In the 1980’s, a large study was performed to identify the pathologic findings that truly influenced the risk of recurrence and the overall survival in endometrial cancer. Some easily determined uterine and extra-uterine factors were identified including the cell type, tumor grade, depth of invasion of the uterine muscle (myometrial invasion), metastases to the pelvic and para-aortic lymph nodes, and metastases to the fallopian tubes and ovaries. These findings ushered in the era of “surgical staging” of endometrial cancer, which had previously been staged by physical examination alone. Complete surgical staging requires a careful exploration of the abdomen and pelvis, a total hysterectomy, removal of both tubes and ovaries, and selective biopsy of the pelvic and para-aortic lymph nodes.

At the time, the only available mode of surgery to accomplish this staging was traditional open surgery (laparotomy). However, in the 1990’s improvements in laparoscopic equipment made it feasible to perform comprehensive staging without the large incision required for a laparotomy. Laparoscopic procedures (sometimes referred to as “keyhole” surgery) allow the surgeon to access the abdomen and pelvis through small incisions (usually 5-10 mm in diameter each). Because the uterus, cervix, tubes and ovaries can be removed through the vagina, there is no need for a larger incision. The first minimally invasive surgery to comprehensively stage endometrial cancer was a laparoscopic-assisted vaginal hysterectomy with removal of the tubes and ovaries and laparoscopic nodal sampling. Techniques for total laparoscopic hysterectomy and staging quickly followed. Presently, approximately 60% of endometrial cancers in the United States are managed via minimally invasive surgery, many utilizing robotic-assisted laparoscopy. Laparoscopy has been proven superior to laparotomy with regard to postoperative pain and recovery time in a number of clinical scenarios including endometrial cancer staging. The three to four day hospital stay following a laparotomy is typically reduced to one postoperative day for women that undergo minimally invasive staging. More importantly, the typical 6 week home recovery for laparotomy is routinely shortened to approximately 2 weeks for laparoscopy. Many studies have proven the equivalence of laparotomy and laparoscopy with regard to the risk of recurrence and survival in patients with endometrial cancer.

There is some controversy among oncologists regarding this point, but in general all patients with high grade (grade 3) serous stage I ovarian cancer are administered chemotherapy, Some, but certainly not all, oncologists would also recommend the administration of chemotherapy for moderately well-differentiated (grade 2) serous ovarian cancer. In addition, in the setting where comprehensive surgical staging has not been performed, most oncologists would recommend that adjuvant chemotherapy be administered.

Many risk factors have been associated with an increased prevalence of ovarian cancer. Risks include a personal history of disease, family history, genetics, age, and reproductive factors.

Parity is another risk factor as nulliparous women have an increased risk of being diagnosed with ovarian cancer (2). Conversely, women who have given birth have a lower chance of developing ovarian cancer; in general, the lifetime risk of developing ovarian cancer decreases with each live birth (2). Lastly, nutrition plays a role, as a diet high in saturated fat and meat is associated with an increased risk of ovarian cancer. Factors associated with a decrease in risk include higher parity, use of oral contraception, and gynecologic procedures such as hysterectomy and tubal ligation (4). In fact, oral contraceptive use is one of the most significant methods for decreasing the risk of ovarian cancer.

The most important risk factor is a family history of breast or ovarian cancer. Women who have had breast cancer are at greater risk of developing ovarian cancer. The risk of ovarian cancer after breast cancer is highest in women who have a family history of breast cancer. In contrast to the 1.8% general population at risk for ovarian cancer, a family history of ovarian cancer in a first-degree relative (mother, daughter, sister) triples a woman’s lifetime risk of developing ovarian cancer (2). The risks further increase with two or more afflicted first-degree relatives (~7%). Up to 10% of ovarian cancers result from an inherited tendency to develop the disease. While 90% of diagnosed epithelial ovarian cancers occur sporadically, 10% are associated with the inheritance of an autosomal dominant genetic aberration (3). Women who have inherited high-penetrance cancer susceptibility genes, such as mutated BRCA1 or BRCA2 genes or those constituents of Lynch syndrome (hereditary nonpolyposis colorectal cancer, HNPCC), are at a greatly increased risk of developing ovarian cancer. Women who have had breast cancer are at greater risk of developing ovarian cancer. Women who have inherited high-penetrance cancer susceptibility genes, such as mutated BRCA1 or BRCA2 genes are at a greatly increased risk of developing ovarian cancer. A woman with BRCA1 mutation has a lifetime risk of 39% to 70 % of developing ovarian cancer and a risk of 11 to 25% for BRCA2 carriers (1). The NIH consensus statement concluded that women at increased risk should have at least an annual comprehensive gynecological examination (pelvic and rectovaginal), serum marker CA125, and transvaginal/abdominal ultrasound, despite the lack of data supporting the use of these measures for ovarian cancer screening (5). To reduce the morbidity and mortality from ovarian cancer one must identify early rather than advanced stage disease.

