Ovarian Cancer

When a woman is diagnosed with cancer, she needs to consider her family’s history of cancer. Some cancers are inherited; however, most are spontaneous. If there is a concern with a family pattern of cancer, then a thorough family history should be taken. Sometimes this leads to formal genetic counseling with blood testing for specific gene mutations. If you have a specific gene mutation putting you at risk for breast or ovarian cancer, then surveillance testing or procedures are different from those with a spontaneous cancer. Therefore, start with telling your oncologist your family history. I'm not sure what is standard, but my gynecologist is going to give me internal ultrasounds to check my ovaries yearly until I'm 40 years old. Then when I turn 40, the plan right now is to have my ovaries removed. Unless anything funny looks like it's going on, then they get pulled then. I should note I'm 32 right now, so that may change.
My breast specialist thought this plan was fine so we're running with it.

Breast and ovarian cancer survivors, especially those with, hormone-sensitive cancers, may worry about using ovarian stimulating hormones either during fertility preservation prior to cancer treatment or during survivorship. For fertility preservation purposes, embryo or egg banking are options for many young women. In this process, hormones are used to induce the ovaries to produce multiple eggs in one month (normally an ovary produces a single egg per month). Clinical hormonal stimulation protocols have been modified to work for women with hormone-sensitive cancers. The one study that looked at cancer recurrence rates for breast cancer survivors who underwent this procedure, found that these women did not have an increased risk for cancer recurrence compared to those who did not have ovarian stimulation.

Survivors of hormone-sensitive cancers may also discuss using this protocol with their fertility specialist. However, they may first wish to examine their ovarian reserve, the number of immature eggs in their ovaries, as chemotherapy, radiation, and surgery for cancer treatment may have significantly reduced this number.
Breast and ovarian cancer survivors, especially those with, hormone-sensitive cancers, may worry about using ovarian stimulating hormones either during fertility preservation prior to cancer treatment or during survivorship. For fertility preservation purposes, embryo or egg banking are options for many young women. In this process, hormones are used to induce the ovaries to produce multiple eggs in one month (normally an ovary produces a single egg per month). Clinical hormonal stimulation protocols have been modified to work for women with hormone-sensitive cancers. The one study that looked at cancer recurrence rates for breast cancer survivors who underwent this procedure, found that these women did not have an increased risk for cancer recurrence compared to those who did not have ovarian stimulation.

Survivors of hormone-sensitive cancers may also discuss using this protocol with their fertility specialist. However, they may first wish to examine their ovarian reserve, the number of immature eggs in their ovaries, as chemotherapy, radiation, and surgery for cancer treatment may have significantly reduced this number.

The robotic system is generally recommended in the setting of early-stage cervical cancer to perform a radical hysterectomy or radical trachelectomy. It is also very commonly used to perform simple hysterectomy and lymph node removal in the setting of uterine cancer. It may also be used when performing prophylactic removal of the tubes and ovaries in patients with hereditary breast and ovarian cancer syndromes.

The robotics approach may also be used in very select cases of patients with isolated recurrent disease.
The robotic system is generally recommended in the setting of early-stage cervical cancer to perform a radical hysterectomy or radical trachelectomy. It is also very commonly used to perform simple hysterectomy and lymph node removal in the setting of uterine cancer. It may also be used when performing prophylactic removal of the tubes and ovaries in patients with hereditary breast and ovarian cancer syndromes.

The robotics approach may also be used in very select cases of patients with isolated recurrent disease.

Having one gynecologic cancer does not increase your risk of having other types of gynecologic cancer. However, women with a hereditary cancer syndrome are at increased risk of developing a gynecologic cancer. These syndromes include Hereditary Breast and Ovarian Cancer (HBOC) caused by a BRCA mutation as well as Lynch syndrome, also called hereditary nonpolyposis colorectal cancer (HNPCC). Women with HBOC syndrome have markedly elevated risks of breast cancer and ovarian cancer, with a lifetime risk of breast cancer of 50 to 85 percent and a 15 to 40 percent chance of developing ovarian cancer. There is also an increased risk of a second breast cancer diagnosis.

