Ovarian Cancer

Ovarian cancer is a type of cancer that starts in the ovaries. More than 22,000 people in the United States are diagnosed with ovarian cancer each year.

The ovaries are part of the reproductive system. The female reproductive system usually has 2 ovaries, one on each side of the uterus. Each ovary is about the size of a walnut and has 3 parts:

  • The epithelium covers the surface of the ovary and protects it.
  • Germ cells produce the egg that is released each month. The egg travels through the fallopian tubes into the uterus. When fertilized, it can result in pregnancy.
  • Sex cord-stromal cells produce sex hormones, such as estrogen.

If a cancer starts to grow in the epithelial cells of the ovaries, it is called epithelial ovarian cancer. Most cases of ovarian cancers — about 9 out of 10 — start in these cells.

Another part of the body near the ovaries and fallopian tubes is the peritoneum. This is a thin layer of tissue that lines the abdominal cavity. It also lines some of the organs in the abdomen and pelvis. The cells of the peritoneum, fallopian tubes, and epithelium are all related and similar in appearance.

Because their cells are so similar, fallopian tube cancer and peritoneal cancer are treated the same ways as epithelial ovarian cancer. You can develop peritoneal or fallopian tube cancer even if you have had your ovaries removed.

Ovarian cancer is a broad term that sometimes includes epithelial ovarian, fallopian tube, and peritoneal cancers. All 3 of these cancers are thought about and treated the same way.

Find information on other types of ovarian cancer. 

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Risk Factors

Studies have found that these factors increase risk for ovarian cancer:

  • Age: Risk increases as you get older
  • Weight: Having had obesity in early adulthood increases your risk
  • Ethnicity: Risk is higher among North American, Northern European, and Ashkenazi-Jewish people
  • Having endometriosis
  • Not having a child until age 35, not being able to have a child, or never having a child
  • Having a history of ovarian, breast, or colorectal cancer on either side of the family
  • Having had breast cancer

 

Signs & Symptoms

There are several signs and symptoms of ovarian cancer. They are often overlooked because they may not seem like a big deal and can be caused by other health problems. They include:

  • Bloating
  • Pelvic or abdominal (belly) pain
  • Trouble eating or feeling full quickly
  • Feeling like you have to urinate (pee) right away or often
  • Change in type or timing of your bowel movements

You should see a doctor if these symptoms:

  • Are new or unusual
  • Last for more than two weeks
  • Occur often (more than 12 times a month)
  • Are severe 
  • Don’t respond to anything you would normally do to treat them, like changing your diet, getting more exercise, or resting

 

Screening

There are currently no approved blood tests or scans used to screen for ovarian cancer in people at average risk for it.

Some people are at high risk for ovarian cancer because they have a family history of ovarian cancer or have higher risk based on genetics. Doctors may recommend that these people have regular CA-125 blood tests and/or transvaginal ultrasounds. However, surgery to remove the ovaries and fallopian tubes before cancer has been detected has been the only method shown to reduce the risk of death.
 

Learn More About Ovarian Cancer

Our booklet on ovarian cancer explains how the cancer is diagnosed and the ways in which it is treated. It also lists resources that can help you and your loved ones.

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Diagnosis and Staging

Diagnosis

If you have signs or symptoms of ovarian cancer, your doctor may do a:

Pelvic and rectal exam: During this exam, the doctor inserts fingers into the vagina and rectum to check the pelvis. This is done to see if your ovaries are larger than normal.

Transvaginal or pelvic ultrasound (sonogram): Your doctor inserts a small ultrasound wand into the vagina to help them see the ovaries, fallopian tubes, and uterus.

CA-125 blood test: Ovarian cancer cells produce a protein called CA-125. Levels are sometimes higher than normal in people with ovarian cancer. CA-125 is not a perfect test and can be falsely elevated even if you do not have ovarian cancer.

CT scan: For this test, you lie on a bed that moves through an x-ray tube to take pictures of your internal organs. The test may use a contrast dye. Let your doctor know if you have had an allergic reaction to contrast dye in the past.

If your doctor thinks you have ovarian cancer based on your symptoms, exam, scans, or ultrasound, you should ask for a referral to a gynecologic oncologist. This type of doctor specializes in the diagnosis and treatment of cancers that occur in the ovaries or other female reproductive organs. Any surgery to look for ovarian cancer should be done by a gynecologic oncologist. Studies have found that ovarian cancer patients are more likely to have a better outcome if their surgery is done by this kind of doctor.

