Ovarian Cancer

Basic Information

Ovarian cancer is cancer that begins in the ovaries. One ovary is located on each side of your uterus in the pelvis. They are each connected to the uterus through the fallopian tube, the tube through which the eggs travel to be fertilized in the uterus (womb).

The ovaries contain three kinds of tissue. Ovaries contain germ cells cells that produce eggs (ova) that are formed on the inside of the ovary. Each month from puberty until menopause, women normally produce an egg that makes its way to the surface, where it is shed into the fallopian tube. The ovaries also contain cells, called stromal cells, which produce most of the female hormones, estrogen and progesterone. A layer of tissue called epithelium covers the ovary. Most ovarian cancers start in this epithelial covering.

Because ovarian epithelial cancers arise from cells on the surface of the ovary, they tend to spread throughout the pelvis and abdomen, even when the tumor is small. Cancer cells break off from the tumor surface and circulate through the abdominal cavity, where they can implant and begin growing. They can circulate as far up as the underside of the diaphragm, the muscle that separates the lungs from the abdomen. They also can spread to the omentum, an apron of fatty tissue that covers the intestines.

Because the ovary is richly supplied with lymphatic vessels, the cancer cells also tend to migrate into the lymph nodes that cluster around the aorta. Lymphatic vessels are similar to veins except they are thinner and more delicate and carry clear lymph fluid. Lymph nodes are small bean-shaped collections of immune cells that fight infection. The aorta runs along the back of the abdomen.

Types of Ovarian Cancer

There are several types of ovarian cancer, but this website discusses only epithelial ovarian tumors.

Benign epithelial ovarian tumors

Most epithelial ovarian tumors are benign, do not spread, and usually do not lead to serious illness. There are several types of benign epithelial tumors, including serous adenomas, mucinous adenomas, and Brenner tumors.

Tumors of low malignant potential: When viewed under the microscope, some ovarian epithelial tumors do not clearly appear to be cancerous. These are called tumors of low malignant potential (LMP tumors). They are also known as borderline epithelial ovarian cancer. These differ from typical ovarian cancers in that they do not invade the ovarian stroma (the supporting tissue of the ovary). Likewise, if they spread outside the ovary, for example, into the abdominal cavity, they do not usually invade the lining tissue of the abdomen.

These cancers affect women at a younger age than the typical epithelial ovarian cancers. LMP tumors grow slowly and are also a less life-threatening disease than most ovarian cancers. Although they can be fatal, this is not common. Because of this, LMP tumors are treated differently, and a separate treatment pathway is presented in this report.

Epithelial ovarian cancers

Cancerous epithelial tumors are called carcinomas. About 85% of ovarian cancers are epithelial ovarian carcinomas. Epithelial ovarian carcinoma cells have several features that can be identified under the microscope. These features are used to classify epithelial ovarian carcinomas into serous, mucinous, endometrioid, and clear cell types. Although these cancers may grow a little differently, they are all treated the same way.

Undifferentiated epithelial ovarian carcinomas don't look like any of these four subtypes, and they also tend to grow and spread more quickly. In addition to their classification by cell type, epithelial ovarian carcinomas are also given a grade and a stage. The staging system is described in the staging section.

The grade is on a scale of 1, 2, or 3. Grade 1 epithelial ovarian carcinomas more closely resemble normal tissue, grow more slowly, and tend to have a better prognosis (outlook for survival). Grade 3 epithelial ovarian carcinomas less closely resemble normal tissue, are more aggressive, and usually have a worse outlook.

The tumor stage describes how far the tumor has spread from where it started in the ovary.

What Causes Ovarian Cancer?

A risk factor is anything that increases a person's chance of getting a disease such as cancer. Different cancers have different risk factors. For example, unprotected exposure to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for cancers of the lung, mouth, larynx, bladder, kidney, and several other organs.

Researchers have discovered several specific factors that increase a woman's likelihood of developing epithelial ovarian cancer. These risk factors do not apply to other less common types of ovarian cancer, such as germ cell tumors and stromal tumors.

Most women with ovarian cancer do not have any known risk factors. It is important to remember that risk factors increase the odds of getting a disease but do not guarantee it will occur. Only a small number of women who have risk factors will develop ovarian cancer.