Lynch syndrome is associated with cancer diagnosis at an early age and the development of multiple cancer types, particularly colon and endometrial cancer. Until recently, the majority of attention and research related to Lynch syndrome has focused on colorectal cancer. However, women with Lynch syndrome have a 27 to 71% risk of endometrial cancer, which equals or exceeds their risk of colorectal cancer. This is significantly higher than the 3% risk of endometrial cancer in the general population. In addition, women with Lynch syndrome have a 8-11% risk of ovarian cancer, compared with 1.5% in the general population. The management of endometrial and ovarian cancer risks in women with HBOC or Lynch syndrome includes surveillance, chemoprevention and risk-reducing surgery.
Having one gynecologic cancer does not increase your risk of having other types of gynecologic cancer. However, women with a hereditary cancer syndrome are at increased risk of developing a gynecologic cancer. These syndromes include Hereditary Breast and Ovarian Cancer (HBOC) caused by a BRCA mutation as well as Lynch syndrome, also called hereditary nonpolyposis colorectal cancer (HNPCC). Women with HBOC syndrome have markedly elevated risks of breast cancer and ovarian cancer, with a lifetime risk of breast cancer of 50 to 85 percent and a 15 to 40 percent chance of developing ovarian cancer. There is also an increased risk of a second breast cancer diagnosis.

Lynch syndrome is associated with cancer diagnosis at an early age and the development of multiple cancer types, particularly colon and endometrial cancer. Until recently, the majority of attention and research related to Lynch syndrome has focused on colorectal cancer. However, women with Lynch syndrome have a 27 to 71% risk of endometrial cancer, which equals or exceeds their risk of colorectal cancer. This is significantly higher than the 3% risk of endometrial cancer in the general population. In addition, women with Lynch syndrome have a 8-11% risk of ovarian cancer, compared with 1.5% in the general population. The management of endometrial and ovarian cancer risks in women with HBOC or Lynch syndrome includes surveillance, chemoprevention and risk-reducing surgery.

The main difference between chemotherapy and radiation therapy is the fact that chemotherapy is a systemic treatment and radiation is a local treatment. In this sense radiation is similar to surgery and would only address the area which is receiving radiation. With chemotherapy, once it is injected into your blood stream, it goes everywhere in your system. That is like a double-edge sword though because often it affects organs which do not necessarily need to receive chemotherapy such as your hair, your nails, your bone marrow, or kidney etc. But the fact that it addresses your entire system has the advantage of killing any cancer cell that potentially has cut loose through your system. More and more research is done on creating mechanisms towards targeted therapy that is to direct chemotherapy towards the cancer cells only and avoid side effects of chemotherapy by sparing the normal tissues. The main difference between chemotherapy and radiation therapy is the fact that chemotherapy is a systemic treatment and radiation is a local treatment. In this sense radiation is similar to surgery and would only address the area which is receiving radiation. With chemotherapy, once it is injected into your blood stream, it goes everywhere in your system. That is like a double-edge sword though because often it affects organs which do not necessarily need to receive chemotherapy such as your hair, your nails, your bone marrow, or kidney etc. But the fact that it addresses your entire system has the advantage of killing any cancer cell that potentially has cut loose through your system. More and more research is done on creating mechanisms towards targeted therapy that is to direct chemotherapy towards the cancer cells only and avoid side effects of chemotherapy by sparing the normal tissues.

The majority of cases of ovarian cancer (approximately 75%) are diagnosed at stage III or IV (spread of cancer outside the ovaries and into the abdominal cavity or beyond). The primary difference is in prognosis. The percent of women with stage I ovarian cancer who are alive 5 years after diagnosis is around 83-89%. For women with stage II ovarian cancer, that number drops to 65-70%. For women with stage III, it drops to 32-45%; and for stage IV cancers, the number of women alive 5 years after their diagnosis is less than 20%.

The primary treatment for all stages of ovarian cancer is surgery. After surgery, chemotherapy is recommended for most women, regardless of stage. The majority of cases of ovarian cancer (approximately 75%) are diagnosed at stage III or IV (spread of cancer outside the ovaries and into the abdominal cavity or beyond). The primary difference is in prognosis. The percent of women with stage I ovarian cancer who are alive 5 years after diagnosis is around 83-89%. For women with stage II ovarian cancer, that number drops to 65-70%. For women with stage III, it drops to 32-45%; and for stage IV cancers, the number of women alive 5 years after their diagnosis is less than 20%.