The only way to know if you do or do not have ovarian cancer is for a doctor to perform surgery or take a biopsy (a sample) of the tissue. The sample is then sent to a pathologist, a doctor who is an expert at studying cells. They will determine if it is ovarian cancer.

Staging & Types of Ovarian Cancer

You will need to have surgery to learn your cancer’s stage. During surgery, the gynecologic oncologist will remove as much of your cancer as possible along with any organs the cancer has spread to. This is called debulking. 

The stage is a measure of how far the cancer has spread. These are the stages of ovarian cancer:

Stage I (1): Cancer cells are found only in one or both ovaries.

Stage II (2): The cancer has spread to another area of the pelvis but has not spread to the abdomen.

Stage III (3): The cancer has spread to the lining of the abdomen or lymph nodes.

Stage IV (4): The cancer has spread beyond the abdomen to organs such as the lungs or liver.

 

There are 3 grades of ovarian cancer: Grade 1, Grade 2, and Grade 3. The grade explains how fast the cells are growing. The lower the grade, the slower the growth. Low-grade serous epithelial cancer tends to be diagnosed in younger women and is slower growing. It is most often treated with surgery and often chemotherapy and/or hormone therapy. High-grade ovarian cancer is most often treated with surgery followed by chemotherapy.

High-grade serous adenocarcinoma is the most common type of epithelial ovarian cancer. It is seen in 7 out of every 10 people with epithelial ovarian cancer. The treatment section below focuses on high-grade serous ovarian cancer.

 

Treatment Planning

Treatment options will depend on:

  • The type of ovarian cancer you have
  • The stage of the cancer
  • Your general health
  • If you inherited a genetic mutation
  • If your tumor has certain biomarkers that make it likely to respond to certain treatments.

As you plan your treatment, 2 things you will want to consider are:

  • What is the goal of each treatment? This may be a cure, or it may be treatment to help you live longer with a good quality of life.
  • What are the side effects of each treatment? Ask how side effects may affect your quality of life. Find out what you and your health care team can do to help you manage them.

Get more details about cancer treatment side effects and how to manage them.

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Genetic and Biomarker Subtypes

Once you have been diagnosed, your doctor will do 2 other tests to see what treatments will work best for you.

Genetic Tests for Hereditary Cancer: Testing Your Genes

Everyone diagnosed with ovarian cancer should receive genetic counseling and be offered genetic testing. Ideally, this would be done before you complete chemotherapy.

A genetic test looks at your blood or saliva. It can show if you inherited a mutation (a change in your genes) that increases your risk for ovarian cancer. About 1 in 10 people who are diagnosed with ovarian cancer were born with a hereditary cancer mutation. This type of mutation can also be passed on to children. This type of testing can be called genetic testing, germline testing, or testing for hereditary cancer.

The most common inherited mutation tied to ovarian cancer occurs in the BRCA genes. People who inherit a BRCA1 (breast cancer gene 1) or BRCA2 (breast cancer gene 2) mutation are at increased risk for both breast and ovarian cancer. In a group of 100 people with ovarian cancer, 10 to 15 people are likely to have a BRCA1 or BRCA2 mutation.

Your health care team may test you for only BRCA mutations. Or they may do a genetic test that also looks for other inherited mutations. A genetic counselor can review your family cancer history to help you decide which inherited mutations you should be tested for. They can also help you understand the results. These mutations could include:

  • BRCA1 and BRCA2
  • BRIP1
  • RAD51C
  • RAD51D
  • BARD1
  • STK11
  • Genes linked to Lynch syndrome (MLH1, MSH2, MSH6, PMS2) or other family cancer syndromes

 

Talking to a genetic counselor before testing can help you understand your genetic testing options. Talking to one after testing can help you understand your results. If you have ovarian cancer, genetic testing is considered medically necessary and is covered by insurance. Knowing whether you have an inherited genetic mutation is important.

Genetic testing will help your doctor know what treatments will work best for you. It will also let you know if you are at higher risk for any other cancers and if you should talk to family members about genetic counseling and testing.

 

Biomarker Testing: Testing Your Tumor

Your doctor may also test your tumor. This can be called biomarker testing, tumor profiling, molecular testing, somatic testing, or genomic testing. Testing your tumor helps your doctor understand what is making the cancer grow and spread.