Aging

Most ovarian cancers develop after menopause. A woman is considered menopausal when she has gone a year without a menstrual period. Half of all ovarian cancers are found in women over the age of 63.

Reproductive history

Women who started menstruating at an early age (before age 12), had no children or had their first child after age 30, and/or experienced menopause after age 50 may have an increased risk of ovarian cancer. A relationship seems to exist between the number of menstrual cycles in a woman's lifetime and her risk of developing ovarian cancer.

Fertility drugs

The use of the fertility drug clomiphene citrate over several years, especially without getting pregnant, may increase your risk for developing ovarian tumors, particularly a type known as borderline epithelial ovarian cancer (or tumors of low malignant potential). If you are taking this drug, you should discuss its potential risks with your doctor. However, infertility also increases the risk of ovarian cancer, even without use of fertility drugs.

Family history of ovarian cancer, breast cancer, or colorectal cancer: Ovarian cancer risk is increased if your mother, sister, or daughter have, or have had, ovarian cancer, especially if they developed ovarian cancer at a young age. You can inherit an increased risk for ovarian cancer from relatives on your mother's side or father's side of the family. About 10% of ovarian cancers result from an inherited tendency to develop the disease. If there is a family history of cancer due to an inherited mutation of the breast cancer gene BRCA1 or BRCA2, you will have a very high risk of ovarian cancer. Also, a mutation leading to inherited colorectal cancer can also lead to ovarian cancer. Many cases of familial epithelial ovarian cancer are caused by inherited gene mutations that can be identified by genetic testing.

Breast cancer

If you have had breast cancer, you also have an increased risk of developing ovarian cancer. There are several reasons for this. Some of the reproductive risk factors for ovarian cancer may also increase breast cancer risk. Also, if you have a strong family history of breast cancer, you may have an inherited mutation of the BRCA1 or BRCA2 gene.

Talcum powder

It has been suggested that talcum powder applied directly to the genital area or on sanitary napkins may be carcinogenic (cancer-causing) to the ovaries. Most but not all studies suggest a slight increase in risk of ovarian cancer in women who used talc on the genital area. In the past, talcum powder was sometimes contaminated with asbestos, a known cancer-causing mineral. This may explain the association with ovarian cancer in some studies. Body and face powder products have been required by law for more than 20 years to be asbestos-free. However, proving the safety of these newer products will require follow-up studies of women who have used them for many years. There is no evidence at present linking cornstarch powders with any female cancers.

Hormone replacement therapy

Some studies suggest that women using estrogens after menopause may have a slightly increased risk of developing ovarian cancer, while other studies have not found any effect on ovarian cancer risk. A recent study suggested that women using estrogens for more than 10 years almost doubled their ovarian cancer risk. The decision to use hormone replacement therapy (HRT) after menopause should be made by a woman and her doctor after weighing the possible risks and benefits. Factors to consider include other risk factors for ovarian cancer, breast cancer, osteoporosis (thinning and weakening of bones), and the severity of menopausal symptoms.

Can Ovarian Cancer Be Prevented?

Most women have one or more risk factors for ovarian cancer. However, most of the common factors only slightly increase your risk, so they only partly explain the frequency of the disease. So far, knowledge about risk factors has not been translated into practical ways to prevent most cases of ovarian cancer.

There are several ways you can reduce your risk of developing epithelial ovarian cancer. However, some of these strategies reduce the risk only slightly, while others decrease it much more. Some strategies are easily followed, and others require surgery. If you are concerned about your risk of ovarian cancer, you may want to discuss this information with your health care team.

Oral contraceptives

The use of oral contraceptives (birth control pills) decreases the risk of developing ovarian cancer, especially among women who used them for several years. It is unclear if oral contraceptives reduce the ovarian cancer risk in women who have the BRCA1 or BRCA2 gene mutation.

Tubal ligation or hysterectomy

Tubal ligation is a surgical procedure to "tie" the fallopian tubes to prevent pregnancy. When performed after childbearing, tubal ligation may reduce the chance of developing ovarian cancer. A hysterectomy may also reduce your risk.

