Ovarian cancer

What is ovarian cancer?

Ovarian cancer happens when abnormal cells in your ovaries grow and divide in an uncontrolled way, forming a tumour. There are several types, named after the cell where the cancer first develops.

Your ovaries are two small organs, one on each side of your womb, that store your eggs and produce the hormones oestrogen and progesterone. Cancer of the ovary, fallopian tube and the lining of your tummy (peritoneum) are often grouped together and treated in the same way, because they behave similarly.

What are the symptoms of ovarian cancer?

The main symptoms to look out for, especially if they happen frequently (12 or more times a month) or are new for you, are:

• persistent bloating or a swollen tummy that doesn't come and go
• feeling full quickly, or loss of appetite
• pain or discomfort in your tummy or pelvis
• needing to pee more often or more urgently.

The symptoms of ovarian cancer are common and can be caused by many other conditions, so having them doesn't necessarily mean you have cancer. However, the symptoms can be easy to mistake for something less serious, so it's important to get them checked by your doctor.

You might also notice:

• indigestion
• constipation or diarrhoea
• back pain
• extreme tiredness for no obvious reason
• unexplained weight loss
• unusual vaginal bleeding, including between periods, heavier periods, or any bleeding after the menopause
• pain during sex.

These symptoms often overlap with other conditions. Irritable bowel syndrome (IBS) can also cause bloating and bowel changes, but IBS symptoms tend to fluctuate with diet, while ovarian cancer symptoms are usually more persistent.

Menopause and urinary tract infections can cause similar changes too, but they don't typically come with the pelvic pain or early fullness seen in ovarian cancer.

The first step to noticing a change is knowing what's normal for you.

What are the causes of ovarian cancer and who is at risk?

The exact cause of ovarian cancer isn't fully understood. It starts when cells in or near your ovaries develop changes in their DNA that tell them to grow and multiply out of control.

A number of factors can raise your risk, including:

• getting older – risk increases with age, especially from your mid-forties onwards, and is greatest for those aged 75 to 79
• an inherited faulty gene, such as BRCA1, BRCA2, or genes linked to Lynch syndrome (an inherited condition that raises cancer risk) – rarer gene changes such as RAD51C, RAD51D, BRIP1 and PALB2 can also play a part
• a family history of ovarian or breast cancer, particularly in a parent, sibling or child
• a previous diagnosis of breast or bowel cancer, or previous radiotherapy for another cancer
• having endometriosis (an often painful condition where tissue similar to your womb lining grows elsewhere in the body) or diabetes
• starting your periods at a young age, or going through the menopause late (over 55)
• never having been pregnant, or having your first baby later in life
• never having used hormonal contraception, such as the pill
• taking hormone replacement therapy (HRT) – this slightly raises risk, and the increase depends on the type of HRT, how long you take it, your age and general health
• being overweight or obese
• smoking, which is particularly linked to a type called mucinous ovarian cancer
• past exposure to asbestos, an insulating material used in construction and shipbuilding until it was banned in the UK in the late 1990s.

Some factors may lower your risk. Taking the combined contraceptive pill reduces risk, with protection lasting for at least 30 years after you stop. Having children and breastfeeding also reduce risk, likely because you ovulate less often during pregnancy and while breastfeeding.

Are there different types of ovarian cancer?

Ovarian cancer is grouped by the type of cell it starts in.

• Epithelial ovarian cancer: This is by far the most common type, making up around 9 in 10 cases. It starts in the cells covering the ovary, fallopian tube or peritoneum, and includes several subtypes, the most common being serous ovarian cancer.
• Germ cell tumours: These are rare, at around 1 in 20 cases. They start in the egg-producing cells and mostly affect younger women, including children and teenagers.
• Stromal tumours: These are also rare, at around 1 in 20 cases. They develop in the hormone-producing connective tissue of the ovary and are often, though not always, found at an earlier stage than other types.
• Primary peritoneal cancer: This is rare. The cells look like a common type of epithelial ovarian cancer, but the disease starts in the lining of your pelvis or tummy rather than the ovary itself, so it can develop even after your ovaries have been removed.

