Ovarian Cancer

Ovarian cancer is the second most common gynecologic malignancy after endometrial cancer. The peak incidence occurs in women in their 50s and 60s. Risk factors include uninterrupted ovulation (ie, no pregnancies or oral contraceptive use) and inherited genetic mutations (BRCA1 mutations).

Symptoms develop late and are usually nonspecific; vague abdominal or gastrointestinal discomfort is common. As a result, 75% of patients present with stage III or stage IV disease (see Table 118-3). Large abdominopelvic masses, ascites, or both may be detected during routine pelvic examination. Ovaries in postmenopausal women are small and normally not palpable; thus, any palpable ovary in a postmenopausal patient suggests ovarian cancer, and prompt evaluation is warranted. If cancer is suggested by pelvic ultrasound, the mass is surgically resected for definitive diagnosis, staging, and treatment.

Initial treatment involves surgical removal of visible tumor. The decision to recommend chemotherapy is based on the tumor stage, the patient's comorbidities, and the results of a discussion of the risks and benefits of therapy. Although chemotherapy may be well tolerated, cure rates for advanced stage disease are low.

Combination chemotherapy is given IV over several months, except to patients with early-stage disease or histologically borderline tumors. Treatment rarely includes radiation therapy. The serum CA 125 marker is useful for monitoring treatment response and disease status in many women, especially those with serous tumors. For patients with recurrent disease, modalities such as new generation chemotherapeutic drugs, monoclonal antibody therapy, and gene therapy are being investigated.

Platinum-based chemotherapy given after surgery results in clinical remission in 70% of patients, with median survival of 3 years. Because most ovarian cancer is diagnosed at an advanced stage, the long-term prognosis is poor. A majority of patients experience a recurrence, and the 5-year survival rate seldom exceeds 20%.