Background Facts Ovarian cancer is the fourth commonest cancer in women after cancers of the breast lung and bowel and causes approximately 4,000 deaths each year in the UK. Unfortunately for most affected women the cancer has already spread beyond the ovaries by the time they present to a specialist. This advanced stage of the disease at presentation means that treatments are much less likely to be curative and despite advances in chemotherapy and surgery only approximately 30% of patients survive five years. Approximately 75% of women diagnosed with ovarian cancer die from the disease. Ovarian cancer may occur at any age but it is much more common in post-menopausal women with its peak incidence in women in their sixties. Ovarian cancer appears to becoming more common in the UK as the population ages and possibly also due to social and environmental changes. Most ovarian cancers are sporadic but in about 5% of cases there is a strong family history of cancer, most commonly of either the breast or ovary. It is not thought that HRT has any effect on developing ovarian cancer, and use of the pill actually seems to have some protective effect against developing this disease. The pathology of the different types of ovarian tumours and cysts is very complex, due to the different functions performed by the ovary in healthy life. 85% of ovarian cancers are epithelial, arising from the cells on the surface of the ovary. This overview relates to these most common ovarian tumours, though some facts are common to all tumour types. Symptoms and Presentation The symptoms of ovarian cancer may be vague and not specific to her ovaries, and may therefore at first be ignored by the woman. This also makes the diagnosis sometimes difficult for a GP to make and together these may lead to delay in diagnosis and appropriate referral. Almost any symptoms may occur with ovarian cancer, its presentation commonly mimicking other diseases. The commonest symptoms are due to pressure on other organs within the tummy (abdomen) either from tumour deposits or from fluid accumulation (ascites). Bowel problems such as IBS, indigestion or constipation are common, as are abdominal swelling or a change in bladder symptoms. More obvious gynaecological symptoms such as abnormal vaginal bleeding or pain with intercourse are less frequent. Such symptoms are common to many other conditions but the development of new abdominal symptoms in a middle-aged lady is always a concern. Treatment Surgery for Ovarian Cancer Staging and Tumour Debulking Treatment for ovarian cancer usually involves both surgery and chemotherapy. The aims of surgery are firstly to accurately assess the extent of the disease (staging), and secondly to remove the tumour deposits (cytoreduction or tumour debulking). Removal of the entire visible tumour (optimal debulking) improves the sensitivity to chemotherapy and improves the long term outcome for the patient. Surgery usually involves removal of both ovaries and fallopian tubes, the uterus (if the woman has not previously had a hysterectomy) some fatty tissue attached to the gut called the omentum, together with biopsies from other sites where the tumour tend to spread to. These include lymph nodes both within the pelvis and from close to the aorta, the main artery from where the ovarian blood supply arises. Further biopsies are often taken from the peritoneum which lines the abdominal cavity, under the diaphragm and on the surface of the gut. Frozen Section Suspicious ovarian tumours are often examined by a pathologist immediately after surgical removal as a frozen section examination, while the surgeon continues with other essential parts of the operation. This gives 90% accuracy as to the diagnosis, and can allow the surgeon to be more conservative surgically, for example it may prevent the need for lymph node biopsies to be performed, reducing the post-operative discomfort to the patient, or in a young woman it may prevent the need for a hysterectomy to be performed thus preserving her fertility. Skin Incision Surgery for suspected ovarian cancer is usually performed through a midline vertical incision on the lower abdomen. This allows the surgeon access to the whole abdominal cavity as well as the pelvis, and may be extended upwards if the cyst is very large or surgery is required in the upper abdomen. A dissolvable skin stitch is usually used beneath the surface which gives a good cosmetic result. Steristrip skin closures are used in addition, and a waterproof dressing applied for the first few days. Once mobile after the operation you may shower and simply pad the dressings dry. The steritrips usually start to peel off after about 7 days by when the skin should have healed. The dressing is changed after about three days. Anaesthetic Because vertical abdominal incisions are more painful than low transverse scars an epidural is usually sited as well as a standard general anaesthetic. The epidural is used for pain relief both during and after the operation for up to 72 hours. Epidurals are very advantageous, ensuring that you wake up from the operation feeling comfortable, and greatly reduce the amount of strong pain killers such as morphine which would otherwise be required. This reduces nausea and vomiting after the operation. Epidurals also help to limit the blood loss during the operation and are normal practice for all major abdominal surgery. The