Ovarian cancer

Ovarian cancer is a malignant tumour that grows in an ovary, in a fallopian tube or in the lining of the abdominal cavity. What makes it dangerous is not how fast it grows but how ordinary its first symptoms are: the tummy bloats, you feel full after a few mouthfuls, the lower abdomen aches, you need the toilet more often. For years these are put down to age or to diet. What separates an occasional heavy feeling from illness is not the sensation itself but the fact that it comes back almost every day and started recently.

Symptoms that keep coming back day after day

Four signs deserve attention if they last more than two or three weeks and occur on most days:

• bloating that does not settle. Not the kind that follows a large meal or comes before a period, but persistent: the waistband is tight and the tummy does not go down by the evening;
• feeling full quickly and losing your appetite. You eat half your usual plateful and simply cannot manage more;
• pain or pressure low in the abdomen and in the pelvis, sometimes spreading to the lower back;
• needing to pass urine often or suddenly without the signs of a urine infection.

Less often, and more often at a later stage, there is also constant tiredness, weight loss without dieting, heartburn, constipation or diarrhoea, pain during sex, vaginal bleeding after the menopause, and a tummy that grows even though the rest of you is getting thinner.

Most people diagnosed are over fifty, but ovarian cancer also occurs in young women and in those whose ovaries have already been removed: the tumour can begin in a fallopian tube or in the peritoneum.

Why these symptoms are so easily blamed on something else

The same sensations are produced by conditions that are dozens of times commoner: irritable bowel syndrome, harmless ovarian cysts, fibroids, endometriosis, coeliac disease, diverticular disease and the changes of the menopause. Most women with these symptoms will not turn out to have cancer, and that is not a reason to leave them unexamined.

One rule is worth remembering, because it is where time is most often lost. Irritable bowel syndrome almost never begins for the first time after the age of fifty. If a woman over fifty is told for the first time in her life that it "sounds like irritable bowel", that is a diagnosis of exclusion, and the ovaries should be looked at first. The same applies to "gastritis" that does not respond to treatment and to bloating explained away by the menopause.

Vaginal bleeding after the menopause is a separate warning. Most of the time it does not come from the ovary, but it always needs investigating and is never simply normal.

When you need urgent help

Get help immediately — call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single European number is 112) or go to an emergency department — if:

• the abdomen has swollen suddenly, there is cramping pain and vomiting, and nothing passes, neither stool nor wind: this is how a bowel obstruction shows itself;
• very severe pain comes on within minutes on one side of the lower abdomen, with sickness, vomiting, cold sweat or fainting: an ovarian mass may have twisted or burst;
• the abdomen is filling rapidly and you have become breathless even at rest;
• you become short of breath, get a sharp chest pain, cough up blood, or one calf swells and becomes painful: tumours make the blood clot more readily, and a clot is sometimes the first sign of the disease;
• there is heavy vaginal bleeding with weakness and dizziness;
• there is a high temperature together with abdominal pain.

Ask to be seen the same day, though without an ambulance, if abdominal pain is worse each day, if you have stopped eating and drinking, or if you develop a fever after recent surgery or chemotherapy.

What raises the risk

The main factor is age: the risk rises noticeably after the menopause. The rest is a matter of inheritance, hormonal history and general health:

• inherited gene faults, above all BRCA1 and BRCA2, and the genes behind Lynch syndrome;
• ovarian, breast, womb or bowel cancer in a mother, sister or daughter, and sometimes on the father's side too;
• having had breast cancer;
• endometriosis;
• periods starting early and the menopause arriving late, or never having been pregnant — in other words, more ovulations over a lifetime;
• hormone replacement therapy, which raises the risk slightly and stops doing so after it is discontinued;
• excess weight and smoking;
• previous radiotherapy to the pelvis.

It matters that having the ovaries removed does not take the risk to zero: some of the tumours we call ovarian cancer actually start in the fallopian tube or in the peritoneum. Symptoms appearing after such an operation must therefore never be dismissed with "there is nothing left there to go wrong".

What genuinely lowers the risk

Ovarian cancer cannot be prevented entirely, but a few things are established:

• combined hormonal contraception lowers the risk appreciably, and the protection lasts for years after stopping it;
• pregnancies and breastfeeding;
• tying or removing the fallopian tubes when pelvic surgery is being done anyway;
• stopping smoking and getting weight into a healthy range.

