What is ovarian cancer?

Ovaries are part of the female reproductive system that produce eggs from which children are born. All women have two ovaries. They also produce hormones like estrogen and progesterone.

Cancer that arises from the ovaries is ovarian cancer.

How common is ovarian cancer?

Ovarian cancer is the 6th most common cancer in Indian women, but it is the leading cause of cancer related deaths. Around 1,00,000 women are affected by this cancer in India currently.

What are the types of ovarian cancer?

Ovarian cancers are divided into 3 groups

• Epithelial tumours, which begin in the thin layer of tissue that covers the outside of the ovaries and is like the peritoneum. Nearly 90% of the ovarian cancers are of this variety and have a tendency to spread to the peritoneum. These tumours are usually diagnosed at a late stage.
• Stromal tumours, which begin in the ovarian tissue that contains hormone-producing cells and constitute 7% of all ovarian cancers. These tumours are usually diagnosed at an earlier stage than other ovarian tumours.
• Germ cell tumours, which begin in the egg-producing cells. These rare ovarian cancers tend to occur in younger women.

What causes ovarian cancer?

The exact cause of ovarian cancer is not known. There are some factors that increase the chances of getting ovarian cancer and these are called risk factors.

The most common risk factors for ovarian cancer are

• Older age Ovarian cancer can occur at any age but is most common in women over 50 years of age.
• Inherited gene mutations A small percentage of ovarian cancers are caused by gene mutations that are inherited from one’s parents. The genes known to increase the risk of ovarian cancer are called breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2). These genes also increase the risk of breast cancer.
• Family history of ovarian cancer People with two or more close relatives with ovarian cancer have an increased risk of being affected by the disease.
• Hormone replacement therapy The risk of ovarian cancer is increased in women who have taken hormone replacement pills for a long period of time and have had pills with high doses of oestrogen.
• Menstrual history Beginning menstruation at an early age or starting menopause at a later age, or both, may increase the risk of ovarian cancer.

What are symptoms of ovarian cancer? How is it diagnosed?

In the initial stages, ovarian cancer is confined to the ovaries. When it is in this stage, it usually does not produce any symptoms and is difficult to detect unless some tests are performed for other reasons. Over 75% of the ovarian cancers are diagnosed in an advanced stage when it has spread to other regions in the abdominal cavity.

Advanced-stage ovarian cancer may cause few and nonspecific symptoms that are often mistaken for more common non-cancerous conditions.

The common symptoms of ovarian cancer are:

• Abdominal bloating or swelling
• Decreased appetite and feeling full after eating
• Weight loss
• Discomfort in the lower abdomen
• Changes in bowel habits, such as constipation
• A frequent need to urinate

How many stages of ovarian cancer are there?

There are 4 stages of ovarian cancer. In the first stage, cancer is confined to one or both the ovaries.

In the second stage, the cancer has spread outside the ovaries but is confined to the area around it (pelvic cavity).

In the third stage (advanced stage), the cancer has spread to the other regions of the abdominal cavity, specifically its lining called the ‘peritoneum’ or to the glands around the ovaries (lymph nodes).

In the fourth stage (metastatic stage), the cancer has spread to organs like the lungs and the liver.

Cytoreductive surgery and HIPEC for advanced ovarian cancer

What is advanced ovarian cancer?

Advanced ovarian cancer is cancer that has spread beyond the ovaries into the abdominal cavity but has not gone to other organs like the liver and the lungs.

Advanced ovarian cancer is ‘stage 3’ ovarian cancer

In this stage, the tumour cells spread to the lining of the abdominal cavity called the peritoneum. The peritoneum is a thin membrane (sheet) the covers the surface of organs in the abdominal cavity like the liver, stomach, intestines, pancreas and gall bladder. Ovarian cancer cells form small nodules (like grains of rice) on the peritoneum. This leads to accumulation of fluid in the abdominal cavity leading to swelling as discomfort. In later stages, these nodules can produce blockage of the intestines due to which the person is unable to eat. In more advanced cases, there is fluid collection around the lungs as well (pleural effusion).

