Version May 2024
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OVARIAN CANCER OVERVIEW — Ovarian cancer is the second most common cancer of the reproductive organs among females in the United States. It most commonly occurs between the ages of 50 and 65 but can occur in younger or older people as well. For a person with ovaries, the lifetime risk of developing ovarian cancer is approximately 1.4 percent.
There are several different types of cancer that can start in the ovary; the most common is called epithelial ovarian cancer (the word "epithelial" describes a type of cell). This topic review will discuss the diagnosis and staging of epithelial ovarian cancer. The treatment of ovarian cancer is discussed separately. (See "Patient education: Treatment of ovarian cancer (Beyond the Basics)".)
RISK FACTORS — Certain factors increase a person's risk of developing ovarian cancer, including:
●Never having been pregnant.
●Having started menstrual periods at an early age (before age 12) or having gone through menopause at a late age (after age 52).
●A family history of ovarian, breast, or endometrial (uterine) cancer, particularly if the person inherits a specific type of genetic abnormality called a BRCA1 or BRCA2 mutation. (See "Patient education: Genetic testing for hereditary breast, ovarian, prostate, and pancreatic cancer (Beyond the Basics)".)
●A family history of a genetic condition called Lynch syndrome (hereditary nonpolyposis colorectal cancer [HNPCC]).
OVARIAN CANCER SIGNS AND SYMPTOMS — During the early stages of ovarian cancer, symptoms may be present but are often vague and ill-defined. Symptoms may include pelvic or abdominal discomfort, increased abdominal size or bloating, decreased appetite, feeling full after eating a small amount of food, or urinary symptoms (urgency and frequency).
In some cases, ovarian cancer is initially suspected when a mass or lump is felt during a routine pelvic examination. However, a mass is not always detectable in the early stages of ovarian cancer. Even when a mass is detected, it does not necessarily mean it is cancerous. There are many common noncancerous conditions (such as ovarian cysts) that can cause masses.
Sometimes, an ovarian mass is found on an imaging study (ultrasound, computed tomography [CT], or magnetic resonance imaging [MRI]) that is done for another reason.
Because many people do not have symptoms or the initial symptoms are vague and nonspecific, the majority of people have advanced-stage disease by the time ovarian cancer is diagnosed. At this point, the person may have more prominent symptoms such as abdominal distention (swelling), nausea, or a significant loss of appetite.
OVARIAN CANCER DIAGNOSIS — If ovarian cancer is suspected based on symptoms and/or an abnormal physical examination, imaging tests of the abdomen and pelvis are usually recommended as an initial step in the evaluation. Imaging tests may include ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI). These tests do not provide enough information by themselves to definitively diagnose ovarian cancer, although they may provide important information about the location and/or extent of a possible cancer.
The only way to diagnose ovarian cancer with certainty is through surgery (see 'Initial surgery' below). In some cases (for example, if surgery is not possible or if the person is a candidate for chemotherapy prior to surgery), a nonsurgical procedure may be done instead. This involves removing tissue or fluid from the abdomen or chest with a needle (called a biopsy, paracentesis, or thoracentesis) for testing.
Tumor markers (CA 125) — While there is no blood test that can definitively diagnose ovarian cancer, a blood test called CA 125 may be done when cancer is suspected. Its role in evaluating for ovarian cancer is limited because the level may be elevated for many other reasons that are not ovarian cancer, especially before the onset of menopause; in addition, it may be negative even when a person has ovarian cancer. However, if CA 125 is elevated after menopause, or very elevated prior to menopause, this increases suspicion for ovarian cancer and may support a decision to proceed with surgery to make a diagnosis.
Also, if CA 125 is elevated at the time ovarian cancer is diagnosed, it is useful to check it again periodically. This helps doctors to evaluate how well treatment is working and check for a return of cancer after treatment.
Your doctor may order a CA 125 test during an initial evaluation and/or prior to or immediately following surgery.
The use of CA 125 as a screening test for ovarian cancer is discussed separately. (See "Patient education: Screening for ovarian cancer (Beyond the Basics)".)
Initial surgery — A surgical procedure called exploratory laparotomy is typically recommended when ovarian cancer is suspected. Sometimes a laparoscopy, which is less invasive, may also be considered with a smaller ovarian mass. Surgery is most successful in accurately diagnosing and treating ovarian cancer when it is performed by a gynecologic oncologist, a clinician who has had extensive training in the management of cancers of the female reproductive system.
