Ovarian cancer is difficult to detect in the first stages of the disease with most signs and symptoms presenting when cancer has spread. However, women experience symptoms during all stages of the disease, with many seemingly nonspecific and subtle. Gynecologic oncologist Dr. Lisa Diver calls it the “cancer that whispers” due to fact that the symptoms that appear at first are not easily identifiable as cancer-related. Do not hesitate to talk to your healthcare provider about any new symptom you are feeling as early detection of any form of disease is crucial in treatment and recovery.

Ovarian cancer often presents with several signs and symptoms including:

• Feeling full quickly (early satiety)
• Abdominal bloating
• Abdominal discomfort and/or pain
• Pelvic pain
• Nausea and/or vomiting
• Changes in bowel movements (e.g., constipation or diarrhea)
• Back pain
• Urinary symptoms (feeling the need to urinate urgently or often)
• Fatigue (extreme or chronic)
• Upset stomach or heartburn
• Bleeding from the vagina (especially after menopause)
• Unusual discharge from the vagina
• Pain during sex

Ovarian cancer usually develops from three kinds of cell tissue: epithelial, germ, and stromal. The type of tumor that grows depends on the age of the patient, with the vast majority of cases occurring in post-menopausal women.

Epithelial cell. 85-95% of ovarian cancer originates in the epithelium tissue-the lining cells of the ovary itself. This type is most common in patients older than 50 years of age. There are four subtypes of epithelial cell carcinomas: serous, endometrioid, mucinous, and clear cell. The endometrioid and mucinous subtypes may be associated with endometriosis.

Germ cell. (5-8% occurrence rate) The germ cells make the eggs in the ovaries. This type of ovarian cancer is found mostly in children and young adults (20-30 years of age) and is considered highly malignant.

Stromal cell. (3-5%  occurrence rate) Stromal cells are structural components of the ovary and secrete the hormones estrogen and progesterone.

Other types. Rarer types of ovarian cancers are ovarian sarcomas, Krukenberg tumors, and some ovarian cysts that become cancerous.

Medical researchers have yet to fully understand the causal links to why women develop ovarian cancer. However, many theories (e.g., Morgam. M. et al. 2020; Reid. B et al., 2017) have been developed that link genetics, family history, and hormonal influences to explain the development of ovarian cancer. Healthcare providers may recommend genetic counseling if there is a family history of ovarian cancer. The highest risk for ovarian cancer is associated with genetic mutations found in human germlines BRCA1 and BRCA2. Lifestyle and environmental factors associated with increased risk for developing ovarian cancer are age, hormonal replacement therapy, poor diet, and a history of smoking. There are a few factors that may protect a woman against ovarian cancer, including breastfeeding, early first birth, early menopause, and late menarche. This risk reduction is related to the decreased number of ovulatory cycles a woman has throughout her lifetime.

Decreased Risk

• Breastfeeding for 18 months or longer
• Early menopause
• Multiparity (risk decreases with each pregnancy)
• Hysterectomy
• Late menarche
• Low-fat diet
• Oral contraceptive use
• Tubal ligation

Increased Risk

• Early menarche
• Delayed childbearing
• Endometriosis
• Family history of ovarian cancer
• High-fat diet
• Late menopause
• Low parity
• Genetic syndromes
• Estrogen replacement therapy (more than five years)

Remember that the early symptoms and/or signs of ovarian cancer are subtle and nonspecific. Be open and honest with your healthcare provider about your family history and any new symptoms or strangeness you are feeling, especially in the abdominal and pelvic region. Regular visits to your gynecologist and pelvic exams are effective means to catch many forms of cancer and treat them before advanced stages.

Your physician may do the following if he or she suspects ovarian cancer:

Blood tests. Checks for elevated levels of biomarker CA-125 ( a protein found in high concentration in ovarian cancer cells).

Imaging. Includes a transvaginal ultrasound, CT scan, or an MRI scan.

