The ovaries are part of the female reproductive system which also includes the fallopian tubes, uterus (womb), cervix (the neck of the uterus), vagina (birth canal) and vulva (external genitals).
The ovaries are two small, grape-shaped organs. They are found in the lower part of the abdomen (the pelvic cavity). There is one ovary on each side of the uterus, close to the end of the fallopian tubes. Each ovary is made up of:
- epithelial cells – found on the outside of the ovary in a layer known as the epithelium
- germinal (germ) cells – found inside the ovaries, these cells eventually mature into eggs (ova)
- stromal cells – form connective (supporting) tissue within the ovaries, and produce the female hormones oestrogen and progesterone.
Each month, the ovaries release an egg (ovum) in a process called ovulation. The egg travels down the fallopian tube into the uterus. If the egg is fertilised by a sperm, it will implant itself into the lining of the uterus and grow into a baby. If the egg is not fertilised by a sperm, the lining is shed and flows out of the body through the vagina. This flow is known as a woman’s period (menstruation).
Oestrogen and progesterone cause ovulation and menstruation. As a woman gets older, the ovaries gradually produce less of these hormones. When the levels of oestrogen and progesterone fall low enough, a woman’s periods will become irregular and finally stop. This is known as menopause. After menopause, it is no longer possible to conceive a child. The ovaries also become smaller.
Ovarian cancer is a malignant tumour in one or both ovaries. It can start in any of the three cell types found in the ovary (see table opposite).
Epithelial ovarian, fallopian tube and peritoneal cancers all develop in the same type of cell and are very similar. Recent research suggests that many epithelial ovarian cancers start in the fallopian tubes. Ovarian cancer often spreads from the ovaries to the diaphragm, the lining of the abdomen (peritoneum), and the sheet of fatty tissue that hangs inside the abdomen (omentum).
What types of ovarian cancer are there?
There are many types of ovarian cancer. The table on the opposite page lists the three most common types. Some women (usually younger women) are diagnosed with a borderline ovarian tumour. This is not considered to be cancer because, although it can spread, it does not usually invade other organs. For this reason, borderline tumours are also known as low malignant potential tumours.
Epithelial ovarian cancer
- This type of ovarian cancer starts in the fallopian tubes, on the surface of the ovary (epithelium) or in the peritoneum
- Epithelial ovarian cancer is the most common type of ovarian cancer (about 9 out of 10 cases)
- Subtypes include serous, mucinous, endometrioid and clear cell cancers
- Usually develops in women over 60
Germ cell ovarian cancer
- This type of ovarian cancer starts in the egg-producing (germinal) cells
- This is a rare type of ovarian cancer (about 4% of cases)
- Usually develops in adolescents and women under 40
Stomal cell (or sex cord-stromal tumours)
- A rare cancer that starts in the cells that produce the female hormones oestrogen and progesterone
- Usually occurs in women between 40 and 60
- May produce extra hormones, such as oestrogen
How common is ovarian cancer?
Each year, about 1400 Australian women are diagnosed with ovarian cancer. The average age at diagnosis is 63. It is the eighth most common cancer in women in Australia. Ovarian cancer is more commonly diagnosed in women over 50.
What are the symptoms of ovarian cancer?
In its early stages, ovarian cancer usually has no symptoms. This means it is typically diagnosed when the cancer is more advanced.
If symptoms occur, they may include: pressure, pain or discomfort in the abdomen or pelvis; swollen or bloated abdomen; appetite loss or feeling full quickly; changes in toilet habits (e.g. constipation, diarrhoea, passing urine more often, increased flatulence); indigestion and nausea; tiredness; unexplained weight loss or weight gain; changes in menstrual pattern or bleeding after menopause; or pain during sex.
If these symptoms are new for you, are severe or continue for more than a few weeks, keep a record of how often they occur and make an appointment to discuss them with your general practitioner (GP).
These symptoms can also occur in many other conditions and do not necessarily mean you have cancer, but it is best to have a check-up.
Ovarian Cancer Australia has produced a symptom diary to help women record any symptoms and talk about their health concerns with their doctor. Visit ovariancancer.net.au/signs-and-symptoms.
How important are genetic factors?
Most women diagnosed with ovarian cancer do not have a family history of the disease.
