Seventh most commonly diagnosed cancer globally. In UK highest incidence in females between 75-79 Usually affects women > 65
The most important risk factor for ovarian cancer is a family history of breast or ovarian cancer Incidence of OC is rising in the UK
Most lethal gynaecological malignancy-Poor prognosis as presents late due to asymptomatic development – often diagnosed at advanced stage ( called silent killer )
Treatment options have seen major new developments with innovation for e.g in biomarker development , PARP inhibitors , immunotherapy etc- substantially increasing survival
Risk factors-Increasing age – rare below 40 without inheritable component Infertility Family history- one of the strongest and most significant risk factor ○ the more family members with ovarian cancer are the more they are likely to get the disease ○ about 18 % of EOC cases are associated with a germline mutation ○ amplified threat is associated with family h/o other cancers as colorectal and breast cancer Endometriosis PCOS Older age at menopause Hormone replacement therapy ( data not very clear and magnitude may be moderate ) Early age at menarche and late age at menopause Cigarette smoking ( mucinous carcinomas ) Pelvic inflammatory disease Obesity Diet ( if this is a risk or not remains unresolved ) Alcohol – possible but magnitude may be small Talcum powder use in genital areas -has been studied widely of a possible link between – a recent JAMA has not found any statistically significant relationship between use of talc and the development of ovarian cancer ( O’Brien, Katie M et al. “Association of Powder Use in the Genital Area With Risk of Ovarian Cancer.”JAMAvol. 323,1 (2020): 49-59. doi:10.1001/jama.2019.20079 )
Parity -parous women have 30 % to 60 % lower risk Oral contraceptive use – consistent data and the protective effect increases with longer duration of use lactation-reduces risk by suppressing gonadotrophins – studies have shown slight protective effect from breast feeding Among high risk women b/l prophylactic oophorectomy reduces the risk by at least 90 % Hysterectomy and tubal ligation Exercise and physical activity.
WHO classification –Epithelial surface tumour – majority about 80 % to 90 % , Ovarian germ cell Sex cord tumour Metastatic ovarian cancer Miscellaneous OC.
Serous carcinomas Mucinous carcinomas Endometrioid carcinomas Clear cell carcinomas Transitional cell Mixed Undifferentiated.
Assessment -Often asymptomatic in early stages – hence majority of EOC’s remain clinically undetected until patients have developed late stage disease and only about 25 % are detected in stage 1 Always ask about family history It is important to undertake abdominal and pelvic examinations but this may miss OC Stages III and IV are defined by peritoneal and extraperitoneal metastatic spread OC is considered a terrible disease due to its asymptomatic nature , no active screening and early detection techniques A symptom diary which can be downloaded from the website Target Ovarian Cancer can be helpful in assessment
Epithelial cell OC is the most predominant pathologic subtype -the major histo types of EOC are different in origination , pathogenesis , molecular alterations , risk factors and hence eventual prognosis Etiology of OC is poorly understood It is thought that most tumours originate from other gynaecological Amongst EOC serous and endometrioid OC are the most common morphological group is seen commonly in women aged 45-74 at diagnosis.
Often asymptomatic in early stages – hence majority of EOC’s remain clinically undetected until patients have developed late stage disease and only about 25 % are detected in stage 1 Always ask about family history It is important to undertake abdominal and pelvic examinations but this may miss OC Stages III and IV are defined by peritoneal and extraperitoneal metastatic spread OC is considered a terrible disease due to its asymptomatic nature , no active screening and early detection techniques A symptom diary which can be downloaded from the website Target Ovarian Cancer can be helpful in assessment
Found in 1981 OC125 -an antibody that recognises CA125 ( Carbohydrate antigen ) , it is the most extensively studied biomarker for possible use in early detection of OC Also known as mucin 16 ( muc 16 ) it is a transmembrane glycoprotein derived from the epithelium of coelomic and Mullerian origin In the original study by Bast et al 35 U/mL was accepted as a cutoff for ULN for CA125 in the 1st generation CA125 assays Its use is recommended by most guidelines including NICE and has played an important role in detection monitoring response to chemotheapy , relapse and disease progression CA 125 is raised in about 90 % of patients with advanced OC but only in 50 % of patients with stage 1 disease The test has limited sensitivity and specificity It can also be elevated in other conditions as ○ malignancies -breast , mesothelioma , non-Hodgkins lymphoma, gastric cancer and leiomyoma ,leiomyosarcoma of GI origin ○benign conditions as endometriosis , pregnancy , ovulatory cycles , liver diseases , congestive heart failure , tuberculosis In premenopausal women avoid testing during periods There is an inverse relationship between serum CA125 levels and survival in OC , CA125 is not suitable for screening as the PP value is less than 4 % It is accepted in clinical practice that CA125 is a better marker in post-menopausal women most likely due to the fact that OC is more commonly diagnosed in these patients
Cervical examination Color Doppler USG CA 125 CT Transvaginal sonography Transabdominal USG MRI Please consider the fact that CA125 and US can both miss OC hence the guidelines advice to proactively reassess and refer to secondary care if symptoms persist Target Ovarian Cancer also suggests that practice nurse should enquire about symptoms of OC during cervical screening as up to 31 % of woman can get confused between the two
Refer urgently-physical examination reveals ascites and or a pelvic or abdominal mass which is not obviously uterine fibroids NICE clearly specifies that in England and Wales this is for an assessment within 2 weeks.
If particularly over 50 and persistent abdominal distension ( bloating ) feeling full ( early satiety ) and or loss of appetite pelvic or abdominal pain increased urinary urgency and / or frequency
check if she c/o unexplained weight loss , fatigue or changes in bowel habit if any woman 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome ( IBS ) -IBS rarely presents for the first time in women of this age check if OC is suspected
If OC is not suspected ask her to return if her symptoms become more frequent and or / persistent
if CA 125 > 35 IU/ mL arrange an US of pelvis and abdomen If US suggests OC -refer urgently for further investigations
assess carefully for other possible clinical reasons for her symptoms if no other reason is apparent ask her to return if her symptoms become more frequent and or persistent
Recommends that OC should be considered in women presenting with recurrent UTIs associated with negative MSUs and dip tests particularly if they are 50 and above.
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CA 125 and Epithelial Ovarian Cancer: Role in Screening, Diagnosis, and Surveillance Kristen Pepin, MD; Marcela del Carmen, MD, MPH; Amy Brown, MD, MPH; Don S. Dizon, MD
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Ovarian cancer: recognition and initial management Clinical guideline [CG122]