Ovarian cancer is often diagnosed late because of its vague symptoms

In Malaysia, ovarian cancer is the fourth commonest cancer in women and tenth most common overall. — 123rf.com

The ovaries are two of the female organs adjacent to the uterus.

Their dual functions are the storage of eggs for reproduction and the production of female sex hormones.

The latter helps in the development of the breasts, vagina, uterus, fallopian tubes and female body shape during puberty; and regulates the menstrual cycle.

Tumours can be non-cancerous (benign) or cancerous (malignant).

Benign tumours do not spread; they may require treatment, but are rarely life-threatening.

Malignant tumours, however, can spread to other parts of the body and are life-threatening.

As such, it is important to detect them early.

According to the National Cancer Registry 2012-2016, malignant ovarian tumours are the fourth most common cancer in women, and the tenth most common overall.

The highest incidence was in those aged 65 to 69.

The overall lifetime risk was one in 167 (meaning that a woman has a 0.006% chance of developing ovarian cancer in her lifetime).

Breaking it down by ethnicity, the lifetime risk was one in 160 for Malays, one in 169 for Chinese and one in 164 for Indians.

Risk factors

Two main factors increase the risk of ovarian cancer: age and family history.

One of the risk factors for ovarian cancer is having your first child after the age of 30. — AFP filepic

Increasing age increases the risk of ovarian cancer as most cases occur above the age of 50 years.

However, there are some instances of ovarian cancer in younger women.

The risk of ovarian cancer is increased if two or more relatives on the same side of the family (whether maternal or paternal) have ovarian or breast cancer.

This is because of the inheritance of faulty mutations in the BRCA1 or BRCA2 genes.

The rare familial condition known as hereditary non-polyposis colorectal cancer (HNPCC), can slightly increase the risk of ovarian, uterus, stomach, colon, pancreatic, biliary and bladder cancers.

This condition is due to the inheritance of the faulty genes MLH1, MSH3 and MSH6.

The following factors can also slightly increase the risk of ovarian cancer:

• A long menstrual history, i.e. periods starting before 12 years of age and menopause after 50 years of age
• Having the first child after 30 years of age
• Not having children
• Not breastfeeding
• Endometriosis, and
• Using oestrogen-only hormone replacement therapy (HRT).

Smoking may also specifically increase the risk of mucinous ovarian cancer.

Types and stages

There are three main types of ovarian tumours, which are differentiated based on the part of the ovary they arise from, i.e. epithelial, germ cell and sex cord stromal.

Malignant epithelial tumours develop from the outer surface of the ovary.

They account for 90% of all ovarian cancers and are further categorised into six types: serous, mucinous, endometrioid, clear cell, transitional cell and undifferentiated.

Germ cell tumours develop from the cells that produce eggs.

Most occur in younger women and about 90% are curable with preservation of fertility.

Sex cord stromal tumours arise from the ovarian connective tissue.

They are rare and usually considered low-grade cancers with about 70% presenting in stage 1.

There are four stages in ovarian cancer:

• Stage 1: The cancer is confined to one or both ovaries.
• Stage 2: The cancer is outside the ovary or ovaries, but has spread no further than the pelvic region, i.e. to the uterus, bladder or lower intestines only.
• Stage 3: The cancer involves one or both ovaries with spread beyond the pelvic region into the abdominal cavity (but not the liver) and/or to nearby lymph nodes.
• Stage 4: The cancer has spread to other parts of the body, e.g. the liver, lungs and/or brain.

As different cancers grow at different rates, they are graded according to their expected growth.

The tumour grade is based on how much it resembles normal tissue.

Low grade cancer grows slowly, whereas high grade ones grow and spread rapidly.

The tumour grades are:

• Grade 0: The tissue is borderline cancerous with low malignant potential, i.e. unlikely to spread and usually curable.
• Grade 1: Well-differentiated with many healthy-looking cells.
• Grade 2: Moderately differentiated with more abnormal cells than healthy ones.
• Grade 3: Poorly differentiated or undifferentiated cells with lack of normal tissue.
• Grade GX: Cannot be evaluated.

Symptoms

Unfortunately, many women do not take note of their symptoms until they are at the advanced stages.

This is because ovarian cancer symptoms are often vague or may resemble those of other less serious conditions.

The four primary symptoms of ovarian cancer are:

• Persistent abdominal/pelvic pain
• Persistent bloating
• Eating difficulty or feeling full quickly
• Needing to pass urine frequently

Sometimes, there may be other symptoms that occur on their own or at the same time as those above.

They include changes in bowel habits, e.g. diarrhoea or constipation, fatigue, and back pain.

The issue is that many of the above symptoms do occur from time to time in many people, and are often due to other, non-serious conditions.

However, suspicion that you might have ovarian cancer should occur when the symptoms are:

• Persistent, i.e. they do not go away
• Frequent, i.e. they are present for more than 12 days a month
• Becoming progressively worse
• New, i.e. they started in the last 12 months
• Unusual, i.e. do not feel normal.

The above are well summarised in the Ovarian Cancer Awareness Month infographic (see below) from the Malaysian International Representative Committee of the Royal College of Obstetricians and Gynaecologists, and the Malaysian Gynaecological Cancer Society – an appropriate project as International Women’s Day was on March 8.

It is prudent for any woman who experiences any of the above symptoms on most days of the month to seek medical attention from a general practitioner and/or gynaecologist.

This is especially so for anyone with increased risk of ovarian cancer.

Although the symptoms may be due to some other condition, it is best to have a medical evaluation.

Better to be safe than sorry!

Diagnosis

There is no effective and reliable diagnostic test for ovarian cancer.

If there are signs and symptoms of ovarian cancer, the following tests are available, especially for those at increased risk:

• Pelvic examination can detect an enlarged ovary or fluid in the abdominal cavity.

  The examination of the vagina, uterus, ovaries and rectum can detect any unusual changes like a mass.

  However, some cancers are very small and cannot be detected on pelvic examination.

• Transvaginal ultrasound involves the insertion of a probe into the vagina to look at the ovaries and uterus.

  This examination is especially appropriate for those at increased risk for ovarian cancer or those with an abnormal pelvic examination.

• CA-125 blood estimation measures the level of a protein that is increased in ovarian and fallopian tube cancers.

  However, CA-125 is not a key marker of ovarian cancer as some benign tumours, e.g. fibroids and endometriosis, can also increase CA-125, and some ovarian cancers do not produce sufficient CA-125 for a positive test.

  Because of these reasons, CA-125 is not routinely used as a screening test for those at average risk, but rather, as a baseline for monitoring those on treatment.

• A computed tomography (CT) scan is a detailed X-ray examination that can inform on whether the ovarian cancer has spread to other organs.

  It does not detect small tumours well, but may detect spread to adjoining organs.

• Magnetic resonance imaging (MRI) may be helpful in examining the brain and spinal cord, to which the cancer could have spread.
• A positron emission tomography (PET) scan involves intake of radioactive glucose that is taken up by rapidly growing cancer cells, which can then be detected by areas of radioactivity.

  This provides useful information on whether abnormal areas seen in other tests are likely to be cancerous.

Treatment

Treatment includes surgery, chemotherapy, radiation or a combination of these methods.

The outcome of ovarian cancer depends on many factors, e.g. age, stage and type of cancer, and overall health.

The majority of ovarian cases are diagnosed when they are at advanced stages, i.e. stages 3 and 4, where survival rates are low.

As such, early detection is critical.

---

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.