The primary treatment for all stages of ovarian cancer is surgery. After surgery, chemotherapy is recommended for most women, regardless of stage.

My personal course of treatment followed that for Ovarian Cancer since that was my primary cancer. Upon my surgery it was found that there was a tumor that filled my entire uterus. The wording on my pathology report is "the endometrial and left ovarian tumors appear to be independent primaries. The cul de sac and right ovary tumors likely represent metastasis from the left ovary" My gyn/oncologist refered to the Ovarian Cancer as primary and the Uterine Cancer as Secondary Primary. I had a TAH/BSO (Total Abdominal Hysterectomy and Bilateral Salpingo-Oopherectomy) This is the removal of the uterus including the cervix as well as the tubes and ovaries using an incision in the abdomen. I also had my omentum and appendix removed. This was followed by 6 cycles of Chemo; Carboplatin and Taxol. My personal course of treatment followed that for Ovarian Cancer since that was my primary cancer. Upon my surgery it was found that there was a tumor that filled my entire uterus. The wording on my pathology report is "the endometrial and left ovarian tumors appear to be independent primaries. The cul de sac and right ovary tumors likely represent metastasis from the left ovary" My gyn/oncologist refered to the Ovarian Cancer as primary and the Uterine Cancer as Secondary Primary. I had a TAH/BSO (Total Abdominal Hysterectomy and Bilateral Salpingo-Oopherectomy) This is the removal of the uterus including the cervix as well as the tubes and ovaries using an incision in the abdomen. I also had my omentum and appendix removed. This was followed by 6 cycles of Chemo; Carboplatin and Taxol.

They warning signs were vague if looked at them indivdually which is what I did, but there were many and in hindsight I should have put them all together. Let me state that I had stopped fertility treatmenmts in January 2004, 11 months prior to my diagnosis in November 2004 at the age of 42. In January 2004 I had my last internal and external sonongram to measure uterine lining & ovary activity and there was no sign of any tumors. Durining my TAH/BSO debulking surgery 3 tumors were removed. One the size of a human head, one the size of a grapfruit and one completely filled the uterus. About 2 months prior to my diagnosis. I experienced some horrible low abdominal cramping. Due to other long standing gyn issues I no longer menstruated through I did occasionally ovulate so I thought it was bad cramps. I had really bad back pain but again I expereinced lower back pain on and off for many years. I am a big girl what you might call reubenesque, but I have a shape, a noticable waist, body in proportion. Even being a big girl I did enough physical activity to not get out of breathe easily and that was happening. I also started to "loose" my waist line the way a pregnant woman does and my abdomen was getting bigger yet at the same time I simply could not eat at all and my abdomin was hard and my stomach was physically painful. What I learned at my disgnosis was that I had ascites which is free floating fluid in the abdomen & it was putting pressure on all my organs specifically my stomach and my lungs, not enabling them to expand and contract the way they needed to which caused pain. By the time I was diagnosed I looked like I was 5 or 6 months pregnant. Nothing fit. I was constantly urinating, or had the urge to and nothing happened. I also experienced constipation & diarrhea within the same day on a daily basis for about 2 weeks. This ended up being a result of my tumors putting pressure on my organs as they grew. When I did mange to get a little food down I expereinced horrible indigestion. It was the GI issues that finally had me go to the doctor. They warning signs were vague if looked at them indivdually which is what I did, but there were many and in hindsight I should have put them all together. Let me state that I had stopped fertility treatmenmts in January 2004, 11 months prior to my diagnosis in November 2004 at the age of 42. In January 2004 I had my last internal and external sonongram to measure uterine lining & ovary activity and there was no sign of any tumors. Durining my TAH/BSO debulking surgery 3 tumors were removed. One the size of a human head, one the size of a grapfruit and one completely filled the uterus. About 2 months prior to my diagnosis. I experienced some horrible low abdominal cramping. Due to other long standing gyn issues I no longer menstruated through I did occasionally ovulate so I thought it was bad cramps. I had really bad back pain but again I expereinced lower back pain on and off for many years. I am a big girl what you might call reubenesque, but I have a shape, a noticable waist, body in proportion. Even being a big girl I did enough physical activity to not get out of breathe easily and that was happening. I also started to "loose" my waist line the way a pregnant woman does and my abdomen was getting bigger yet at the same time I simply could not eat at all and my abdomin was hard and my stomach was physically painful. What I learned at my disgnosis was that I had ascites which is free floating fluid in the abdomen & it was putting pressure on all my organs specifically my stomach and my lungs, not enabling them to expand and contract the way they needed to which caused pain. By the time I was diagnosed I looked like I was 5 or 6 months pregnant. Nothing fit. I was constantly urinating, or had the urge to and nothing happened. I also experienced constipation & diarrhea within the same day on a daily basis for about 2 weeks. This ended up being a result of my tumors putting pressure on my organs as they grew. When I did mange to get a little food down I expereinced horrible indigestion. It was the GI issues that finally had me go to the doctor.