Exploratory laparotomy — During the procedure, the surgeon makes an abdominal incision (usually vertically) and examines the organs within the pelvis and abdomen for signs of cancer. Samples of tissue and fluid are taken from the following areas:
●Within the abdominal cavity (also called the peritoneal cavity)
●The ovary and tube
●Neighboring lymph nodes
●Other abdominal organs
●The omentum (the apron of fat that covers and connects the organs of the abdomen and pelvis)
●The surface of the diaphragm
While still in the operating room, the surgeon sends the tissues for microscopic examination by a pathologist, a clinician who has specialized training in the examination of tissues. The pathologist examines the tissue samples during the surgery and then immediately notifies the surgeon as to whether definite signs of cancer are present. A more thorough examination of the fluid and tissue samples performed after the surgery is completed to ensure that the initial diagnosis was correct.
If the pathologist finds evidence of ovarian cancer on frozen section analysis, the surgeon will then attempt to remove as much of the cancerous tissue as possible. This procedure is termed surgical staging and is an important first step in the treatment of ovarian cancer.
In most cases, the uterus, both fallopian tubes, and both ovaries are also removed during an exploratory laparotomy (figure 1). Usually, the doctor will remove the ovary that has a mass, not just biopsy it, since biopsy can spread cancer cells and result in a more advanced cancer. In people who still get a monthly period (have not been through menopause), removal of one ovary will not result in menopause or infertility if the remaining ovary is healthy. If the cancer has spread to other organs, those organs, or affected portions of them, may be removed as well. As much tumor as possible is removed. Doctors call this "debulking" or "cytoreduction." Treatment outcomes are best in cases in which surgery removes all visible tumor (termed "optimal debulking"). Having the surgical procedure performed by a gynecologic oncologist (a doctor who specializes in cancer of the female reproductive system) provides the best chance for optimal debulking.
In some cases, if a person is of childbearing age and wishes to preserve the ability to get pregnant in the future, it may be possible to leave the uterus, one fallopian tube, and one ovary in place. This is only possible if these structures seem to be unaffected by the cancer. If you are interested in this approach, your doctor can talk to you about your options prior to surgery.
Exploratory laparoscopy — In some situations, a less invasive procedure called exploratory laparoscopy may be performed. In this procedure, a flexible tube (called a laparoscope) is inserted through a small incision in the abdomen. The laparoscope has a camera that the surgeon uses to visualize the contents of the abdomen and pelvis.
This less invasive approach may be chosen for a young person with a mass that is unlikely to be an ovarian cancer. It may also be done in rare cases where open exploratory surgery is not possible because the person is in poor health or the disease is far advanced. However, an open laparotomy is generally preferred because it allows the surgeon to more easily and completely visualize the abdominal contents and remove any suspicious masses.
Diagnostic biopsy — For advanced-stage ovarian cancer, treatment is shifting from initial surgery to treating with chemotherapy before interval "debulking" surgery. If your doctor is considering this strategy, a biopsy to confirm ovarian cancer is necessary before initiating chemotherapy. This may be performed through an image-guided tissue biopsy or sampling of abdominal or chest fluid.
OVARIAN CANCER STAGING — Based upon the findings during exploratory surgery, the tumor is formally "staged" according to the size, extent, and location of the cancer, as well as how aggressive the tumor is (also referred to as the "grade" of the tumor). Accurate staging during surgery is very important in order to understand the long-term outcome (prognosis) and whether a person is a candidate for additional treatment after surgery.
The stage of an ovarian cancer is designated by a Roman numeral (between I and IV) and a letter (A, B, or C). In general, the stages I, II, III, and IV refer to the location of tumor involvement, while the subdivisions A, B, and C define the extent of tumor involvement. A higher stage of disease indicates more extensive tumor involvement.
Early-stage cancer — Stage I and II disease are considered early-stage ovarian cancer:
●In stage IA and IB disease, the cancer is limited to one or both ovaries, and the capsule or membrane covering the ovaries has not been broken by the cancer's growth.
●In stage IC disease, the capsule of either ovary may have ruptured or there may be signs suggesting that cancer cells have begun to spread within the pelvis (ie, cancerous cells are found in the fluid taken from the peritoneal cavity during surgery).
