Ovarian Cancer Treatment

What Is Ovarian Cancer? What Are Its Types and Risk Factors?

Ovarian cancer can arise from the different cell types that make up the ovary. There are three main types:

1. Epithelial Ovarian Cancers (EOC): The most common type (approximately 90% of all ovarian cancers). It arises from the epithelial cells covering the outer surface of the ovary. It usually occurs at an older age (after menopause). It is further divided into subtypes such as serous (the most common subtype, often high-grade and aggressive), mucinous, endometrioid, and clear cell.
2. Germ Cell Tumors: These arise from the egg-producing (germ) cells. They are seen more often in young women and adolescents. They generally grow quickly but are highly sensitive to chemotherapy, and treatment success is high when caught at an early stage. Subtypes include dysgerminoma, yolk sac tumor, embryonal carcinoma, choriocarcinoma, and immature teratoma.
3. Sex Cord-Stromal Tumors: These are rare tumors arising from the hormone-producing (estrogen, testosterone) or supporting (stromal) tissue of the ovary. Types include granulosa cell tumor and Sertoli-Leydig cell tumor. They can sometimes cause symptoms related to hormone secretion.

Risk Factors for Ovarian Cancer: Compared with many other cancer types, the risk factors are less clear-cut, but some factors can increase the risk:

• Advanced Age: Risk increases with age and is most common after menopause (for the epithelial type).
• Family History and Genetic Predisposition: One of the most important risk factors. A family history (in first- or second-degree relatives such as a mother, sister, aunt, or grandmother) of ovarian, breast, colon, or endometrial cancer increases the risk. Approximately 15-25% of ovarian cancers are associated with inherited genetic mutations. The most notable of these are BRCA1 and BRCA2 gene mutations (which also increase breast cancer risk). Other hereditary cancer syndromes, such as Lynch Syndrome (HNPCC), also raise the risk. Genetic counseling and testing may be recommended for people with a significant family history.
• Personal History: Having previously had breast, colon, or endometrial cancer. A history of endometriosis (may slightly increase the risk for certain subtypes).
• Reproductive History: Never having given birth (nulliparity), early onset of the first menstrual period, late menopause, and a history of infertility may somewhat increase the risk (the “incessant ovulation” theory).
• Hormone Replacement Therapy (HRT): Long-term use of estrogen-only HRT in particular may slightly increase the risk. The effect of combined HRT is less pronounced.
• Obesity: May increase the risk, particularly after menopause.
• Other Factors: Long-term use of talcum powder in the genital area (controversial), and in some studies a history of Pelvic Inflammatory Disease.

Protective Factors: Factors such as having multiple pregnancies, breastfeeding, long-term (generally >5 years) use of birth control pills, tubal ligation or removal of the tubes (salpingectomy), and removal of the uterus (hysterectomy) have been shown to reduce the risk of ovarian cancer.

What Are the Symptoms of Ovarian Cancer? Why Is Early Diagnosis Difficult?

In its early stages, ovarian cancer usually causes no symptoms or produces symptoms that are very vague and non-specific. These may include common digestive complaints such as bloating, indigestion, and gas, or mild pelvic pain — symptoms that are usually attributed to other causes. This means the disease often goes unnoticed until an advanced stage, when it has typically spread within the abdomen, which is why it is also called the “silent killer.”

Symptoms to Watch For, Especially New-Onset and Persistent (Constant or Frequently Recurring) Symptoms:

• Abdominal Bloating: One of the most common symptoms, especially bloating that does not go away and gradually worsens.
• Pelvic or Abdominal Pain: Pain that may be diffuse or one-sided, constant or intermittent.
• Loss of Appetite or Feeling Full Quickly: Feeling full quickly even after eating a small amount.
• Frequent Urge to Urinate or Sudden Urinary Urgency: Due to pressure on the bladder.

Less Common or Advanced-Stage Symptoms:

• Unexplained fatigue and weakness.
• Indigestion, gas, nausea.
• Changes in bowel habits (constipation or diarrhea).
• Unexplained weight loss, or rarely, weight gain.
• Pain during intercourse (dyspareunia).
• Abnormal vaginal bleeding (especially after menopause or with hormone-secreting tumors).
• Increased abdominal girth due to fluid accumulation (ascites) in the abdomen.
• Back pain.

The Importance and Difficulty of Early Diagnosis: Because there is no effective screening test (the Pap smear is for the cervix and does not screen for ovarian cancer), early diagnosis is generally difficult. For this reason, it is very important for women — especially those with risk factors or those experiencing the persistent symptoms above (lasting longer than a few weeks) — to see a doctor for a gynecological evaluation without delay. Treatment success is much higher in cases diagnosed at an early stage.