Due to the high risk of breast and ovarian cancer, most will recommend mastectomies and then ovary and tube removal as soon as child bearing is completed. This is the greatest risk reduction but is still not 100%. There is no consensus on how to follow patients with mutations regardless of cancer diagnosis or not. The NCI is currently doing clinical trials for patients with known mutations to try and answer this question. Here's a link: http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA#a18 Due to the high risk of breast and ovarian cancer, most will recommend mastectomies and then ovary and tube removal as soon as child bearing is completed. This is the greatest risk reduction but is still not 100%. There is no consensus on how to follow patients with mutations regardless of cancer diagnosis or not. The NCI is currently doing clinical trials for patients with known mutations to try and answer this question. Here's a link: http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA#a18

When the survivor has a deleterious mutation of the BRCA 1 or 2 gene that carries an elevated risk, or if ovarian cancer runs in the family. When the survivor has a deleterious mutation of the BRCA 1 or 2 gene that carries an elevated risk, or if ovarian cancer runs in the family.

In patients with the BRCA gene, ovarian cancer can occur in addition to breast cancer. The risk depends on which BRCA gene mutation they inherited, with BRCA 1 patients having a risk of ovarian cancer as high as 44% and BRCA 2 patients having a risk as high as 27%. For patients without the BRCA gene, the risk is much lower. Breast cancer can metastasize to the ovary, causing tumors called Krukenberg tumors. Years ago, before the advent of medications to suppress estrogen formation by the ovary, many oncologists requested that the ovaries be removed to reduce estrogen in premenopausal breast cancer patients. That is not really done anymore except in extenuating circumstances. At the moment, there is no specific protocol to monitor the ovaries of breast cancer survivors. Some gynecologists will not change their standard care and others will offer sonograms (ultrasounds) both to assess the uterine lining in patients taking Tamoxifen and to look at the ovaries. Sadly, as mentioned in other questions on this site, ovarian cancer can be sneaky and not show up on scans. My thought is to not worry too much unless you are BRCA positive. Please ask your doctor if you qualify for testing. In patients with the BRCA gene, ovarian cancer can occur in addition to breast cancer. The risk depends on which BRCA gene mutation they inherited, with BRCA 1 patients having a risk of ovarian cancer as high as 44% and BRCA 2 patients having a risk as high as 27%. For patients without the BRCA gene, the risk is much lower. Breast cancer can metastasize to the ovary, causing tumors called Krukenberg tumors. Years ago, before the advent of medications to suppress estrogen formation by the ovary, many oncologists requested that the ovaries be removed to reduce estrogen in premenopausal breast cancer patients. That is not really done anymore except in extenuating circumstances. At the moment, there is no specific protocol to monitor the ovaries of breast cancer survivors. Some gynecologists will not change their standard care and others will offer sonograms (ultrasounds) both to assess the uterine lining in patients taking Tamoxifen and to look at the ovaries. Sadly, as mentioned in other questions on this site, ovarian cancer can be sneaky and not show up on scans. My thought is to not worry too much unless you are BRCA positive. Please ask your doctor if you qualify for testing.

