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Ovarian Cancer (Ab Ovo)
Ovarian cancer is the fifth most common cancer in women after lung, breast, colorectal and pancreatic cancers. It accounts for only 3% of cancers in women, and fortunately, the incidence of this type of cancer has dropped by about 1% over the past 20 years. Unfortunately, diagnosis is often late because symptoms and signs are very subtle and often changeable. Ovarian cancer is not just a cancer of old age, it can occur at any age, even in infancy, however, the incidence of this cancer does rise significantly after the age of 50.
There are certain risk factors for ovarian cancer, notable among which are family history and a number of associated genetic syndromes. A blood relative with ovarian cancer increases the risk of the cancer in their female relatives by 5%. Hereditary breast and ovarian cancer syndrome affects one in 500 women and is an autosomal dominant disorder that results in mutations in the BRCA1 and/or BRCA2 genes. The other is Lynch II syndrome, a hereditary nonpolyposis colorectal cancer syndrome that is also autosomal dominant and can increase the risk of ovarian cancer by 12%. However, most women diagnosed with ovarian cancer have no family history and the cause remains unknown. When ovarian cancer develops and is limited to one ovary without early detection, it usually spreads first to the unaffected ovary and uterus, but can spread to the liver, lungs, adrenal glands, spleen, and other intraperitoneal organs.
Some factors that reduce risk include the protective effects of oral contraceptives, late menarche, early menopause, multiple births (having more than one child), and breastfeeding. Progesterone appears to have a protective effect, but this is controversial because a 2009 Danish study showed an increased risk with all HRT (the study was with estrogen alone (unopposed) or with estrogen and progestin (progestin is a A synthetic progesterone compound) was carried out). Further research using prophylaxis with natural bioidentical hormones is needed to resolve this controversy, as earlier studies suggested a protective effect of HRT. There are some modifiable factors such as weight loss (to avoid obesity), smoking cessation, and reducing diets high in starch and fats that can reduce the risk of this cancer Studies have shown that a balanced diet rich in carotene, vitamins C and E, and unsaturated fat Diet, along with moderate physical activity, can both help reduce the risk of ovarian cancer.
Early diagnosis is difficult because the signs and symptoms are often subtle and nonspecific, and unless you look for the disease with specific diagnostic laboratory and radiological tests, you are unlikely to catch it early. Some symptoms include abdominal pain and fullness, back pain, nausea, constipation, diarrhea, fatigue, pelvic pain, and urinary symptoms. If these symptoms persist, laboratory testing should be considered in women over the age of 40, who are at high risk for ovarian cancer. Testing usually involves CBC, metabolome and serum CA125 levels. CA 125 is a cancer marker that is quite sensitive and specific for ovarian cancer, but there are other conditions that can raise it, such as pelvic inflammatory disease (PID), endometriosis, ovarian cysts, and pregnancy. CA 125 is a good test but not perfect because it is elevated in 90% of patients with advanced disease but only in more than 50% of patients with stage I tumors. In addition, several other useful markers include the beta subunit of human chorionic gonadotropin (beta-HCG), serum alpha-fetoprotein (AFP), neuron-specific enolase (NSE), and lactate dehydrogenase enzyme (LDH). Diagnosis can also be made with diagnostic imaging, such as Doppler transvaginal ultrasonography (ultrasonography or US), often used for initial evaluation of pelvic masses. US helps identify benign ovarian lesions, such as simple cysts, and lesions that appear more malignant, such as complex solid tumors. Other radiologic imaging modalities that are useful to the diagnostician are CT scans and gadolinium-enhanced MRI.
Treatment usually involves (after thorough diagnostic testing and staging) surgical removal of the mass/tumor. Depending on the stage of the disease, other organs may also be removed, such as the appendix, which is often removed due to its potential metastatic target. After the tumor is removed, chemotherapy is usually started with a combination of platinum and taxane drugs. Carboplatin and paclitaxel are two commonly used chemotherapy drugs. For those women beyond reproductive age, total hysterectomy is usually considered, while radiation therapy is reserved for palliative and persistent disease that recurs after chemotherapy.
Prognosis is somewhat complicated as it is based on the stage of the disease and histologic grade (type of tumor etiology) which usually plays a role in the recurrence rate. For example, if epithelial ovarian cancer is diagnosed at stage I (histologically) with low malignant potential and has a 10-year survival rate of 95 – 99%.
Screening for ovarian cancer should include an annual physical exam and directed work with markers and imaging only when necessary. Routine screening with CA 125 produces too many false positives and misses too many tumors early on to be a good general screening test. BRCA analysis should be reserved for offspring with BRCA1 and BRCA2 gene mutations and is not recommended as a general screening tool. The current recommendation for women who meet the high- or very-very-risk criteria for ovarian cancer is to screen with transvaginal ultrasonography every six months on days 1 to 10 of the menstrual cycle and measure CA 125.
The message here is that women need to be diligent in their annual physicals and not ignore persistent symptoms that could point to a more serious underlying condition.
Roett, M. Evans, P., “Ovarian Cancer: An Overview,” American Family Physician, Vol. 80, No. 6, September 15, 2009, pp. 609-616.
www.ncbi.nlm.nih.gov/pubmed/10933270 (accessed October 8, 2009)
www.medicinenet.com/script/main/art.asp?articlekey=103822 (accessed 8 October 2009)
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