| Ovarian Cancer: Facts, Treatments, and the Vermont Response | ||
| by Elayne Clift | ||
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Ovarian cancer is serious but fairly rare. It is the fifth leading cause of cancer-related deaths among women in the United States and accounts for about 3 percent of all cancers in women in the US. According to the National Cancer Institute, ovarian cancer begins either in the cells on the surface of the ovary, called epithelial cancer, or in egg cells, where growths are identified as malignant germ cell tumors. Fallopian tube cancer and primary peritoneal cancer are similar to ovarian epithelial cancer and are staged and treated in the same way. Like other cancers, ovarian cancer spreads through the lymph system. An estimated 22,000 cases were expected in 2013 with about 14,000 deaths anticipated. The exact causes are still unknown. Risk factors for ovarian cancer include a family history of the disease, the presence of certain genetic mutations including those found in BRCA1 and BRCA2, and a genetic link to a hereditary form of colon cancer called Lynch syndrome. Women who have used estrogen-only hormone replacement therapy (HRT) or taken fertility drugs or who are obese or very tall are also more vulnerable. Heavy use of talcum powder in the genital area, suspected as a risk factor, does not appear to pose a general threat, but it can be relevant in one type of relatively rare ovarian cancer. About 5 to 7 percent of ovarian cancer cases are associated with inherited risk. Some women who are known to have genetic mutations that can lead to ovarian cancer choose to reduce their risk by having surgery to remove the ovaries and fallopian tubes. This surgery can also help reduce the risk of breast cancer in women with the BRCA1 or BRCA2 gene mutation. Screening tests for ovarian cancer remain inaccurate. There is no proven testing method for asymptomatic women or women without risk factors. The independent organization, US Preventive Services Task Force, found no evidence of benefits of screening for ovarian cancer in 2004, a finding that was reconfirmed in 2012. In its 2012 report, the task force also warned that “screening asymptomatic women can result in unnecessary interventions, including surgery.” |
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Diagnosis of ovarian cancer is difficult because it doesn’t always present clear symptoms until the disease has advanced. Warning signs include indigestion, gas and other bowel disturbances, loss of appetite or weight, feeling full or bloated, lower abdominal pain or discomfort, unexplained weight gain, frequent urination, fatigue, backache, nausea, vomiting, nonmenstrual vaginal bleeding, or painful intercourse. For midlife women these symptoms are relatively common so they can be overlooked or attributed to stress. These symptoms are key to early detection, but the US Preventive Task Force points out that there is still an uncertain ability to offer effective treatment of ovarian cancer at an early enough stage to improve the ultimate outcome.
Diagnostic tests for ovarian cancer include pelvic ultrasound, CT scanning, MRI, and surgery, the only conclusive diagnostic tool. Most ovarian cancers that are not obviously widespread are staged at surgery when tissue samples are examined under a microscope. Staging is the process of determining how widespread a cancer is. This process is important because ovarian cancers have different prognoses at different stages and are treated differently. The accuracy of the staging may determine whether or not a patient will be cured. Once the cancer has been given a stage, it does not change, even when it recurs or metastasizes. Once surgery has determined the extent of the primary tumor, the absence or presence of metastasis to nearby lymph nodes, and the absence or presence of distant metastasis, the information is combined to determine the final stage. There are four main stages of ovarian cancer. In Stage I the cancer is only within the ovary (or ovaries) or fallopian tube(s). It has not spread to organs and tissues in the abdomen or pelvis, lymph nodes, or to distant sites. Stages IA, IB, and IC further define how the cancer has developed and presents itself. In Stage II the cancer is in one or both ovaries or fallopian tubes and has spread to other organs (such as the uterus, fallopian tubes, bladder, the sigmoid colon, or the rectum) within the pelvis. It has not spread to the lymph nodes or distant sites. Stages IIA and IB further refines the disease. Stage III indicates that the cancer is in one or both ovaries or fallopian tubes and has spread beyond the pelvis to the lining of the abdomen or has spread to lymph nodes in the back of the abdomen. There are several substages at this level. Stage IV signals the most advanced stage of ovarian cancer. In this stage, the cancer has spread to the inside of the spleen, liver, lungs, or other organs located outside the peritoneal cavity. There are two substages at this level as well.
