Sibley Memorial Hospital's Knowledge is Power lecture series on Ovarian Health. Presented by Marilyn Jerome Foust, M.D., on September 13, 2012.

1. Ovarian Cancer
Marilyn C. Jerome, M.D.
5215 Loughboro Road, Suite 500
Washington, DC 20016

2. Ovarian cancer
Definition
Incidence
Risk factors
Genetic testing
Symptoms
Testing+tumor markers
Screening

3. Definition
Ovarian cancer forms from ovarian tissue on the
surface of the ovary (epithelial cancers)
Or from malignant germ cells
Fallopian tube cancers act and are treated as ovarian

4. Incidence
Lifetime incidence is 1.48%
NCI estimates:
22,000 new cases per year, with 15,000 deaths
Compare to breast cancer with 229,000 new cases and 39,000
deaths

5. Numbers
Ovarian cancer is the ninth most common cancer of
women but fifth in mortality
The majority of cases are diagnosed after the cancer
has spread to adjacent organs
Early detection improves survival outcome

6. Risk Factors
1. Family History: a first degree relative with ovarian
cancer increases risk to 5%, 2 relatives:7%
2. Hereditary breast and ovarian cancer: BRCA 1 & 2
mutation carriers, Lynch Syndrome
3. Age
4. Nulliparity: pregnancy is protective
5. Hormones: prolonged HRT, fertility drugs are
controversial
6. Other cancers: breast, colon, uterine, rectum

7. What is BRCA 1 & 2
Genetic mutations that occur in less than 1% of the
population
If you are Ashkenazi: 2.5%
These genes protect against breast and ovarian
cancer
Can be inherited from maternal or paternal sides of
the family
Autosomal dominant inheritance: 50% of children of
an affected woman will carry
1 in 10 women with ovarian cancer have gene
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8. Significance of BRCA 1 &2
Breast cancer incidence increases from 12% to 75-
85%
First degree relative with breast cancer increases risk
2 times ( negative for BRCA)
Ovarian cancer incidence increases from 1.4% to 25-
40%
First degree relative with ovarian cancer increases
risk 3 times ( negative for BRCA)
Increased risk of a second breast cancer
Increased risk for family members
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9. Am I a candidate for genetic testing?
Who should be tested
1. Multiple family members with breast and ovarian
cancer: multiple generations, multiple family
members, <50 years old, maternal or paternal side
2. Premenopausal breast cancer
3. Male breast cancer
4. Ashkenazi Jewish background
5. Bilateral breast cancer, breast and ovarian
6. Triple negative breast cancer

10. Preventive strategies in BRCA carriers
Increased surveillance: twice yearly exams and
sonograms, CA-125
Preventive bilateral salpingo-oophorectomy after
childbearing
Breast surveillance: twice yearly exams, yearly
mammography and MRI, preventive medication
(tamoxifen), preventive mastectomy
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11. Factors that decrease risk
1. Oral contraceptives: 4 years of use reduces risk
50%
2.Tubal ligation and hysterectomy
3. Bilateral salpingo-oophorectomy reduces risk-but
not 100%
4. BSO also reduces risk of subsequent breast
cancers by 50%

12. hard hharfrightening?
hard hharfrightening?
hard hharfrightening?
1. Highest mortality of the gynecologic cancers
2. Symptoms can be vague and often do not appear
until the cancer is advanced: order an ultrasound
early sooner than later
3. Symptoms often present for months before
diagnosis is made
4. Often diagnosed at later stages
5. Requires extensive surgery and chemotherapy
6.Long term survival rates are improving but still not
great

13. Symptoms
1. Bloating, abdominal distention
2. Clothing doesn’t fit
3. Pelvic pain, often vague, including pressure in
abdomen, pelvis, back or legs
4. Urinary urgency, bladder pressure
5. Early satiety-feeling full when eating
6. Persistent gas, nausea, indigestion
7. Change in bowel habits
8. Painful intercourse
9. Fatigue
10. Advanced ovarian cancer: shortness of breath

