Being diagnosed with ovarian cancer (OC) can be overwhelming, so understanding more about the disease and the treatment options, specifically surgery, can help the patients and their carers to make informed decisions with their healthcare practitioners. This article covers these topics and provides further resources for detailed information.

Understanding ovarian cancer

Overview 

OC is a cancer of the ovaries that plays a pivotal role in the reproduction process (giving birth). It is characterised by the abnormal growth of cells in them, and at later stages, the cancer can spread to nearby reproductive (or other) organs and lymphatic nodes. The affected organs can include:^1,2

• Ovaries: two ovaries situated left and right side, they produce eggs for pregnancy and hormones like Oestrogen,
• Fallopian tubes: tubes that connect the ovaries and the uterus, in which the eggs from the ovaries move to the uterus (present on both sides)
• Uterus: a hollow and muscular pear-shaped organ, in which the egg is fertilised by the sperm and where the baby grows

OC is the leading cause of death in women diagnosed with gynaecological cancers, including in the UK. It is also the eighth most frequent cause of death in women. These statistics are partly because OC is usually undetected at earlier stages, when women are usually asymptomatic or have nonspecific symptoms, like:^1,3

• Abdominal fullness
• Abdominal swelling  
• Bloating
• Nausea
• Early satiety (feeling full earlier than normal) 
• Fatigue
• Change in bowel movements
• Urinary symptoms 
• Back pain 
• Painful intercourse (dyspareunia)
• Unusual weight loss

The disease’s stage, whether detected early or at advanced stages, is an essential factor as it affects the chances of being fully treated. NICE UK grouped the symptoms and provided guidance, aimed at healthcare practitioners and patients suffering from OC and their carers, to raise awareness of the disease and its initial investigations, thus enabling earlier referral and optimal treatment.

Types of ovarian cancer

Since the ovaries have three main types of cells, each one can develop into three different types of tumour. 

Epithelial tumours

This type of OC starts from the cells that cover the outer surface of the ovary and is considered the most common type, presenting around 90% of OC cases. It is further subdivided based on several criteria, including how the cells look under the microscope, to either:³

• Serious, high and low grade
• Clear cell
• Endometrioid
• Mucinous 
• Other rare types

Germ cell tumours

This is a less common type of OC, around 5%, and starts from the cells that produce the female eggs (also called ova).³

Stromal tumours

They start in tissues that support the ovary and produce the female hormones oestrogen and progesterone. This type occurs in about 2-5% of patients.³

It is important to note that experts classify fallopian tube cancers and primary peritoneal cancers as epithelial OC due to the similarity in disease profile and current treatments between them.³

The disease stage, type and the patient’s medical background are used to determine the best treatment options. Within the last few years, the available therapies for OC have improved. More precise and less invasive surgical techniques have also been developed, and new effective medications are being authorised.^3,4 

Surgery remains the gold standard for treating OC. The two main objectives of surgery are to take tissue samples for diagnosis and determination of the stage of the disease (staging) and to remove as much of the tumour as possible (debulking).⁴

Surgery options

Ovariectomy

In ovariectomy, both ovaries are removed. This surgical option is used for staging and debulking to treat early ovarian cancer, in which cancer is present only in the ovaries. It can be performed by open surgery or as a minimally invasive procedure. Generally, ovariectomy is advised for newly diagnosed tumours that are limited to one or both ovaries and the pelvic cavity without spreading to other areas (no metastasis).⁴

Extended cytoreduction surgery

When the OC tumour has advanced (stages II, III and IV), extended cytoreduction is performed using open surgery to eliminate all cancer tumours with a thickness of >1 cm (debulking). Several steps are part of this surgical procedure to ensure its success. Firstly, fluid samples are collected from the space within the abdomen that contains the intestines, the stomach, and the liver (also called the peritoneal cavity) to evaluate if cancer has spread to this space. Surgeons, then, check this entire cavity to assess the absence of any suspicious extra ovary tumours. In the case of no suspicious masses, biopsies (small tissue samples) from different parts of the peritoneal cavity are collected and examined to make sure that the cancer did not spread in this region (metastasis). Finally, surgeons start to remove the primary tumour, the place in which the tumour first appeared. The surgery choice depends on where is the tumour and if the cancer has spread to nearby regions or organs, like:⁴

Bilateral salpingo‑oophorectomy 

To remove the ovaries and the fallopian tubes on both sides

Hysterectomy 

To remove the womb (uterus)

Omentectomy 

To remove the layer of fatty tissue that covers some of the abdominal organs, like the stomach and intestines. 

Lymph node dissection 

To dissect and remove both lymph nodes that are near the pelvis (pelvic) and the heart’s aorta (paraaortic)

Specific surgery options to maintain fertility

In early cases of OC, stage 1 in which the tumour is present on only one side of the ovaries, surgical options exist. If the patient is young (20‑45 years old) and wants to maintain the ability to conceive a child, ovariectomy on only the affected side can be performed to preserve the other healthy side. This allows the reproductive system to function normally and makes it possible to have a child and be cancer-free.⁴

In later stages of OC, a surgical option to remove the tumour and maintain fertility is possible after giving chemotherapy. The objective of this approach is to shrink the tumour size before doing the surgery (debulking), thus, preventing cancer from spreading after the surgery.⁴

In this case, a sample from the tumour is collected before chemotherapy to assess the tumour type and give the best anticancer drugs. If cancer is still detected after surgery, radiation therapy will be applied to the whole abdomen. This detection is done by a laparotomy, which is an operation to look inside your abdomen and pelvis to see if cancer has spread.⁴

Before, during, and after surgery patient care

Patient care before, during, and after surgery, also called per-operative care, is extremely important for the optimal success of the surgery. Healthcare practitioners developed a strategy called Enhanced Recovery After Surgery (ERAS) to help OC patients recover faster after their surgery and make their quality of life better. The strategy focuses on the importance of:⁵ 

• Educating the patient 
• Avoiding longer fasting times
• Balancing fluid intake
• Starting to eat as early as possible 
• Increasing movement and using opioids sparingly
• Managing pain

Accordingly, prehabilitation programs are now becoming an integral part of OC patient care, especially for those who underwent extended cytoreduction surgery.⁵

Summary

OC is a difficult gynaecological cancer because it is usually detected at later stages. Although therapies for this cancer type are becoming increasingly effective, early detection provides better treatment outcomes. Surgery remains the main treatment option for OC treatment, with several options depending on the disease stage and the need to to maintain the ability to become pregnant and give birth.

Patient care is an integral aspect of the current treatment plan to ensure the patient’s well-being and higher chances of treatment success.

Additional resources

For more information about the disease, surgery options, peri-operative recommendations, and follow-up, check the following:

• What is OC?
• Ovarian cancer
• Aring for OC surgery
• After having OC surgery
• Follow Types of OC surgeries
• Prepup for OC

Frequently asked questions

What is the best surgery for OC?

As mentioned before, there is one size fits all. The choice of surgery depends on different factors, like disease stage and personal preferences (being fertile).⁴

How long can OC cancer patients survive?

The survival of OC depends on several factors, like staging, cancer type and grade (high or low). Generally, longer survival rates decrease with the advanced stages of OC.⁶

What is the most aggressive type of epithelial OC?

The high-grade serous OC subtype is considered the most aggressive and common form of OC.⁷