1 Ovarian Cancer HSCI 367 14 November 2013 Melissa Banks Jessica Bryan Joseph Gariby Adrianna Mitchell Patrice

Thompson

Ovarian cancer is fatal for women and misdiagnosed repeatedly. Only 15 percent of women are diagnosed early with a five-year survival rate higher than 35 percent (Ovarian Cancer National Alliance, 2013). Women have to modify their lifestyle to accommodate for the physical and mental affects of living with ovarian cancer. This paper will review the history and etiology, incidence and prevalence, public health ramifications, signs and symptoms, diagnosis, treatment, and prognosis of ovarian cancer. History and Etiology The earliest record of cancer dates back to around 1500 B.C, however, little is known about the history of ovarian cancer other than its high incident rate during the industrialized revolution. This type of cancer, since its earliest recording in the 1800s, was thought to be due to environmental or hormonal changes (Johns Hopkins Pathology, 2013), or due to cancer cells in the fallopian tubes migrating into the ovaries. (Ovarian Cancer National Alliance, 2013). Ovarian cancer has been significantly correlated to developmental changes that occur over a lifespan and conflicting information states ovarian cancer is inherited while others disagree with the findings. Most women affected by the disease are in their early to late forties when most dramatic body changes occur, such as menopause. Several studies since then have found a significant relationship between high expression levels of RCAS1 (receptor binding cancer antigen expressed on SiSo cells) and ovarian cancer (Center for Disease

2 Control and Prevention, 2013). There is no direct screening methods for early detection, therefore most cases go undetected until it is in the irreversible stages of cancer, when the chances of survival are significantly reduced (Blanco et al., 2013). Incidence and Prevalence The American Cancer Society projects in 2013 predict there will be 22,240 new cases of ovarian cancer diagnosed and 14,030 deaths (SEER Cancer Statistics, 2013). Since, the War on Cancer was declared 40 years ago, ovarian cancer mortality rates have negligibly improved (Ovarian Cancer National Alliance, 2013). Even though ovarian cancer only accounts for three percent of all cancers, it is the eighth most common, the fifth leading cause of cancer-related deaths in women (11.4 per 100,000), and the leading cause of gynecologic cancer deaths (Center for Disease Control and Prevention, 2013). A woman has a 1-in-72 chance of developing ovarian cancer and a 1-in-95 chance of dying. Incident rates of ovarian cancer in 2006 included 18.6 percent of women between the ages of 45 to 54 and 23 percent between the ages of 55 to 64 (Ovarian Cancer National Alliance, 2013). Survival rates for ovarian cancer are much lower than other cancers. Seventyfive percent of women will survive one year, 44 percent will survive five years, and only 34 percent will survive ten years. According to the SEER website and the most current data (from 2010), there are 186,138 women currently living with ovarian cancer, up from 3,400 the previous year (Ovarian Cancer National Alliance, 2013). Ovarian cancer is the most deadly of gynecologic cancers and a hard one to diagnose, treat, and survive. Only 15 percent of cases are discovered early, and incident rates are decreasing at a rate of only one percent each year. On a positive

3 note, prevalence is increasing on an average of 1.6 percent a year for the last 10 years, which indicates survivors are living longer (Ovarian Cancer National Alliance, 2013). Public Health Ramifications Ovarian cancer can be fatal if not diagnosed early. One way to reduce the risk is by using oral contraceptives. Oral contraceptive use as a preventive measure is not fully understood, but studies have shown if used for more than five years, a womans chance of development is reduced by 58 percent for up to 20 years. On the other hand, a 5-year use of oral contraceptives do not thwart off ovarian cancer after 20 years from last use. Alternatively, other contraceptives such as intrauterine devices, or infertility treatments have been shown to increase a womans chance of developing ovarian cancer (Tworoger, Fairfield, Colditz, Rosner, & Hankinson, 2007). Pros and cons of these

types of methods have to be assessed. For instance, oral contraceptives are known to increase development of cervical cancer (Roland, Rodriguez, Patterson, & Trivers, 2013). In conclusion, oral contraceptives play a vital role in reducing morbidity and mortality in the public healths fight against ovarian cancer Ovarian cancer survivors have to contend with more than just the disease. Some struggle with low levels of emotional and social support, self-efficacy and minimal counseling. Studies have shown this causes poor quality of life, issues with depression, increased anxiety, and hopelessness. To combat these negative effects, ovarian cancer survivors require more education about living with the disease and adaptation skills to manage and reduce levels of stress associated with ovarian cancer. When these types of services are offered and used, survivors report an increase in quality of life (Roland et al., 2013). In conclusion, oral contraceptives and social support are imperative to public

