Ovarian Cancer

Background and Epidemiology

• 5th most common cancer in women in the UK.  Lifetime risk of around 2% (6700 new cases each year; incidence of around 17/100,000)
• Peak incidence between the ages of 60-65 (although incidence rises with age)
• Very high mortality (most patients present late with stage III disease which has a mortality of between 60-80%)
  • Most common cause of death from a gynaecological cancer
  • Survival rates decrease with age

Aetiology and Risk Factors

• Family history of breast/ovarian cancer increases the risk, particularly if there is an underlying BRCA1 or BRCA2 mutation contributing
• Age
• Lifestyle
  • Smoking
  • Obesity
• Nulliparity
  • Early menarche and late menopause also
  • Note that the use of the oral contraceptive decreases the risk of ovarian cancer, as does breast feeding, early menopause
• Endometriosis

Presentation

• NB Most patients will first present with vague, non-specific symptoms.  A high index of suspicion for ovarian cancer should be present in women presenting with
  • Persistent abdominal distension (bloating)
  • Ascites
  • Early satiety and/or loss of appetite and/or fatigue
    • Patient can also be short of breath, have indigestion, constipation/diarrhoea
  • Non-specific abdominal/pelvic pain
  • Increasing urinary urgency and/or frequency (where UTI has been excluded)
  • Symptoms of irritable bowel syndrome if >50 years old
• Other symptoms/signs include
  • Unusual abdominal mass (+/- pain/tenderness)
  • Abnormal uterine bleeding

Investigation

• First line: Measure CA125
  • If >35 IU/ml, or if the clinical history/examination warrants (e.g. mass), arrange abdominal/pelvic USS
  • If both are normal, and no other causes can be found, the patient is unlikely to have a malignancy but should return for investigations if symptoms/signs worsen
  • In women <40, measure AFP and β-HCG also to investigate germ cell tumours
  • Calculate the Risk of Malignancy Index (see here)- if >250, high risk for malignancy and requires further investigation
• Abdominal / Pelvis CT should be performed if ovarian cancer is suspected
• Biopsy
  • Either laparoscopic or percutaneous image guided biopsy (ideally before treatment)

Management

• Apparent stage I (localised) disease
  • Perform lymph node assessment (retroperitoneal) to check for lymph node spread
    • If there is spread or if tumour is high grade (3), consider chemotherapy (containing carboplatin x6)
    • If there is no spread and the patient has low grade, localised disease, surgery may be an option
      • NB This is extremely rare
• Management of advanced (stage II-IV) disease
  • Chemotherapy (ideally with paclitaxel + platinum based chemo) and surgery (resection of all macroscopic disease) can be attempted for radical treatment
  • Palliative care may be more appropriate depending on patient wishes and extent of disease
• Monitoring and prognosis
  • CA125 may be used to clinically monitor response to treatment, in combination with imaging
  • Whilst up to 75% of patients will show a response to treatment and may even achieve remission, 75% of these patients will relapse with chemotherapy-resistant disease which will usually be fatal

NB The patient’s family may be offered genetic testing if the patient is particularly young or if there is a significant family history