Some women have an inherited faulty gene that increases the risk of developing ovarian cancer. However, not all women who inherit a faulty gene develop ovarian cancer, and not all women with an inherited faulty gene have a family history of cancer.
The main genetic condition known to increase the risk of ovarian cancer is hereditary breast/ovarian cancer, usually caused by a fault in the BRCA1 and BRCA2 genes. Less commonly, Lynch syndrome is associated with ovarian cancer. About 15–20% of women with ovarian cancer are found to have a fault in one of the BRCA genes or other similar genes.
Other genetic conditions continue to be discovered and are often included in genetic tests for cancer risk. Genetic testing aims to detect faulty genes that may increase the risk of developing cancer.
Many women diagnosed with ovarian cancer are eligible for a Medicare rebate for a genetic test. Your specialist or a familial cancer centre will assess your eligibility and, with your permission, order a blood test to check whether you have the BRCA1, BRCA2 or another similar mutation. Knowing whether you have a particular faulty gene may help determine suitable treatment options (see Targeted therapy below).
If the faulty gene causing the cancer is found, Medicare- funded testing can be offered to other family members who have no signs of cancer. For more information about genetic testing, talk to your specialist or local familial cancer centre, or call 13 11 20.
What are the causes and risk factors of ovarian cancer?
The causes of most ovarian cancers are unknown, but the risk factors include:
age – ovarian cancer is most common in women over 50 and in women who have stopped menstruating (have been through menopause), and the risk increases with age
genetic factors – up to 20% of serous ovarian cancers (the most common subtype) are linked to an inherited faulty gene, and a smaller proportion of other types of ovarian cancer are also related to genetic faults (see above)
family history – having one or more close blood relatives diagnosed with ovarian, breast, bowel or uterine cancers, or having Ashkenazi Jewish ancestry
reproductive history – women who have not had children or who had children over the age of 35 may be slightly more at risk
lifestyle factors – such as smoking and being overweight
hormonal factors – including early puberty or late menopause, or using oestrogen-only hormone replacement therapy (HRT) for five years or more.
Some factors reduce the risk of developing ovarian cancer. These include having children, breastfeeding, using the combined oral contraceptive pill for several years, and having your fallopian tubes tied (tubal ligation) or removed.
There is currently no effective screening test for ovarian cancer. If your doctor suspects you have ovarian cancer, you may have some of the tests and scans described in this chapter. These tests can show if there are any abnormalities that need to be followed up with a biopsy.
The only way to confirm a diagnosis of ovarian cancer is by taking a tissue sample (biopsy) and looking at the cells under a microscope. This is usually done during surgery (see page 28), which means that the cancer is diagnosed and treated at the same time.
The doctor will check for any masses or lumps by feeling your abdomen. To check your uterus and ovaries, they will place two fingers inside your vagina while pressing on your abdomen with their other hand. You may also have a vaginal examination using a speculum, an instrument that separates the walls of the vagina.
An internal examination is not painful but may be uncomfortable. The doctor may also perform a digital rectal examination, placing a gloved finger into the anus to feel the tissue behind the uterus where cancer cells may grow.
The Cervical Screening Test (which has replaced the Pap test) does not diagnose ovarian cancer. It looks for human papillomavirus (HPV), which causes most cases of cervical cancer but not ovarian cancer.
CA125 blood test
You may have blood tests to check for proteins produced by cancer cells. These proteins are called tumour markers. The most common tumour marker for ovarian cancer is CA125.
The level of CA125 may be higher in some women with ovarian cancer. However, it can also rise for reasons other than cancer, including ovulation, menstruation, irritable bowel syndrome, liver or kidney disease, endometriosis or fibroids.
The CA125 blood test is not used for screening for ovarian cancer in women who do not have any symptoms. It can be used:
A CA125 test is more accurate in diagnosing ovarian cancer in women who have been through menopause (postmenopausal) than those who haven’t (premenopausal). Women with early-stage ovarian cancer often have normal CA125 levels. This is why doctors will often combine CA125 tests with an ultrasound (see below).
If you are found to have ovarian cancer that produces CA125, the blood test may be used to check how well the treatment is working. Falling CA125 levels may mean it’s working, and rising CA125 may mean the treatment is not working effectively, but the CA125 level is only one item used by the treating team to assess a woman’s response to treatment.
CA125 blood tests are sometimes included in follow-up tests. See more on follow tests below.