Most uterine malformations are just bad luck. Daughters of women who took DES when they were pregnant are at higher risk of uterine and cervical problems. Smoking in and of itself is associated with a higher risk of cervix cancer. Virtually all cervical cancer is caused by the HPV virus, which is a sexually transmitted infection. Women who smoke and are exposed to HPV may be at increased risk of developing precancerous changes on their pap smear and need to see their gynecologist yearly. Most uterine malformations are just bad luck. Daughters of women who took DES when they were pregnant are at higher risk of uterine and cervical problems. Smoking in and of itself is associated with a higher risk of cervix cancer. Virtually all cervical cancer is caused by the HPV virus, which is a sexually transmitted infection. Women who smoke and are exposed to HPV may be at increased risk of developing precancerous changes on their pap smear and need to see their gynecologist yearly.

Tough question...
I have to say that the most difficult issue is wondering how many other family members have inherited this gene mutation.
I deal with all issues in my life in a positive way. I am a very positive person & I ALWAYS look for the funny & the good in life.
I try to enjoy every day & help others. I love my friends & my family. Tough question...
I have to say that the most difficult issue is wondering how many other family members have inherited this gene mutation.
I deal with all issues in my life in a positive way. I am a very positive person & I ALWAYS look for the funny & the good in life.
I try to enjoy every day & help others. I love my friends & my family.

I had the pet because I was having terrible back pain keeping me awake at night. My breast cancer was grade 3 her2+ as well so any pain more than 2 weeks they have investigated this way. My gyn recommended trying to ultrasound the ovary just after a period but trying to pinpoint WHEN I am going to have a period and then lining the date of US up with that has been impossible. My first question is why did you have a PET scan? They are generally reserved for patients with cancers of other kinds. PETs light up in areas of rapid metabolism. It could be related to normal ovarian function. I need more information because the pelvis is not generally evaluated with a PET.

Great question. Not many. Most ovarian cancer just happens because of bad luck. Less than 25% of ovarian cancer is caused by an inherited identifiable genetic mutation. Certainly a patient with a family history of ovarian cancer should be evaluated to determine if she qualifies for BRCA testing. This can be done either by a formally-trained genetic counselor or by less-formally-trained healthcare providers who have been educated about risk assessment for various cancers including ovarian cancer. Ovarian cancer happens to about 1% of women with no risk factors. If a first degree relative has ovarian cancer, the risk goes up to 4%. If the patient has a BRCA mutation, the risk can be as high as 44%. With Lynch syndrome, a combination of uterine, colon, ovarian, and a few other cancers, the risk is between 10-15%. Women who have never had a baby, who had early menarche and late menopause, and who have never taken the pill are at slightly higher risk given that there ovaries never took a break from ovulating. There is controversy over whether "super ovulation" (using medications to increase the number of eggs ovulated) used in infertility patients increases the risk of ovarian cancer. Patients with any of these factors are evaluated regularly and advised to report any changes in bowel or bladder habits or pelvic symptoms that might be associated with ovarian cancer (see prior question). Great question. Not many. Most ovarian cancer just happens because of bad luck. Less than 25% of ovarian cancer is caused by an inherited identifiable genetic mutation. Certainly a patient with a family history of ovarian cancer should be evaluated to determine if she qualifies for BRCA testing. This can be done either by a formally-trained genetic counselor or by less-formally-trained healthcare providers who have been educated about risk assessment for various cancers including ovarian cancer. Ovarian cancer happens to about 1% of women with no risk factors. If a first degree relative has ovarian cancer, the risk goes up to 4%. If the patient has a BRCA mutation, the risk can be as high as 44%. With Lynch syndrome, a combination of uterine, colon, ovarian, and a few other cancers, the risk is between 10-15%. Women who have never had a baby, who had early menarche and late menopause, and who have never taken the pill are at slightly higher risk given that there ovaries never took a break from ovulating. There is controversy over whether "super ovulation" (using medications to increase the number of eggs ovulated) used in infertility patients increases the risk of ovarian cancer. Patients with any of these factors are evaluated regularly and advised to report any changes in bowel or bladder habits or pelvic symptoms that might be associated with ovarian cancer (see prior question).

