Ovarian Cancer 101: Symptoms, Causes, Stages, Diagnosis & Treatment

What is Ovarian Cancer?

The ovaries are located in the pelvis, in between the stomach and the legs. This part of the body produces eggs for reproduction, and also produces female hormones such as estrogen and progesterone. There are two ovaries in women, one on each side of the body. When pregnancy occurs, the eggs travel down from the ovaries through tubes known as the fallopian tubes into the womb, where the fertilised egg settles and eventually becomes an infant. When cancer develops in the cells of the ovaries, it is known as ovarian cancer. 

Ovarian cancer is a cancer which affects the female reproductive system, the ovaries. It is the fifth most common cancer among women in Singapore, and the second most common female genital tract cancer. Usually, it affects women aged 40 to 60. Learn more about what is cancer from our article here. 

Ovarian Cancer Survival Rate

The outlook for ovarian cancer is poor, with a 5 year survival rate averaging 50%. Majority of cases are detected late in advanced stages. Recurrence rate for advanced ovarian cancer is as high as 80% and may require repeated surgery and chemotherapy. 

Types of Ovarian Cancer

There are many types of ovarian cancers. These are categorised into the three different types of cells which can be found in the ovaries. Each of these types of cells can develop into different tumors:

• Epithelial cells are the cells covering the outer surface of an ovary. Epithelial tumors are the most common type of ovarian cancer. 
• Germ cells are the cells that produce the eggs. 
• Stromal cells can be found in tissue cells that hold the ovary together. They produce the female hormones estrogen and progesterone.

Epithelial Ovarian Cancer

Epithelial ovarian cancer develops from epithelial cells. They are further grouped according to their appearance under a microscope. This cancer can be divided into: serous, mucinous, endometrioid, clear cell and borderline. Treatment for these subdivisions of epithelial cancer are often similar. 

Clear cell ovarian cancer, in particular, is rare but accounts for 25% of epithelial ovarian cancer in East Asian women (China, Japan, Korea, Mongolia). Risk factors for this form of epithelial ovarian cancer include family history of having clear cell ovarian cancer, having a history of endometriosis (a condition where tissue similar to the tissue lining the inside of the uterus grows outside the uterus), and having the inherited condition Lynch Syndrome, which increases susceptibility to several types of cancers. 

Germ Cell Ovarian Cancer

Germ cell tumors make up 3% of ovarian cancers. They originate from germ cells and are more common in young people. Not all germ cell tumours are cancers.

Sex-Cord Stromal Ovarian Tumors

These tumors are made up of the stromal cells, making up 5% of ovarian cancer cases.

Ovarian Cancer Staging

Similar to other cancers, staging determines advancement of the cancer of the ovary in the body. Typically, ovarian cancer staging refers to the spread from the ovaries to the pelvis to the abdomen or other organs. 

Stage 1

Cancer is on one of both ovaries. It has not spread to other parts of the body. 

Stage 2

Cancer has spread beyond the ovaries to the pelvic region. This can involve the uterus, fallopian tubes, bladder and rectum.

Stage 3

Cancer has spread beyond the pelvis to the abdominal region. 

Stage 4

Cancer has spread beyond the abdomen to other organs such as the liver and lungs.

There may also be mention of grade or differentiation of the tumor. This is determined by how the cancer cells look under the microscope. Grading is divided into three groups: one, two and three. It indicates how quickly the cancer cells could divide and grow.

Ovarian Cancer Symptoms

Ovarian cancer is hard to detect early, as its symptoms are common in other non-cancerous conditions. The main symptoms of ovarian cancer include: 

• Bloating
• Pelvic or belly pain 
• Difficulty eating or feeling full quickly 
• Urinary symptoms, such as feeling the need to go to the toilet often, or constantly feeling urgent 

As the cancer grows, symptoms may include:

• Pressure or pain in the abdomen, pelvis, back, or legs
• Swollen or bloated abdomen caused by fluid build-up or a tumor, and weight loss
• Nausea, indigestion, gas, constipation, or diarrhoea
• Shortness of breath
• Unusual vaginal bleeding (heavy periods, or bleeding after menopause)​
• Fatigue (extreme tiredness)
• Stomach upset
• Back pains
• Pain during sex
• Constipation

Symptoms of ovarian cancer can appear to look like symptoms of other conditions. It is important to know what is an individual’s usual body functioning, and what is abnormal. Seek a consultation with a doctor if concerned about having any of the above symptoms. 