How Is Ovarian Cancer Diagnosed? The Pathway Followed When Suspected

When symptoms or examination findings raise suspicion of ovarian cancer, Prof. Dr. Nuray Bozkurt initiates the diagnostic process in Ankara, generally following these steps:

1. Detailed History-Taking and Risk Factor Assessment: The patient’s complaints, their duration and severity, family history, and other risk factors are carefully reviewed.
2. Pelvic Examination: The presence of abdominal swelling, tenderness, or a palpable mass, the size and mobility of the ovaries, and the condition of the uterus and surrounding tissues are assessed. A rectovaginal examination (performed via both the vagina and rectum) can also provide important information.
3. Transvaginal and Abdominal Ultrasonography (USG): This is the most important first-line test for imaging the ovaries and other pelvic organs. The presence, size, and internal structure of any ovarian cysts or masses (simple or complex — does it contain solid areas, septations, or papillary projections?) and their blood flow (via Doppler) are assessed. The abdomen is checked for fluid (ascites). Ultrasound findings provide important clues as to whether a mass is benign or malignant, but they alone cannot provide a definitive diagnosis.
4. Blood Tests (Tumor Markers):
   
   • CA-125: A tumor marker that is frequently elevated, particularly in epithelial ovarian cancers. Elevated levels are more significant in postmenopausal women. However, it may be normal in early-stage cancers and can also be elevated in many benign conditions (myoma/fibroid, endometriosis, infection, pregnancy, liver disease, and even during menstruation). It is more valuable for monitoring response to treatment and detecting recurrence than for diagnosis.
   • HE4 and the ROMA Score: HE4 is another marker. The ROMA score, calculated together with CA-125, can help estimate the likelihood that a mass is malignant.
   • In Young Patients: If a germ cell tumor is suspected, markers such as AFP, Beta-hCG, and LDH are checked.
   • When a Stromal Tumor Is Suspected: Hormones such as Inhibin A/B and estrogen may be checked.
5. Advanced Imaging Methods: If cancer is strongly suspected, or to assess the extent of the disease, tests such as CT, MRI, or PET-CT may be requested. These tests evaluate the abdominal organs, lymph nodes, and distant organs (lungs, liver), providing preliminary information for staging.
6. Definitive Diagnosis and Surgical Staging: The definitive diagnosis and staging of ovarian cancer are usually made during surgery. The suspicious ovarian tissue or tumor is removed during the operation, and a rapid pathological examination (frozen section) may be performed intraoperatively. If the cancer diagnosis is confirmed, surgical staging and cytoreductive (tumor-debulking) surgery are performed in the same session by a Gynecological Oncology Surgeon. Rarely, diagnosis can also be made before surgery via ultrasound-guided biopsy or by draining fluid from the abdomen (paracentesis).

Why Is Ovarian Cancer Staging Important?

Staging determines how far the cancer has spread from its point of origin. This is critical for selecting the most appropriate treatment and for gaining insight into the disease’s prognosis. Staging is generally carried out according to the FIGO (International Federation of Gynecology and Obstetrics) system and consists of 4 basic stages (Stage I: confined to the ovary, Stage IV: spread to distant organs).

Ovarian Cancer Treatment Methods: A Specialized Oncology Team Is Essential!

Ovarian cancer treatment is quite complex and must be planned and carried out by a multidisciplinary team led by a Gynecological Oncology Surgery specialist, together with a Medical Oncologist and a Radiation Oncologist. Treatment is determined based on the cancer’s stage, histological type, grade, and the patient’s age and overall health status.

1. Surgical Treatment (Surgery):

• Surgery is the cornerstone of ovarian cancer treatment.
• Goals:
  
  • Definitive Diagnosis: Removal and pathological examination of the suspicious mass.
  • Surgical Staging: Precisely determining the extent of the cancer (the uterus, the other ovary, the tubes, lymph nodes, omentum, and intra-abdominal surfaces are examined and samples are taken).
  • Cytoreduction (Debulking): Removing all visible tumor tissue as completely as possible. In advanced-stage disease, leaving no residual tumor (optimal debulking) or leaving residual tumor no larger than 1 cm is one of the most important factors for treatment success and survival.
• Procedures Performed: The standard operation generally includes Total Abdominal Hysterectomy (removal of the uterus), Bilateral Salpingo-Oophorectomy (removal of both tubes and ovaries), Omentectomy (removal of the intra-abdominal fatty tissue), and Pelvic and Para-aortic Lymph Node Dissection (removal of the lymph nodes), as well as biopsies of suspicious intra-abdominal areas.
• Approach: These operations are generally performed via open surgery (laparotomy), since the abdomen must be fully assessed and the tumor completely removed. In selected early-stage cases, laparoscopic or robotic surgery may also be considered.
• Fertility-Sparing Surgery: Very rarely, in very young patients with a one-sided, early-stage tumor of a specific type (germ cell or borderline) who wish to have children, removal of only the affected ovary and tube while preserving the uterus and the other ovary may be considered. This requires very close follow-up.
• Importance: It is critically important that these operations be performed by an experienced Gynecological Oncology Surgeon.