anaesthetist will also usually cannulate a central large vein in the neck as well as an artery and a peripheral vein in the wrist. Most of these drips and cannulae will be inserted while you are asleep to minimize discomfort. A urinary catheter is introduced to monitor the urine output. Once the epidural is removed and you are mobile the catheter may be removed. Possible Bowel Surgery Some form of bowel surgery is required in about 20 % of cases of surgery for ovarian cancer; hence it is routine practice to cleanse the bowel pre-operatively with a purgative such as Picolax® to make any bowel surgery safer. The need for bowel surgery can often be predicted by pre-operative CT scans. Such bowel surgery may involve shaving tumour deposits off the surface of the bowel with subsequent repair, excision of an affected segment of bowel, or bypass of a stricture. When a diseased segment of bowel is excised the healthy cut ends are then usually joined together. It is extremely rare to need to form a colostomy or other stoma unexpectedly during an ovarian cancer operation. The possible need for a stoma will usually be predicted and discussed pre-operatively with the patient. Such cases will also be counselled by nurse specialists and the site of possible stomas marked pre-operatively. Primary or Interval Debulking Surgery Surgery for ovarian cancer may either be performed first before chemotherapy, or may be performed at an interval in the middle of a course of chemotherapy. This ‘sandwich’ approach to treatment is known as interval debulking surgery or IDS. IDS has proved to be a very safe way of treating patients with advanced ovarian cancer, allowing the surgeon to operate when the patient is more stable rather than when they are acutely unwell, and is currently being evaluated for other potential benefits to patients. Sometimes injections are given to boost the white blood count when surgery is being undertaken following recent chemotherapy. Hospital Stay Hospital stay following ovarian cancer surgery is usually around 7-10 days. A lot depends on the patient’s general condition and age, and whether chemotherapy is commenced while still in hospital. Chemotherapy for Ovarian Cancer Several different chemotherapy drugs are licensed for the treatment of ovarian cancer. This is an overview of the two drug regimes that we use most often: Carboplatin and a combination of Carboplatin and Paclitaxel. It is not comprehensive, but is designed to answer peoples most commonly asked questions. The Consultant Oncologist will explain what options are available and what are the relative merits and drawbacks of each possible treatment. The Clinical Nurse Specialist will also be there to answer any further concerns and offer their experience and knowledge to help you. First line treatment for most patients with ovarian cancer will include a platinum containing compound called Carboplatin. This is often given together with Paclitaxel (Taxol®). These drugs are given slowly by an intravenous drip, usually as an out-patient during the course of one day. Six cycles of treatment are normally given, each three weeks apart. Occasionally additional cycles of Carboplatin may be given. The combination of Carboplatin and Paclitaxel is now the first line treatment for ovarian cancer within the UK, and has been endorsed by NICE (The National Institute for Clinical Excellence). It is a powerful combination and for some people, especially the elderly or very infirm single agent treatment with Carboplatin alone is preferred as it is much better tolerated than the combination of the two. A blood count is performed before each successive cycle, and the dose of chemotherapy is calculated according to your kidney function. Side-effects of Chemotherapy Carboplatin and Paclitaxel both cause some degree of nausea or vomiting and lethargy. Anti-sickness tablets (anti-emetics such as metoclopramide) are routinely given to counter this. The three weekly timing of chemotherapy means that one is not ‘out of action’ for the whole three weeks between doses. Most people find that the worst of the side-effects take effect after three or four days, last for another three or four days and then gradually improve before the next cycle. All chemotherapy drugs are very powerful and may have potentially dangerous side-effects such as suppression of the bone marrow, toxic effects on the kidneys, or even allergic reactions. It is important for patients to report any adverse symptoms to the Nurse Specialist or Oncologist so that any further doses may be adjusted. Paclitaxel commonly causes a peripheral neuropathy resulting in numbness and/or tingling in the fingers and toes which in the worst cases may make simple tasks such as doing up buttons difficult. Fortunately this usually resolves at least in part, and sometimes the dose of Paclitaxel needs to be reduced. Paclitaxel always causes significant hair loss (alopecia). This is usually almost total hair loss by the time of completion of the treatment. A cold cap may help to slow or reduce the hair loss, but it may be quite painful. Carboplatin if given alone usually causes some hair thinning, but this is much less marked than with Paclitaxel. Further information will be available at your treatment centre, from the Clinical Nurse Specialist and from the Consultant Oncologist. The treatment of recurrent ovarian cancer is beyond the scope of this overview.