Imaging and investigations
Your doctor may recommend a number of imaging scans and investigations to determine the extent and stage of the disease. You may also have chest x-rays to check the lungs for cancer or fluid.
A pelvic ultrasound uses echoes from soundwaves to create a picture of your uterus and ovaries on a computer. A technician called a sonographer performs the scan. It can be done in two ways:
You will lie on an examination table while the sonographer moves a small handheld device called a transducer over your abdominal area.
The sonographer will insert a small transducer wand into your vagina. It will be covered with a disposable plastic sheath and gel to make it easier to insert. Some women find this procedure uncomfortable, but it should not be painful. Talk to your doctor and the sonographer if you feel distressed or concerned. You can ask for a female sonographer if that makes you feel more comfortable.
The transvaginal ultrasound is often the preferred type of ultrasound, as it provides a clearer picture of the ovaries and uterus.
A CT (computerised tomography) scan uses x-ray beams to take pictures of the inside of the body. It is used to look for signs that the cancer has spread, but a CT scan may not be able to detect all ovarian tumours. CT scans are usually done at a hospital or radiology clinic.
You will be asked not to eat or drink for several hours (fast) before the scan. A liquid dye, sometimes called the contrast, may be injected into one of your veins to help make the pictures clearer. The contrast makes your organs appear white on the scan, so anything unusual can be seen more clearly.
The dye may make you feel hot all over and leave a bitter taste in your mouth. You may also feel the need to pass urine. These side effects usually ease quickly, but tell the person carrying out the scan if they don’t go away.
The CT scanner is a large, doughnut-shaped machine. You will lie on a table that moves in and out of the scanner. The scan takes 10–20 minutes, but it may take extra time to prepare and then wait for the scan. While a CT scan can be noisy, it is painless. Most women can go home as soon as the CT scan is over.
The dye used in a CT scan usually contains iodine. If you have had an allergic reaction to iodine or dyes during a previous scan, tell the medical team beforehand. You should also let them know if you’re diabetic, have kidney disease or are pregnant.
A PET (positron emission tomography) scan highlights abnormal tissues in the body, and it can be more accurate than a CT scan.
The results are often used to help with planning before surgery, and to check on how the treatment is working. Medicare only covers the cost of PET scans for ovarian cancer that has returned, so they are not often used for the initial diagnosis.
Before the scan, you will be injected with a small amount of radioactive glucose solution. This makes cancer cells show up brighter on the scan because they take up more of the glucose solution than normal cells do. You will be asked to sit quietly for 30–90 minutes while the glucose solution moves around your body, then you will be scanned for high levels of radioactive glucose.
Any radiation will leave your body within a few hours. Let your doctor know beforehand if you are diabetic, pregnant, think you might be pregnant, or are breastfeeding.
Some women have a bowel examination (colonoscopy) to make sure that their symptoms are not caused by a bowel problem. The doctor will insert a thin, flexible tube with a small camera and a light (colonoscope) through the anus into the bowel.
Before the test, you will have to change your diet and take prescribed laxatives to clean out your bowel completely (bowel preparation). The process varies for different people and between hospitals. Your doctor will give you specific instructions and talk to you about what to expect. On the day, you will probably be given an anaesthetic so you don’t feel any discomfort.
A colonoscopy usually takes about 20–30 minutes. You will need to have someone take you home afterwards, as you may feel drowsy or weak.
Staging and grading ovarian cancer
The tests described above help show whether you have ovarian cancer and whether it has spread to other parts of the body. This process is called staging and it helps your health care team recommend the best treatment for you.
In most instances, your doctor will not have enough information to work out the stage of the ovarian cancer until after surgery.
The staging system most commonly used for ovarian cancer is the International Federation of Gynecology and Obstetrics (FIGO) system. It divides ovarian cancer into four stages. Each stage is further divided into sub-stages, such as A, B, C, which indicate increasing amounts of tumour.
Stages I–II mean that it is early ovarian cancer. Stages III–IV mean the cancer is advanced. About 7 out of 10 women with ovarian cancer are diagnosed at stages III or IV.
Stages of ovarian cancer (FIGO system)
Stage I Cancer is in one or both ovaries only.
Stage II Cancer is in one or both ovaries and has spread to other organs in the pelvis (uterus, fallopian tubes, bladder or bowel).
