Ovarian cancer

The ovaries are 2 small, oval-shaped organs in the pelvis (the lower area between the hips). One sits on either side of the womb (uterus), close to the fallopian tubes, which link the ovaries to the womb. A layer of tissue called the peritoneum supports the ovaries.

About 7,400 women are diagnosed with cancer of the ovary (ovarian cancer) each year in the UK.

The surface of the ovaries, the fallopian tubes and the peritoneum lie very close together. Doctors think most ovarian cancers start in the cells at the end of the fallopian tube and then travel to the ovaries or the peritoneum.

Cancers of the ovary, fallopian tube and peritoneum are often grouped together because they're so similar, and they're treated in the same way.

Ovarian cancer can affect anyone who has ovaries and fallopian tubes. That includes women, transgender (trans) men and people assigned female at birth.

Epithelial ovarian cancer is the most common type of ovarian cancer. It starts in the epithelial cells, and there are different sub-types.

Serous is the most common sub-type. At least 8 in 10 (80%) ovarian cancers are serous cancers. They are usually high grade, which means they can grow more quickly.

Other types are much less common:

• clear cell
• endometrioid
• mucinous

These are usually diagnosed at an earlier stage than serous cancers.

Borderline ovarian tumours are also made up of abnormal epithelial cells, but they aren't cancer and they grow slowly. They may spread to nearby tissue. They don't grow in that tissue, though, and they don't spread to other parts of the body.

To find out whether you have ovarian cancer, your doctor will first ask about your symptoms. They'll also do an internal vaginal examination, which lets them check for any lumps or swelling.

A CA125 blood test checks the level of a protein called CA125 in your blood. In ovarian cancer, this level may be higher than normal.

Ultrasound scans are also used to check the organs in your pelvis and tummy area.

If the scan shows any abnormal areas, your doctor will arrange for you to see a specialist, called a gynaecological cancer specialist. You should be seen within 2 weeks.

If your doctor finds a lump in your pelvis or fluid in your tummy (ascites), they'll refer you to a specialist straight away.

Sometimes ovarian cancer is diagnosed after you've been admitted to hospital with a symptom that's making you unwell.

The specialist doctor will usually start by asking about:

• your general health
• any previous health problems
• any history of cancer in your family

They'll then do another internal examination. If you haven't had a CA125 blood test and an ultrasound scan yet, the doctor will arrange these for you.

Your doctor may use your test results to work out your Risk of Malignancy Index (RMI) score. This system checks how likely it is that your symptoms are caused by cancer.

The RMI looks at:

• whether you have gone through menopause
• the levels of CA125 in your blood
• the results of your ultrasound

Your specialist doctor will arrange some further tests. These help confirm whether you have ovarian cancer and let the doctor plan your treatment.

A CT scan uses a series of X-rays to build up a 3D picture of the inside of your body.

Swelling in the tummy is sometimes caused by a build-up of fluid. This is called ascites, and it can happen with ovarian cancer.

If you have ascites, your doctor may want to take a sample of the fluid and test it for cancer cells. First, the doctor injects a little local anaesthetic into the skin of your tummy to numb the area. Then they gently pass a small needle through the skin and draw some fluid into a syringe.

The fluid is sent to the laboratory to be examined.

In a biopsy, the doctor takes a small sample of tissue from the lump or abnormal area. The sample goes to the laboratory, where it is looked at under a microscope.

Your doctor or nurse may talk to you about a blood test for genetic testing. It looks for a change (mutation) in the BRCA genes, which can cause ovarian cancer.

The results help your doctor decide whether certain targeted therapy drugs could be helpful for you.

Waiting for test results can be a difficult time. The charity Macmillan Cancer Support has more information that may help.

The stage of ovarian cancer describes where the cancer started and which other areas it may have spread to. The grade describes how the cancer cells look under the microscope compared with normal cells.

Your doctor doesn't usually know the exact stage until the cancer has been removed with surgery. If you haven't had surgery, they use your test results to decide the stage.

Knowing the stage and grade supports your doctors in planning the best treatment for you.

A team of specialists will meet to talk about the best possible treatment for you. This is called a multidisciplinary team (MDT).

Your cancer doctor and specialist nurse will explain the different treatments and their side effects. They'll also talk with you about the things you should think about when you make decisions on treatment.

With ovarian cancer, surgery is usually the main treatment. The aim is to take out all of the cancer, or as much of it as the surgeon can. This normally means removing the womb, the ovaries and the fallopian tubes.

If your ovarian cancer is at a very early stage, you may be able to have a different operation that keeps your fertility.