What is the treatment of advanced ovarian cancer?

• Extreme, Sudden onset bloating
• Pelvic or abdominal pain
• Difficulty eating or feeling full quickly
• Urinary Symptoms (urgency or frequency)

Which treatment should be done first- surgery or chemotherapy?

Some patients have very advanced disease and cannot undergo surgery due to poor general health or when it is not possible for the surgeon to remove the tumour completely. In such patients, chemotherapy is given first followed by surgery. In patients who are in good general health and the tumour can be removed completely, surgery is performed first.

What is the benefit of surgery?

Surgery is the cornerstone of treatment. The patient survival is directly related to the quality of the surgery. The more radical (accurate in removing the cancer completely) the surgery, the longer the patient survival. This has been proved in many studies carried across the world.

What does this surgery comprise of and what is it called?

This surgery comprises of removal of the entire peritoneum lining the inner walls of the abdominal cavity, the uterus, ovaries and the fallopian tubes, the omentum (fat apron), lymph nodes and gall bladder. Other areas like the spleen, part of the small and large intestine and the appendix may be removed if required. This is a major surgery that takes 4-6 hours and requires considerable amount of skill and experience to perform. This surgery is called cytoreductive surgery (CRS) and is not the same as ‘debulking surgery’ which is commonly performed for ovarian cancer.

Can this surgery be performed laparoscopically?

No, this surgery cannot be performed laparoscopically or by robotic assitance. A big cut is required for performing this surgery. If a small cut is put or this surgery is performed by laparoscopy, some tumour will always be left behind, leading to cancer recurrence.

Can patients tolerate such a surgery and what are the common side effects?

This surgery is more complicated than routine surgery so some side effects can occur. However, most patients tolerate such a surgery fairly well. Patients spend 1-2 days in the intensive care unit (ICU), 8 to 12 days in the hospital and get back to their normal lives in 6-8 weeks following surgery.

Immediately after surgery, the patient is at risk for developing infection, bleeding, kidney and lung related side effects. These are prevented by giving adequate intravenous fluids, antibiotics and good physiotherapy.

Some of side effects that occur after recovery from the surgery are feeling tired, decreased appetite and abdominal discomfort. Patients are advised to take small frequent meals rich in calories and plenty of fluids.

The results depend on the surgeon’s skills, the supportive teams like intensive care, nursing and physiotherapy and the decision to perform the surgery or not. With proper care and treatment, most of the side effects can be prevented.

Can patients lead a normal life after this surgery?

The goal of this surgery is to enable patients to lead a normal cancer-free life for a prolonged period. Patients are able to go home walking and perform their daily activities with a little help soon after getting discharged from the hospital. Most of them regain their physical strength and appetite by 4-6 weeks following surgery. The removal of organs mentioned above does not affect the health and normal life of patients in any way.

HIPEC (hyperthermic intraperitoneal chemotherapy)

What is HIPEC?

HIPEC is a form of intraperitoneal delivery of chemotherapy (IPEC) which involves inserting the chemotherapy agents directly into the abdominal/peritoneal cavity. Giving chemotherapy directly within the peritoneal cavity at normal temperatures has been shown to be effective in front-line treatment in ovarian cancer. In HIPEC the chemotherapy solution is heated to 42-43 degrees and circulated in the peritoneal cavity for 60-90 minutes. Heat enhances the destruction of cancer cells.

Why is HIPEC needed after radical surgery?

HIPEC acts on microscopic disease which is not visible to the naked eye and thus, reduces the chances of recurrence.

When is HIPEC used in ovarian cancer?

HIPEC can be used in the following ways in the treatment of ovarian cancer

• At the time of the first surgery (primary or interval cytoreduction)
• In certain patients with recurrent tumours when surgery is planned
• As a part of a ‘Second look’ surgery in certain patients.

Which patients benefit from HIPEC?

Recently, one study showed that HIPEC leads to a longer survival in patients who have surgery following few cycles of chemotherapy (also called interval cytoreductive surgery). Whereas, further research is needed to further define its role, it is beneficial in patients who are young (<70 years of age), in good general health and have a low risk of complications.