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Treatment depends on the stage of disease at time of diagnosis, the type of cells that make up the tumor, and how rapidly the cancer is growing. The current standard medical options are chemotherapy and surgery. Some immunotherapies are available in settings where research is being conducted. The good news is that ovarian cancer has unusual traits that make it more treatable than some other cancers. It is less likely to spread through the bloodstream and lymph system to other organs such as the lungs or brain. And most ovarian cancers are sensitive to chemotherapy, experts say. The key is early detection, along with prompt diagnosis and accurate staging. But according to a 2013 article in the New York Times, “widespread, persistent flaws in the care of women with [ovarian cancer] persist” (Denise Grady, New York Times, March 11, 2013). The article attributes such poor care to the fact that “most women are treated by doctors and hospitals that see few cases of the disease and lack expertise in the complex surgery and chemotherapy that can prolong life.” It stresses the importance of gynecologic oncologists in terms of ensuring optimum care, a position taken by the advocacy group Ovarian Cancer National Alliance as well. One study conducted at the University of California/Irvine and cited in the New York Times article found that “surgeons who operate on ten or more women a year for ovarian cancer and hospitals that treat 20 or more women a year were more likely to adhere to guidelines set by the National Comprehensive Cancer Network, an alliance of 21 major cancer centers with expert panels that analyze research and recommend treatments.” Patients operated on in such facilities lived longer than those whose care “fell short.” According to the American Cancer Society, women with Stage I ovarian cancer have a 90 percent chance of surviving for at least five years. In comparison, Stage IV prognoses vary according to the type of ovarian cancer a woman has and range between 17 and 69 percent for five-year survival. An estimated 70 to 80 percent of women aren’t diagnosed until the disease has advanced. According to its website, the UVM Medical Center Gynecologic Cancer Program “provides exceptional care, support and education to women from Vermont and northern New York facing ovarian, cervical and uterine cancer.” It is the only venue in the state that offers comprehensive gynecologic cancer care services provided by three gynecological oncologists as well as other staff. Dr. Gamal Eltabbakh, a gynecological oncologist, has been at UVM for 17 years in addition to maintaining a private practice. He considers Vermont to be on the cutting edge of treatment for ovarian cancer because as a small state most cases are treated by specialists.
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“Three gyn-oncologists for a state like Vermont is good,” he says. “Many parts of the country don’t have as many per capita as we do. And we have a strong primary care population. Not too many people are uninsured here, so they are able to see a doctor, unlike many uninsured people who can’t go to a doctor for many years.” Eltabbakh has noticed several changes in the incidence and treatment of ovarian cancer since he’s been practicing in Vermont. For example, probably due to reduced use of HRT, he has observed a slight drop in cases of ovarian cancer in his practice. There have also been changes in treatment, including the increased use of intraperitoneal chemotherapy in some cases. With this method, the chemotherapy is injected through a catheter directly into the abdominal cavity instead of administered intravenously. Dr. Elise Everett is also a gynecologic oncologist on staff at the UVM Medical Center and Vermont Cancer Center. She notes that women with ovarian cancer treated at UVM Medical Center receive high-quality, evidence-based, compassionate care through an interdisciplinary approach and available clinical trials. Working with women who have ovarian cancer can be stressful, Everett admits, but “the rewards outweigh the stressors,” she says. “Women are incredibly strong, and they help me as much as I help them. They have incredible hope, bravery, and strength, and that’s invigorating. Establishing a rapport with patients, being able to offer treatment, and helping in such a difficult time—it’s a great gift to do that. I become quite close with my patients, and being part of their lives at such a difficult time is an honor. If I ever face a similar challenge in my own life, I hope to be as poised and graceful as my patients are.” The expertise and compassion of doctors like Eltabbakh, Everett, and their colleague Dr. Cheung Wong, division director of the department, are part of what makes ovarian cancer care in Vermont special. In the face of a diagnosis like ovarian cancer, women are clearly in good hands at the UVM Medical Center’s program. |
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Elayne Clift writes frequently about health issues for Vermont Woman from Saxton's River, Vermont.
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