Chemotherapy for ovarian cancer uses anti-cancer (cytotoxic) drugs to destroy cancer cells. Most people have carboplatin together with paclitaxel.

You may have chemotherapy before surgery, after surgery, or both. If surgery isn't possible, chemotherapy is sometimes given on its own as the main treatment.

For ovarian cancer, targeted therapies go after something in or around the cancer that supports its growth.

You may have a type of targeted therapy called a PARP inhibitor drug. You take it as a tablet for as long as it works for you (this is called maintenance treatment).

Another drug, bevacizumab (Avastin®), may also be used if the cancer has spread further in the pelvis.

You may have some treatments as part of a clinical trial.

It can be very hard to hear that ovarian cancer has come back again. You may feel shocked, and the thought of having treatment again can be difficult to face.

Your doctor and specialist nurse are there to help and support you. They'll explain the best treatment options for you. The aim is to control the cancer for as long as possible.

Your treatment will depend on:

• the treatment you had before
• how long it kept the cancer away
• if you had any difficult side effects from previous treatments

You'll usually have more chemotherapy and a targeted therapy drug. Sometimes further surgery is possible.

You may have different treatments over several years to control the cancer.

Your doctor may also talk to you about having newer treatments in a clinical trial.

Hormonal therapy for ovarian cancer works by blocking or reducing oestrogen, which may slow the growth of the cancer. Doctors may suggest it if the cancer comes back and you don't want more chemotherapy, or you want to put it off for a while. It's usually given for low-grade cancers.

The medicines are the same ones used to treat breast cancer, and they include tamoxifen and letrozole.

Radiotherapy uses high-energy rays to treat cancer. Doctors don't often use it for ovarian cancer, but it may be given to control symptoms such as bleeding or pain in the pelvic area. This is called palliative radiotherapy.

A type of radiotherapy called stereotactic ablative radiotherapy (SABR) may be used if the cancer is only in one other part of the body, for example a lymph node, or the lung or brain.

Treatments for ovarian cancer often improve any symptoms you have. If the cancer is more advanced, you may see a specialist doctor or nurse who can give expert support in managing symptoms.

Sometimes advanced ovarian cancer causes symptoms because of a build-up of fluid in the:

• tummy (called ascites)
• lung (called a pleural effusion), if the cancer has spread to the lung

Your doctor will arrange to have the fluid drained away. After this you'll feel more comfortable and less breathless.

If ovarian cancer is growing close to the bowel, it can press on the bowel and cause a blockage, so the bowel contents can't pass through easily. A blocked bowel (bowel obstruction) can also happen after surgery to the abdomen, when tissues stick together. These are called adhesions.

Symptoms can include:

• tummy pain
• bloating
• feeling sick
• vomiting large amounts
• constipation
• diarrhoea

There are different ways to manage it, and your doctor and nurse will talk this over with you.

Treating the cancer may improve a bowel obstruction. But sometimes you may need surgery to remove the blocked section of bowel.

A blocked bowel can also be managed by giving you fluids through a drip for a time. Sometimes your doctor may suggest nutrients through a tube. This goes either into the stomach (enteral nutrition) or into a vein (parenteral nutrition).

Once your ovarian cancer treatment has finished, you'll have regular check-ups. To begin with, these are usually every few months.

If new symptoms appear, or any symptoms you had before come back, contact your specialist doctor or nurse. You don't need to wait for your next follow-up appointment.

It can take a while to work out what feels normal for you. You may find yourself worrying that every ache or pain means the cancer is returning. Your specialist nurse can support you and explain which symptoms to look out for.

Your doctor may sometimes do a CA125 blood test as part of your follow-up care, though it isn't always needed.

If your CA125 level starts to rise, it may be a sign that the ovarian cancer has come back. You might then need further tests, like a CT scan.

Doctors usually advise waiting until cancer symptoms develop before you have more treatment. The reasons are these:

• starting treatment before there are symptoms doesn't improve treatment results
• you have shorter periods of time between treatments
• you have side effects sooner

Even so, you and your specialist doctor can begin to talk about the options for further treatment.

Ovarian cancer and its treatment can cause physical and emotional changes, and these may affect your sex life. If you haven't been through menopause, your treatment will usually bring it on.

You may also have changes like scars or hair loss that affect how you feel about your body. Usually, difficulties slowly improve after treatment. Your nurse can support you with more advice.

Even if you already live a healthy life, you may choose to make some positive changes after your treatment for ovarian cancer. Changes like eating well and keeping active can support your body as it recovers, and they can improve your health and wellbeing.