Cancer Research UK : Ovarian Cancer symptoms, diagnosis and treatment

Ovarian Cancer symptoms, diagnosis and treatment

The ovarian cancer treatment information on these pages is designed for use by health professionals. If you are looking for information because you or someone you know is receiving treatment for cancer, then the CancerHelp UK pages on ovarian cancer treatment will be more relevant and useful. You may also be interested in our clinical trials database. CancerHelp UK also has detailed information on more than 30 types of cancer.

The information on ovarian cancer treatment on this page includes symptoms, diagnosis and staging, surgery, chemotherapy, treatment of disease relapse and prophylactic surgery.

Symptoms of ovarian cancer

Symptoms of ovarian cancer are frequently vague and are difficult to distinguish from other conditions.

The more common symptoms of ovarian cancer include abdominal pain and bloating, fatigue, weight loss, urinary symptoms and occasionally abnormal vaginal bleeding1-4. One audit in the UK reported that nearly 80% of patients had had symptoms for less than four weeks when they presented at general practice, and 73% of these were referred within four weeks (most within two)5.

Diagnosis and staging of ovarian cancer

If ovarian cancer is suspected, an urgent referral should be made to a dedicated diagnostic centre at the nearest Cancer Unit6.

A risk of malignancy index (RMI) has been developed which combines the results of transvaginal ultrasound examination (U), menopausal status (M) and blood levels of the ovarian cancer marker CA125 (measured in U/ml)7-10. All RMI use the basic formula: RMI = U x M x CA125, but differ in the scores that are assigned to U and M. It has been shown that using a cut-off value for the RMI of 200 (regardless of scoring system) achieves sensitivities ranging from 70% to 87% and specificities ranging from 89% to 97%)7-12.

Use of measures such as the RMI and clinical examination enables the gynaecologist to refer patients with likely ovarian cancer to a specialist gynaecological oncologist who should undertake surgery for suspected ovarian cancer13, 14.

The primary intervention in a woman with suspected ovarian cancer is to obtain histological confirmation of the disease. This is generally undertaken at a laparotomy, whereby, the disease can also be staged. The FIGO staging15 is shown in Table 6.1.

Table 6.1: the main stages of ovarian cancer

Download this table (20.0KB)

Surgical treatment of early ovarian cancer according to menopausal status

In younger patients, where fertility is an issue, the appropriate surgery is to diagnose and stage the disease while importantly, retaining the woman’s fertility. This is because, in many cases, the cancer will be a germ cell tumour or early ovarian cancer (Stage 1A), which are amenable to non-radical surgical interventions16-19. In women who have completed their families, or are post-menopausal, it is recommended that the uterus, fallopian tubes and ovaries are removed and relevant biopsies performed15.

Surgical treatment of advanced ovarian cancer

In a situation where there is very advanced disease, all of which cannot be excised by surgery, many surgeons perform ‘debulking’ surgery, endeavouring to leave behind as little tumour as possible. This is thought to improve the efficacy of adjuvant chemotherapy, but the evidence to support this is questionable. Two studies are presently ongoing to address this important question, one called EORTC 55971, and a second called CHORUS.

Adjuvant chemotherapy in early ovarian cancer

Immediately following surgery, many women are given adjuvant chemotherapy, normally using a platinum compound. In women with no residual disease, the recent randomized controlled trial (RCT) ICON1, indicated that platinum-based chemotherapy does improve survival20. Another RCT investigating the effectiveness of adjuvant chemotherapy (ACTION) found no difference in overall survival but that disease-free survival was improved in women in the treatment arm21. A meta-analysis of five trials of adjuvant chemotherapy compared with no further treatment in early ovarian cancer (including the two mentioned above) showed an improvement in both overall survival and disease-free survival (hazards ratios of 0.71,95% CIs 0.63 to 0.80; and 0.68, 95%CIs 0.59 to 0.79, respectively)22. A pre-planned combined analysis of the ICON1 and ACTION trials also came to the same conclusion23.

Adjuvant chemotherapy in advanced ovarian cancer

In more advanced disease, some studies have reported improved survival when paclitaxel is combined with a platinum agent24, 25. However, the largest study, ICON3, suggested that there was no difference in outcome with combination therapy26. Debate continues with regard to these findings, and NICE recommendations are that women requiring chemotherapy should have a platinum agent administered, and the possible addition of paclitaxel should be discussed on an individual basis27.

Treatment of ovarian cancer relapse: chemotherapy

In relapsed disease, the main determinant of continued survival and, indeed, response to further chemotherapy is the time interval from completion of the last therapy. Disease which develops within six months from the end of treatment would be deemed resistant to that therapy, and further therapy will be individualised. Outside this time period, further responses to platinum can be anticipated, or to paclitaxel if it was not used previously. A recent randomised controlled trial (ICON4) revealed that in relapsed disease (occurring after at least 6 months from cessation of treatment), the combination of carboplatin and paclitaxel afforded a better survival when compared to single agent carboplatin28. This finding contradicts those of ICON3 but, of course, the disease processes at relapse may be different.