Testing your tumor for these biomarkers may help your doctor decide which treatment is right for you or if there is a clinical trial for you to consider. These tests can include:

  • BRCA: Even if you are not born with a BRCA mutation, your cancer cells may develop one. So, even if your genetic tests showed you did not inherit a BRCA1 or BRCA2 mutation, your doctor will want to test your tumor for them. Testing positive may mean a treatment called a PARP inhibitor may work for you after chemotherapy.
  • HRD (Homologous recombination deficiency): If you test positive for HRD or LOH (loss of heterozygosity), a PARP inhibitor may be a treatment option.
  • MSI-high or dMMR: If your tumor tests MSI-high (MicroSatellite Instability-High) or dMMR (deficient MisMatch Repair), immunotherapy may be a treatment option.

Testing for multiple biomarkers is sometimes called comprehensive biomarker testing, next generation sequencing, second generation sequencing, or massively parallel sequencing. There are many different companies that offer this kind of testing. Your doctor may recommend a specific company or test. The cost of these biomarker tests varies based on the type of insurance you have. Some companies offer financial assistance or payment plans.

Preparing for Your Doctor’s Visit

If you have ovarian cancer, this worksheet can help you talk with your health care team about treatment options, side effects, and more.

A doctor and a patient

Treatment and Side Effects

Try to prepare in advance for each doctor’s visit. Write down a list of questions before any appointment. This can help you feel more organized and comfortable in talking to and working with your health care team.

You do not have to rush to decide about your treatment. Ask questions if you do not understand anything about your treatment or the terms your doctors are using. Bring someone along for support or to take notes. Also, consider asking if you can record your conversations with your doctor. It’s a lot of information to take in at one time. Having the recording will allow you to re-listen to the conversation as you consider your options. You may also want to talk to an oncology nurse. The nurse can help you understand your options and may have more time to talk through questions than your doctor does.

Get Help Preparing for Treatment Decisions

Open to Options is a decision support counseling program that can help you prepare for an appointment in which you will be making a treatment decision.

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Review Your Treatment Options

There are several approaches to treating ovarian cancer. Surgery and chemotherapy are the main treatments.

Surgery is one of the main treatments for ovarian cancer. During surgery, the gynecologic oncologist will remove as much of your cancer as possible. This is called debulking. One or both of your ovaries, fallopian tubes, uterus/cervix, the omentum (an organ in the abdomen), biopsies of the peritoneum, and possibly some of the nearby lymph nodes will be removed. If the cancer has spread, other organs may also need to be removed. These could include parts of your bowel, spleen, liver, or — less likely — gallbladder, or parts of your stomach or bladder.

Any surgery to look for ovarian cancer should be done by a gynecologic oncologist. If you do not have one in your town or city, consider traveling to a major medical center that does. The gynecologic oncologist who does the surgery can refer you to a local doctor for the rest of your treatment.

Learn more about surgery

Chemotherapy is the other main treatment for ovarian cancer. These drugs work by killing all fast-growing cells in your body. It may be given before or after surgery. Studies have found that overall survival may be the same whether the first treatment is chemotherapy or surgery. Your doctors will talk to you about which treatment approach they think is best for you.

Chemotherapy is typically given in cycles of about 2-4 weeks. Giving the treatment in cycles gives your body time to recover. It is typically given intravenously (using an IV). This can be through a vein in your arm or through a port, which is an IV placed under your skin in your upper chest. The port can be removed when it is no longer needed. Some chemotherapy drugs can also be given directly into the abdomen. This is called intraperitoneal chemotherapy. For this treatment, a thin tube, or catheter, will be used to put the chemotherapy into the tissue that lines the abdomen.

For most patients, their first chemotherapy treatment will be a platinum drug plus a taxane.

View chemotherapy treatment options

Targeted therapy “targets” a specific change in some cancers that help them grow, divide, and spread. Doctors decide to use it based on the findings of biomarker tests.

View targeted therapy treatment options

Immunotherapy uses the body’s natural defenses to identify, attack, and kill cancer cells. It may be an option if you have certain biomarkers.

View immunotherapy treatment options

Clinical trials are research studies to test new treatments or learn how to use existing treatments better. Many trials focus on advanced ovarian cancer. However, there are also trials to improve early diagnosis, stop the cancer from coming back, reduce side effects, or improve quality of life.

