Ovarian Cancer: The overlooked threat among women’s cancers

Ovarian cancer, often termed a silent killer, remains underdiagnosed due to vague symptoms and lack of screening. With high mortality rates in advanced stages, awareness, genetic testing, and early detection are crucial to improve survival and long-term outcomes.

By Dr Geetha Nagasree​

Ovarian cancer enjoys a reputation of being a silent killer. Is it really a silent killer? Just how significant is the disease? Ovarian cancer gives out several clues; however, we fail to pick them up. The various risk factors are clearly known, yet we tend to ignore this precious subgroup. Though screening is not routinely recommended, tests to detect the disease in its early stages are available. Ovarian cancer, despite being a common cancer, remains under a shroud, and time has come to focus on its awareness almost as much as it’s more popular sisters, breast cancer and cervical cancer.

​Ovarian cancers rank third behind cancers of the breast and cervix in Indian women, endometrial cancer making the last of the quartet. The numbers of ovarian cancers in India is startling! studies combining various population registries have shown that that India may have the most number of ovarian cancers globally, and the second highest incidence in the world. It is the 7th most common cancer worldwide. Its incidence is 2.5 % of all female cancer cases, but accounts for 5 % of the deaths.

​90% of the cases are seen in the post menopausal age group of 54 to 65 years. The most dangerous statistic is that almost 60% are diagnosed with the disease having spread more than locally when survival ( 5 year survival )is around 29%.Survival when disease is restricted locally is around 90%. The difference in this statistic is very significant, especially since clear risk factors exist. The incidence is four fold amongst first degree relatives of patients with ovarian cancers, and two folds amongst second degree relatives. Two distinct genetic mutations which cause increased incidence of ovarian cancer are identified. These account for 20% of cases which are due to these inherited mutations, mainly BRCA 1 and BRCA 2. Other risk factors include obesity, tall height (due to growth hormone exposure early in life), cigarette smoking, physical inactivity and nulliparity.

​The late recognition of signs and symptoms is one of the major obstacles in recognizing the disease. The other major obstacle is the absence of reliable screening tests. Ultrasonography of the abdomen and CA125 , a blood test may detect the disease relatively early, but it has to be deployed with a high index of suspicion, and the routine usage outside of high risk cases is not yet warranted.

​Symptoms of ovarian cancer typically include vague abdominal pain, distension, feeling of fullness or bloating, frequency of micturition, early satiety after having food, constipation, and back pain and menstrual disorders. These symptoms are very nonspecific and can be frequently ignored to be something else. The awareness and a high index of suspicion help in getting timely diagnostic tests done early and with better outcomes. Nowadays, there are genetic studies which make an evaluation of one’s propensity for developing ovarian cancer. Ovarian cancer has a strong genetic basis as well. In certain high risk cases with strong family history and genetic predisposition, prophylactic removal of ovaries and fallopian tubes are done, but this is however, a highly individualistic choice made after discussion with ones doctor. The choice to remove her breast to prevent breast cancer by the Hollywood star Angelina Jolie has brought these therapies to the focus and forefront.

​Surgery remains the mainstay of treatment for patients with ovarian cancer. All evidence of the disease is removed surgically and in this process, the ovaries, the fallopian tubes as well as the uterus are removed. At times, if the disease is extensive, intestine, liver or spleen may need to be removed.

​There have been numerous studies which have shown that extensive removal of disease at time of first surgery itself in expert hands gives the best long term survival. At times, it may not be possible to remove 100% of the disease without risking complications. In such a scenario, subsequent chemotherapy is given to dissolve the remainder of the microscopic or macroscopic disease. Sometimes, if the disease is too extensive, initial chemotherapy is given to lessen the disease burden and this is followed up then by surgery.

​Chemotherapy is often given as an adjuvant measure to control the ovarian cancer. Chemotherapy may be in the form of injections or tablets. Nowadays, special chemotherapy agents which act on specifically targeted cells which reduce the complications of chemotherapy are given with good result. Two special forms of chemotherapy find a special mention- HIPEC (Hyperthermic Intra Peritoneal Chemotherapy) in which chemotherapy agents are heated to 41 to 43 degrees Celsius and circulated inside the abdomen for 90 minutes. This is done once entire tumour malignancy is removed from the abdomen during surgery and accounts for microscopic residual disease thus resulting in better outcomes. But it is indicated in selected patients only and requires special training. PIPEC (Pressurized Intra Peritoneal Chemotherapy) requires specialized equipment, where chemotherapy is converted to aerosol and injected intra abdominally. The advantage is that the chemotherapy has maximum local effect and lesser systemic side effects. This is reserved for more advanced version of the disease.

​Radiotherapy is of limited use in ovarian cancer and is used often in stage IV disease where tumour is spread to distal areas. Radiotherapy is given mainly for pain relief.Newer modalities like immunotherapy which uses the patient’s own immunity to act against the cancer cells is being evaluated and is available mainly in the setting of clinical trials.

​There is a fundamental shift in the approach towards the treatment of cancers, especially ovarian cancer. It is approached as treating a chronic disease with flare ups once in a while like Diabetes Mellitus or Hypertension. But a positive attitude and outlook improves the outcomes, adding not just years to the life of the patient but also life to the years of the patient.

(The author is a senior surgical oncologist in Care Hospitals, Gachibowli)