2. Chemotherapy:

• Chemotherapy is the other cornerstone of ovarian cancer treatment. It aims to destroy cancer cells with medication.
• When Is It Used? It is administered as standard treatment after surgery (adjuvant chemotherapy) in almost all stages (except for certain very early-stage, low-risk cases) to reduce the risk of recurrence. It is also used in advanced-stage or recurrent disease. It can sometimes be given before surgery (neoadjuvant) to shrink the tumor.
• Administration: It is generally given as a combination of Carboplatin and Paclitaxel, intravenously, every 3 weeks, for a total of 6 cycles. Methods such as chemotherapy delivered directly into the abdomen (intraperitoneal – IP) or heated chemotherapy (HIPEC) may also sometimes be used.
• Managed by the Medical Oncologist.

3. Targeted Therapies:

• These are drugs that target specific molecules involved in the growth and spread of cancer cells.
• PARP Inhibitors (Olaparib, Niraparib, etc.): These are used for maintenance therapy or treatment, particularly in patients with a BRCA gene mutation or platinum-sensitive recurrent disease. This has been a very important advance.
• Anti-angiogenic Drugs (Bevacizumab): These slow tumor growth by preventing the formation of new blood vessels. They are generally added to chemotherapy and used in maintenance therapy.
• Managed by the Medical Oncologist.

4. Radiotherapy (Radiation Therapy):

• Its role in ovarian cancer treatment is limited. It is generally used less often than chemotherapy and surgery. It is mostly used (palliatively) to control localized recurrences or symptoms such as pain and bleeding.

5. Hormone Therapy:

• Its role is quite limited. It may occasionally be tried in certain hormone-receptor-positive, low-grade, or recurrent tumor types, or in stromal tumors.

Post-Treatment Follow-up and Prognosis (Disease Course)

After treatment is completed, patients must be kept under regular, close follow-up to detect any recurrence of the disease early and to manage treatment side effects. Follow-up is generally carried out jointly by the Gynecological Oncologist and the Medical Oncologist, and includes physical examination, CA-125 blood testing, and imaging methods when needed.

Unfortunately, the prognosis (disease course) of ovarian cancer is more serious than that of many other cancer types, because it is often diagnosed at an advanced stage. The most important factors affecting prognosis are the stage at diagnosis, the tumor’s histological type and grade, the amount of residual tumor after surgery (debulking success), and the patient’s response to chemotherapy. Survival rates are much better in patients caught at an early stage, while rates decline in advanced stages. However, thanks to recent advances in surgical techniques, new chemotherapy regimens, and especially targeted therapies (PARP inhibitors, Bevacizumab), survival times and quality of life have improved significantly even for patients with advanced-stage disease.

It is also important for patients to receive psychological support, maintain a healthy diet, and benefit from approaches that support quality of life during and after treatment. Family screening and counseling may also be needed for patients found to carry a genetic mutation.

The Role and Support of Prof. Dr. Nuray Bozkurt in the Ovarian Cancer Process in Ankara

As one of the physicians patients first turn to and trust in a serious, specialist-requiring process such as ovarian cancer, Prof. Dr. Nuray Bozkurt takes on the following important roles in Ankara:

• Risk Assessment and Awareness: She informs patients with a family history or other risk factors about their risks and recommends the necessary follow-up or counseling.
• Early Suspicion and Diagnostic Steps: She carefully evaluates patients presenting with suspicious symptoms and performs or orders the necessary initial diagnostic tests, such as examination, ultrasonography, and tumor markers (CA-125, etc.).
• Urgent and Appropriate Referral: When there is strong suspicion of ovarian cancer or a diagnosis is made, she refers the patient without delay to experienced Gynecological Oncology Surgery specialists and fully equipped oncology centers in Ankara. This swift and appropriate referral is vital to the success of treatment.
• Coordination and Communication: She can support the patient’s communication with the oncology team and the coordination of the treatment process.
• Post-Treatment Gynecological Follow-up: After cancer treatment is completed, she monitors the patient’s general gynecological health in line with the oncology team’s recommendations.
• Empathetic Support and Counseling: She provides patients and their families with accurate information, morale, and psychological support during this challenging diagnosis and treatment process. She answers questions and works to ease concerns. Being accessible is important (0538 983 18 78)(0312 284 00 12).

Important Note: Prof. Dr. Nuray Bozkurt emphasizes that the surgical and medical management of ovarian cancer treatment must be carried out by Gynecological Oncology and Medical Oncology specialists. Her role is early suspicion, an accurate diagnostic start, and, most importantly, swiftly getting the patient to the right specialists.

If you or a loved one has persistent symptoms such as abdominal bloating, pelvic pain, or loss of appetite, or if there is a family history of ovarian cancer, please do not delay seeking a gynecological evaluation. You can schedule an appointment with Prof. Dr. Nuray Bozkurt at our clinic in Ankara for an initial evaluation and consultation. If a suspicious finding arises, the process of referring you to specialist oncology teams for the most accurate, up-to-date treatment will be initiated. For an appointment, please contact us at 0538 983 18 78.