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understanding
ovarian cancer

Ovary is an important reproductive organ of women. Ovarian cancer is when abnormal cells in the ovary begin to multiply out of control and form a tumour. In fact, ovarian cancer is common among women in Hong Kong.

facts of 20191

*Research of Hong Kong Cancer Registry, Hospital Authority

*Research of Hong Kong Cancer Registry, Hospital Authority

Symptoms

Ovary is located deep inside the pelvis and ovarian cancer is therefore not easy to be diagnosed through general examinations. However, certain symptoms should draw one’s attention, which include but not limited to:2

  1. Fatigue and poor appetite
  2. Abdominal bloating, discomfort or even pain in the abdomen
  3. Gastrointestinal discomfort
  4. Urine frequency and urgency
  5. A sudden change in bowel habits, can be in the form of constipation or diarrhoea
  6. Pain during sexual intercourse

Causes and Types

The exact cause of ovarian cancer is unknown. However, it has been postulated that the tiny damages and recoveries of ovarian tissues as a result of ovulation may induce ovarian cancer.3 According to medical studies, ovarian cancer is also related to fallopian tube pathogenesis and inherited genetic mutations.4

Epithelial Cells


Epithelial Cells Tumours start in the outer surface of the ovaries,5 account for about 90% of ovarian cancer cases5 and are the most common type of ovarian cancer.

Stroma


Stromal Cell Tumours start from ovarian stroma and tissues responsible for producing female hormones oestrogen and progesterone,5 and are a rare type of ovarian cancer.

Germ Cells


Germ Cell Tumours start from egg-producing cells and are a rare type of ovarian cancer.
Three common types of Ovarian Cancers

Ovarian Cancer Risk Factors

The following groups of women may be at increased risk of having ovarian cancers, and may need more attention:2
  • 45+
    years old
  • Have No
    Full-term
    pregnancy
  • Late
    Menopause
    than ordinary women
  • Family
    History
    of ovarian cancer
    (especially mother,
    sisters or aunts)
  • Personal
    History
    of breast cancer
  • BRCA
    Gene
    mutations

Genetics and Hereditary Factors

In recent years, a number of medical studies found that apart from physiological and environmental factors, genetics and hereditary factors were main causes of ovarian cancer. Numerous studies now confirm that individuals carrying or inherited with BRCA1 or BRCA2 mutations are associated with higher risk of ovarian cancer.6
01
It is estimated that up to 15% of ovarian cancer patients have BRCA1 or BRCA2 mutations.7
02
Up to 44% of women with a mutation in either the BRCA1 or BRCA2 gene will develop ovarian cancer by age 80.6
What are BRCA1 and BRCA2 mutations?
BRCA stands for BReast CAncer susceptibility gene. There are two BRCA genes: BRCA1 and BRCA2. They are tumor suppressor genes which everyone has. BRCA1 and BRCA2 genes produce proteins that function to repair damaged DNA, thus maintaining the stability of genetic material inside cells. Mutations in these genes mean they do not work properly and damaged DNA cannot be repaired properly, which can lead to cancers, including ovarian cancer6.

Diagnoses & Treatment

Nowadays, the medical community no longer simply sees ovarian cancer as one “single” disease. Instead, to treat ovarian cancer, doctors have to carefully differentiate the disease based on its type and subtype and then provide appropriate treatment for each patient.

Stage I11

The cancer is only in the ovaries. Stage I can be subdivided into:

IA
Cancer is only in one ovary, but not on the outside surface of the ovary. No cancer cells are found in ascites or washings.
IB
Cancer is in both ovaries, but not on the outside surface of the ovaries. No cancer cells are found in ascites or washings.
IC
Cancer is in one or both ovaries and even on the surface of one or both ovaries or in ascites.

Stage II11

Cancer is in one or both ovaries and it has spread to other organs or tissues within the pelvis. Cancer has not spread outside the pelvis or to any lymph nodes. Stage II can be subdivided into:

IIA
Cancer cells have spread to fallopian tubes, uterus or both.
IIB
Cancer cells have spread to other organs or tissues in the pelvis, such as bladder, rectum or the peritoneum within the pelvis.