Stage III Cancer is in one or both ovaries and has spread beyond the pelvis to the lining of the abdomen (peritoneum) or to nearby lymph nodes.
Stage IV The cancer has spread further to distant organs such as the lung or liver.
Grades of ovarian cancer
Grading describes how the cancer cells look compared to normal cells. It helps work out how aggressive the cancer cells may be. Treatment has a greater chance of success if the grade is lower.
Grade 1 The cancer cells look similar to normal cells and are probably growing relatively slowly.
Grade 2 The cancer cells appear slightly abnormal and might grow more rapidly.
Grade 3 The cancer cells look very different from normal cells and may grow quickly.
Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of the disease in an individual person.
Epithelial cancer The stage and grade of the cancer will influence the outcome. If epithelial ovarian cancer is diagnosed and treated before the cancer has spread outside the ovary (stage I), it has a good prognosis. Many women with more advanced cancer may respond well to treatment, but the cancer often comes back (recurs) and further treatment is needed.
Germ cell and stromal cell tumours – These can usually be treated successfully.
Borderline tumour – This usually has a good prognosis.
Discussing your prognosis and thinking about the future can be challenging and stressful. It may help to talk with family and friends. You can also call Cancer Council 13 11 20 if you need more information or emotional support.
Your doctor will consider many factors in assessing your prognosis. These include: test results; the type of ovarian cancer you have; the grade; genetic factors; your response to treatment; and other factors such as your age, fitness and overall health.
Which health professionals will I see?
Your GP will probably arrange the first tests to assess your symptoms. If these tests do not rule out cancer, you will usually be referred to a gynaecological oncologist, who specialises in treating women with ovarian cancer.
The gynaecological oncologist may arrange further tests, advise you about treatment options and perform any recommended surgery. You will be cared for by a range of health professionals who specialise in different aspects of your treatment. This is often referred to as a multidisciplinary team (MDT) and may include;
gynaecological oncologist – diagnoses and performs surgery for cancers of the female reproductive system, e.g. ovarian, cervical, uterine, vulvar and vaginal cancers
gynaecological pathologist – specialist doctor who examines tissue removed from the abdomen or ovaries under a microscope
medical oncologist – specialist doctor who treats cancer with drug therapies including chemotherapy and targeted therapy
radiation oncologist – specialist doctor who treats cancer by prescribing and coordinating a course of radiation therapy
radiation therapist – plans and delivers radiation therapy
radiologist – specialist who reads and interprets diagnostic scans (e.g. x-rays, CT and PET scans)
nurse – administers drugs and provides care, information and support throughout treatment
cancer nurse/ cancer care coordinator – coordinates your care, liaises with other members of the MDT and supports you and your family throughout treatment
dietitian – recommends an eating plan to follow while you are in treatment and recovery
physiotherapist, occupational therapist – assist with physical and practical problems, including restoring mobility after treatment, and recommending aids and equipment
social worker – links you to support services and helps you with emotional, practical or financial issues
counsellor, clinical psychologist – help you manage your emotional response to diagnosis and treatment
palliative care specialists and nurses – work closely with the GP and oncologist to help control symptoms and maintain quality of life
familial cancer specialist, genetic counsellor – provide advice about genetic conditions; perform and interpret genetic test results for you and your family
Making treatment decisions
Sometimes it is difficult to decide on the type of treatment to have. You may feel that everything is happening too fast. Check with your doctor how soon your treatment should start, and take as much time as you can before making a decision.
Understanding the disease, the available treatments and possible side effects can help you weigh up the pros and cons of different treatments and make a well-informed decision that’s based on your personal values. You may also want to discuss the options with your doctor, friends and family.
You have the right to accept or refuse any treatment offered. Some women with more advanced cancer choose treatment even if it offers only a small benefit for a short period of time. Others want to make sure the benefits outweigh the side effects so they have the best possible quality of life.
Talking with doctors
When your doctor first tells you that you have cancer, you may not remember the details about what you are told. Taking notes or recording the discussion may help. Many women like to have a family member or friend go with them to take part in the discussion, take notes or simply listen.
If you are confused or want clarification, you can ask for further explanation– see page 63 for a list of suggested questions. If you have several questions, you may want to talk to a nurse or ask the office manager if it is possible to book a longer appointment.
