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Ovarian Cancer

Author: Agustin A Garcia, MD, Associate Professor of Medicine, University of Southern California Keck School of Medicine
Contributor Information and Disclosures

Updated: Dec 13, 2007

Introduction

Background

Ovarian cancer is the most common cause of cancer death from gynecologic tumors in the United States. Early disease causes minimal, nonspecific, or no symptoms. Therefore, most patients are diagnosed in an advanced stage. Overall, prognosis for these patients remains poor. Standard treatment involves aggressive debulking surgery followed by chemotherapy. Many histological types of ovarian tumors are described. However, more than 90% of malignant tumors are epithelial tumors. Therefore, the remainder of this article focuses on these tumors. For specific information on malignant lesions of the ovaries, see Malignant Lesions of the Ovaries.

Pathophysiology

Ovarian carcinoma can spread by local extension, lymphatic invasion, intraperitoneal implantation, hematogenous dissemination, and transdiaphragmatic passage. Intraperitoneal dissemination is the most common and recognized characteristic of ovarian cancer. Malignant cells can implant anywhere in the peritoneal cavity but are more likely to implant in sites of stasis along the peritoneal fluid circulation. As discussed later, these mechanisms of dissemination represent the rationale to conduct surgical staging, debulking surgery, and intraperitoneal administration of chemotherapy. On the other hand, early hematogenous spread is clinically unusual, although it is not infrequent in patients with advanced disease.

Frequency

United States

Approximately 22,430 new cases of ovarian cancer are diagnosed annually. Estimates indicate that 1 in 70 women will develop ovarian cancer in her lifetime. Ovarian cancer accounts for 3.3% of all new cases of cancer.

Mortality/Morbidity

  • Overall, the prognosis of ovarian cancer remains poor, with a 45% 5-year survival rate. Approximately 15,280 women die every year in the United States from ovarian cancer.
  • The prognosis of ovarian cancer is closely related to the stage at diagnosis.
  • Ovarian cancer is staged using the International Federation of Gynecology and Obstetrics (FIGO) staging system. Approximately 20%, 5%, 58%, and 17% of women present with stage I, II, III, and IV, respectively. Despite this, the 5-year survival rate for ovarian cancer has improved significantly in the last 30 years. The overall survival rate in 1975-1977 was 36%, compared to 45% in 1995-2002.

Sex

  • Ovarian cancer affects females.

Age

  • The disease is uncommon in patients younger than 40 years, after which incidence increases.
  • Most cases are diagnosed in the seventh decade of life.

Clinical

History

  • The signs and symptoms of ovarian cancer are nonspecific. Most patients present with symptoms of several months' duration.
  • Symptoms include the following:
    • Abdominal/pelvic pain
    • Vaginal bleeding
    • Bloating
    • Abdominal distension
    • Irregular menses
    • Change in bowel habit

Physical

  • Physical findings are uncommon in patients with early disease.
  • Patients with more advanced disease present with the following:
    • Ovarian or pelvic mass
    • Ascites
    • Pleural effusion
    • Abdominal mass or bowel obstruction

Causes

Traditionally, ovarian cancer has been suggested to originate from cells in the serosa of the ovary. However, some authors suggest a different cell of origin. The precise cause of ovarian cancer is unknown, but several risk and contributing factors have been identified.

  • Reproductive factors
    • Parity is an important risk factor. Women who have been pregnant have a 50% decreased risk for developing ovarian cancer compared to nulliparous women. Multiple pregnancies offer an increasingly protective effect.
    • Oral contraceptive use decreases the risk of ovarian cancer.
    • These factors support the theory that risk for ovarian cancer is related to ovulation and that conditions that suppress this ovulatory cycle play a protective role.
    • Ovarian cancer may develop from an abnormal repair process of the surface of the ovary, which is ruptured and repaired during each ovulatory cycle. Therefore, the probability of ovarian cancer may be related to the number of ovulatory cycles.
  • Genetic factors
    • Family history plays an important role in the risk of developing ovarian cancer.
    • The lifetime risk for developing ovarian cancer is 1.6% in the general population. This compares to a 4-5% risk when 1 first-degree family member is affected, rising to 7% when 2 relatives are affected.
    • A history of breast cancer increases a woman's risk of developing ovarian cancer.
  • Hereditary ovarian cancer
    • Families in which multiple members have ovarian cancer (alone or associated with other tumors) are defined as having hereditary ovarian cancer.
    • Fewer than 5% of all ovarian cancers have a hereditary predisposition. At least 2 syndromes are clearly identified, as follows:
      • Breast/ovarian cancer syndrome: This is associated with early onset of breast or ovarian cancer. Inheritance follows an autosomal dominant transmission. It can be inherited from either parent. Most cases are related to the BRCA1 gene mutation. BRCA1 is a tumor suppressor gene that inhibits cell growth when functioning properly; the inheritance of mutant alleles of BRCA1 leads to a considerable increase in risk for developing ovarian cancer.
      • Lynch II syndrome or hereditary nonpolyposis colorectal cancer: These families are characterized by a high risk for developing colorectal, endometrial, stomach, small bowel, breast, pancreas, and ovarian cancers. This syndrome is caused by mutations in the mismatch repair genes.