Stage III11

Cancer is in one or both ovaries and it has spread outside the pelvis to abdominal tissues. It may spread to lymph nodes in the back part of the abdomen behind the peritoneum. Stage III can be subdivided into:

IIIA
Tumours are found outside the pelvis but limited to the lymph nodes at the back of the abdomen only with sizes of around 10 mm; or in the abdomen with sizes visible only under the microscope.
IIIB
Cancer has spread to peritoneum with size of ≦2cm, visible to the naked eyes. Cancer cells may have spread to lymph nodes in the back of the abdomen.
IIIC
Cancer has spread to peritoneum with size of >2cm, visible to the naked eyes. In addition, cancer cells may have spread to lymph nodes in the back of the abdomen, or also spread to the outer surface of liver or spleen.

Stage IV11

Cancer has spread to distant organs such as lungs, brain or skin; and may have also spread to the inside of the liver and spleen or to distant lymph nodes. Stage IV can be subdivided into:

IVA
Cancer cells are found in fluid around the lungs, but not anywhere else outside the abdomen.
IVB
Cancer has spread to the inside of liver or spleen, to distant lymph nodes, or to other organs outside the abdomen.

Diagnosis

Various examination methods can be used to diagnose ovarian cancer.
Examination Methods3
01

Vaginal examination

To examine the uterus and ovaries through vagina to detect any mass inside the ovaries.

02

Ultrasound scan

To find out where the tumour is.

03

CT scan and MRI scan

To help detect the location of the tumour.

04

Blood test

Women with ovarian cancer or benign ovarian lesions may have an elevated CA125 level. However, some patients with early-stage ovarian cancer have a normal CA125 level.

05

Laparoscopy and diagnosis

A small incision is made near the navel while the patient is under general anaesthesia. A laparoscope is then used to examine the tissues inside the abdominal cavity and if tumor is found, a sample of the tumor will be taken for pathological diagnosis.

06

Laparotomy

If needed, doctors may perform this surgery to examine, diagnose and treat the patient.

07

Biopsy

To classify the cell type.

08

Chest X-ray, gastroscopy, and colonoscopy

If ovarian cancer is highly suspected, these examinations may be needed to determine the area affected by the tumour.

Surgery
Chemotherapy
Radiotherapy
Targeted therapy

Treatment

Ovarian treatment decisions should be made based on the factors such as cancer cell type and staging of the disease. Common treatment options include surgery, chemotherapy, radiotherapy and targeted therapy.

Surgery

Surgery is the most common treatment option for ovarian cancer in most cases.11 The main purpose of the surgery is to remove the tumour. Depending on the staging of the tumour, resection of the uterus, the ovaries or fallopian tubes, or the protective adipose tissues on the surface of organs in the abdominal cavity (omentum) may be performed. Sometimes, the lymphatic tissues around the ovaries may also have to be resected.2

Surgery

Surgery is the most common treatment option for ovarian cancer in most cases.11 The main purpose of the surgery is to remove the tumour. Depending on the staging of the tumour, resection of the uterus, the ovaries or fallopian tubes, or the protective adipose tissues on the surface of organs in the abdominal cavity (omentum) may be performed. Sometimes, the lymphatic tissues around the ovaries may also have to be resected.2

Chemotherapy

Its underlying mechanism is to destroy cancer cells, usually by stopping their ability to grow and divide. Chemotherapy may be used before and after the surgery. For example, adjuvant chemotherapy is used after the surgery to lower the risk of recurrence, whereas neoadjuvant chemotherapy is used before the surgery to shrink the tumour to enhance efficacy of the surgery.Traditionally, there are two classes of chemotherapy drugs for the treatment of ovarian cancer - Taxanes and Platinum Agents.2 However, chemotherapy has side effects that may affect the appearance of patients or cause discomfort to patients, such as hair loss, fatigue, loss of appetite, vomiting, etc.2

These side effects are usually temporary.2 Patients should always inform their healthcare professionals as soon as possible in case of any discomfort.

Chemotherapy

Its underlying mechanism is to destroy cancer cells, usually by stopping their ability to grow and divide. Chemotherapy may be used before and after the surgery. For example, adjuvant chemotherapy is used after the surgery to lower the risk of recurrence, whereas neoadjuvant chemotherapy is used before the surgery to shrink the tumour to enhance efficacy of the surgery.Traditionally, there are two classes of chemotherapy drugs for the treatment of ovarian cancer - Taxanes and Platinum Agents.2 However, chemotherapy has side effects that may affect the appearance of patients or cause discomfort to patients, such as hair loss, fatigue, loss of appetite, vomiting, etc.2

These side effects are usually temporary.2 Patients should always inform their healthcare professionals as soon as possible in case of any discomfort.