A second opinion
You may want to get a second opinion from another specialist to confirm or clarify your doctor’s recommendations or reassure you that you have explored all of your options. Specialists are used to people doing this.
Your doctor can refer you to another specialist and send your initial results to that person. You can get a second opinion even if you have started treatment or still want to be treated by the first doctor. You might decide you would prefer to be treated by the doctor who provided the second opinion.
Taking part in a clinical trial
Your doctor or nurse may suggest you take part in a clinical trial. Doctors run clinical trials to test new or modified treatments and ways of diagnosing disease to see if they are better than current methods. For example, if you join a randomised trial for a new treatment, you will be chosen at random to receive either the best existing treatment or the promising new treatment.
Over the years, trials have improved treatments and led to better outcomes for women diagnosed with ovarian cancer.
It may be helpful to talk to your specialist or clinical trials nurse, or to get a second opinion. If you decide to take part, you can withdraw at any time. For more information, call Cancer Council 13 11 20 or visit australiancancertrials.gov.au.
The treatment for ovarian cancer depends on the type of ovarian cancer you have, the stage of the cancer, your general health and fitness, your doctors’ recommendations, and whether you wish to have children.
Treatment options by type of ovarian cancer
Epithelial – Surgery is the main treatment for all stages of epithelial ovarian cancer. The aim is to remove as much of the cancer as possible. Sometimes, additional treatment is needed.
- Stage I ovarian cancer is usually treated with surgery alone. Some women will be offered chemotherapy after surgery if there is a high risk of the cancer coming back.
- Stages II, III and IV are usually treated with a combination of surgery and chemotherapy. New targeted therapy drugs are being offered to women with a BRCA mutation. In some cases, radiation therapy is offered.
Germ cell – This is usually treated with surgery and/or chemotherapy.
Stromal cell – This is usually treated with surgery, sometimes followed by chemotherapy or targeted therapy.
Borderline tumour – This is usually treated with surgery only.
Your gynaecological oncologist will talk to you about the most suitable type of surgery, as well as the risks and any possible complications. These may include infertility. If having children is important to you, talk to your doctor before surgery and ask for a referral to a fertility specialist.
Ovarian cancer is staged surgically. This means that the surgery will help the doctor work out how far the tumour has spread within the pelvic cavity.
You will be given a general anaesthetic and will have either a laparoscopy (with 3–4 small cuts in your abdomen) or a laparotomy (with a long, vertical cut from your bellybutton to your bikini line). The type of surgery you have will depend on how certain the gynaecological oncologist is that cancer is present and how far they think the cancer has spread. A laparoscopy may be used to see if a suspicious mass is cancerous; however, most women with advanced cancer will have a laparotomy.
The gynaecological oncologist will look inside your pelvis and abdomen for signs of cancer, and take tissue and fluid samples (biopsy). During the operation, the samples are usually sent to a specialist called a pathologist, who immediately examines them for signs of cancer. This is called a frozen section analysis or biopsy.
If cancer is present, the gynaecological oncologist will continue the operation and remove as much of the cancer as possible. This is called surgical debulking.
Surgery for ovarian cancer is complex. To ensure the best result, it is recommended that you are treated by a gynaecological oncologist at a specialist centre for gynaecological cancer. Call Cancer Council 13 11 20 for information about specialist centres in your area.
Types of surgery
Depending on how far the cancer has spread, you may have one or more of the procedures listed below.
Total hysterectomy and bilateral salpingo-oophorectomy
Most women with ovarian cancer will have an operation to remove the uterus and cervix, along with both fallopian tubes and ovaries.
Unilateral salpingo- oophorectomy
If the cancer is found early and it is only in one ovary, some young women who still wish to have children may have only one ovary and fallopian tube removed.
The omentum is a sheet of fatty tissue attached to the stomach and bowel. It hangs down in front of the intestines. Ovarian cancer often spreads to the omentum and it may need to be removed.
The pelvis contains large groups of lymph nodes. Cancer cells can spread from your ovaries to nearby lymph nodes. Your doctor may suggest removing some in a lymphadenectomy (also called lymph node dissection).
If cancer spreads to the bowel, some of the bowel may be removed. A new opening called a stoma may be created (colostomy or ileostomy). This is usually temporary. See page 49 for more details.
Removal of other organs
Ovarian cancer can spread to many organs in the abdomen.
