Introduction
The diagnosis of ovarian cancer brings with it many questions and a need for clear, understandable answers. We hope this National Cancer Institute (NCI) booklet will help. It describes the symptoms, detection, diagnosis, and treatment of this disease. Having this important information can make it easier for women and their families to handle the challenges they face.
Cancer researchers continue to study and learn more about ovarian cancer. The Cancer Information Service and the other sources of NCI information listed under "National Cancer Institute Information Resources" can provide the latest, most accurate information on ovarian cancer. Publications mentioned in this booklet and others are available from the Cancer Information Service at 1-800-4-CANCER. Also, many NCI publications may be viewed or ordered on the Internet at http://cancer.gov/publications.
Words that may be new to readers appear in italics. Definitions of these and other terms related to ovarian cancer can be found in the Dictionary. For some words, a "sounds-like" spelling is also given.



The Ovaries
The ovaries are a pair of organs in the female reproductive system. They are located in the pelvis, one on each side of the uterus (the hollow, pear-shaped organ where a baby grows). Each ovary is about the size and shape of an almond. The ovaries have two functions: they produce eggs and female hormones (chemicals that control the way certain cells or organs function).
Every month, during the menstrual cycle, an egg is released from one ovary in a process called ovulation. The egg travels from the ovary through the fallopian tube to the uterus.
The ovaries are also the main source of the female hormones estrogen and progesterone. These hormones influence the development of a woman's breasts, body shape, and body hair. They also regulate the menstrual cycle and pregnancy.

The ovaries and other female reproductive organs



Understanding Ovarian Cancer
Cancer is a group of many related diseases that begin in cells, the body's basic unit of life. To understand cancer, it is helpful to know about normal cells and what happens when they become cancerous.
The body is made up of many types of cells. Normally, cells grow, divide, and produce more cells when the body needs them. This orderly process helps to keep the body healthy. Sometimes, however, cells keep dividing when new cells are not needed. These extra cells form a mass of tissue, called a growth or tumor. Tumors can be benign or malignant.
• Benign tumors are not cancer. They often can be removed and, in most cases, they do not come back. Cells in benign tumors do not spread to other parts of the body. Most important, benign tumors are rarely a threat to life.
Ovarian cysts are a different type of growth. They are fluid-filled sacs that form on the surface of an ovary. They are not cancer. Cysts often go away without treatment. If a cyst does not go away, the doctor may suggest removing it, especially if it seems to be growing.
• Malignant tumors are cancer. Cells in these tumors are abnormal and divide without control or order. They can invade and damage nearby tissues and organs. Cancer cells can also spread (metastasize) from their original site to other parts of the body.
A malignant tumor that begins in the ovaries is called ovarian cancer. There are several types of ovarian cancer. Ovarian cancer that begins on the surface of the ovary (epithelial carcinoma) is the most common type. This is the type of cancer discussed in this booklet. Ovarian cancer that begins in the egg-producing cells (germ cell tumors) and cancer that begins in the supportive tissue surrounding the ovaries (stromal tumors) are rare and are not discussed in this booklet. The Cancer Information Service and the other NCI sources listed under "National Cancer Institute Information Resources" can provide information or suggest resources that deal with these types of ovarian cancer.
Ovarian cancer cells can break away from the ovary and spread to other tissues and organs in a process called shedding. When ovarian cancer sheds, it tends to seed (form new tumors) on the peritoneum (the large membrane that lines the abdomen) and on the diaphragm (the thin muscle that separates the chest from the abdomen). Fluid may collect in the abdomen. This condition is known as ascites. It may make a woman feel bloated, or her abdomen may look swollen.
Ovarian cancer cells can also enter the bloodstream or lymphatic system (the tissues and organs that produce and store cells that fight infection and disease). Once in the bloodstream or lymphatic system, the cancer cells can travel and form new tumors in other parts of the body.