(1) Rock JA, Jones III HW. TeLinde’s operative gynecology. 10th ed. 2008. Philidephia, Pa. Lippincott Williams & Wilkins. Pp 1307-1312

(2) Schorge JO, Modesitt SC, Coleman RL, Cohn DE, Kauff ND, Duska LR, Herzog TJ. SGO White Paper on ovarian cancer: etiology, screening and surveillance. Gynecol Oncol. 2010; 119(1) 7-17

(3) Clarke-Pearson DL. Screening for ovarian cancer. N Engl J Med. 2009l 361(2): 170-177

(4) Rein BJD, Gupta S, Dada R, Safi J, Michener C, Argawal A. (Review Article) Potential markers for detection and monitoring of ovarian cancer. Journal of oncology. Vol 2011

(5) Ovarian Cancer: Screening, Treatment, and Followup. NIH Consensus Statement 1994 April 5-7;12(3):30

Common symptoms in patients with ovarian cancer include new changes in bowel or bladder function, bloating, early fullness after eating, and/or abdominal pain. A workup for diagnosis of ovarian cancer should begin with complete physical exam including a pelvic and rectal exam and likely some type of imaging. Pelvic ultrasound is a not reliable method for screening asymptomatic women but should be considered in women with symptoms or women in whom a mass is found on exam. At times, CT scans to evaluate the entire abdomimal cavity will lead to a higher suspicion for cancer and recommendations for surgical recommendation.

Definitive diagnosis of ovarian or tubal cancer generally involves the removal of at least one ovary so that pathology can be determined. This can be done at surgery and often a rapid interpretation is provided by pathology to the surgeon during the surgery. If cancer is found, the standard staging surgery by a gynecologic oncologist or surgeon trained in staging would include removal of both tubes and ovaries, hysterectomy, omentectomy, lymph node dissection and biopsies. Select young women of childbearing age and certain tumor types may be candidates for fertility preserving surgery.

Yes the risk for ovarian cancer is 40% for a BRCA1 mutation and 20% for a BRCA2 mutation.

Women who are diagnosed with early-stage ovarian cancer (Stages I to II) have five-year survival rates that range from 57% to 90% (1). In contrast, the five-year survival rates for patients who are diagnosed with advanced stage disease range from 18% to 45% (1). Despite advances in surgery and platinum based chemotherapy the mortality rates of individuals with ovarian cancer remain poor. In the past 40 years, the median five-year survival rate for women with advanced-stage cancer has increased from 37% to 46% (2,3).

(1) American Cancer Society: Ovarian Cancer. Atlanta, American Cancer Society. Date last modified: 10/13/2010. Available at:http://www.cancer.org/cancer/ovariancancer/detailedguide/ovarian-cancer-survival-rates. Accessed: 06/06/2011

(2) peer review paper -http://www.cancer.org/cancer/ovariancancer/detailedguide/ovarian-cancer-survival-rates

(3) Schorge JO, Modesitt SC, Coleman RL, Cohn DE, Kauff ND, Duska LR, Herzog TJ. SGO White Paper on ovarian cancer: etiology, screening and surveillance. Gynecol Oncol. 2010; 119(1) 7-17

Pelvic examination, transvaginal ultrasound, and serum CA125 level is the current the standard in screening for ovarian cancer. As this multimodal method is not without flaws, efforts are underway to strengthen its screening ability, or find better methods altogether.

Clinically CA-125 is useful to follow women diagnosed with ovarian cancer for prognosis, surveillance, and optimization of care.

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.

Unfortunately, the majority of ovarian carcinoma cases are diagnosed at advanced stages (Stages III and IV), when the disease has already metastasized to the peritoneal cavity or other surrounding organs, such as the liver or lungs (1). Less than 20% of ovarian cancers are detected when the cancer is still confined to the ovary (Stage I).

(1) National Cancer Society: Cancer Facts & Figures 2010. Atlanta, American Cancer Society; 2010.