Treatment: Ovarian Cancer

What is Ovarian Cancer?

Cancer occurs when the cells of the body grow and spread to other parts of the body uncontrollably. Ovarian cancer, as the name suggests, affects the ovaries, which stores the eggs needed for childbirth. Since the cancer is in the ovaries, people assigned male at birth (TAMAB)  cannot have ovarian cancer; however, numerous studies have shown that transgender men (men assigned female at birth) may have an increased risk.  

Statistics show that ovarian cancer makes up 2.5% of cancer cases and about 5% of all cancer-related deaths in those assigned female at birth (TAFAB); hence, it has a low survival rate, making it the fifth most common cause of cancer death in TAFAB after lung, breast, colorectal, and pancreatic cancers. The low survival rate of this disease is mostly due to late detection of the condition. Early detection of ovarian cancer is important in disease management and to increase chances of survival. Ovarian cancer is typically diagnosed at a late stage, mostly because it has no effective screening strategy.¹

Signs and Symptoms

1. Lack of appetite or feeling satisfied quickly when eating

2. Bloated and swollen stomach

3. Abnormal vaginal discharge

4. TAFAB who are past menopause sometimes experience vaginal bleeding

5. Constipation

6. Abnormal and frequent urination

7. May experience pain in the abdominal region

8. May experience pain in the back and pelvic area

9. Diarrhoea

10. Abnormal weight loss

Causes and Risk Factors

1. Family History and Related Genetic Syndromes

A family history of ovarian cancer is the biggest risk factor for the condition. When one of your relatives has ovarian cancer, your chances of developing the disease in your lifetime is raised by 5% – while when two of your relatives have the diagnosis your chance is further raised by 7%.² There are also certain genetic mutations that, when present, increase your risk of getting ovarian cancer. These same genes increase your chance of getting other cancers like breast cancer. These hereditary genes are present in 1 in every 500 of TAFAB, and are responsible for 23% to 54% risks associated with ovarian cancer.³

2. Endometriosis

Endometriosis (derived from the word “endometrium” and refers to the tissue that lines the uterus) is a gynaecological condition in which the endometrium grows outside the uterus. This condition is mostly characterised by an abnormal menstrual flow (heavy), severe menstrual cramps and painful sexual intercourse. This complex condition affects about 10% of all TAFAB of a reproductive age, and makes their life difficult. Endometriosis can lead to sudden miscarriage and also can cause infertility.⁴ Studies have shown a strong relationship between ovarian cancer and a diagnosis of endometriosis.⁵

3. Delay in Giving Birth

TAFAB who give birth at a later age have an increased risk of ovarian cancer than those who give birth at a younger age.⁶

4. Amount of Children

TAFAB who give birth to a smaller number of children (low parity) are at increased risk of ovarian cancer, and those giving birth to a lot of children (high parity) have decreased risk of that disease.

5. Age of Menstruation 

TAFAB who menstruate at a younger age have an increased risk of ovarian cancer as compared with TAFAB who experience late menarche (menstruate at a later age).⁷

Other risk factors include smoking, physical inactivity, high-fat diet and late menopause. It is also important to note that several of TAFAB with ovarian cancer have no family history of the disease or no known cause of the disease.

Types of Ovarian Cancer

There are three types of ovarian cancer:

Epithelial Ovarian Cancer

This type of cancer starts outside the ovaries. It is the most common type of ovarian cancer, which makes up about 85-95% of all cases and it usually occurs in TAFAB who are 50 years and above.⁸

Stromal Cancer

This type of cancer begins with the ovarian cells that produce the hormones. Doctors can easily identify this type at an early stage. It accounts for 5-8% of all ovarian cancer cases.

Germ cell cancer

This type starts in the egg cell and occurs in TAFAB at about 18 years and younger. It is a very rare condition as it accounts for less than 2% of all cases.

Stages of Ovarian Cancer

Source: International Federation of Gynecology and Obstetrics (FIGO) Classification for Stages and Prognosis of Ovarian Cancer

Stage One

• Description: Tumour is in one or both ovaries
• Rate of survival for 5 years: 90% survival rate

Stage Two

• Description: Cancer cells spread to the uterus, fallopian tube and other parts of the pelvis
• Rate of survival for 5 years: Between 60% - 80% survival rate

Stage Three

• Description: Cancer cells have spread outside the pelvis to the abdomen area, liver, intestines and nearby lymph nodes
• Rate of survival for 5 years: 20% survival rate

Stage Four

• Description: Cancer cells have spread beyond the abdomen (distant metastases)
• Rate of survival for 5 years: Survival rate is less than 10%

Early Signs and Diagnosis of Ovarian Cancer

Ovarian cancer is easily treatable if detected early; however, because the ovaries are seated deeply in the abdominal cavity, it is unusual to be able to feel a tumour present and symptoms do not occur until the disease reaches its later stage which makes early detection difficult as TAFAB with this condition have little or no symptoms. Any unusual symptoms should be reported to your doctor who will most likely perform a pelvic examination.

