Ovarian Cancer

Definition | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Ovarian cancer is a malignant tumour that arises from the cells of the ovaries. It is the fifth most common cancer in women in the UK and is often diagnosed at a late stage due to its subtle and non-specific symptoms.

Aetiology

Ovarian cancer can develop from different types of cells within the ovary, leading to various subtypes. The most common types are:

• Epithelial Ovarian Cancer: The most common type, originating from the surface epithelium of the ovary. It includes subtypes such as serous, endometrioid, and mucinous carcinomas.
• Germ Cell Tumours: Rare and typically affect younger women. They arise from the cells that produce eggs.
• Stromal Tumours: Also rare, these arise from the connective tissue cells that hold the ovary together and produce hormones.

Risk Factors

Several factors can increase the risk of developing ovarian cancer:

• Age: Most cases occur in women over the age of 50, with the highest risk in those over 65.
• Family History: A family history of ovarian, breast, or colorectal cancer increases the risk, particularly with BRCA1 or BRCA2 gene mutations.
• Genetic Mutations: Inherited mutations in BRCA1 and BRCA2 genes significantly increase the risk of ovarian cancer.
• Reproductive History: Women who have never been pregnant or had their first pregnancy after age 35 have a higher risk.
• Hormone Replacement Therapy (HRT): Long-term use of HRT may slightly increase the risk.
• Endometriosis: Women with endometriosis have an increased risk of developing certain types of ovarian cancer.
• Obesity: Higher body mass index (BMI) has been associated with an increased risk of ovarian cancer.

Clinical Presentation

Ovarian cancer is often called the "silent killer" because its symptoms are vague and can be easily attributed to other conditions. Common symptoms include:

• Abdominal Bloating: Persistent bloating that does not come and go.
• Pelvic or Abdominal Pain: Persistent pain in the lower abdomen or pelvis.
• Difficulty Eating or Feeling Full Quickly: A common symptom, particularly in advanced stages.
• Urinary Symptoms: Urgency or frequency, often mistaken for a urinary tract infection (UTI).
• Unexplained Weight Loss: Particularly if accompanied by other symptoms.
• Fatigue: Persistent and unexplained tiredness.
• Changes in Bowel Habits: Such as constipation or diarrhoea, particularly if persistent.
• Postmenopausal Bleeding: Although rare, any vaginal bleeding after menopause should be investigated.

Investigations

If ovarian cancer is suspected, the following investigations are typically performed:

• CA125 Blood Test: A blood test measuring the level of CA125, a protein that can be elevated in ovarian cancer. However, it is not specific and can be raised in other conditions.
• Pelvic Ultrasound: The first-line imaging test to assess the ovaries and identify any masses or abnormalities.
• Transvaginal Ultrasound (TVUS): Provides a more detailed view of the ovaries and is often used alongside a pelvic ultrasound.
• CT Scan or MRI: Used to assess the extent of the disease if a mass is detected and to help plan treatment.
• Biopsy: In some cases, a biopsy may be performed to confirm the diagnosis, although surgery is often required for definitive diagnosis and staging.
• Genetic Testing: Recommended for women with a strong family history of ovarian or breast cancer, or those diagnosed at a young age, to identify BRCA mutations.

Management

The treatment of ovarian cancer depends on the stage at diagnosis, the type of cancer, and the patient’s overall health:

Primary Care Management

As a Physician Associate, your role includes recognising the early signs and symptoms of ovarian cancer and facilitating timely referral to secondary care. Educating patients on the importance of reporting persistent, unexplained symptoms is also crucial.

Secondary Care Management

Treatment in secondary care typically involves a combination of the following:

• Surgery:
  • Debulking Surgery: The goal is to remove as much of the tumour as possible, which may involve removing the ovaries, fallopian tubes, uterus, and surrounding tissues.
  • Oophorectomy: Removal of one or both ovaries, depending on the extent of the disease.
• Chemotherapy: Often given after surgery (adjuvant chemotherapy) to kill any remaining cancer cells. In some cases, chemotherapy may be given before surgery (neoadjuvant chemotherapy) to shrink the tumour.
• Targeted Therapy: Drugs like PARP inhibitors (e.g., olaparib) are used in patients with BRCA mutations or recurrent ovarian cancer.
• Radiotherapy: Not commonly used for ovarian cancer but may be considered in certain cases, particularly for palliative care.
• Hormone Therapy: May be used in certain types of ovarian cancer, such as those that are oestrogen receptor-positive.
• Follow-Up Care: Regular monitoring and follow-up are essential to detect any recurrence early.

When to Refer

Urgent referral to a gynaecologist or oncologist is warranted in the following situations:

• Persistent symptoms such as bloating, pelvic pain, or urinary changes that are unexplained by other conditions.
• An elevated CA125 level, particularly if accompanied by symptoms or abnormal findings on ultrasound.
• A suspicious mass detected on pelvic or transvaginal ultrasound.
• Patients with a strong family history of ovarian or breast cancer, particularly those with known BRCA mutations.

References

1. NHS (2024) Ovarian Cancer. Available at: https://www.nhs.uk/conditions/ovarian-cancer/ (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Ovarian Cancer: Recognition and Initial Management. Available at: https://www.nice.org.uk/guidance/cg122 (Accessed: 26 August 2024).
3. British Medical Journal (2024) Ovarian Cancer: Diagnosis and Management. Available at: https://www.bmj.com/content/359/bmj.j3770 (Accessed: 26 August 2024).
4. Target Ovarian Cancer (2024) Ovarian Cancer Information and Support. Available at: https://www.targetovariancancer.org.uk/ (Accessed: 26 August 2024).

Back to Top