Ovaries are the small, ovoid structures on either side of the uterus. Whenever we talk about cancers in women, we must be aware of masses or tumours – benign and malignant, of the ovaries. Although cancers of the ovary are the fifth most common cancer in women after breast, colorectal, lung and uterus; they are the most common cause of death in women due to cancer. Women with ovarian cancer have the least 5 year survival rate as compared to all other cancers. This is because cancer of the ovaries is a ‘silent killer’ – 70% of ovarian cancer is diagnosed in advanced stages, which means that the disease is already widely spread in the abdomen by the time it is diagnosed.
Treatment at that late stage cannot cure but can simply help at improving the Quality of Life (QoL) parameters. The scenario is so alarming that any mass or tumour in the ovaries brings on fear and a panicky tendency to operate on all such patients. The patients themselves are frightened about any ovarian enlargement or mass. This may lead to excessive and unnecessary surgery in patients with benign disease and less than recommended surgery in those with ovarian cancer. With better knowledge about ovarian tumours available in the recent past, algorithms and protocols have been set in place which help decrease errors in management. It is important to understand and know your ovaries so that you can participate in the decision making process with your gynaecologist.
Every year 220,000 women develop epithelial ovarian cancer (the most common type of ovarian cancer) worldwide. However, its important to know these facts – the lifetime risk of developing ovarian cancer is 1 in 60; 90% of ovarian cancers occur in women more than 45 years; the highest chance of getting ovarian cancer is after the age of menopause; the highest risk, among women in menopause, is between 60-64 years. With this data, its clear that in a young, pre-menopausal woman, its less likely that the tumour or mass detected in her ovary is cancer. In fact, in premenopausal women, almost all ovarian masses are benign. This is the first take-home message.
One must consider factors which indicate high risk for ovarian cancer as well as those favourable factors in women which make risk of ovarian cancer low. An important factor is age. Younger women, less than 40 years, are less likely to get cancer of the ovaries and if they do, survival rates are better than older women: 93% vs 31% at 1 year and 84% vs 14 % at 5 years. Epidemiological studies have shown that the risk of ovarian cancer is reduced by states in which ovulation or release of egg does not occur. This means that pregnancy and the use of oral contraception pills are protective, and prevent development of ovarian cancer. Ovarian cancer is also known to be decreased in women who have had sterilization procedures because of absence of menstrual products regurgitating backwards on the ovary. Processes in which egg formation is stimulated in larger than normal numbers, as in IVF (Test Tube Baby), have been implicated, though not proven, for increased risk of ovarian cancer. Endometriosis and the common hormonal syndrome, PCOS, have also been linked with ovarian cancer. Many ovarian cancers are hereditary and 3 main hereditary types have been identified – ovarian cancer alone; ovarian and breast cancer; and ovarian and colon (large intestine) cancer. The most important risk factor for ovarian cancer is Family History of ovarian cancer in a first degree relative (mother, daughter, sister). The highest risk is if 2 or more first degree relatives have ovarian cancer. The risk is less if 1 first degree relative and 1 second degree relative (grandmother or aunt) has ovarian cancer. All women simply must know whether there is history of cancer in the female members of her family – breast, ovarian or colon and even history of cancers in male members of her family – male breast, colon, prostate. A family history of cancer, especially certain cancers, puts a woman at higher risk for ovarian cancer which then requires higher alertness. This is the second take home message.
In the younger, pre-menopausal age group, most ovarian masses are cysts. A cyst is defined as a fluid filled structure less than 30 mm. The incidence of symptomatic ovarian cysts being malignant is 1 in 1000 in premenopausal women and the risk of malignancy increases to 3 in 1000 women after menopause. Estimating which cyst is benign or malignant can be problematic without doing surgery, however most ‘simple’ cysts are benign. A Simple Cyst is one which, on ultrasound, is lesser than 50 mm in diameter; has thin, smooth walls; no internal structures; and clear fluid inside the cyst. Such cysts in women who do not have any symptoms are ‘functional’, physiological and usually resolve and disappear without any medical or surgical intervention by the doctor within 2-3 months.
Simple Ovarian Cysts are common even in older women after menopause, though lesser frequent than in younger pre-menopausal women. In the older age group one is frightened of any growth anywhere. Before the easy availability of expert ultrasound, all ovarian cysts in the post menopause age group were considered as an indication for surgery; not anymore because of low risk of malignancy, less than 1%, of many of these cysts even in this age group. Such older, post menopausal patients with no symptoms and simple cysts less than 5 cm and normal blood level of tumour markers like CA 125 can also be simply watched conservatively without resorting to surgery.
So the treatment of women with no symptoms and simple cysts less than 5 cm (with normal CA125 in older women) is to simply watch by repeated ultrasound (plus CA125 in older women) and wait for them to go away without panicking into surgical treatment. This is the third take home message.
