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Saturday, May 15th

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Ovarian Cancer

Ovarian cancer is a disease in which malignant (cancerous) cells are found in the ovary. An ovary is one of two small, almond–shaped organs located on each side of the uterus that produce female hormones and store eggs or germ cells.

How prevalent is ovarian cancer?
Ovarian cancer is the fifth leading cause of new cancer cases, and accounts for 4 per cent of all cancers in women. In women age 35–74, ovarian cancer is the fourth leading cause of cancer related deaths. An estimated one woman of age 55 will develop ovarian cancer during her lifetime. No reliable statistics is available for India, however, the American Cancer Society estimates that each year approximately 25,500 new cases of ovarian cancer are diagnosed and 14,500 women die of ovarian cancer.

What is the general outlook for women diagnosed with ovarian cancer?
Because each woman diagnosed with ovarian cancer has a different profile, it is impossible to give a general prognosis. If diagnosed and treated early, when the cancer is confined to the ovary, the 5–year survival rate approaches 93% (78–98% depending upon tumor type, stage, and grade). Unfortunately, due to ovarian cancer’s “Quiet” symptoms, only 24% of all cases are found at this early stage. Because many ovarian cancers are not detected early, the overall 5–year survival rate for women with ovarian cancer is only between 35% and 47%, depending upon the type of tumor.

Risk Factors of Ovarian cancer
Probably the highest risk is in women who have a strong family history of it. There are some genetically–inherited patterns of disease with mutations involving two specific chromosomes – numbers 13 and 17. These are related to two specifically described syndromes, called BRCA2, for No. 13, and BRCA1 for No. 17.

These genes are primarily related to breast cancer, but also are associated with increased risk of ovarian cancer. Currently, many women are considered to be at risk who have certain life style characteristics, such as never having or had children, never using birth control pills.

The highest incidence is in the post–menopausal age group, with the peak being in women in their late fifties and in older women. In fact, many of these risk factors are similar to those found in persons at higher risk of breast cancer.

Ways to detect ovarian cancer in its early stages
There are tests that can be performed, including ultrasound, blood tests such as the CA–125 test, and advanced imaging tests, such as PET–scan, MRI (magnetic resonance imaging) and CT–scan.

Truthfully, though, while these tests may be practical to perform in women at high risk, there is no cost–effective way for testing the average woman. This is a problem for our population to face. The tests mentioned can be quite expensive.

There are the obvious direct costs, of course, but also hidden costs resulting from, for example, the impact of falsely abnormal results, which can lead to unnecessary additional tests, even to unnecessary surgery. Applied to the general population, the net effect is that routine screening for this disease is not recommended at this time.

Different kinds of ovarian cancer
The most common type is epithelial, that is, involves the surface cells of the ovary. The ovary also contains other types of cells, resulting in the fact that the ovaries are capable of developing many kinds of malignancies, including lymphomas and other types of odd tumors. The most common, however, is epithelial, followed by germ cell and then what are termed stromal tumors.

Treatment is available for ovarian cancer?
There are two general approaches. One is surgery followed by chemotherapy, and the other is what we call neo–adjuvant chemotherapy. In this treatment plan, chemotherapy is administered first, followed by surgery if indicated.

There are differences of opinion about which treatment is best. Traditionally, we have felt that surgery should be performed prior to initiation of chemotherapy, for two reasons. First, it reduces the size or bulk of the tumor and improves the patient’s symptoms relatively quickly. Second, it clearly establishes the diagnosis. This means that having the tissue in hand enables us to determine exactly what type of ovarian cells are involved, also that the cancer did not in fact arise in some other part of the abdomen – for example the intestine. On the other hand, there are published reports showing that people also respond very well to neo–adjuvant chemotherapy. When the surgery follows the chemotherapy, it enables us to determine how well the patient has responded to the therapy, also to re–sect or remove whatever residual cancer may be present.

Surgery alone is successful only in patients who have very, very early cancers, what is called Stage I. These are confined to the ovary as confirmed by surgical samples. Radiation therapy is useful in some cases, but is used less in this country than some other places.

Ovarian cancer is said to occur mostly in menopausal women, can it happen earlier?
Yes. It can happen in pre–menopausal women, but less frequently. Most of the women are likely to be in their forties, although we certainly have seen it much earlier. Some of the non–epithelial tumors can occur in very young girls, in the 7 to 11 age group. So, unfortunately, it can happen in all age groups.

What can a woman do to lessen the chance of getting ovarian cancer?
There is evidence that being on oral contraceptives provides some degree of protection against developing ovarian cancer. This appears to be related to their duration of use. In addition, women who are thought to be at high risk should not delay child–bearing.

In some instances, for persons who are at very high risk, we discuss the possibility of prophylactic oophorectomy, that is, removing the ovaries as a preventive measure. Clearly, that involves an operation and renders that person menopausal, and is usually reserved for individuals at high risk who have completed childbearing.

Although the operation will prevent ovarian cancer from developing, it cannot prevent the possible occurrence of what is called primary peritoneal cancer, which some of these women are at risk for as well. The cells lining the abdominal cavity are the same kind of cell that lines the ovary and may also become cancerous. Fortunately this is rare. So, oophorectomy offers significant protection, but the outcome cannot be guaranteed.


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