Pregnancy and breast-feeding

Having one or more children, particularly if your first child is born before you are age 30, plus prolonged (one year or more) breast-feeding also may decrease your risk. Although these measures slightly reduce risk, they do not guarantee protection against ovarian cancer. Doctors do not recommend making choices about when to have a child specifically for the purpose of reducing ovarian cancer risk, especially since using oral contraceptives has a greater impact on this risk.

Diet

Results of some studies suggest that a high-fat diet may increase ovarian cancer risk.

Prevention strategies for women with a family history of ovarian cancer

Genetic counseling can predict whether you are likely to have one of the gene mutations associated with an increased ovarian cancer risk. If your family history suggests that you might have one of these gene mutations, genetic testing can be done.

Before undergoing genetic testing, you should discuss its benefits and potential drawbacks. Genetic testing can determine if you or members of your family carry certain gene mutations that cause a high risk of ovarian cancer. For some women with a strong family history of ovarian cancer, knowing that they do not have a mutation that increases their ovarian cancer risk can be a great relief for them and their children. Knowing that you do have such a mutation can be very stressful, but many women find this information helpful in making important decisions about certain prevention strategies for them and their children.

Use of oral contraceptives is one way to decrease ovarian cancer if you are at high risk for this disease. However, some studies have indicated that oral contraceptives might increase your breast cancer risk if you have a strong family history of breast cancer. Other studies, on the other hand, have not found any increase in breast cancer risk among women with BRCA mutations who take oral contraceptives. Additional research is needed to learn more about the risks and benefits of oral contraceptives for women at high ovarian and breast cancer risk.

A prophylactic oophorectomy is surgery to remove both of the ovaries before an ovarian cancer occurs. This is a controversial operation because it causes premature menopause in premenopausal women and may be unnecessary. It generally is recommended only for certain very high-risk patients over age 40. This operation lowers ovarian cancer risk a great deal but does not entirely eliminate it. In some women with a very high risk of ovarian cancer (due to a strong family history) who have had both ovaries removed, cancers can still form in the lining cells of the pelvic cavity where the ovaries were previously located. This type of cancer, known as primary peritoneal carcinoma, occurs more often in women with BRCA gene mutations. Recent studies suggest that having both ovaries removed can also lower the risk of developing breast cancer among women with BRCA gene mutations.

As noted in the section on known risk factors for ovarian cancer, risk gene mutations and women with a strong family history who have not undergone genetic testing may benefit from screening tests.

Finding Ovarian Cancer Early

About 25% of ovarian cancers are found at an early stage. Early detection improves the chances that ovarian cancer can be treated successfully. When ovarian cancer is found early at a localized stage, about 90% of patients live longer than 5 years after diagnosis.

Regular pelvic examinations

Yearly pelvic examinations and Pap smears to check the pelvic area should begin at age 18 or when you become sexually active, whichever comes first. During this exam, the health care professional feels the ovaries and uterus for size, shape, and consistency.

Although the Pap test is effective in detecting cervical cancer early, it cannot detect most ovarian cancers. Most of the ovarian cancers that are detected through Pap smears are already advanced. Although a pelvic examination is routinely recommended because it can find some reproductive system cancers at an early stage, most early ovarian tumors are difficult or impossible for even the most skilled examiner to feel.

Seeing a doctor if you have symptoms: Early cancers of the ovaries tend to cause symptoms that are relatively vague. These symptoms include abdominal swelling (due to a mass or accumulation of fluid), unusual vaginal bleeding, pelvic pressure, back pain, leg pain, and digestive problems such as gas, bloating, indigestion, or long-term stomach pain. Most of these symptoms can also be caused by other less serious conditions.

By the time ovarian cancer is considered as a possible cause of these symptoms, it may have already spread beyond the ovaries. Also, ovarian cancer can rapidly spread to the surface of nearby organs. Nonetheless, prompt attention to symptoms can improve the odds of early diagnosis and successful treatment. If you have symptoms of ovarian cancer, report them to your health care professional right away.

Screening tests for ovarian cancer: Screening tests and examinations are used to detect a disease, such as cancer, in people who do not have any symptoms. Women with a high risk of developing epithelial ovarian cancer, such as those with a very strong family history of this disease, may be screened with transvaginal sonography (an ultrasound test performed with a small instrument placed in the vagina) and blood tests.