In some cases, parts of the liver, diaphragm, bladder and spleen may be removed if it is safe to do.
All tissue and fluids removed during surgery are examined for cancer cells by a pathologist. The results will help confirm the type of ovarian cancer you have, if it has spread (metastasised), and its stage. It may not be possible to remove all the cancerous tissue. Surgery is often followed by chemotherapy, which will shrink or destroy any remaining cancer cells.
What to expect after surgery
When you wake up from surgery, you will be in a recovery room near the operating theatre. Once you are fully conscious, you will be taken back to your bed on the hospital ward.
Tubes and drips
You will have several tubes in place, which will be removed as you recover:
- a drip inserted into a vein in your arm (intravenous drip) will
give you fluid, medicines and pain relief
- a small plastic tube (catheter) may be inserted into your bladder
to collect urine in a bag
- a tube may be inserted down your nose into your stomach
(nasogastric tube) to drain stomach fluid and prevent vomiting
- tubes may be inserted in your abdomen to drain fluid from the site of the operation.
After an operation, it is common to feel some pain, but this can be controlled. For the first day or two, you may be given pain medicine through a drip or via a local anaesthetic injection into the abdomen (a transverse abdominis plane or TAP block) or spine (an epidural). Some patients have a patient-controlled analgesia (PCA) system. This machine allows you to self-administer a measured dose of pain relief by pressing a button. Let your doctor or nurse know if you are in pain so they can adjust the medicine. Managing your pain will help you to recover and move around more quickly.
It is common to have daily injections of a blood thinner to reduce the risk of blood clots. These injections may continue for some time after the operation and while you’re having chemotherapy. A nurse will show you how to give this injection to yourself before you leave hospital.
Compression devices and stockings
Some women have to use compression devices or wear elastic stockings to keep the blood in their legs circulating. Once you are moving around, compression devices will be removed so you can get out of bed, but you may still wear the stockings for a couple of weeks.
You can expect some light vaginal bleeding after the surgery, which should stop within two weeks. Your doctor will talk to you about how to keep the wound clean once you go home to prevent it becoming infected.
Length of stay
You will probably stay in hospital for 4–7 days for a big operation, less for a laparoscopy or smaller operation.
Taking care of yourself at home after surgery
Your recovery time will depend on the type of surgery you had, your general health, and your support at home. Most women are able to fully return to their usual activities after 4–8 weeks.
Rest – Take things easy and do only what is comfortable. You may like to try meditation or some relaxation techniques to reduce tension.
Work – Depending on the nature of your work, you will probably need 4–6 weeks leave from work.
Lifting – Avoid heavy lifting (more than 3–4 kg), hanging out the washing, or vacuuming for at least six weeks. Use a clothes horse or dryer instead of hanging the washing on a line. If you have a partner or children, ask them to help around the house. You can also check with a social worker if it’s possible to get help at home.
Driving – You will most likely need to avoid driving for a few weeks after the surgery. Check
with your car insurer for any conditions regarding major surgery and driving.
Bowel problems – You may have constipation following the surgery. It is important to avoid straining when passing a bowel motion, so you may need to take laxatives.
Nutrition – To help your body recover from surgery, focus on eating a balanced diet (including proteins such as lean meats and poultry, fish, eggs, milk, yoghurt, nuts, seeds and legumes/beans).
Sex – Sexual intercourse should be avoided for about six weeks after the operation to give your wounds time to heal. Ask your doctor when you can resume sexual intercourse and explore other ways you and your partner can be intimate, such as massage.
Exercise – Your health care team will probably encourage you to start walking the day after the surgery. Exercise has been shown to help people manage some of the common side effects of treatment, speed up a return to usual activities and improve overall quality of life. Start with a short walk and go a little further each day. Speak to your doctor if you would like to try more vigorous exercise.
Bathing – Take showers instead of baths, and avoid swimming for 4–6 weeks after surgery.
Your doctor should have all the test results within two weeks of surgery. Further treatment will depend on the type of ovarian cancer, the stage of the disease and the amount of any remaining cancer. If the cancer is advanced, it’s more likely to come back, so surgery will usually be followed by chemotherapy, and occasionally by targeted therapy. Radiation therapy is not often recommended.
Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs. The aim is to destroy cancer cells while causing the least possible damage to normal, healthy cells. Chemotherapy may be used at different times:
Most women will have chemotherapy after surgery (adjuvant chemotherapy) as there may be some cancer cells still in the body. Chemotherapy usually starts 2–4 weeks after surgery. The drugs you receive will depend on the stage of the cancer and your general health. For ovarian cancer, a combination of several drugs is usually given in repeating cycles spread over 4–5 months. Your treatment team will provide details about your specific schedule.
Some women with stage III or stage IV ovarian cancer have chemotherapy before surgery (neoadjuvant chemotherapy). The aim is to shrink the tumours to make them easier to remove. This usually involves three cycles of chemotherapy, followed by surgery, and then another three cycles.
Chemotherapy may be recommended as the main treatment if you are not well enough for a major operation or when the cancer cannot be surgically removed.
Chemotherapy is usually given as a combination of two drugs, or sometimes as a single drug. It’s delivered as a liquid drip into a vein (intravenous drip). To reduce the need for repeated needles, some women have a small medical appliance or tube placed beneath their skin through which they receive chemotherapy. This may be a port-a-cath, a peripherally inserted central catheter (PICC), or another type of catheter.
You will usually have chemotherapy as an outpatient (also called a day patient), but some women need to stay in hospital overnight.
Let your oncologist know if you are taking nutritional or herbal supplements as these can interact with chemotherapy and may lessen the effect.
Each chemotherapy treatment is called a cycle and is followed by a rest period to give your body time to recover. Ask your doctor about the treatment plan recommended for you.
This is a way of giving chemotherapy directly into the abdominal cavity – the space between the abdominal organs and the abdominal wall.
The drugs are given through a tube (catheter) that is put in place during surgery and removed once the course of chemotherapy ends.
Intraperitoneal chemotherapy is used only in specialised units in Australia. It may be offered to women with stage III disease with less than 1 cm of tumour remaining after surgery.
Some studies have shown it may be more effective than giving chemotherapy through an intravenous drip.
Ask your doctor for more information about this type of treatment and the advantages and side effects.
Blood tests during chemotherapy
Before each chemotherapy session, you will have blood tests to ensure your body’s healthy cells have had time to recover. If your blood count has not recovered, your doctor may delay treatment. Some women also have blood tests during treatment to check their tumour markers, such as CA125 (see page 14). If the CA125 level was high before chemotherapy, it can be monitored to see if the treatment is working.
Side effects of chemotherapy
Chemotherapy can affect healthy cells in the body, which may cause side effects. Not all women will have side effects, and they will vary according to the drugs you are given. Your health care team will talk to you about what to expect and how to manage any side effects.
Fatigue – Your red blood cell level (haemoglobin) may drop, which can cause you to feel tired and short of breath. Travelling to and from treatment can also be exhausting.
Nausea – Some chemotherapy drugs may make you feel sick or vomit. You will generally be given anti-nausea medicines with each chemotherapy session to help prevent or reduce nausea and vomiting. Whether or not you feel sick is not a sign of how well the treatment is working.
Changed bowel habits – Many women become constipated while on chemotherapy. This may be caused by anti-nausea drugs or because what you can eat changes. Your doctor will talk to you about taking laxatives. Diarrhoea (loose, watery bowel movements) is another possible side effect.
Hair loss – It is likely that you will lose your head and body hair, depending on the chemotherapy drug you receive. The hair will grow back after treatment is completed, but the colour and texture may change. For more details, call Cancer Council 13 11 20. If you have private health insurance, check with your provider whether you are entitled to a rebate on a wig purchased because of hair loss associated with chemotherapy.
Risk of infections – Chemotherapy reduces your white blood cell level, making it harder for your body to fight infection. Colds and flu may be easier to catch and harder to shake off, and scratches
or cuts may get infected more easily. You may also be more likely to catch a more serious infection and need to be admitted to hospital. Contact your doctor or go the nearest hospital if you have a temperature of 38°C or over or other signs of infection.
Joint and muscle pain – This may occur after your treatment session. It may feel like you have the flu, but the symptoms should disappear within a few days. Taking paracetamol may help.
Numbness or tingling in your hands and feet – This is called peripheral neuropathy, and it can be a side effect of certain chemotherapy drugs. Let your doctor know if this happens, as your dose of chemotherapy may need to be adjusted.