14. Is it GI or ovarian cancer?
1. GI symptoms often fluctuate
2. Ovarian symptoms worsen over time
3. Have a pelvic exam
4. If GI symptoms do not improve, see your
gynecologist
5. Gynecologic exam is important: although not all
ovarian cancers are easily palpable, evaluation of
symptoms can lead to further testing

15. Diagnosis
1. Pelvic exam: ovarian enlargement
2. Rectal exam: mass near rectum
3. Abdominal exam: fluid (ascites), mass
4. Pelvic ultrasound
5. Tumor markers
6. CT scan

16. Pelvic ultrasound
1. Ultrasound to visualize pelvic anatomy
2. Abdominal and vaginal approaches
3. Full bladder
4. Visualizing the ovaries
5. Characteristics of ovarian cyst
6. Characteristics of cancer: bilaterality, complex
cysts with solid components,septations, thickened
walls, nodularity, pelvic fluid collection

17. CA-125
1. Ovarian cancer marker not specific or sensitive
enough for diagnosis
2. Used to monitor the effects of treatment
3. Can be elevated due to other conditions
4. Often normal levels in early stage disease

18. Tumor markers: What is new?
THERE IS NO AVAILABLE TUMOR MARKER FOR
OVARIAN CANCER SCREENING
Ova 1: evaluates 5 tumor markers
more sensitive than CA-125
for ovarian masses that will be surgically excised
referral to oncologist
HE4: combines with CA-125 and menopausal status
to predict malignancy
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19. CT scan and other tests
1. Preoperative test to determine involvement of
adjacent organs, bowel and bladder, omentum, lymph
nodes
2. CT scan may be used to biopsy a mass
3. Used to monitor recurrence
4. Chest x-ray
5. Abdominal and pelvic MRI
6. Colonoscopy-invasion of colon

20. Routine Screening
1. Pelvic exam
2. Discuss family history with MD
3. Genetic testing for high risk individuals
4. Pelvic ultrasounds and tumor markers for high risk
individuals, more frequent exams
5. No good screening tool for women of average risk:
a screening test must have be able to reliably detect
early stage disease without excessive false positives
(e.g. mammography)

21. Screening high risk women
1. Pelvic exams twice yearly
2. Ultrasounds twice yearly
3. Tumor markers: CA-125
4. Prophylactic oophorectomy

22. Screening in low risk women?
Screening women of average
risk
Studies do not prove that screening women of
average risk improve mortality statistics
Ovarian cysts are often found on ultrasound, most of
which are not malignant
Once these are found, follow-up is needed to prove
that they are not growing
Reducing anxiety / increasing anxiety
Increased testing can lead to increased surgical
procedures with inherent risks of surgery

23. Prophylactic Oophorectomy
1. Preventive removal of both ovaries and fallopian
tubes to prevent ovarian cancer, not 100% (2-3%
incidence of occult malignancy)
2. Recommended for BRCA 1 & 2 carriers after
childbearing
3. May be recommended for those with strong family
history of breast and ovarian cancer without a known
mutation
4. Decreases ovarian cancer risk 95% and breast
cancer by 50%
5. Can be done laparoscopically with minimal
recovery time

24. Are there risks to prophylactic
oophorectomy?
1. Surgical risks include bleeding, infection, injury to
bowel or urinary tract
2. Menopausal symptoms
3. Possible increased risks of osteoporosis and
cardiac disease.

25. Can I still get ovarian cancer if
my ovaries have been
removed?
1. Peritoneal carcinomatosis or primary peritoneal
cancer
2. Symptoms can be vague

26. Conclusion
Improve understanding of frequency of ovarian
cancer
Understand significance of certain symptoms
Importance of genetic testing for high risk individuals
Understand importance of annual examinations
Usefulness of radiologic and blood tests
Risks and benefits of ovarian cancer screening