The incidence of ovarian cancer is rising in Australia – it is estimated that in 2016, nearly 1,500 new cases of ovarian cancer will be diagnosed in Australia. Based on the statistics in 2012, the risk of a woman being diagnosed with ovarian cancer by 85 years old is 1 in 82. In 2016, the incidence of ovarian cancer is expected to increase with age until the age group of 65 to 69 years old; then, it will decrease for the age group of 70 to 74 years old before increasing for the age group of 80 to 89 years old. (Source: Cancer Australia)
The majority of ovarian cancers are already at an advanced stage when diagnosed, with significant tumour in the abdomen and surrounding tissue. There is no evidence at present that screening for ovarian cancer helps to prevent the disease or increase survival rates; however, screening may be advisable for certain ‘high risk populations’ such as those with a strong family history, gene mutation carriers, and Ashkenazi Jewish women. Our gynaecologic oncologist will conduct a thorough medical history to determine specific risks and advise on any ‘risk reduction’ preventative surgeries as necessary.
Most women will have symptoms such as abdominal or pelvic pain, urinary frequency or incontinence, a change in bowel habit, indigestion, and unexplained weight gain or loss as well as more vague symptoms such as reduced appetite, abdominal bloating and ‘fullness’, fatigue, and pressure in the abdominal and pelvic areas.
A thorough investigation, using a combination of physical examination, ultrasound, CT scans, blood tests, and medical history, is done to enable accurate assessment of the patient’s condition and consideration of the best treatment options.
A thorough diagnostic 'work-up' is particularly important for women with the above symptoms that persist for longer than a month, and especially if they are over 40 years old or have a family history of ovarian or breast cancer.
Note: Not all lumps and cysts in the ovaries are cancerous – some may be benign (not cancerous). To confirm the nature of any mass in the ovaries, it may be necessary to do a special type of biopsy called a ‘frozen section’, while under general anaesthesia – the biopsy is immediately assessed by a pathologist, and the results are returned while the patient is still in the operating theatre so any action required can be taken at the same time (naturally, in accordance with the discussion and agreement between the patient and our gynaecologic oncologist prior to the operation).
Treatment and Surgery
There will be different treatment options depending on whether the cancer is only inside the ovaries (in 10% to 15% of cases) or has spread to other areas of the abdomen (in 85% of cases). A decision on whether a surgical approach is best will be made following careful consideration of the patient’s pre-existing medical conditions as well as discussion at the Western Australian Gynaecologic Cancer Service’s Tumour Board Multidisciplinary Team Meeting between our gynaecologic oncologist and a panel of expert gynaecological pathologists and medical oncologists.
If the tumour has spread, then the goal will be to remove all signs of visible disease, through a procedure known as a debulking operation. In addition to removing the ovaries and uterus, this procedure will also include extensive examination of all the usual places that tumour cells may hide, such as in the lymph nodes, liver, bowel, diaphragm, and other abdominal organs.
The gold standard is to achieve ‘optimal debulking’, which is when no disease is visible at the conclusion of the surgery. Our certified gynaecologic oncologist has the expertise and extensive experience necessary to ensure that there is a high chance of reaching this goal and will also discuss any available procedures that can help to preserve fertility, if appropriate, prior to surgery.
Chemotherapy and / or Radiation Therapy
In most cases, chemotherapy is a vital part of the treatment for ovarian cancer.
In certain cases, depending on the distribution of the tumour, it may be considered more effective for the patient to undergo a course of chemotherapy before an operation in order to reduce the size of tumour so that surgery has a better chance of successfully eliminating all visible disease. Thus, a patient may be given three to four cycles of chemotherapy followed by a less extensive debulking operation, which is then followed by another three to four cycles of chemotherapy. This is known as ‘neoadjuvant chemotherapy with interval debulking’. This has been shown to achieve similar results and rates of survival compared to initial surgery followed by chemotherapy.
Chemotherapy is usually delivered intravenously (into the bloodstream) but in certain cases, the use of Intraperitoneal Chemotherapy may be considered appropriate. This is when chemotherapy is delivered directly into the abdominal cavity via a special catheter (tubing). Note that it must be used in conjunction with an ‘optimal debulking’ procedure in order to be fully effective. While this technique does produce more side effects at the time of treatment, it provides an improved survival advantage when compared to intravenous chemotherapy alone, especially in the case of advanced disease.
After Surgery and Treatment
After the cancer is treated, our gynaecologic oncologist will discuss the best follow-up regime that is tailored to suit each individual patient. There are normally reviews every six months for the first two years, extending to 12-monthly reviews for the next three years. For patients living outside Perth’s metropolitan area, arrangements can be made for on-going follow-up with their local general practitioner or gynaecologist.
Evidence that regular blood tests and reviews improve outcomes in gynaecological cancers is lacking. However, it may be reassuring to have on-going follow-up for five years after diagnosis. Our gynaecologic oncologist will discuss with the patient regarding the recommendations that are tailored to suit her specific needs.
If the patient has had chemotherapy or radiation after surgery, follow-up may be shared between our gynaecologic oncologist and the medical oncologist or radiation oncologist.