Radiotherapy

Radiotherapy eliminates tumour cells through high-energy X-rays. Since the position of the ovaries are deep for the radiations to work well, doctors may recommend radiotherapy if the cancer is located close to the pelvis.2

Radiotherapy

Radiotherapy eliminates tumour cells through high-energy X-rays. Since the position of the ovaries are deep for the radiations to work well, doctors may recommend radiotherapy if the cancer is located close to the pelvis.2

Targeted therapy

Targeted therapy is a relatively new cancer therapy that targets a specific or unique feature of cancer cells.11

A type of targeted therapy is called PARP inhibitors, which work in the following ways:15

  • Cancer cells grow quickly. This fast growth creates DNA damages in cancer cells that must be repaired in order for the cancer to keep growing.
  • Cancer cells with defect in DNA repair may rely on PARP, which is an enzyme that helps repair DNA damages.
  • If PARP is allowed to do its repair job, cancer cells can survive and continue to grow. That is why it is important to try to stop PARP.
  • PARP inhibitors stop PARP from repairing damage in cancer cells and trap PARP, so cancer cells are more likely to die.
  • By preventing damage repair and harming cancer cells, PARP inhibitors can help stop cancer cells from growing.

Another type of targeted therapy is called angiogenesis inhibitors, which work in the following ways:18

  • For cancers to grow and spread, they need to make new blood vessels to nourish themselves (called angiogenesis).
  • One of the chemical signals that controls angiogenesis is through the regulations of vascular endothelial growth factor (VEGF).
  • Angiogenesis inhibitors block the growth of blood vessels that support cancer growth by attaching to VEGF, which then slows or stops cancer growth.

Targeted therapy

Targeted therapy is a relatively new cancer therapy that targets a specific or unique feature of cancer cells.11

A type of targeted therapy is called PARP inhibitors, which work in the following ways:15

  • Cancer cells grow quickly. This fast growth creates DNA damages in cancer cells that must be repaired in order for the cancer to keep growing.
  • Cancer cells with defect in DNA repair may rely on PARP, which is an enzyme that helps repair DNA damages.
  • If PARP is allowed to do its repair job, cancer cells can survive and continue to grow. That is why it is important to try to stop PARP.
  • PARP inhibitors stop PARP from repairing damage in cancer cells and trap PARP, so cancer cells are more likely to die.
  • By preventing damage repair and harming cancer cells, PARP inhibitors can help stop cancer cells from growing.

Another type of targeted therapy is called angiogenesis inhibitors, which work in the following ways:18

  • For cancers to grow and spread, they need to make new blood vessels to nourish themselves (called angiogenesis).
  • One of the chemical signals that controls angiogenesis is through the regulations of vascular endothelial growth factor (VEGF).
  • Angiogenesis inhibitors block the growth of blood vessels that support cancer growth by attaching to VEGF, which then slows or stops cancer growth.

01
I am receiving treatment for ovarian cancer. Is there anything I need to pay attention to in daily care?
Patients normally face numerous difficulties in their fight against cancer. Apart from various physical discomforts, they may also experience fluctuating mental state along the progression of the disease and treatment. The following healthcare methods can help patients continuously fight against cancer in their daily life.

Having enough rest:2 Ovarian cancer patients may be required to stay in hospital for about a week after receiving surgery. Many patients may feel tired and need a longer period of time to rest. During that time, they can duly arrange their daily routines but should never overestimate their capability.

Paying attention to diet:2 Some patients may have gastrointestinal discomfort, such as constipation, diarrhoea or abdominal pain, etc. Eating more food rich in dietary fibre can help relieve constipation; drinking more water helps facilitate bowel movement, and replenishes water loss from diarrhoea; and having meals of smaller portion but at higher frequency helps avoid eating too much and eases the burden on the intestines and stomach.

Avoiding carrying heavy stuff:2 Patients should use tools more often to help lift heavy stuff or ask their family members to share the housework.

Doing moderate exercises:2 Moderate exercises can benefit the body. Types and frequency of exercises to be taken should be based on each person's condition, and take it step by step.

Lymphatic massage:2 Patients may have leg swelling problem caused by lymphedema after receiving the lymph node removal. Massaging or exercising the swollen part can improve the circulation of lymphatic fluid; and wearing specially-designed clothes plays a part in deswelling; patients may consult their healthcare professionals for relevant patient support activities.