Transvaginal sonography is helpful in finding a mass in the ovary, but it does not accurately detect which masses are cancers and which are benign diseases of the ovary.

Blood tests for ovarian cancer may include measuring the amount of CA-125. The amount of this protein in the blood is higher in many women with ovarian cancer. However, some noncancerous diseases of the ovaries can also increase the blood levels of CA-125, and some ovarian cancers may not produce enough CA-125 to cause a positive test result. When these test results are positive, it may be necessary to do more x-ray studies or to take samples of fluid from the abdomen or tissue from the ovaries to find out if a cancer is really present.

In preliminary studies of women at average risk of ovarian cancer, these screening tests did not lower the number of deaths caused by ovarian cancer. Therefore, transvaginal sonography and the CA-125 blood test are not recommended for ovarian cancer screening of women without known strong risk factors. Researchers continue to study ways to improve ovarian cancer screening tests. They hope that further improvements will make these tests effective enough to lower the ovarian cancer death rate.

Tests and Exams to Diagnose Ovarian Cancer

If there is a reason to suspect that you may have ovarian cancer, the doctor will use one or more methods to find out if the disease is really present. If these tests find ovarian cancer, more tests will be done to find out how far the cancer has spread.

History and Physical Exam

When your doctor "takes a history," he or she will ask you a series of questions about your symptoms and risk factors. Ovarian cancer may cause several signs and symptoms. However, most of these may also be caused by benign (noncancerous) diseases and by cancers of other organs.
Prolonged swelling of the abdomen (due to a tumor or accumulation of fluid called ascites) Digestive problems including gas, loss of appetite, bloating, long-term abdominal pain, or indigestion
Unusual vaginal bleeding is a rare sign of ovarian cancer. It is a strong warning of some type of abnormality, although not necessarily ovarian cancer. Bleeding that occurs between periods, is heavier, or lasts longer than usual is considered abnormal. Any postmenopausal bleeding, staining, or persistent vaginal discharge is abnormal. A woman of any age who has unusual vaginal bleeding should tell her doctor immediately.
Pelvic pressure (feeling as though you have to urinate or defecate all the time)
Pelvic pain is a nonspecific symptom. It may be caused by ovarian cancer, other cancers, or by several benign conditions.
Leg pain
Back pain

If ovarian cancer is suspected, your doctor will use one or more methods to be absolutely certain that the disease is present and to determine the stage of the cancer.
Consultation with a Specialist

If your pelvic examination or other tests suggest that you may have ovarian cancer, you will need a doctor or surgeon who specializes in treating women with this type of cancer. A gynecologic oncologist is a doctor who is specially trained in treating cancers of the female reproductive system.
Blood Tests

Certain blood tests are useful in evaluating ovarian cancer. The simplest is a complete blood count (CBC). This tests for anemia (from too few red blood cells), which could be the result of internal bleeding. It also tests whether you are producing normal numbers of infection-fighting white blood cells and platelets (blood particles that help prevent bleeding). A second test is a general blood chemistry test. This tells about your liver and kidney function and your blood mineral balance.

Your doctor will also perform a blood CA-125 test. CA-125 is a tumor marker, a substance that is elevated in the blood of many women with ovarian cancer. It is often very high when the cancer is advanced. After treatment, it will return to normal levels if the cancer goes into remission or if it is completely removed by surgery.
Imaging Studies

Imaging methods such as computed tomography (CT) scans, magnetic resonance imaging (MRI) studies can confirm whether a pelvic mass is present. Although these studies cannot confirm if the mass is a cancer, they are useful if your doctor is looking for spread of ovarian cancer to other tissues and organs.

Ultrasound

An ultrasound uses sound waves to create an image on a video screen. Sound waves are released from a small probe placed in the woman's vagina or on the surface of her abdomen. The sound waves create echoes as they enter the ovaries and other organs. The same probe detects the echoes that bounce back, and a computer translates the pattern of echoes into a picture. Because ovarian tumors and normal ovarian tissue often reflect sound waves differently, this test may be useful in detecting tumors and in determining whether a mass is solid or a fluid-filled cyst.