More on Ovarian Cancer

Overview: Ovarian Cancer
Differential Diagnoses & Workup: Ovarian Cancer
Treatment & Medication: Ovarian Cancer
Follow-up: Ovarian Cancer
References
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References

  1. Hess LM, Benham-Hutchins M, Herzog TJ, Hsu CH, Malone DC, Skrepnek GH. A meta-analysis of the efficacy of intraperitoneal cisplatin for the front-line treatment of ovarian cancer. Int J Gynecol Cancer. May-Jun 2007;17(3):561-70. [Medline].

  2. Elit L, Oliver TK, Covens A, Kwon J, Fung MF, Hirte HW. Intraperitoneal chemotherapy in the first-line treatment of women with stage III epithelial ovarian cancer: a systematic review with metaanalyses. Cancer. Feb 15 2007;109(4):692-702. [Medline].

  3. [Best Evidence] Armstrong DK, Bundy B, Wenzel L, Huang HQ, Baergen R, Lele S. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med. Jan 5 2006;354(1):34-43. [Medline].

  4. Alberts DS, Liu PY, Hannigan EV, et al. Intraperitoneal cisplatin plus intravenous cyclophosphamide versus intravenous cisplatin plus intravenous cyclophosphamide for stage III ovarian cancer. N Engl J Med. Dec 26 1996;335(26):1950-5. [Medline].

  5. Cochrane Database of Systematic Reviews [database online]. John Wiley & Sons, Ltd; Jan 2006.

  6. Garcia AA. Salvage therapy for ovarian cancer. Curr Oncol Rep. Sep 1999;1(1):64-70. [Medline].

  7. Goff BA, Mandel LS, Melancon CH, Muntz HG. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. Jun 9 2004;291(22):2705-12. [Medline].

  8. Markman M, Liu PY, Wilczynski S, et al. Phase III randomized trial of 12 versus 3 months of maintenance paclitaxel in patients with advanced ovarian cancer after complete response to platinum and paclitaxel-based chemotherapy: a Southwest Oncology Group and Gynecologic Oncology Group trial. J Clin Oncol. Jul 1 2003;21(13):2460-5. [Medline].

  9. Mazzeo F, Berliere M, Kerger J, et al. Neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy in patients with primarily unresectable, advanced-stage ovarian cancer. Gynecol Oncol. Jul 2003;90(1):163-9. [Medline].

  10. McGuire WP, Hoskins WJ, Brady MF, et al. Cyclophosphamide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer. N Engl J Med. Jan 4 1996;334(1):1-6. [Medline].

  11. NCI Clinical Announcement on Intraperitoneal Chemotherapy in Ovarian Cancer. January 5, 2006: National Cancer Institute; [Full Text].

  12. Ozols RF, Bundy BN, Greer BE, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. J Clin Oncol. Sep 1 2003;21(17):3194-200. [Medline].

  13. Parmar MK, Ledermann JA, Colombo N, du Bois A, Delaloye JF, Kristensen GB. Paclitaxel plus platinum-based chemotherapy versus conventional platinum-based chemotherapy in women with relapsed ovarian cancer: the ICON4/AGO-OVAR-2.2 trial. Lancet. Jun 21 2003;361(9375):2099-106. [Medline].

  14. Pfisterer J, Plante M, Vergote I, du Bois A, Hirte H, Lacave AJ. Gemcitabine plus carboplatin compared with carboplatin in patients with platinum-sensitive recurrent ovarian cancer: an intergroup trial of the AGO-OVAR, the NCIC CTG, and the EORTC GCG. J Clin Oncol. Oct 10 2006;24(29):4699-707. [Medline].

  15. Rebbeck TR, Lynch HT, Neuhausen SL, Narod SA, Van't Veer L, Garber JE. Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med. May 23 2002;346(21):1616-22. [Medline].

  16. Rose PG, Nerenstone S, Brady MF, Clarke-Pearson D, Olt G, Rubin SC. Secondary surgical cytoreduction for advanced ovarian carcinoma. N Engl J Med. Dec 9 2004;351(24):2489-97. [Medline].

  17. Sifri R, Gangadharappa S, Acheson LS. Identifying and testing for hereditary susceptibility to common cancers. CA Cancer J Clin. Nov-Dec 2004;54(6):309-26. [Medline].

  18. U.S. Preventive Services Task Force. Screening for ovarian cancer: recommendation statement. U.S. Preventive Services Task Force. Am Fam Physician. Feb 15 2005;71(4):759-62. [Medline].

  19. van der Burg ME, van Lent M, Buyse M, et al. The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. Gynecological Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer. N Engl J Med. Mar 9 1995;332(10):629-34. [Medline].

  20. Vasey PA, Jayson GC, Gordon A, et al. Phase III randomized trial of docetaxel-carboplatin versus paclitaxel-carboplatin as first-line chemotherapy for ovarian carcinoma. J Natl Cancer Inst. Nov 17 2004;96(22):1682-91. [Medline].

  21. White R, Le Van D, McDuff D. Helping the patient in denial: the role of the family in intervention. Md Med J. Jun 1995;44(6):462-6. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Agustin A Garcia, MD, Associate Professor of Medicine, University of Southern California Keck School of Medicine
Agustin A Garcia, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Karen Loeb Lifford, MD, Director of General Gynecology, Associate Program Director, Department of Obstetrics and Gynecology, Instructor, Brigham and Women's Hospital, Harvard Medical School
Karen Loeb Lifford, MD is a member of the following medical societies: Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Antonio V Sison, MD, Program Director, Department of Obstetrics and Gynecology, Robert Wood Johnson University Hospital
Antonio V Sison, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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