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Ovarian Cancer (Ab Ovo)
Ovarian cancer is the 5th most common cancer in women after lung, breast, colorectal and pancreatic cancer. It accounts for only three percent of cancers in women, and fortunately, the incidence of this type of cancer has decreased by about 1% over the past twenty years. Unfortunately, diagnosis is usually late because there are very subtle and often protean signs and symptoms. Ovarian cancer is not only a cancer of old age, it can occur at any age, even in infancy, however, after the age of 50, the incidence of this cancer increases significantly.
There are certain risk factors for ovarian cancer, the main ones being family history and some related genetic syndromes. A blood relative with ovarian cancer increases the risk of this cancer in a female relative by 5%. There is a syndrome of hereditary breast and ovarian cancer that occurs in one in 500 women and as an autosomal dominant genetic disorder results in a BRCA1 and/or BRCA2 gene mutation. The other is Lynch syndrome II, an inherited nonpolyposis colorectal cancer syndrome, again autosomal dominant, that increases the risk of ovarian cancer by 12%. However, most women diagnosed with ovarian cancer have no family history and the etiology remains unknown. When ovarian cancer occurs and is not detected early when it is localized to one ovary, the cancer usually first spreads to the unaffected ovaries and uterus, but it can spread to the liver, lungs, adrenal glands, spleen, and other intraperitoneal organs.
Some things that reduce the risk are the protective effects of oral contraceptives, late menarche, early menopause, multiparity (having more than one child), and breastfeeding. Progesterone appears to be protective, but there is controversy as a 2009 Danish study suggests that all HRT leads to an increased risk (the study was done with estrogen alone (unopposed) or estrogen and progestin (progestin is a synthetic compound of progesterone). Further studies In order to clarify this controversy, natural bioidentical hormones will need to be used for prevention, as earlier studies have shown that HRT has a protective effect. can reduce the risk of this cancer A well-balanced diet high in carotene, vitamins C and E and unsaturated fats with moderate physical activity has been shown to help reduce the risk of ovarian cancer.
There are many difficulties with early diagnosis due to the fact that the signs and symptoms are very often subtle and non-specific, and if you do not go looking for this disease with specific diagnostic laboratory and radiological tests, you will probably not find it soon. Some symptoms include abdominal pain and fullness, back pain, nausea, constipation, diarrhea, fatigue, pelvic pain, and urinary symptoms. Laboratory testing should be considered in women over 40 years of age if these symptoms persist, as they are a population at higher risk for ovarian cancer. Testing usually includes a CBC, metabolic panel, and serum CA 125 levels. CA 125 is a cancer marker that is fairly sensitive and specific for ovarian cancer, but there are some other conditions that can raise this marker, such as pelvic inflammatory disease (PID), endometriosis, ovarian cysts, and pregnancy. CA 125 is a good test, but not perfect, as it is elevated in 90% of patients with advanced disease but only in 50% of stage I tumors. In addition, there are other markers that are useful in their own right and include the human chorionic beta subunit gonadotropin (Beta-HCG), serum alpha-fetoprotein (AFP), neuron-specific enolase (NSE) and lactate dehydrogenase (LDH). Diagnosis is also made by diagnostic imaging such as Doppler transvaginal ultrasound (ultrasonography or US), often used as an initial assessment of the pelvic mass. US is useful in distinguishing benign ovarian lesions, such as simple cysts, from those that appear more malignant, such as complex solid tumors. Other radiological imaging methods useful for diagnosis are CT scan and MRI with gadolinium.
Treatment usually involves (after thorough diagnostic testing and staging) surgical excision of the mass/tumor. Depending on the stage of the disease, other organs may also be removed, for example, the appendix is generally removed because of its potential target for metastasis. After the tumor is removed, chemotherapy is typically started with a combination of platinum and taxane-based agents. Carboplatin and Taxol are two chemotherapy agents that are often used. Total hysterectomy is often considered for women of reproductive age, while radiation therapy is reserved for palliative and persistent disease that recurs after a chemotherapy regimen.
Prognosis is a bit complicated because it is based on the staging of the disease as well as the histological grade (the type of tumor etiology) which typically plays a role in the recurrence rate. For example, epithelial ovarian cancer (histologically) has a low malignant potential if diagnosed at stage I and has a 95-99% survival rate at 10 years.
Ovarian cancer screening should include an annual physical examination and marker-guided examinations and imaging only when warranted. Routine screening with CA 125 produces too many false positives and misses too many tumors early to be a good general screening test. BRCA analysis should be reserved for offspring with mutated BRCA1 and BRCA2 genes, it is not recommended as a general screening tool. The current recommendation for women who meet criteria for high risk or very high risk of ovarian cancer is screening with transvaginal ultrasound and a CA 125 measurement every six months during days 1 through 10 of their menstrual cycle beginning at age 35.
The take-home message is that women need to be diligent about their annual physicals and not ignore persistent symptoms that may indicate a more serious condition.
Roett, M. Evans, P., “Ovarian Cancer: An Overview”, American Family Physician, Vol. 80, No. 6, 15 September 2009, pp. 609-616.
www.ncbi.nlm.nih.gov/pubmed/10933270 (Accessed 8/10/2009)
www.medicinenet.com/script/main/art.asp?articlekey=103822 (Accessed 8/10/2009)
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