4 health, and are directly tied to reducing ovarian cancer rates, or improving a survivors quality of life. Signs and Symptoms Signs of ovarian cancer are not exclusive, thus the reason why women associate it with normal changes in the body. Most ovarian cancer cases are misdiagnosed because these symptoms mirror those of gastrointestinal diseases. Therefore, correlating the identifiable markers with the ovarian cancer symptom index will be crucial in diagnosing this type of cancer as early as possible to increase chances of survival (Bankhead, Kehoe, & Austoker, 2005). Some identifiable markers include persistent bloating, pelvic or abdominal pain, feeling full and urinary urgency lasting. The symptom index clearly states that these symptoms need to be present for less than one year, but longer than 12 days out of the month to be identified as markers. However, due to these ambiguous symptoms, women statistically have a greater chance of not having ovarian cancer (Rossing, Wicklund, Cushing-Haugen, & Weiss, 2010). One problem with the symptoms of ovarian cancer is the way the symptoms are conveyed. For example, distension goes undetected due to the inability to fully understand that distension and bloating are not the same. Persistent distension was found to be prevalent in those with ovarian cancer where bloating or fluctuating change in the abdominal region were not associated. In conclusion, the symptoms closely related to early detection of ovarian cancer are persistent distension, mass, bloating, and abdominal pain with gastrointestinal and urinary symptoms (Rossing et al., 2010).

5 Diagnosis The diagnosis of ovarian cancer has a significant affect on what type of treatment a patient might receive. If the treatment is insufficient to the severity of the cancer, it will be fatal. Physicians use several methods to detect and diagnose ovarian cancer early. These methods include: Pelvic scans, the CA-125 exam, MRIs, lab tests, Positron Emission Tomography/Computed Tomography (PET/CT) scans, Transvaginal Doppler Ultrasounds, biopsies, and laparoscopies (Cancer Treatment Centers of America, 2013). For a doctors first step in diagnosing ovarian cancer, he or she will use pelvic scans to detect nodules or bumps in the abdominal or pelvic areas. A CA-125 exam is a blood test used to measure the level of the CA-125 protein. High levels may indicate ovarian cancer or less serious conditions such as endometriosis or inflammation. The blood test is primarily used to monitor the CA-125 protein levels in the patient's blood that are suspected of having ovarian cancer. If the protein levels in the blood continue to rise, then ovarian cancer is suspected (Cancer Treatment Centers of America, 2013). There are four lab tests used to evaluate the extent of ovarian cancer. The Genomic Tumor Assessment test examines a tumors cause of growth, whether it is due to DNA mutation, or a personal or environmental factor. The Oncotype DX Test is used to determine if chemotherapy would be an effective treatment and to predict the cancer's likelihood of reoccurring. Tumor Molecular Profiling examines the tumor's molecular makeup of various proteins, enzymes, genes, and hormones. Finally, the Nutritional Panel test identifies a vitamin or mineral deficiency due to treatment that could decrease quality of life (Cancer Treatment Centers of America, 2013). PET scans reveal the structure and function of tumor cells in a single imaging

6 session and aids in monitoring CA-125 levels. CT scans are used after physical checkups to locate any suspicious tumors, determine the size of the tumor, to visually check where the tumor may have spread that may possibly affect other organs, and see if the lymph nodes are enlarged (Cancer Treatment Centers of America, 2013). A Transvaginal Doppler Ultrasound shows real-time action movements of organs, and most importantly, displays an increase blood flow to the ovaries, a strong indicator of cancerous tissue. A laparoscopy allows the doctor to see ovaries and other pelvic areas in real-time to confirm the stage of the cancer, further on, implementing an effective treatment plan. Even with all the new technology, a biopsy is the most common procedure for diagnosing ovarian cancer (Ovarian Cancer National Alliance, 2013). Treatment and Prognosis Treatment is dependent on the stage of ovarian cancer, and stage determines a patients 5-year survival rate. Stage I is localized in one or both ovaries and has a 5year survival rate of 85 percent. In stage II, the cancer spreads to the uterus, fallopian tubes, or other areas surrounding the pelvis, and survival rate decreases by 10 percent. In stage III, the cancer spreads to the lymph nodes, and pelvis area, and a patients survival rate dramatically decreases to 35 percent. Only 10 percent of survivors live to five years in stage IV. In this stage, cancer spreads outside the abdomen and metastasizes to other organs (Coleman, 2013; Johns Hopkins Pathology, 2013). The primary treatment for stage I ovarian cancer is surgically removing the cancer from the ovaries. The two goals of surgery are staging and debulking. Debulking is the removal of cancerous tumors in the abdomen, and includes a colostomy. Stage II ovarian cancer patients typically have a hysterectomy, but may undergo a bilateral