Any cyst that does not fit into the strict definitions and criteria of Simple Cyst is called a Complex Cyst. Most cysts, including complex cysts, in young women are benign. Even when identified as benign, complex ovarian masses may require surgery. Ultrasound by the transvaginal route, not abdominal route, is the most effective way of evaluating an ovarian tumour. It can be used to identify certain features suggestive of benignity or malignancy. This ‘Pattern Recognition’ by ultrasound is very sensitive and specific in complex cysts although no single ultrasound finding can definitely say whether a cyst is benign or malignant. Certain conditions have very typical features on ultrasound that make a definitive diagnosis – enough to be able to do treatment or surgery on basis of that diagnosis. Three of these benign conditions very well identified on ultrasound are Haemorrhagic Corpus Luteum Cyst, Endometriosis and Dermoid Cyst. The latter two will require surgery. Of the two surgical techniques, laparoscopy or open surgery, laparoscopy is considered the best and the ‘gold standard’ for these conditions. This is the fourth take home message.
As is true for all cancers, women diagnosed with advanced stage (Stage 3 or 4) have poor survival rates. On the other hand, women diagnosed with early stage (Stage 1) can be cured. The aim is to screen and diagnose ovarian cancer to pick up as early stage as possible. Ovarian cancer is termed as a ‘silent killer’ but it is increasingly recognised that the majority of women with ovarian cancer experience some symptoms more frequently, more severely and more persistently than women who do not have the disease. Bleeding after menopause is a very important complaint which is not normal and must be investigated. There is a complete algorithm devoted to the investigation and workup of postmenopausal bleeding and ovarian cancer investigation is part of it. The Guideline Development Group has therefore not included this, although it should be investigated, in the following alert symptoms for ovarian cancer: persistent abdominal distention (bloating); feeling full (early satiety); pelvic or abdominal pain; increased urinary frequency, urgency or a woman of 50 years age or more with symptoms diagnosed as Irritable Bowel Syndrome. These symptoms present within last 12 months and persisting or frequent more than 12 times in one month, especially if woman is 50 years of age or more, are significant to investigate for ovarian cancer. Other than this, one should be alert to symptoms not specific to ovarian cancer like unexplained weight loss, changes in bowel habits and fatigue. Unlike earlier times when all postmenopausal women were subjected to routine ultrasound of pelvis and CA 125 as ovarian cancer screening program, its now not considered necessary anymore. This is because there is no convincing evidence that ultrasound and CA125 screening of all women can detect early-stage, curable ovarian cancer in sufficient numbers, without an excessive number of non-malignant masses precipitating unnecessary surgery. Ovarian cancer also does not have a pre-invasive stage, like cervical cancer, which can be picked up by such screening programs. Investigating women with these symptoms leads to early pick up of ovarian cancer. Therefore, most important is to remain alert to symptoms which have been found to have higher presence in women with ovarian cancer. This is the fifth take home message.
The best outcome in women with diagnosed ovarian cancer is in doing an open surgery, removal of both tubes and ovaries, lymph nodes removal, several biopsies and a full ‘staging’ procedure carried out by a trained gynae-oncologist at a cancer centre. However, many older, post-menopausal women have benign ovarian cysts. Therefore such a protocol is neither advisable nor feasible for all patients with ovarian tumours. No currently available tests for ovarian cancer offer 100% sensitivity or specificity of diagnosis. Ultrasound is unable to differentiate between benign and malignant with 100% accuracy. CA125, the blood test which is a tumour marker for ovarian cancer, is raised only in 50% of early ovarian cancers and is raised even in benign conditions. So the best way to identify women at high risk that their ovarian tumour is a cancer is to use Risk of Malignancy Index (RMI) which is a scoring system using ultrasound features, CA125 value and menopausal status. Using this RMI, one can triage patients into Low Risk, Moderate Risk or High Risk for Ovarian Cancer. Low Risk women have a less than 3 % risk of cancer and can be managed by the gynaecologist; Medium Risk women have approximately 20% risk of cancer and are managed in a cancer unit; High Risk women have more than 75% risk that their ovarian tumour is cancer and are best referred and managed at a cancer centre for the most optimal outcome and survival. This is an important sixth take home message.
In summary,
• Ovarian cancer is rare in young, premenopausal women and most of their ovarian tumours are likely to be benign.
• A family history of ovarian, breast and colon cancers in female and male members of the family should make one alert because it is associated with a higher risk of ovarian cancer.
• Women with simple ovarian cysts can be treated by observation and conservatively for several months, without immediate recourse to surgery.
• Younger women, who are candidates for surgery are best operated laparoscopically, which is the ‘gold standard’ as compared to open surgery.
• Women, especially above 50 years age, should be alert to certain symptoms which have been found to be more present in women who should be investigated for ovarian cancer rather than use ultrasound and CA 125 as screening tools in all patients.
• Older women with ovarian tumours should be triaged to identify level of risk which will determine where and how they are best treated for optimal outcome and survival in ovarian cancer.
Symptoms which should alert one to visit the doctor for investigations for ovarian cancer:
persistent abdominal distention (bloating)
feeling full (early satiety)
pelvic or abdominal pain
increased urinary frequency and/or urgency
symptoms diagnosed as Irritable Bowel Syndrome (IBS) in a woman of 50 years age or more since IBS rarely occurs for the first time in this age group
Post-menopausal bleeding
These symptoms are significant to investigate for ovarian cancer if:
present within last 12 months
and persisting or frequent more than 12 times in one month
especially if woman is 50 years of age or more
Symptoms not specific to ovarian cancer but suspicious of any cancer:
unexplained weight loss
changes in bowel habits
fatigue
Examination findings which require referral to a gynaecologist to rule out ovarian cancer
fluid in abdominal cavity (ascites) and/or
pelvic or abdominal mass