Laparoscopy. Involves the insertion of a thin tube with a camera into a small hole in the abdomen. This allows for a clear picture of the ovaries and a tissue sample may be taken for a biopsy.

Biopsy. This involves the microscopic investigation of a tissue sample taken from a suspected tumor. A biopsy is performed to confirm that the abnormality found in previous tests contains cancerous cells.

The oncologist will classify the cancer to understand the extent to which it has spread. These stages run from stage I through stage IV- with the lower the number signifying less cancer spreading. Tissue samples, or biopsies, are taken from various parts of the abdomen and pelvis and examined by a pathologist to identify the stage of ovarian cancer. Pathologists and oncologists use three factors to stage:

1. (T) The extent and/or size of the tumor
2. (N) The spread of cancerous cells into local lymph nodes
3. (M) The metastasis of cancer to distant sites

Higher numbers of T, N, or M mean a more advanced stage of cancer.6 After these factors have been grouped in different subcategories, the classification of ovarian cancer is made.

Stage I. Cancer is localized to the ovary (or ovaries) or fallopian tube(s) and has not spread to the lymph nodes or distant sites.

Stage II. Cancer is in the ovary (ovaries) or fallopian tubes and has spread to nearby organs (i.e., uterus, bladder, colon) and has not spread to nearby lymph nodes or distant sites.

Stage III. Cancer is in the ovary (or both ovaries) and/or fallopian tubes, has spread and/or grown into nearby organs and has spread into pelvic area lymph nodes. Cancer has not spread to distant sites.

Stage IV. Cancer cells have spread in the fluid around the lungs with no spread to the liver, spleen, intestine, or lymph nodes that are outside the abdomen. The latest stage is the spread of cancer cells to the liver, spleen, lymph nodes, lungs, and bones.

The diagnostic process of any suspected tumor will feel overwhelming, especially in the beginning. Remember to reach out and ask for support from your loved ones. Asking for help when you need it gives you the time and space to take care of yourself and work towards treatment and recovery.

Chemotherapy, surgery, and radiation are all treatments used to treat ovarian cancer. Surgery is usually the first step in treatment where a surgeon will remove as much of the tumor as possible. The extent of surgery depends on how much cancer has spread throughout surrounding tissues. The ovaries, uterus, cervix, and/or fallopian tubes may need to be removed if the cancer has spread outside of the ovaries. After surgery, the remaining cancer cells will be subjected to chemotherapy. Chemotherapy medications are administered through an IV and may also be injected directly into the abdomen to allow the medicine to come into direct contact with metastasized cells. Radiation kills cancer cells that remain after surgery and chemotherapy treatment.

Hormone therapy. The use of hormones or hormone-blocking drugs to treat cancer is known as hormone therapy. Hormones are rarely used to treat epithelial ovarian cancer but are used to treat the less common stromal tumors. Some hormone therapies administered are LHRH (luteinizing-hormone-releasing) agonists, Tamoxifen© (anti-estrogen drug), and aromase inhibitors (drugs that block pro-estrogen proteins).

Targeted therapy. Targeted therapy is a form of treatment for cancer that uses medications that attack cancer cells without damaging normal cells. These drugs can identify a cancer cell and stop them from reproducing by targeting the inside of the cancerous cells. Targeted therapies interrupt the growth, division, repair, and intracellular communication systems of specific cancer cells. Common targeted therapy drugs are angiogenesis inhibitors, PARP (poly (ADP)-ribose polymerase) inhibitors, larotrectinib, and entrectinib.

Advanced ovarian cancer symptoms are usually quite significant and difficult to manage.8 Thankfully, with a treatment plan in place for fighting cancer, these symptoms will be relieved with time and effective drug management. Treatment for ovarian cancer is intense and can cause a variety of new symptoms caused by the side effects of the treatment itself. Your healthcare provider oncology team will help you along this difficult path and your symptoms will be relieved with their care and advisement and the support system around you.