Ovarian Cancer: Who's at Risk?
The exact causes of ovarian cancer are not known. However, studies show that the following factors may increase the chance of developing this disease:
• Family history. First-degree relatives (mother, daughter, sister) of a woman who has had ovarian cancer are at increased risk of developing this type of cancer themselves. The likelihood is especially high if two or more first-degree relatives have had the disease. The risk is somewhat less, but still above average, if other relatives (grandmother, aunt, cousin) have had ovarian cancer. A family history of breast or colon cancer is also associated with an increased risk of developing ovarian cancer.
• Age. The likelihood of developing ovarian cancer increases as a woman gets older. Most ovarian cancers occur in women over the age of 50, with the highest risk in women over 60.
• Childbearing. Women who have never had children are more likely to develop ovarian cancer than women who have had children. In fact, the more children a woman has had, the less likely she is to develop ovarian cancer.
• Personal history. Women who have had breast or colon cancer may have a greater chance of developing ovarian cancer than women who have not had breast or colon cancer.
• Fertility drugs. Drugs that cause a woman to ovulate may slightly increase a woman's chance of developing ovarian cancer. Researchers are studying this possible association.
• Talc. Some studies suggest that women who have used talc in the genital area for many years may be at increased risk of developing ovarian cancer.
• Hormone replacement therapy (HRT). Some evidence suggests that women who use HRT after menopause may have a slightly increased risk of developing ovarian cancer.
About 1 in every 57 women in the United States will develop ovarian cancer. Most cases occur in women over the age of 50, but this disease can also affect younger women.
As we learn more about what causes ovarian cancer, we may also learn how to reduce the chance of getting this disease. Some studies have shown that breast feeding and taking birth control pills (oral contraceptives) may decrease a woman's likelihood of developing ovarian cancer. These factors decrease the number of times a woman ovulates, and studies suggest that reducing the number of ovulations during a woman's lifetime may lower the risk of ovarian cancer.
Women who have had an operation that prevents pregnancy (tubal ligation) or have had their uterus and cervix removed (hysterectomy) also have a lower risk of developing ovarian cancer. In addition, some evidence suggests that reducing the amount of fat in the diet may lower the risk of developing ovarian cancer.
Women who are at high risk for ovarian cancer due to a family history of the disease may consider having their ovaries removed before cancer develops (prophylactic oophorectomy). This procedure usually, but not always, protects women from developing ovarian cancer. The risks associated with this surgery and its side effects should be carefully considered. A woman should discuss the possible benefits and risks with her doctor based on her unique situation.
Having one or more of the risk factors mentioned here does not mean that a woman is sure to develop ovarian cancer, but the chance may be higher than average. Women who are concerned about ovarian cancer may want to talk with a doctor who specializes in treating women with cancer: a gynecologist, a gynecologic oncologist, or a medical oncologist. The doctor may be able to suggest ways to reduce the likelihood of developing ovarian cancer and can plan an appropriate schedule for checkups.



Detecting Ovarian Cancer
The sooner ovarian cancer is found and treated, the better a woman's chance for recovery. But ovarian cancer is hard to detect early. Many times, women with ovarian cancer have no symptoms or just mild symptoms until the disease is in an advanced stage. Scientists are studying ways to detect ovarian cancer before symptoms develop. They are exploring the usefulness of measuring the level of CA 125, a substance called a tumor marker, which is often found in higher-than-normal amounts in the blood of women with ovarian cancer. They also are evaluating transvaginal ultrasound, a test that may help detect the disease early. The Cancer Information Service can provide information about this research.
A large-scale study, known as the PLCO (Prostate, Lung, Colorectal, and Ovarian) Cancer Screening Trial, is currently evaluating the usefulness of a blood test for the tumor marker known as CA-125 and a test called transvaginal ultrasound for ovarian cancer screening.



Recognizing Symptoms
Ovarian cancer often shows no obvious signs or symptoms until late in its development. Signs and symptoms of ovarian cancer may include:
• General abdominal discomfort and/or pain (gas, indigestion, pressure, swelling, bloating, cramps)
• Nausea, diarrhea, constipation, or frequent urination
• Loss of appetite
• Feeling of fullness even after a light meal
• Weight gain or loss with no known reason
• Abnormal bleeding from the vagina
These symptoms may be caused by ovarian cancer or by other, less serious conditions. It is important to check with a doctor about any of these symptoms.
To help find the cause of symptoms, a doctor evaluates a woman's medical history. The doctor also performs a physical exam and orders diagnostic tests. Some exams and tests that may be useful are described below:
• Pelvic exam includes feeling the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum to find any abnormality in their shape or size. (A Pap test, a good test for cancer of the cervix, is often done along with the pelvic exam, but it is not a reliable way to find or diagnose ovarian cancer.)
• Ultrasound refers to the use of high-frequency sound waves. These waves, which cannot be heard by humans, are aimed at the ovaries. The pattern of the echoes they produce creates a picture called a sonogram. Healthy tissues, fluid-filled cysts, and tumors look different on this picture.
• CA-125 assay is a blood test used to measure the level of CA-125, a tumor marker that is often found in higher-than-normal amounts in the blood of women with ovarian cancer.
• Lower GI series, or barium enema, is a series of x-rays of the colon and rectum. The pictures are taken after the patient is given an enema with a white, chalky solution containing barium. The barium outlines the colon and rectum on the x-ray, making tumors or other abnormal areas easier to see.
• CT (or CAT) scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine.
• Biopsy is the removal of tissue for examination under a microscope. A pathologist studies the tissue to make a diagnosis. To obtain the tissue, the surgeon performs a laparotomy (an operation to open the abdomen). If cancer is suspected, the surgeon performs an oophorectomy (removal of the entire ovary). This is important because, if cancer is present, removing just a sample of tissue by cutting through the outer layer of the ovary could allow cancer cells to escape and cause the disease to spread.
If the diagnosis is ovarian cancer, the doctor will want to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to what parts of the body. Staging may involve surgery, x-rays and other imaging procedures, and lab tests. Knowing the stage of the disease helps the doctor plan treatment.