Targeted therapy drugs can get inside cancer cells and block particular proteins (enzymes) that tell the cancer cells to grow. These drugs are used to treat some types of ovarian cancer. They may also be used in certain situations (e.g. if chemotherapy has not been successful). Genetic testing will help determine if you have a particular faulty gene that may respond to targeted therapy drugs.
Bevacizumab is a targeted therapy drug used to treat advanced epithelial tumours. It works by stopping the cancer developing new blood vessels and growing. Bevacizumab is given with chemotherapy every three weeks as a drip into a vein (infusion). It is commonly given in repeating cycles.
Olaparib is a new treatment for women with high-grade epithelial ovarian cancer who have the BRCA1 or BRCA2 gene mutation. This drug is usually given after chemotherapy to help stop the cancer growing. It is taken as a tablet twice a day.
Other targeted therapy drugs may be available on clinical trials (see above). Talk with your doctor about the latest developments and whether you are a suitable candidate.
Side effects of targeted therapy
Although targeted therapy minimises harm to healthy cells, it can still have side effects. It is important to discuss any side effects with your doctor immediately. If left untreated, some can become life- threatening. Your doctor will monitor you throughout treatment.
The most common side effects experienced by women taking bevacizumab include wound-healing problems, bleeding, high blood pressure and kidney problems. In very rare cases, small tears (perforations) may develop in the bowel wall.
The most common side effects experienced by women taking olaparib include nausea, fatigue, vomiting, and low blood cell counts. More serious side effects include bone marrow or lung problems.
Radiation therapy (also known as radiotherapy) uses x-rays to damage cancer cells. The radiation is targeted at cancer sites in your body, with the aim of reducing the cancer’s growth and improving symptoms.
Radiation therapy for ovarian cancer may be used to treat the pelvis or other sites of cancer that have spread further away. It may be used after chemotherapy or on its own as a palliative treatment.
Before treatment starts, the radiation oncology team will explain the treatment schedule and the possible side effects. You will lie on a table under a machine that delivers radiation to the affected parts of the body. You will not feel anything during the treatment, which will take only a few minutes each time. You may be in the room for a total of 10–20 minutes for each appointment.
The number of radiation therapy sessions you have will depend on the type and size of the cancer. You may have a few treatments or daily treatment for several weeks.
Side effects of radiation therapy
The side effects of radiation therapy vary. Most are temporary and disappear a few weeks or months after treatment. Radiation therapy for ovarian cancer is usually given over the abdominal area, which can irritate the bowel and bladder.
Common side effects include feeling tired, diarrhoea, needing to pass urine more often and burning when you pass urine (cystitis), and a slight burn to the skin around the treatment site. More rarely, you may have some nausea or vomiting. If this occurs, you will be prescribed medicine to control it.
Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It is best thought of as supportive care.
Many people think that palliative treatment is for people at the end of their life, but it may be beneficial for people at any stage of advanced ovarian cancer. It is about living for as long as possible in the most satisfying way you can.
As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. The treatment may include chemotherapy and radiation therapy. If you are experiencing swelling and are uncomfortable, you may have a procedure called paracentesis or ascitic tap to drain the extra fluid from your abdomen.
Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, practical, emotional, spiritual and social needs.
You may find this checklist helpful when thinking about the questions you want to ask your doctor about the disease and treatment. If your doctor gives you answers that you don’t understand, ask for clarification.
- What type of ovarian cancer do I have?
- Has the cancer spread? What stage is it?
- What treatment do you recommend and why?
- Do I have more than one treatment option? If not, why not?
- What are the risks and possible side effects of each treatment?
- Are the side effects temporary or permanent? How can any
side effects be managed?
- How long will treatment take? Will I have to stay in hospital?
- How will the treatment affect my sex life and fertility?
- What are my fertility options?
- What sort of genetic testing can I have?
- Am I entitled to receive genetic counselling?
- Are the latest tests and treatments for ovarian cancer available
in this hospital?
- If I have to travel for treatment, is there any government
funding available to help with the cost?
- Are there any clinical trials or research studies I could join?
- How frequently will I need check-ups after treatment?
- Who should I go to for my follow-up appointments?
- Are there any complementary therapies that might help me?
- Should I change my diet during or after treatment?
- Should I exercise? When should I start? How much should I do?
- If the cancer comes back, how will I know?
- What are my treatment options if the cancer comes back?