Abdominal bloating. Abdominal bloating caused by tumor growth is relieved during cancer treatments. When the bloating is caused secondary to cancer due to food or indigestion, physicians may prescribe ocreotide to relieve symptoms. You can also reduce bloating symptoms by avoiding processed foods, carbonated beverages, and gas-producing foods (i.e., broccoli and cabbage). Gentle movements help to move gas through the body too.

Ascites. Ascites is the build-up of fluid in the abdomen and can be caused by cancer cells blocking the lymph system which moves excess fluid out of the abdomen. This symptom is relieved with cancer treatment as the reduction of cancer cells stop the blockage of lymph ducts. In some cases, a surgeon will perform a paracentesis to drain excess abdominal fluid.

Constipation. Constipation may be a sign of bowel obstruction. Large ovarian tumors can extend into the lower bowels and cause a blockage. In these cases, the obstruction is relieved through surgical intervention. If the bowel is not obstructed, constipation can be treated with medication, drinking enough fluids, easily-digested foods that are soft, and mild exercise.

Pelvic pain. OTC (over-the-counter) pain medications are the first line of pain management for the discomfort caused by pelvic pain. Anti-inflammatory pain medications like acetaminophen and ibuprofen are commonly used. Talk to your healthcare provider for appropriate dosage and possible contraindications. If the pain is not managed effectively by these medications, opioids may be prescribed. Morphine, fentanyl patches are hydromorphone commonly prescribed to manage stronger pain symptoms.

Weight loss. Weight loss is another unfortunate occurrence in advanced ovarian cancer. In these cases, working with a licensed dietician under the guidance of your physician is the best course of action to maintain weight. A nutritionist can help you make a menu that is simple, nutritious, and calorie-rich, to stay your course in healing and recovery.

• Acupuncture
• Guided imagery
• Massage therapy
• Nutritional therapy
• Chiropractic therapy

Alternative therapies for cancer are most beneficial in relieving symptoms of discomfort and pain, providing nutritional support, relaxation, and stress-relieving techniques. Relaxation techniques can help manage anxiety and pain symptoms. Proper nutrition and herbal therapy that does not interfere with chemotherapy or immunotherapy drugs are also beneficial. A healthy mind is wonderful for healing and recovery from cancer treatment and the disease itself. Eating well and finding positive outlets, like movement therapy and mental health support, are excellent self-care methods to help you along the difficult path in your battle against cancer. Help is out there! Support groups, family members, and friends are at your disposal, all you need to do is reach out.

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American Cancer Society. (2020, June 10). Targeted therapy for ovarian cancer. Retrieved from cancer.org:https://www.cancer.org/cancer/ovarian-cancer/treating/targeted-therapy.html

Chun. C. (2019, November 1). Managing advanced ovarian cancer symptoms. Retrieved from Healthline: https://www.healthline.com/health/ovarian-cancer/managing-advanced-ovarian-cancer-symptoms

Markman, M. (2020, November 05). Ovarian cancer types. Retrieved from Cancer Treatment Centers of America:https://www.cancercenter.com/cancer-types/ovarian-cancer/types

Morgan, M., et al. (2020, April 03). Cancers arising in the ovary. Retrieved from Clinicalgate: https://clinicalgate.com/cancers-arising-in-the-ovary-2/

Reid, B., et al. (2017). Epidemiology of ovarian cancer: a review. Cancer, Biology, & Medicine, 14(1), 9-32. Retrieved from Cancer, Biology, & Medicine: http://www.cancerbiomed.org/index.php/cocr/article/view/1004/1108

Roett, M. A., Evans, P. (2009). Ovarian cancer: An overview. American Family Physician, 80(6), 609–616. Retrieved from PubMed: https://pubmed.ncbi.nlm.nih.gov/19817326/

Survivornet. (2020, December 14). Ovarian cancer: Overview. Retrieved from Survivornet: https://www.survivornet.com/journey/ovarian-cancer/