Remaining optimistic:2 An optimistic and peaceful mood helps patients deal with physical and mental stress and even daily life stress during the treatment. Patients may relax themselves by sharing their feelings and thoughts with their relatives, friends and wardmates.
02
I am an ovarian cancer patient. Why do doctors advise me to undergo BRCA genetic testing?
Doctors may consider personalized treatment regimens based on the genetic testing results of ovarian cancer patients. For an ovarian cancer patient, genetic testing increases treatment choices and improves treatment efficacy; for ovarian cancer patient with germline BRCA mutation, testing results help remind the patient’s family of their potentially increased cancer risks so as to protect the family’s health.
03
Is BRCA genetic testing internationally recognized?
Currently, there are different guidelines for ovarian cancer patients to undergo BRCA genetic testing across the international medical community. The American Congress of Obstetricians and Gynecologists suggests that ovarian cancer patients may choose to undergo genetic testing and BRCA1 or BRCA2 gene mutation testing with the help of genetic counseling,12 while American Society of Clinical Oncology advises that women with epithelial ovarian cancer may consider receiving a BRCA gene test even if they don’t have a family history of it.16
04
What is genetic counseling?
Before a gene test, well-trained doctors, nurses or genetic counselors will give genetic counseling to those who are to be tested. In addition to explaining the test methods and risks, the doctors, nurses or genetic counselors will analyse in detail the clinical significance of different test results, and the possible impacts on the subjects and their families in respect of emotion, birth plan, screening and treatment. And the subjects will then decide whether to receive a gene test or not.17
(Note: The Hong Kong Academy of Medicine reminds the public that if they receive a gene test without proper guidance, counseling or data background, they may be exposed to additional medical risks or even receive incorrect test results; moreover, without the explanations by professionals, they may be caught in unnecessary anxiety or have a false sense of security.)
05
Can Pap test be used to detect ovarian cancer?
Pap test is only used for the detection of cervical cancer, it is not a test for ovarian cancer.13 However, some ovarian cancers are found accidentally through Pap tests, but those are usually late-stage cases.13

The principle of the Pap test is to collect cells from the cervix to test for the presence of cancerous cells under a microscope. On rare occasions, ovarian cancer cells travel away from ovaries through fallopian tubes or uterus to the cervix, hence ovarian cancer are sometimes found by doctors through a Pap test. However, this is not always the case and Pap test is not a reliable method to screen for cancer.
06
Will ovarian cysts and chocolate cysts develop into ovarian cancer?
Ovarian cysts and chocolate cysts are commonly found in women of reproductive age, but they are not ovarian cancer.14 Ovarian cysts are correlated with menstrual cycle and may occur during or after ovulation every month. The common types include “endometriosis” (also known as “chocolate cyst”), “cystadenoma”, “ovarian teratoma” and “polycystic ovary syndrome”.

Some women may have severe menstrual cramps due to ovarian cysts which can be diagnosed by pelvic examination or medical imaging examination. Treatment may not be necessary for ovarian cysts, as long as periodic examinations by doctors are done regularly to monitor if the cysts get larger; some cysts can be removed by surgery.

FAQ

To Caregiver

If you are a caregiver of ovarian cancer patients, you play a very important role in their life and medical care during and after the treatment. Despite this, never forget to take care of your own physical and mental health. Only by doing this can you fight against the cancer together with the patients. The following recommendations may provide you with more ideas about caregiving:

Equip yourself with knowledge about ovarian cancer

Equip yourself with knowledge about ovarian cancer

It is definitely not easy for cancer patients to undergo the diagnostic and therapeutic process. They are in great need of empathy from people around them. Keeping abreast of the latest information about ovarian cancer can help you better understand the possible changes in their body and conditions and facilitate the communication between you and patients.

Learn to alleviate your stress

Learn to alleviate your stress

As a caregiver, you would certainly experience physical and mental strain as well. Learning some stress-relieving tips can help you deal with your nervousness, anxiety or depression.

Promptly ask for help

Promptly ask for help

You are also an ordinary person with physical and capability limitations. Just be open-minded, and seek help from your relatives and friends, professionals, or community resources if you have any difficulties at work. You are not alone.

Pour out

Pour out

You may have a lot of feelings and emotions if the people around you are sick or you have to provide care for others. Why not share your feelings or stress with your relatives and friends, professionals or patient groups in order to reduce your negative feelings?