Risk Factors of Ovarian Cancer

The cause of ovarian cancer is unknown. There are some risk factors for women to look out for: 

• Women who have never been pregnant
• Women who did not have many children 
• Mature pregnancy
• Family history of ovarian cancer 
• Diet high in fat 
• Menstruation starting early or late menopause 
• Endometriosis (a condition where tissue similar to the tissue lining the inside of the uterus grows outside the uterus)
• Menopausal hormone therapy i.e. taking estrogen
• Personal history of cancer, especially that of the breast, uterus, colon, or rectum

Ovarian Cancer Diagnosis

Diagnosis begins with a doctor’s visit. The doctor will ask about family history and symptoms, to collect information to help make a diagnosis. One or more of the following tests may be prescribed: 

Physical Exam

The doctor will do a check on general health, and also press on the abdomen to check for tumors or abnormal fluid build-up in the region. Fluid samples may be taken for further examination of cancer. 

Pelvic Exam

The ovaries and nearby organs are felt by the doctor for any lumps or other changes in the physical shape and size of the organs. 

Blood Tests

Blood tests may be ordered and samples will be taken for laboratory testing, which checks for several substances, including CA-125, which is found on the surface of ovarian cancer cells and on some normal tissues. High CA-125 levels may be a sign of cancer or other conditions. Testing the level of CA-125 is not used in isolation to diagnose ovarian cancer, and is typically used in conjunction with other examinations. 

Ultrasound

The ultrasound device uses sound waves which cannot be heard by people to help create images of internal organs for better viewing. These images are viewed on a computer, and may help to detect the presence of a tumor. For a better view of the ovaries, the device may be inserted into the vagina (transvaginal ultrasound).

Biopsy

A biopsy is the removal of tissue or fluid to look for cancer cells. This is done with other tests, such as blood tests and ultrasound. Based on the blood test and ultrasound results, surgery known as a laparotomy may be suggested to remove tissue and fluid from the pelvis and abdomen. To make a diagnosis of ovarian cancer, surgery is usually required.

Laparoscopy

A thin, lighted tube (a laparoscope) is inserted through a small cut made in the abdomen. Laparoscopy may be used to remove an early ovarian cancer or small, non-cancerous lumps. It may also be used to learn whether cancer has spread.

Can Ovarian Cancer Be Found Early? 

Currently, there are no known or recommended screening tests for ovarian cancer for preventative measures. Screening tests used for cervical cancer, such as a Pap test or HPV (human papillomavirus) test, are not effective in detecting ovarian cancer. Very rarely, Pap tests detect the presence of ovarian cancer, but this is usually when the cancer is at a later stage. 

Ovarian Cancer Treatment

Treatment for ovarian cancer involves surgery and chemotherapy. 

Surgery

Surgery is needed in most cases. The surgeon will perform an operation on the abdomen, otherwise known as laparotomy. This makes a long cut in the wall of the abdomen. If ovarian cancer is detected, the surgeon will remove: 

• Both ovaries and fallopian tubes (salpingo-oophorectomy) 
• The uterus (hysterectomy) 
• The omentum (the thin, fatty pad of tissue covering the intestines)
• Nearby lymph nodes samples of tissue from the pelvis and abdomen

As ovarian cancer is pervasive, surgery usually involves extensive removal of various structures of the female reproductive system. Samples from the abdomen will be extracted and sent to a laboratory for determining the cancer spread. 

At advanced stages, where cancer has spread into the abdominal region, pelvic lymph glands and any secondary cancers in the abdomen are also removed. For women who wish to preserve their childbearing abilities, it is sometimes possible to remove only the affected ovary and fallopian tubes.

Chemotherapy

Chemotherapy is a drug treatment that kills cancer cells. It is usually recommended for women with advanced stage ovarian cancer. For women in the early stages of ovarian cancer, chemotherapy can also be given after surgery to prevent it from coming back. There are side effects of chemotherapy, such as being more vulnerable to catch infections and viruses due to a weakened immune system, fatigue, constipation, numbness in fingers and toes, and hair loss. 

Radiotherapy

This form of treatment, which uses high doses of radiation to kill cancer cells, is occasionally used. If the tumor is only found in the pelvic region, radiotherapy is the treatment of choice. It is also used to destroy cancer cells that remain after surgery.

Ovarian Cancer Prevention

At present, there is no known effective screening tool for ovarian cancer, or vaccine to defend against it. If there is a strong family history of breast or ovarian cancer, it may be appropriate to go for genetic counseling and testing. Prevention includes reducing risk by mitigating risk factors. This could include having children, and keeping a healthy diet, lower in fat. 

Ovarian Cancer Support Group and Resources in Singapore

Established in 2008, the Gynaecology Cancer TEAL Support Group was formed by a group of healthcare professionals to provide peer support among women diagnosed with ovarian and other gynaecologic cancers. This was first started at the National University Cancer Institute, Singapore (NCIS) located at the National University Hospital (NUH). The word TEAL is an acronym for women who are Totally Empowered and Actively Living, and membership to join this group is free. Quarterly activities are conducted, of which include educational talks, seminars, workshops, excursions and year end parties. 

Support for caregivers and patients to tide through difficult times like a cancer diagnosis is highly important for mental and physical well-being. View our list of support groups here.

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