Unfortunately there is no easy and reliable way to diagnose ovarian cancer early. When the cancer is far enough along to start causing symptoms of pelvic pressure, urinary frequency, feeling full after eating small quantities of food, and tummy enlargement from fluid in the abdomen and pelvis, it is almost always at least Stage lll and easily seen with a sonogram or CAT scan or MRI. The symptoms of early ovarian cancer are subtle and often misconstrued as bowel problems. They are sometimes called the ovarian cancer "whisper" because they aren't easily heard. Burping or excess flatulence more than half the time, should prompt a visit to be checked. Most gynecologists will perform a pelvic exam. I would suggest a transvaginal sonogram (TVU) to look for cysts and fluid. If there is fluid in the pelvis that can be sampled with a needle, the diagnosis can be made from finding ovarian cancer cells in the fluid. Usually the TVU is diagnostic at that point anyway and sampling the fluid is just confirming the diagnosis. Sadly, the TVU may not show anything worrisome in the earliest stages of ovarian cancer. Often patients with and without symptoms ask for a CA 125 blood test or the newer OVA1 test to look for cancer. These tests are not good for screening because of the high false positive rate. In my experience they often come back high when there is no obvious abnormality. Then what? The patient undergoes surgery because they get nervous. Hopefully the answer to the dilemma of diagnosing ovarian cancer is right around corner. Unfortunately there is no easy and reliable way to diagnose ovarian cancer early. When the cancer is far enough along to start causing symptoms of pelvic pressure, urinary frequency, feeling full after eating small quantities of food, and tummy enlargement from fluid in the abdomen and pelvis, it is almost always at least Stage lll and easily seen with a sonogram or CAT scan or MRI. The symptoms of early ovarian cancer are subtle and often misconstrued as bowel problems. They are sometimes called the ovarian cancer "whisper" because they aren't easily heard. Burping or excess flatulence more than half the time, should prompt a visit to be checked. Most gynecologists will perform a pelvic exam. I would suggest a transvaginal sonogram (TVU) to look for cysts and fluid. If there is fluid in the pelvis that can be sampled with a needle, the diagnosis can be made from finding ovarian cancer cells in the fluid. Usually the TVU is diagnostic at that point anyway and sampling the fluid is just confirming the diagnosis. Sadly, the TVU may not show anything worrisome in the earliest stages of ovarian cancer. Often patients with and without symptoms ask for a CA 125 blood test or the newer OVA1 test to look for cancer. These tests are not good for screening because of the high false positive rate. In my experience they often come back high when there is no obvious abnormality. Then what? The patient undergoes surgery because they get nervous. Hopefully the answer to the dilemma of diagnosing ovarian cancer is right around corner.

Another great question. It depends on the patient and her level of anxiety. Years ago I was uniformly aggressive in my recommendations. Having survived Stage lll breast cancer myself, I was fully in favor of bilateral mastectomies. As I have aged and met more patients I will share with you that my attitude is a little different. If the patient is not ready to have both her breasts removed then she should not be pressured to have mastectomies. With a combination of breast exams by professionals, MRIs, mammograms and sonograms, these patients can be followed closely until one of two things happens: the patient develops cancer and then the decision is not so much elective as therapeutic, or, if she cannot tolerate the stress of the vigilance and then is ready to undergo more definitive surgery to prevent cancer. In my 20+ year career as a physician, I have rarely met a patient who regretted having bilateral mastectomies, but many who regretted not doing so. As for the ovaries, I remain aggressive. If the patient has a high risk of cancer, I explain that vigilance is far from perfect and the hormonal function of the ovaries can be replaced a number of ways, but ovarian cancer is very difficult to cure. Another great question. It depends on the patient and her level of anxiety. Years ago I was uniformly aggressive in my recommendations. Having survived Stage lll breast cancer myself, I was fully in favor of bilateral mastectomies. As I have aged and met more patients I will share with you that my attitude is a little different. If the patient is not ready to have both her breasts removed then she should not be pressured to have mastectomies. With a combination of breast exams by professionals, MRIs, mammograms and sonograms, these patients can be followed closely until one of two things happens: the patient develops cancer and then the decision is not so much elective as therapeutic, or, if she cannot tolerate the stress of the vigilance and then is ready to undergo more definitive surgery to prevent cancer. In my 20+ year career as a physician, I have rarely met a patient who regretted having bilateral mastectomies, but many who regretted not doing so. As for the ovaries, I remain aggressive. If the patient has a high risk of cancer, I explain that vigilance is far from perfect and the hormonal function of the ovaries can be replaced a number of ways, but ovarian cancer is very difficult to cure.