Empathize your spouse

Empathize your spouse

Try to understand your spouse if the sex life between you and her is affected during chemotherapy, post-surgery, and when her disease has progressed to a later stage. Be considerate to your partner and cherish your time together.

1. Hong Kong Cancer Registry, Hospital Authority. Ovarian & Peritoneal Cancer in 2019. October 2021. Available at: https://www3.ha.org.hk/cancereg/pdf/factsheet/2019/ovary_2019.pdf. Accessed: 13 December 2021.
2. Hong Kong Cancer Fund. Understanding Ovarian Cancer (2015). Available at: https://www.cancer-fund.org/wp-content/uploads/2017/04/Ovarian-Pdf-2015C.pdf. Accessed July 16, 2021.
3. Hospital Authority. Smart Patient: Ovarian Cancer. Available at: https://www21.ha.org.hk/smartpatient/SPW/zh-HK/Disease-Information/Disease/?guid=e7cdd1a8-8f9c-4c59-9f5f-7cffe95d93fa. Accessed July 16, 2021.
4. American Cancer Society. What Causes Ovarian Cancer? Available at: https://www.cancer.org/cancer/ovarian-cancer/causes-risks-prevention/what-causes.html. Accessed July 16, 2021.
5. American Cancer Society. What is Ovarian Cancer? Available at: Available at: https://www.cancer.org/cancer/ovarian-cancer/about/what-is-ovarian-cancer.html. Accessed July 16, 2021.
6. National Cancer Institute. BRCA Mutations: Cancer Risk and Genetic Testing. Available at: https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet. Accessed July 16, 2021.
7. Ramus SJ1, Gayther SA. The contribution of BRCA1 and BRCA2 to ovarian cancer. Mol Oncol. 2009;3(2):138-50. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5527889/pdf/MOL2-3-138.pdf. Accessed July 16, 2021.
8. National Cancer Institute. SEER Cancer Statistics Review. Cancer Stat Facts: Ovarian Cancer. Available at: https://seer.cancer.gov/statfacts/html/ovary.html. Accessed July 16, 2021.
9. Chen S, et al. Meta-Analysis of BRCA1 and BRCA2 Penetrance. J Clinical Oncol 2007;25(11):1329-1333. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267287/pdf/nihms41827.pdf. Accessed July 16, 2021.
10. Alsop K, et al. BRCA Mutation Frequency and Patterns of Treatment Response in BRCA Mutation–Positive Women with Ovarian Cancer: A Report From the Australian Ovarian Cancer Study Group. J Clin Oncol. 2012;30(21):2654-2663. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3413277/pdf/zlj2654.pdf. Accessed July 16, 2021.
11. NCCN Guidelines for Patients - Ovarian Cancer. 2021. Available at: https://www.nccn.org/patients/guidelines/content/PDF/ovarian-patient.pdf. Accessed: July 16, 2021.
12. The American Congress of Obstetricians and Gynecologists. BRCA1 and BRCA2 Mutations. Available at: Ahttps://www.acog.org/Patients/FAQs/BRCA1-and-BRCA2-Mutations?IsMobileSet=false#negative. Accessed July 16, 2021.
13. American Cancer Society. Can Ovarian Cancer Be Found Early? Available at: https://www.cancer.org/cancer/ovarian-cancer/detection-diagnosis-staging/detection.html. Accessed July 16, 2021.
14. The American Congress of Obstetricians and Gynecologists. Ovarian Cysts. Available at: https://www.acog.org/Patients/FAQs/Ovarian-Cysts?IsMobileSet=false. Accessed July 16, 2021.
15. Dana-Farber Cancer Institute. How Do PARP Inhibitors Work In Cancer? July 2016. Available at: https://blog.dana-farber.org/insight/2016/07/how-do-parp-inhibitors-work-in-cancer/. Accessed: December 13, 2021.
16. Konstantinopoulous PA, et al. Journal of Clinical Oncology. 2020;38:1222-1245.
17. Hong Kong Academy Medicine. HKAM responds to human BRCA gene mutation and related medical questions. Available at: https://www.hkam.org.hk/sites/default/files/130528_HKAM_BRCA_statement_Eng_Final.pdf. Accessed: July 16, 2021.
18. National Cancer Institute. Angiogenesis Inhibitors. Available at: https://www.cancer.gov/about-cancer/treatment/types/immunotherapy/angiogenesis-inhibitors-fact-sheet. Accessed July 16, 2021.
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