Computed tomography (CT)

The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a usual chest x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine produces multiple images of the part of your body that is being studied.

Often after the first set of pictures is taken you will receive an intravenous injection of a contrast agent, or dye, which helps better outline structures in your body. A second set of pictures is then taken. Some people get hives or, rarely, more serious allergic reactions like trouble breathing and low blood pressure can occur. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays. The CT scan provides precise information about the size, shape, and position of a tumor and can help find enlarged lymph nodes that might contain cancer that has spread from the ovary. Although large lymph nodes seen in CT scans of a person with ovarian cancer usually contain cancer cells, they may sometimes be enlarged for other reasons.

CT scans can also be used during a biopsy to precisely guide a biopsy needle into a suspected tumor. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table, while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about 1/2-inch long and less than 1/8-inch in diameter) is removed and examined under a microscope.

Magnetic resonance imaging (MRI)

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into very detailed cross-sectional images of parts of the body. A contrast material might be injected just as with CT scans.

Chest x-ray

This procedure may be done to determine whether ovarian cancer has spread (metastasized) to the lungs. This spread may cause tumors to appear in the lungs and often causes fluid to collect around the lungs. This fluid, called a pleural effusion, can be seen with chest x-rays.

Barium enema x-ray

This is a test to see if the cancer has invaded your colon (large intestine) or rectum (it is also used to look for colorectal cancer). After taking laxatives the day before, the radiology technician introduces barium sulfate, a chalky substance, into your rectum and colon. Because barium is impermeable to x-rays, it outlines your colon and rectum on x-rays of your abdomen.

Colonoscopy

A colonoscopy is also done after you have cleaned out your large intestine with laxatives. A doctor inserts a fiberoptic tube into your rectum and passes it through your entire colon. This allows the doctor to see the inside and detect any cancer growing in the colon. It is also used to look for colorectal cancer. Because this is uncomfortable, you will be sedated. Other Tests

Laparoscopy

This procedure uses a thin, lighted tube through which a doctor can view the ovaries, other pelvic organs, and tissue in the area around the bile duct. The tube is inserted through a small incision (cut) in the lower abdomen. Laparoscopy provides a view of organs that can help in planning surgery or other treatments and can help doctors confirm the stage (how far the tumor has spread) of the cancer. Also, doctors can manipulate small instruments through the laparascopic incision(s) to remove small tissue samples to examine under the microscope.

Tissue Sampling (Biopsy)

The only way to determine for certain if a growth in the pelvic region is cancer is to remove a sample of tissue from the suspicious area and examine it under a microscope. This procedure is called a biopsy.

Although in many cancers a biopsy is often done before surgery, in women with ovarian cancer, the cancer sampling generally occurs at the time of surgery. Not only is the entire ovary removed for examination, but the surgeon also removes any other visible cancer than can be removed and performs other biopsies. Ovarian cancer tends to "seed" throughout the abdomen and to the surface of other organs, such as the liver. Often the surgeon can't tell this has happened without a biopsy. The surgeon will try to find out if or how extensively the cancer has seeded by removing small amounts of normal appearing tissue from many sites in the abdomen. The pathologist then examines these under the microscope. This is part of the "staging" procedure for ovarian cancer. Sometimes, in patients with ascites (collection of fluid inside the abdomen), samples of fluid can also be used to diagnose the cancer.

Ovarian Cancer Stages

Staging is the process of finding out how far a cancer has spread. Most ovarian cancers that are not obviously widespread are staged at the time of surgery. Although your doctor may try to estimate the stage of your cancer from the examination and imaging tests (called the clinical stage), this is not always accurate. The pathologic stage, which is assessed during and after surgery, is much more important.

Samples of tissues are taken from different parts of the pelvis and abdomen and examined under the microscope. Staging is very important because ovarian cancers have a different prognosis at different stages and are treated differently. The accuracy of the staging may determine treatment and can help predict whether a patient will be cured. If the cancer is not properly staged, then cancer that has spread outside the ovary may be missed and not treated. Once a stage has been assigned, it does not change, even when the cancer recurs or spreads to new locations in the body.