7 salpingo-oophorectomy or an omentectomy, which is the removal of the fallopian tubes and the ovaries, and removal of fatty tissue (American Cancer Society, 2013). Chemotherapy usually accompanies surgery for women with stage III and IV ovarian cancer. However, in stage IV, chemotherapy is only used to control the growth. Bevacizumab is a drug that can accompany chemotherapy and helps regulate the tumor and the signals the cancer cells send out. Women usually develop holes in their bowel walls, a fatal side effect to this treatment (American Cancer Society, 2013). Hormone therapy is used to treat ovarian stromal tumors in premenopausal women. Targeted therapy is a new treatment that identifies and attacks the inner portion of cancer cells, causing little damage to normal cells. Radiation treatment is the main treatment used for ovarian cancer and causes several side effects such as fatigue, nausea, diarrhea, and vaginal irritation (American Cancer Society, 2013). Survivors who have recurring cancer are placed into one of three groups for treatment to determine what procedures are expected in the future. Recurrent cancer treatments may include resistant chemotherapy, platinum containing regimen or biological therapies (Johns Hopkins Pathology, 2013). Conclusion Overall, there is little success in screening early detection for ovarian cancer. Since the war on cancer was declared, there has been an increase in education for women about signs and symptoms, lowering womens risk by using oral contraceptives, and learning new lifestyle adaptations when living with the disease. Proper diagnosis aids with implementing effective treatment and ultimately increasing the womens chances of survival and to increase their quality of life.

8 References American Cancer Society. (2013). Treatments and Side Effects. Retrieved October 13, 2013 from American Cancer Society: http://www.cancer.org/treatment/treatmentsandsideeffects/index Bankhead, C. , Kehoe, S. , & Austoker, J. (2005). Symptoms associated with diagnosis of ovarian cancer: A systematic review. BJOG: An International Journal of Obstetrics & Gynaecology, 112(7), 857-865. Blanco, A., De la Hoya, M., Osorio, A., Diez, O., Miramar, M., Infante, M., & Balmaa, J. (2013). Analysis of PALB2 Gene in BRCA1/BRCA2 Negative Spanish Hereditary Breast/Ovarian Cancer Families with Pancreatic Cancer Cases. Plos ONE, 8(7), 1-8. doi:10.1371/journal.pone.0067538. Cancer Treatment Centers of America. (n.d.). Ovarian cancer diagnostics and treatment. Retrieved October 21, 2013, from Cancer Treatment Centers of America: http://www.cancercenter.com/ovarian-cancer/diagnostics-and-treatments Center for Disease Control and Prevention. (2013). National Program of Cancer Registires (NPCR). Retrieved October 27, 2013, from CDC: http://apps.nccd.cdc.gov/uscs/toptencancers.aspx Coleman, T. (2013, November). D & D of the Female Reproductive System and Breast. Human Disease Mechanisms. Lecture conducted from California State University, San Bernardino, Ca. Johns Hopkins Pathology. (2013). Ovarian Cancer. Retrieved October 20, 2013, from Johns Hopkins Pathology: http://www.ovariancancer.jhmi.edu

9 Ovarian Cancer National Alliance. (2013). How is ovarian cancer diagnosed? Retrieved October 25, 2013, from Ovarian Cancer National Alliance: http://www.cancer.org/cancer/ovariancancer/detailedguide/ovarian-cancerdiagnosis Ovarian Cancer National Alliance. (2013). Statistics. Retrieved October 27, 2013, from Ovarian Cancer National Alliance: http://www.ovariancancer.org/about-ovariancancer/statistics/ Roland, K. , Rodriguez, J. , Patterson, J. , & Trivers, K. (2013). A literature review of the social and psychological needs of ovarian cancer survivors. PsychoOncology, 22(11), 2408-2418. Rossing, M. , Wicklund, K. , Cushing-Haugen, K. , & Weiss, N. (2010). Predictive value of symptoms for early detection of ovarian cancer. Journal of the National Cancer Institute, 102(4), 222-229. SEER Cancer Statistics. (2013). Ovarian Cancer Statistics. Retrieved Otober 15, 2013, from National Cancer Institute: http://seer.cancer.gov/statfacts/html/ovary.html Tworoger, S. , Fairfield, K. , Colditz, G. , Rosner, B. , & Hankinson, S. (2007). Association of oral contraceptive use, other contraceptive methods, and infertility with ovarian cancer risk. American Journal of Epidemiology, 166(8), 894-901.