, no major medical or professional organization recommends the use of the tests routinely as a screen for ovarian cancer.
There are other screen methods being researched and hopefully in the near future we will reduce the number of deaths with these methods.
The importance of referrals
Anyone suspected to have ovarian cancer should be referred to a gynecologic oncologist. They specialize in treating cancers of the female reproductive system. They will order more imaging tests to determine the type of cancer and stage.
A computed tomography (CT) scan is used to take images of larger tumors; small tumors are hard to detect with a CT scan. A CT scan may also find enlarged lymph nodes, signs of cancer spread to liver or other organs or signs that an ovarian tumor is affecting a patient’s kidneys or bladder. CT scans are not normally used to biopsy a suspected tumor.
A positron emission tomography (PET) scan can spot radioactive deposits. It can be used to detect small clusters of cancer cells. PET scans are even more valuable when combined with a CT scan (PET/CT scan). However, PET scans are expensive and are not always covered by insurance when they are used to look for ovarian cancer.
Laparoscopy is used to help plan surgery or other treatments and can help doctors stage ovarian cancer. It is also used to perform biopsies through the laparoscopic incision. In the case of ovarian cancer, a biopsy is most commonly done by removing the entire tumor. In patients with ascites (fluid buildup inside the abdomen), samples of abdominal fluid can be biopsied to determine if there are cancer cells in the fluid.
Other blood work is also completed. Some germ cell cancers can cause elevated blood levels of the tumor markers human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and/or lactate dehydrogenase (LDH). These may be checked if the oncologist suspects a patient’s ovarian tumor could be a germ cell tumor.
Most ovarian cancers are removed staged at the time of surgery, this is the goal of surgery. Staging determines prognosis depending on the type of cancer and severity. Ovarian cancer is staged using the FIGO system. T stands for tumor, if there is cancer in the lymph nodes it is categorized by the letter N, and if the cancer has metastases an oncologist uses the letter M. All of that information determines the final stage.
Stage I ovarian cancer is only within the ovaries or fallopian tubes. It has not spread to other organs and tissues in the abdomen or pelvis, lymph nodes, or to distant sites. The 5-year survival rate for this stage is about 90%.
Stage II is cancer that started in the ovaries and has spread into the uterus and/or fallopian tubes and has spread to other organs like the bladder, the sigmoid colon, or the rectum. It has not spread to lymph nodes or distant sites. Or cancer that started in the fallopian tubes and has spread into the uterus and/or ovaries. The 5-year survival rate for this stage is about 70%.
Stage III means the cancer has spread from the ovaries and fallopian tubes into the lymph nodes and/or back of the abdomen. The 5-year survival rate for this stage is about 39%.
Stage IV ovarian cancer is the most advanced stage where the cancer has spread to the inside of the spleen, liver, lungs or other organs located outside the peritoneal cavity. The 5-year survival rate for this stage is about 17%.
Typical questions asked by patients with ovarian cancer
PCPs should be prepared to answer any questions asked by someone with ovarian cancer. It is important to be open and honest with your patients. Here are some sample questions you may get asked.
- What type of ovarian cancer do I have?
- Has my cancer spread beyond the ovaries? What are the cell types, microscopic grade, and stage of my cancer? What does that mean?
- What treatments do you recommend for me? Why?
- What risks or side effects should I expect? What are the chances my cancer will recur with the treatments we have discussed?
- What should I do to be ready for treatment?
- Should I follow a special diet?
- Will I be able to have children after my treatment?
- What is my expected prognosis?
- Will I lose my hair?
- What do I tell my children, partner, parents, and other family members?
Treatment options vary depending on the sage and type of ovarian cancer. The oncologist will recommend treatment and it is your job as a PCP to back them up and encouraged your patient to complete treatment. Most often treatment will consist of surgery, chemotherapy, hormone therapy, targeted therapy and/or radiation.
As mentioned above surgery is used to remove the tumor and stage it. Systemic chemotherapy can be useful for cancers that have metastasized in a patient’s body. Targeted therapy is a newer type of cancer treatment that uses drugs or other substances to identify and attack cancer cells while doing little damage to normal cells.
Hormone therapy is the use of hormones or hormone-blocking drugs to fight cancer. This type of systemic therapy is rarely used to treat epithelial ovarian cancer, but is more often used to treat ovarian stromal tumors.
In the past radiation was used more often for ovarian cancer, currently, radiation therapy is only rarely used in the U.S. as the main treatment for this cancer. It can be useful in treating areas of cancer spread though.
In closing, as a PCP you need to be prepared to refer your patient to a gynecologic oncologist, for the best outcome. A specially trained doctor significantly impacts survival rates. If ovarian cancer is suspected get your patient to a gynecologic oncologist.