Ask your cancer care team to explain the staging procedure. Also ask them if they will perform a thorough staging procedure. After surgery, ask about the stage of your cancer so that you can take part in making informed decisions about your treatment. The stages described below are pathologic stages, not clinical (from physical examination and imaging studies). They are developed from the pathologist's report of the findings from your surgery.

What are the Stages of Ovarian Cancer Mean

Ovarian cancer is staged using the AJCC and FIGO system. AJCC stands for American Joint Committee on Cancer and FIGO stands for International Federation of Gynecologists and Obstetricians.

Stage I

The cancer is still contained within the ovary (or ovaries).

Stage IA : Cancer has developed in one ovary and has not spread onto the outer surface of the ovary. Laboratory examination of washings from the abdomen and pelvis did not find any cancer cells.

Stage IB : Cancer has developed within both ovaries and has not spread onto their outer surfaces. Laboratory examination of washings from the abdomen and pelvis did not find any cancer cells.

Stage IC : The cancer is present in one or both ovaries and one or more of the following are present:
Cancer is found on the outer surface of at least one of the ovaries.
In the case of cystic (fluid-filled) tumors, the capsule (outer wall of the tumor) has ruptured (burst).
Laboratory examination found cancer cells in fluid or washings from the abdomen.

Stage II

The cancer is in one or both ovaries and has grown onto or into other organs (such as the uterus, fallopian tubes, bladder, the sigmoid colon, or the rectum) within the pelvis.

Stage IIA : The cancer has spread onto or has grown into the uterus or the fallopian tubes, or both. Laboratory examination of washings from the abdomen did not find any cancer cells.

Stage IIB : The cancer has spread onto or grown into other nearby pelvic organs, such as the bladder, the sigmoid colon, or the rectum. Laboratory examination of fluid from the abdomen did not find any cancer cells.

Stage IIC : The cancer has spread onto or grown into pelvic organs as in stages IIA or IIB, and cancer cells were found in fluid or washings from the abdomen.

Stage III

The cancer involves one or both ovaries, and one or both of the following are present:
Cancer has spread beyond the pelvis to the lining of the abdomen.
Cancer has spread to lymph nodes (glands that fight infection and produce some types of blood cells).

Stage IIIA : During the staging operation, the surgeon can see cancer in the ovary or ovaries but no other sites of disease outside the ovaries are visible. However, when the staging biopsies are checked under a microscope, tiny deposits of cancer are found in the lining of the abdomen. The cancer has not spread to lymph nodes.

Stage IIIB : There is cancer in one or both ovaries, and deposits of cancer large enough for the surgeon to see but smaller than 2 cm (about 3/4-inch) across are present in the abdomen. Cancer has not spread to the lymph nodes.

Stage IIIC : The cancer is in one or both ovaries, and one or both of the following is present:
Cancer has spread to lymph nodes.
Deposits of cancer larger than 2 cm (about 3/4 -inch) across are seen in the abdomen.

Stage IV

This is the most advanced stage of ovarian cancer. The cancer has spread to distant sites such as the inside of the liver (the outside can still be stage III), the lungs, or to other organs located outside of the pelvis or abdomen. Finding ovarian cancer cells in pleural fluid (from around the lungs) is also evidence of stage IV disease.

Recurrent ovarian cancer

This means that the disease has recurred (come back) after completion of treatment.

After the diagnostic tests are done, your cancer care team will recommend one or more treatment options. Consider the options without feeling rushed. If there is anything you do not understand, ask to have it explained. The choice of treatment depends largely on the type of cancer and the stage of the disease. In patients who did not have surgery as their initial treatment, the exact stage may not be known. Treatment then is based on other available information.

Other factors that could play a part in choosing the best treatment plan might include your general state of health, whether you plan to have children, and other personal considerations. Age alone is not a determining factor since several studies have shown that older women tolerate ovarian cancer treatments well. Be sure you understand all the risks and side effects of the various therapies before making a decision about treatment.

The main treatments for ovarian cancer are surgery, chemotherapy, and radiation therapy. In some cases, two or even all of these treatments will be recommended.

Be aware that almost all the treatments make a woman infertile, that is, unable to bear children. If surgery is chosen, most of the time the surgeon removes both ovaries and the uterus. This will result in your not being able to get pregnant, and it will also result in menopause. Both radiation and chemotherapy also cause infertility. If you want to maintain your fertility so that you can have a family after recovering from treatment, discuss this with your doctor. Certain situations in which this is possible are mentioned later in the treatment decision tree.