Learn more about clinical trials

 

Monitoring for Recurrence

Your doctors will monitor you closely after your finish treatment. You may have a CA-125 blood test if your test was higher than normal when you started treatment. If needed, your doctor may also have to come in for scans. These scans can see if the cancer has come back or is no longer being controlled by the treatment you are on.

  • If the cancer comes back in less than 6 months, your cancer is platinum-resistant. This means you will probably not be treated with any other platinum therapies. 
  • If the cancer comes back in more than 6 months, your cancer is platinum-sensitive. This means you are likely to be treated again with platinum-containing therapies.

 

Maintenance Therapy

After you complete your chemotherapy treatment, your doctor may recommend maintenance therapy. Maintenance therapy is used to stop or slow your cancer’s growth or to prevent it from coming back. Chemotherapy and targeted therapy can be used as maintenance therapy to treat ovarian cancer.

 

Side Effects

Ovarian cancer and its treatments can cause a range of side effects. The most common include hair loss, nausea and vomiting, bone marrow suppression (such as anemia, weakened immune system, or risk of bleeding), nerve pain (neuropathy), fatigue, diarrhea or constipation, swelling of limbs (lymphedema), and difficulty with sex and intimacy.

Before your treatment begins, talk to your doctor about the types of side effects that you may experience and how you can manage them. You can also ask your doctor for a referral to a palliative care specialist at any point. Palliative care can address side effects from treatments.

Coping With Ovarian Cancer

The more you know about your ovarian cancer diagnosis, treatment options, and possible side effects, the easier it will be to talk with your health care team to determine the best treatment plan for you. Ovarian cancer can affect all areas of your life. These resources can help:

Getting Support

Cancer stirs up many feelings. It affects you, your family, and your loved ones. It is normal to feel sad, anxious, worried, shocked, stressed, or panicked. Remember that cancer can affect anyone, and every person who has cancer deserves good care and support.

 

Tips for Coping

  • Ask your health care team questions. Keep asking questions if there is something you don’t understand.
  • Know what signs or symptoms you should tell your care team about right away.
  • Control what you can. If you smoke, get help to stop. Find out what type of exercise you can do and how often. Eat healthy foods and try to maintain a healthy weight.
  • Know that you will be more anxious when it gets close to a doctor’s appointment. Be gentle with yourself when you are feeling stressed.

 

Find the Support You Need

  • Share your feelings with friends, family members, a counselor, or a clergyperson or spiritual advisor.
  • A counselor or therapist can help you with anxiety. Other things that can help are yoga, breathing, and relaxation exercises.
  • Ask for help from friends and your community, or ask your caregiver to do so. MyLifeLine — a free service offered by the Cancer Support Community — is a great way to coordinate an online helping network among your friends and family.
  • Contact the patient groups in our booklet to find local and online support groups, helplines, and other ways to get support from others facing ovarian cancer.
  • Ask your health care team about resources for social, emotional, and practical support.
  • If you search for information online, make sure you are using trusted websites. The back page of our booklet lists trusted patient groups.

What's New in Ovarian Cancer

In this episode of Frankly Speaking About Cancer, Dr. Nita Lee discusses the progress that's been made to improve treatment options and survival for women living with ovarian cancer.

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Talking About Ovarian Cancer

When discussing ovarian cancer, there are some helpful terms to know. These are:

  • CA-125: Ovarian cancer cells may produce a protein called CA-125. The CA-125 test can help show if the tumor is responding to treatment or if cancer has come back.
  • Genetic Testing: This test uses blood or saliva to look at your DNA. This can show if you inherited a mutation (a change in your genes). Mutations may increase your risk for ovarian or other cancers.
  • Biomarker Tumor Testing: This test looks at a tumor’s cells to see if there are mutations. This test can provide information about which treatments may work best for you.
  • Gynecologic Oncologist: This doctor treats cancers with medicine and surgery. They focus on cancers that start in female reproductive organs.
  • Medical Oncologist: This doctor treats cancers with medicine.
  • Platinum Sensitive or Resistant: Platinum drugs are a type of chemotherapy. If ovarian cancer comes back less than 6 months after a platinum treatment, it is platinum resistant. If it comes back more than 6 months later, it’s platinum sensitive.

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