Are there different stages of ovarian cancer?

Doctors use the FIGO (International Federation of Gynaecology and Obstetrics) staging system to describe how far ovarian cancer has spread. There are 4 stages, from 1 (earliest) to 4 (most advanced):

• Stage 1: The cancer is only in one or both ovaries or fallopian tubes
• Stage 2: The cancer has also reached nearby pelvic structures, such as the womb, bladder or bowel
• Stage 3: The cancer has spread beyond the pelvis to the lining of the tummy or to lymph nodes
• Stage 4: The cancer has spread to distant organs, such as the liver or lungs.

The doctor may not be able to confirm the exact stage until surgery. Alongside the stage, the cancer will also be given a grade, describing how different the cancer cells look from normal cells under a microscope – higher-grade cells tend to grow and spread faster.

Ovarian cancer is often diagnosed later than doctors would like, which is why getting symptoms checked early matters so much.

How is ovarian cancer diagnosed?

If you are experiencing symptoms, you should discuss this with your GP. They'll ask about your symptoms and your family history of ovarian or breast cancer and may examine your tummy and pelvis. You can ask for a female doctor or nurse for this.

Your GP may arrange:

• a blood test to check for a protein called CA125, which is sometimes linked to ovarian cancer
• an ultrasound scan of your tummy and pelvis, if your CA125 level is high.

If these tests suggest ovarian cancer, you'll usually be referred to a specialist within 2 weeks for further tests, which may include:

• a CT scan
• a needle biopsy, taking a small sample of cells or fluid
• a laparoscopy, examining your ovaries with a camera passed through a small cut in your tummy
• a laparotomy, a larger operation to remove tissue or your ovaries for testing.

Surgery is the only way to confirm a definite diagnosis. There's no national screening programme for ovarian cancer in the UK, because there isn't yet a test reliable enough to catch it early in people without symptoms.

How is ovarian cancer treated?

Non-surgical treatment

• Chemotherapy: Medicine that kills cancer cells. You may have this before surgery, after it, or on its own, and it can also be used if the cancer comes back
• Radiotherapy: High-energy radiation used to treat advanced cancer when other treatments aren't suitable, or to relieve symptoms such as pain or bleeding
• Targeted therapies: Medicines that target the specific processes cancer cells use to grow or survive – an option for some advanced or recurrent cancers.
• Hormone therapy: Blocks the oestrogen that some ovarian cancers need to grow. This is rarely used.
• Immunotherapy: For some advanced cancers, medicines that help your immune system attack cancer cells.

Surgical treatment

Surgery is the main treatment for almost everyone with ovarian cancer, and outcomes tend to be better when it's carried out by a specialist gynaecological cancer surgeon.

1. For early-stage cancer that hasn't spread beyond the ovaries, surgery may remove one or both ovaries and fallopian tubes, and sometimes your womb and cervix.
2. For cancer that has spread, surgery may also remove fatty tissue in your tummy (the omentum), nearby lymph nodes, and sometimes parts of your bowel or other organs.

The aim is to remove as much of the cancer as possible.

If you're younger and hope to have children in the future, ask your specialist team about options to help preserve your fertility, since treatment can affect your periods and fertility.

It's common for ovarian cancer to come back after treatment, which is why regular follow-up appointments matter.

If your cancer cannot be cured, your care will focus on controlling symptoms and helping you live as well as possible for as long as possible, supported by a palliative or symptom control team.

When should I see a doctor?

See a GP if:

• you have any symptoms of ovarian cancer that are new, frequent or unusual for you
• you've already seen a GP but your symptoms haven't gone away, or are getting worse or more frequent.

Most people with these symptoms won't have ovarian cancer, but it's always worth getting checked. It can help to keep a short diary of your symptoms before your appointment.

If you have pain that lasts longer than 2 weeks and doesn't ease with over-the-counter medication, let your doctor know.