Surgery

Surgery for ovarian cancer is done for three reasons. The first is to make the diagnosis of ovarian cancer. The second is to stage the disease. And the third, is to remove as much of the cancer as can be removed (this is called debulking).

Staging and removal of the ovarian cancer are specialized procedures that require the expertise of a gynecologic surgical oncologist who is trained in these procedures. If ovarian cancer is suspected before surgery, a gynecologic oncologist should do the surgery or should be available to assist the doctor doing the surgery.

How much surgery you have depends on how far your cancer has spread and on your general health. For women of childbearing age who have certain kinds of tumors and whose cancer is in the early stage, an effort will be made to treat the disease without removing both ovaries and the uterus.

Almost always, the surgeon makes a vertical incision in the abdomen. Many surgeries on women's pelvic organs can be done with a laparoscope. This means operating through small incisions and viewing the organs with a telescope-like instrument. This is not usually done for ovarian cancer. But, it may be done in some women with stage I cancers.

Several surgical procedures are used to treat ovarian cancer. The medical term for these operations is based on the Greek or Latin names of the organs they remove. The medical name of an operation that removes something usually ends with "-ectomy." So, removing the uterus is a hysterectomy, removing the omentum is an omentectomy, and removing lymph nodes is a lymphadenectomy (also called lymph node biopsy or dissection).

There are two ovaries and two fallopian tubes. Removing one ovary is a unilateral (one side) oophorectomy, and removing both is a bilateral (two sides) oophorectomy. Likewise, removing one or two fallopian tubes is a unilateral salpingectomy or bilateral salpingectomy. Often, several organs are removed in one operation. For example, removing both ovaries and fallopian tubes is a bilateral salpingo-oophorectomy.

The other important surgical procedure is debulking. In this procedure, the surgeon removes as much tumor as possible, even though all of it can't be removed. Most doctors believe this greatly improves a patient's prognosis (outlook for survival). This partial list of names of operations should help you in understanding information you may read about ovarian cancer and in discussing your cancer with your health care professionals. Don't be afraid to ask your cancer care team to explain your condition and recommend treatments in simple, nonmedical terms.

It is important that your surgeon is experienced in ovarian cancer surgery. Many general gynecologists are not prepared to do the appropriate cancer operation, which requires careful staging and, perhaps, debulking. Ask your doctor if he or she is experienced in treating ovarian cancer, can stage your cancer properly, and can perform a debulking procedure if that is needed. Otherwise you may need a second operation.

Removal of both ovaries and/or the uterus means that you will not be able to become pregnant. It also means that you will go into menopause if you have not done so already. Most women remain in the hospital for 3 to 7 days after the operation and can resume their usual activities within 4 to 6 weeks.

Surgery does not change your ability to feel sexual pleasure. You do not need your uterus to reach orgasm. Some women feel less feminine after a hysterectomy; however, such thoughts do not reflect the generally positive outcome concerning sexual function and orgasm.

Chemotherapy

Systemic chemotherapy uses cancer drugs that are injected into a vein or given by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment potentially useful for cancers that have metastasized (spread) beyond the organ they started in.

Radiation Therapy

Radiation therapy uses high-energy x-rays to kill cancer cells. These x-rays may be given in a procedure that is much like having a diagnostic x-ray.

External beam radiation therapy

In this procedure, radiation from a machine outside the body is focused on the cancer. External beam radiation therapy is one type of radiation therapy used for treating ovarian cancer. Treatments are given 5 days a week for several weeks. Each treatment lasts only a few minutes and is similar to having a diagnostic x-ray test. As with a diagnostic x-ray, the radiation passes through the skin and other tissues before it reaches the tumor. The actual radiation exposure is very short, and most of the time is spent precisely positioning the patient so that the radiation is aimed accurately at the cancer.

Brachytherapy

Radiation therapy also may be given as an implant of radioactive materials, called brachytherapy, placed near the tumor or as a radioactive fluid placed into the abdominal cavity. This is rarely done for ovarian cancer.