Imaging and biopsy techniques help in the diagnosis of ovarian cancer. The most common imaging techniques in the pelvic area are transvaginal ultrasonography (TUS or TVUS), magnetic resonance imaging (MRI scan) and computer tomography (CT scan). Sometimes at the early stage, imaging results will not show whether the tumour present is benign or cancerous.  When compared to TUS, MRI is more accurate and specific in finding out whether a tumour is cancerous. But MRI is more expensive and less accessible.⁹

In addition to imaging modalities, a blood test can be done to look for the ovarian cancer biomarker, CA-125. This blood test is very common and readily available. At elevated antigen levels, the biomarker CA-125 can be detected; therefore, this test is highly effective for late-stage diagnosis. Sometimes elevated levels of the CA-125 biomarker are seen during pregnancy or menstruation, hence giving false-positive results.¹⁰

Another marker used in a recent study is HE4. This biomarker has a very high specificity and is present in both early and late-stage ovarian cancer. The limitation of this marker is that it is mostly expressed by patients with epithelial ovarian cancer. Therefore, a combination of CA-125, HE4, other biomarkers and imaging techniques will give more accurate results and diagnosis.^{11, 12}

Treatment Options for Ovarian Cancer

The treatment options for ovarian cancer depend on factors like the type of ovarian cancer and the stage of the cancer.

Surgery

When ovarian cancer is in the early stages and has not spread to other parts of the body, it can be surgically removed.

• Bilateral Salpingo-oophorectomy

Bilateral salpingo-oophorectomy is a total hysterectomy to remove both ovaries (oophorectomy) and fallopian tubes (salpingectomy). TAFAB who have gone through this surgical procedure will not be able to give birth and will not menstruate again.

• Abdominal Hysterectomy

In an abdominal hysterectomy, the uterus is removed by a surgical cut in the lower abdomen. The incision can be made vertically from the belly button or horizontal at the bikini area. This surgical procedure is recommended when the tumour is not possible to remove through the vagina because the fibroids are too big.

Chemotherapy

In chemotherapy, drugs are used to treat cancer. They usually enter the bloodstream directly to reach all parts of the body. Chemotherapy is recommended when ovarian cancer has metastasised to other organs, lymph nodes, and other parts of the body.

Radiotherapy

In radiotherapy, high-energy radiation is used to kill cancer cells. This treatment is used in advanced-stage cancer when other treatment procedures do not work.

Targeted Therapy

In these types of therapies, the drugs used identify and destroy cancer cells but cause little damage to normal cells. These types of therapies are able to affect cancer cells because cancer cells are programmed differently from normal cells and they work by changing the way cancer cells divide, grow and interact with other cells.

Hormone Therapy

Hormone therapy is a treatment procedure where the hormone oestrogen is blocked to prevent the growth of some cancer. Some cancer cells require the hormone oestrogen to grow and metastasise. This treatment procedure is rarely used.

Immunotherapy

Immunotherapy is used mostly as a last resort when other treatment procedures fail. It takes advantage of a person’s own immune system to help kill the cancer cells. This treatment helps the body to recognise and kill cancer cells by boosting the immune response and the immune cells that kill cancer cells.

Palliative Care

Palliative care is a specialised kind of care given to patients who have a serious illness like ovarian cancer and the goal of this care is to relieve symptoms, pain and stress that comes with the disease for both patient and their family. It can be administered at any stage of ovarian cancer together with other treatment regimens.

Side Effects of Treatment

Various treatment regimens may have different or similar side effects. Some side effects include:

1. Nausea, vomiting and fever
2. Hair loss
3. Lack of appetite
4. Diarrhoea or constipation
5. Sore mouth
6. Rashes around the hand and feet
7. Increased chance of infection due to low white blood cell count
8. Fatigue and tiredness
9. Kidney damage or nerve damage leading to neuropathy (long-term effects of chemotherapy)
10. Nerve damage around the ear area leading to hearing impairment (long-term effects of chemotherapy)
11. Early menopause, infertility and vaginal dryness

Recent Research in The Treatment of Ovarian Cancer

Recent drugs, although some are still undergoing FDA approval, have been shown to reduce the progression of the disease and to stop disease recurrence. Examples of such drugs are from the class of PARP inhibitors. PARP inhibitors work by making it difficult for cancer cells to repair themselves. Cancer cells can survive because they repair their DNA when there is damage. Another class of new drugs is called anti-angiogenics which kill cancer cells by blocking blood vessels to starve the tumour.

Summary

Most cases of ovarian cancer are detected at a later stage, so TAFAB should understand their bodies and inform their doctor about any unusual symptoms. If necessary, some detection methods can be combined to help in the diagnosis of the condition. Suitable treatment options will be discussed by your doctor.