Epithelial ovarian cancer (90–95%)
- Incidence (annual). The USA: 22,000 new cases and 15,500 deaths; the UK: 7,000 new cases and 4,300 deaths. More patients die from this malignancy in industrialized western countries than all other gynecologic cancers combined.
- Median age. Sixty years.
- Risk factors. Low parity, family history of breast or ovarian cancer, and living in industrialized western countries. Protective factors include multiparity, breastfeeding, and chronic anovulation.
- Hereditary factors account for 5–10% of all cases. Women with two first- or second-degree relatives having premenopausal breast or ovarian cancer (any age) should be referred to genetic counseling. Testing can identify BRCA-1 or BRCA-2 mutation carriers.
- Screening. No combination of CA-125 ± transvaginal sonography has been shown to reliably detect early disease or decrease mortality.
- Chemoprevention. Oral contraceptive use decreases the incidence of ovarian cancer by up to 50%.
- Surgical prophylaxis. High-risk women (BRCA mutation carriers) may be offered prophylactic bilateral salpingo-oophorectomy (BSO) beginning at age 35 or upon completion of childbearing. This reduces their ovarian cancer risk by 90% and their breast cancer risk by 50%. Primary peritoneal carcinoma can still occur rarely.
- Signs and symptoms. Women with early stage ovarian cancer frequently report symptoms such as bloating, increased abdominal size, and urinary symptoms. Most often these are vague symptoms that are overlooked by the doctor or patient. Early satiety, recent bowel changes, or “indigestion” is a common complaint of advanced disease.
- Physical findings. Early ovarian cancer may be suspected by detection of an adnexal mass on pelvic examination. Advanced disease (Figure 33.1) is more clinically obvious.
- Diagnostic work-up. Transvaginal sonography is the most sensitive method to evaluate an adnexal mass. Computed tomography (CT) of the abdomen/pelvis and a chest radiograph are most helpful for treatment planning in advanced disease. Diagnostic paracentesis is mainly indicated in the absence of an ovarian mass.
Staging (Figure 33.2)
- Ovarian cancer is surgically staged.
- Two-thirds of patients present with stage III–IV disease.