●In stage II disease, other pelvic organs, such as the uterus or fallopian tubes, are involved with the tumor, and there may be early signs that the cancer has spread beyond the pelvis.
Advanced-stage disease — Stages III and IV disease are considered advanced-stage ovarian cancer:
●In stage III disease, the cancer has spread to the abdomen and/or the abdominal lymph nodes but not to more distant areas.
●In stage IV disease, the cancer has spread to other parts of the body such as the liver or lungs.
Recommendations for treatment after surgery depend upon the disease stage. While a course of chemotherapy is recommended after (or occasionally before) surgery for anyone with stage III or IV ovarian cancer, it may or may not be recommended for treatment of stage I or II disease. (See "Patient education: Treatment of ovarian cancer (Beyond the Basics)".)
OVARIAN CANCER TREATMENT — Treatment involves removing all visible evidence of cancer during exploratory surgery; some people are candidates for chemotherapy as well. This is discussed in more detail in a separate topic review. (See "Patient education: Treatment of ovarian cancer (Beyond the Basics)".)
OVARIAN CANCER PROGNOSIS — A number of factors influence the success of treatment for ovarian cancer. Treatment tends to be more successful when the cancer is diagnosed at an early stage and in younger people. One of the most important factors influencing the outcome of treatment is the amount of tumor that remains after the initial surgery (ie, the success of the initial debulking procedure). This is the reason that the surgeon aims to remove as much of the cancerous tissue as possible during the initial surgery. As noted above, this is most likely when the surgeon performing the debulking procedure is a gynecologic oncology specialist.
Complete response — At the end of treatment (surgery and/or chemotherapy), a person is considered to have a "complete response" if the physical examination is normal, there is no evidence of cancer on imaging studies (such as a computed tomography [CT] scan), and the blood levels of CA 125 are normal. However, it is possible for tiny, undetectable amounts of cancer to still be present, even when these criteria are met.
Recurrence — Even people who have a complete response to initial therapy (as determined by physical examination, imaging studies, and/or second-look surgery) can have a recurrence of ovarian cancer at a later time. The likelihood of a tumor recurrence is highest in people with more advanced-stage disease at diagnosis, particularly if the initial debulking surgery was unable to remove all visible tumor.
Signs of recurrent ovarian cancer include new symptoms (eg, abdominal bloating, back pain), a rising blood level of CA 125, or new findings on a follow-up CT scan. Further treatment may not be recommended immediately if the CA 125 level is slowly rising, there are no new symptoms, and a CT scan shows no new abnormalities that could indicate a disease recurrence.
CLINICAL TRIALS — Progress in treating cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials or read about clinical trials at:
●https://www.cancer.gov/about-cancer/treatment/clinical-trials
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (https://www.cancer.net/research-and-advocacy/clinical-trials/welcome-pre-act).
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Ovarian cancer (The Basics)
Patient education: Ovarian cancer screening (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Treatment of ovarian cancer (Beyond the Basics)
Patient education: Genetic testing for hereditary breast, ovarian, prostate, and pancreatic cancer (Beyond the Basics)
Patient education: Screening for ovarian cancer (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Adjuvant therapy of early-stage (stage I and II) epithelial ovarian, fallopian tube, or peritoneal cancer
Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Surgical staging
Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Histopathology
Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis
First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer
Genetic testing and management of individuals at risk of hereditary breast and ovarian cancer syndromes
Intraperitoneal chemotherapy for treatment of ovarian cancer
Medical treatment for relapsed epithelial ovarian, fallopian tube, or peritoneal cancer: Platinum-resistant disease
Overview of hereditary breast and ovarian cancer syndromes
Cancer risks and management of BRCA1/2 carriers without cancer
Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations, and diagnosis
Borderline ovarian tumors
Risk-reducing salpingo-oophorectomy in patients at high risk of epithelial ovarian and fallopian tube cancer
Screening for ovarian cancer
Cancer of the ovary, fallopian tube, and peritoneum: Surgical options for recurrent cancer
Approach to the patient with an adnexal mass
Adnexal mass: Evaluation and management in pregnancy
The following organizations also provide reliable health information.
●People Living With Cancer: The official patient information website of the American Society of Clinical Oncology
●Foundation for Women's Cancer
(www.foundationforwomenscancer.org)
●National Cancer Institute
1-800-4-CANCER
●American Cancer Society
1-800-ACS-2345
●National Ovarian Cancer Coalition
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