Ovarian cancer remains a challenging disease to diagnose, because symptoms manifest late, often when there is spread to other organs. Women may therefore present with diverse symptoms such as breathlessness, bloating , urinary symptoms, heartburn and indigestion. Even though these are common symptoms, if persistent and unexplained, particularly in women over the age of 50, it is important they are not dismissed and that ovarian cancer is considered  1

Although ovarian cancer is often diagnosed in the advanced stages, where cure may not be possible, the disease can still be controlled, improving length and quality of life, with a combination of chemotherapy and surgery. In recent times, radical surgery performed by a multi-disciplinary surgical team has been shown to be of benefit and is being increasingly offered across Scotland 

Unfortunately, there is no screening test currently available for ovarian cancer. The recently reported UKCTOCs trial  2 showed that despite regular ultrasound and blood tests ( CA125) cancers were still not detected at a sufficiently early stage to improve outcomes.

Lifestyle factors can however impact on a woman’s risk of ovarian cancer: pregnancy and breast feeding are protective as is use of the combined oral contraceptive pill. 

We do know however that some women are more at risk due to their family history and inherited genetic mutations (abnormal genes, e.g. BRCA mutation.) Even in these women screening has not been shown to be of any benefit, but risk reducing surgery can be offered. Historically only the ovaries were removed, but it is now recognised that many cancers previously classified as ovarian actually arise in the fallopian tubes, so removal of the fallopian tubes is now recommended as well. Indeed, many women may benefit from a 2 step procedure, with removal of only the fallopian tubes ( hence avoiding an induced menopause) once their family is complete, with removal of the ovaries after the menopause. Such a 2 step approach is being offered in the North of Scotland to women with proven mutations as well as a strong family history of ovarian cancer in the context of the PROTECTOR trial 3

Finally we do know that women with BRCA and other mutations do respond better to certain types of chemotherapy, resulting in a more favourable prognosis even in women with advanced disease. Understanding of these pathways has allowed identification of similar tumour mutations  even  in ovarian cancer patients who do not carry an inherited mutation , thus opening up novel treatment strategies for all women with ovarian cancer.

Early recognition of symptoms and prompt diagnosis is however paramount if these advances in surgery and chemotherapy are to be translated into better outcomes for women 4

Dr Wendy McMullen & Dr Kalpana Ragupathy, Ninewells Hospital, Dundee

1 https://www.nice.org.uk/guidance/cg122

2ukCTOC trial https://www.thelancet.com/action/showPdf?pii=S0140-6736%2821%2900731-5

3 protector trial http://protector.org.uk/information-for-participants/

4   eveappeal.org.uk