Treatment of ovarian cancer relapse: surgery

The role of routine surgery in relapsed disease is another area of controversy29. Surgery can sometimes be helpful in the alleviation of symptoms, but whether its routine use is useful needs addressing through clinical trials. From retrospective studies, it appears that optimum debulking surgery at relapse results in lengthened survival30.

Prophylactic surgery

Prophylactic oophorectomy has been shown to decrease the risk of BRCA-mutation-related gynaecological cancers and breast cancer in BRCA1 and BRCA2 mutation carriers31, 32. In general, in order to reduce the risk of ovarian cancer, prophylactic surgery before the age of 40 years is probably best, as the disease incidence in these women starts to increase after this age. Of great importance is that these women have access to the appropriate specialists, as such a procedure can have extensive psychological consequences33.

References for ovarian cancer symptoms and treatment

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NHS Executive, Ovarian cancer: treatment, in Guidance on commissioning cancer services: Improving outcomes in gynaecological cancers. The manual. 1999, Department of Health: London. p. 30-34.
Scottish Intercollegiate Guidelines Network (SIGN), Epithelial ovarian cancer: A national clinical guideline. 2003.
FIGO Committee on Gynecologic Oncology, Staging classifications and clinical practice guidelines of gynaecological cancers ed. J. Benedet, et al. 2000.
Zanetta, G., et al., Conservative surgery for stage I ovarian carcinoma in women of childbearing age. British Journal of Obstetrics and Gynaecology, 1997. 104 (9): p. 1030-1035.
Low, J.J., et al., Conservative surgery to preserve ovarian function in patients with malignant ovarian germ cell tumors. A review of 74 cases. Cancer, 2000. 89(2): p. 391-8.
Morice, P., et al., Results of conservative treatment in epithelial ovarian carcinoma. Cancer, 2001. 92(9): p. 2412-8.
Schilder, J., et al., Outcome of reproductive age women with stage IA or IC invasive epithelial ovarian cancer treated with fertility-sparing therapy. Gynecol Oncology, 2002. 87: p. 1-7.
Colombo, N., et al., International Collaborative Ovarian Neoplasm Trial 1: A randomized trial of adjuvant chemotherapy in women with early-stage ovarian cancer. Journal of National Cancer Institute, 2003. 95 (2): p. 125-132.
Trimbos, J.B., et al., Impact of adjuvant chemotherapy and surgical staging in early-stage ovarian carcinoma: European Organisation for Research and Treatment of Cancer-Adjuvant ChemoTherapy in Ovarian Neoplasm trial. J Natl Cancer Inst, 2003. 95(2): p. 113-25.
Winter-Roach, B., L. Hooper, and H. Kitchener, Systematic review of adjuvant therapy for early stage (epithelial) ovarian cancer. Int J Gynecol Cancer, 2003. 13(4): p. 395-404.
Trimbos, J., et al., International Collaborative Ovarian Neoplasm Trial 1 and Adjuvant Chemotherapy in Ovarian Neoplasm Trial: two parallel randomized phase III trials of adjuvant chemotherapy in patients with early-stage ovarian carcimona. Journal of National Cancer Institute, 2003. 95 (2): p. 105-112.
McGuire, W.P., et al., Cyclophosphamide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer. N Engl J Med, 1996. 334(1): p. 1-6.
Piccart, M., et al., Randomized intergroup trial of Cisplatin-Paclitaxel versus Cisplatin-Cyclophosphamide in women with advanced epithelial ovarian cancer: three year results. Journal of National Cancer Institute, 2000. 92: p. 699-708.
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NICE, Guidance on the use of paclitaxel in the treatment of ovarian cancer, in Technology appraisal guidance no. 55. 2003.
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Berman, M., Future directions in the surgical management of ovarian cancer. Gynecol Oncology, 2003. 90 (2): p. S33-S39.
Zang, R., et al., Impact of secondary cytoreductive surgery on survival of patients with advanced epithelial ovarian cancer. European Journal of Surgical Oncology, 2000. 26 (8): p. 798-804.
Rebbeck, T.R., et al., Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med, 2002. 346(21): p. 1616-22.
Kauff, N.D., et al., Risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med, 2002. 346(21): p. 1609-15.
Fry, A., et al., Prophylactic oophorectomy versus screening: psychological outcomes in women at increased risk of ovarian cancer. Psycho-Oncology, 2001. 10: p. 231-241.

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