Families with BRCA faults or Lynch syndrome are a separate conversation. There, genetic counselling and preventive removal of the tubes and ovaries once childbearing is complete are discussed: it is the only measure that genuinely lowers deaths in that group.

And an honest word about screening: testing every woman with a CA125 blood test and a scan does not work. Large trials have shown that such screening produces many false alarms, leads to unnecessary operations and does not reduce the number of deaths. That is why women without risk factors are not offered these tests "just in case"; what protects people is taking persistent symptoms seriously.

How it is investigated

The appointment begins with questions and an examination: the doctor feels the abdomen and does an internal examination, looking for a mass or for fluid. You can ask for someone to be present and stop the examination at any point.

• Pelvic ultrasound, usually with an internal probe. This is the main first test: it shows the mass itself, its structure, its blood supply and any fluid in the abdomen.
• CA125 blood test. A support, not a verdict. It rises with endometriosis, fibroids, infection, pregnancy, liver disease and even during a period, and at the same time it stays normal in a proportion of early cancers. A normal CA125 does not rule a tumour out. In younger women, markers for germ cell tumours are added.
• CT scan of the chest, abdomen and pelvis, to see how far the disease extends.
• Taking tissue or fluid: a needle sample guided by ultrasound, a laparoscopy through a small cut, or an operation. Only examining tissue under the microscope makes the diagnosis — neither a blood test nor a scan proves a cancer on its own.
• Genetic testing of blood and of the tumour itself. It matters not only to relatives: the result shapes the choice of treatment.

If the tests find nothing but the symptoms carry on for a month or more, go back. Small tumours, especially after the menopause, are not always visible on a first scan.

How it is treated

The plan depends on the type of tumour, how far it has spread and your general health. The two main treatments are surgery and chemotherapy, and they are nearly always combined.

Surgery. Usually both ovaries and tubes, the womb and the omentum are removed, and samples are taken from several places in the abdomen so that the stage can be established properly. Where the tumour is widespread, the surgeon tries to remove as much visible disease as possible, sometimes along with a length of bowel; how much is removed matters more to the outcome than anything else. In a young woman with early disease or with a germ cell tumour it is sometimes possible to keep the womb and one ovary — a conversation to have before the operation, not after.

Chemotherapy. Platinum-based combinations are used. They are given after surgery, and when the tumour is bulky a few cycles come first to make the operation feasible, with more afterwards.

Targeted drugs. PARP inhibitors are taken for a long period after chemotherapy to delay the disease returning; they work particularly well where there is a BRCA fault. Drugs that curb the growth of the tumour's blood vessels are also used.

Hormone therapy suits some uncommon, slow-growing types. Radiotherapy is used sparingly in ovarian cancer, mainly to relieve pain or stop bleeding.

After treatment and beyond

If the ovaries are removed before natural menopause, the menopause arrives at once and is harder to tolerate than a gradual one: hot flushes, poor sleep, dryness, faster bone loss. It is worth discussing beforehand, because the decision about hormone therapy is an individual one and refusing it by default is not always justified.

Regular follow-up appointments are arranged after treatment. Between them, get in touch without waiting your turn if the bloating and pain come back, if you are again full after a few mouthfuls, or if you become breathless or one leg swells: a recurrence announces itself with the same signs as the original illness.

When a tumour cannot be cured, treatment does not end — the aim changes to holding the disease back and easing symptoms. That is the work of a palliative care team, and it is better involved early rather than at the very end: it clearly improves how people feel and does not replace cancer treatment. Relatives need support too, and asking for it is reasonable.

Online consultation

An online appointment works well as a first step when it is unclear what is going on. The doctor will ask in detail how long and how often the abdomen has been troubling you, what has changed about eating, bowels and passing urine, what periods are doing and whether there have been cancers in the family — and will say whether the situation is urgent and which tests to start with.

It is also a convenient way to go through results you already have: a scan report, a CA125 figure, a CT description. The doctor will explain what the wording of a report means, why a normal blood test does not close the question, and which questions to take to a face-to-face appointment. If the diagnosis has already been made, you can go over the treatment plan, the side effects and how to ease them.

What cannot be done online is examining you, feeling the abdomen, scanning and taking tissue for analysis. And if any of the signs in the urgent section appear, do not write a message — call an ambulance.

This material is for information only and does not replace medical advice.