The below is written by Rachel Gorham, MSN, WHNP-BC, AGN-BC. Ms. Gorham is on the NPWH Board of Directors.
Ovarian cancer is said to be a “silent killer,” but it’s a whisper that needs to be heard. The American Cancer Society estimates in 2019, 22,530 women will be diagnosed and approximately 13,980 will die from ovarian cancer. It ranks fifth in cancer deaths among women. As providers, we have an opportunity during Ovarian Cancer Awareness Month to help patients to better understand this gynecological cancer. I’d like to provide this overview of the basics we should all be well-versed in, and also let you know about some of the promising developments in screening and prevention.
Ovarian cancer typically develops in older women. About half of women are 63 years or older at the time of diagnosis. This cancer develops more commonly in white women than African American women. Factors that can elevate a woman’s risk of developing ovarian cancer include:
- Age: Risk increases with age, and typically develops after menopause.
- Personal or family historyof breast cancer, ovarian cancer, uterine cancer, or colorectal cancer.
- Hormone therapy, particularly for more than five years of estrogen-only therapy.
- Inherited cancer syndromes, including BRCA gene mutations, hereditary nonpolyposis colorectal cancer (also known as HNPCC or Lynch syndrome), Peutz-Jeghers syndrome and MUTYH-associated polyposis.
- Reproductive history:Women who had their first child after the age of 35 or who have never given birth.
- Endometriosis is a condition in which uterine lining grows outside of the uterus.
Women who develop ovarian cancer generally have a poor outcome, with a survival rate of less than 35% over five years. Women who have ovarian cancer often present with advanced disease and staging, which is the most critical factor affecting disease outcome. Most have had symptoms for an extended period before the presentation, which often leads to delays between presentation and treatment. Ovarian cancer symptoms include:
- Pelvic, abdominal or back pain
- Loss of appetite or feeling full quickly
- Changes in bowel or bladder function, such as constipation, urinary frequency, or urinary urgency
- Menstrual changes
- Pain during sex
Currently, there are no societal guidelines that recommend routine screening for ovarian cancer since screenings have not shown to decrease mortality. Patients may require increased monitoring if found to be high-risk of developing ovarian cancer, which includes:
- Family history and/or personal history of breast or ovarian cancer
- Inherited pathogenic variant, such as BRCA gene mutations and Lynch syndrome
- History of infertility or use of assisted reproductive therapies
- Hormone replacement therapy
Surgery is the standard treatment option for patients with ovarian cancer, including:
- Cytoreductive (debulking) surgeries, whichremove as much tumor as possible from the pelvic and abdominal areas. This can improve outcomes and reduce cancer recurrence.
- Coordination with other surgical specialties such as urology, thoracic, hepatobiliary, and neurosurgeons, who can remove secondary tumors in other parts of the body.
- Fertility-sparing surgeryfor early-stage germ cell or stromal tumors confined to one ovary, which can preserve the patient’s ability to have children.
- HIPEC(heated intraoperative peritoneal chemotherapy), a procedure in which cancer-fighting drugs are circulated into the abdominal cavity immediately after surgery. This therapy of direct heated chemotherapy can help kill more cancer cells than chemotherapy given orally or intravenously.
- Inherited cancer syndromesfor patients who are high-risk for developing ovarian cancer (such as BRCA gene mutation carriers), can undergo a risk-reducing surgery such as a bilateral salpingo-oophorectomy.
Recent Advancements in Screening
A good deal of the current research in ovarian cancer is focused on screening and early detection, as early diagnosis is key to a positive prognosis. Recent advancements in this area include a promising test from Queens University Belfast which may allow clinicians to diagnose patients up to two years sooner than current tests allow.
Continued Support for Preventive Effects of OCP
In the last few years, we’ve continued to see evidence that oral contraceptives decrease both ovarian and endometrial cancer risk. Risk reduction is correlated with duration of use. Studies have shown up to 50% reduction in ovarian cancer seen with 15 years of OCP. Furthermore, this risk reduction carries over beyond the general population to higher risk groups, such as BRCA carriers and those with Lynch syndrome BRIP1, RAD51C, or RAD51D mutations. The degree of risk reduction with 1 year of use has been estimated at 33-80% for BRCA1 and 58-63% for BRCA2 carriers. Providers should consider recommending OCP use for all woman with increased risk factors for epithelial ovarian cancer.
There is plenty of work to be done when it comes to advancing screening, prevention, and treatment for ovarian cancer. But every day, Nurse Practitioners and other providers who care for women can work with patients to identify risks, catch symptoms early, and provide support throughout treatment.