"Ovarian cancer is becoming more and more common compared to what we used to see," begins Dr. Sankar Srinivasan, Senior Consultant in Medical Oncology at Apollo Cancer Centre, Chennai. As he speaks, he recalls a case that left a lasting impression: a 42-year-old woman who came in for a routine ultrasound due to bloating and mild abdominal pain. She hadn’t imagined it could be something serious. The scan revealed a stage 3 ovarian cancer—a grim reminder of how elusive the disease can be in its early stages.
Understanding Ovarian Cancer: The Silent Disease
Ovarian cancer, though less common than breast or cervical cancer, is a significant health concern for women. Ovarian cancer can be categorized into three primary types: epithelial, germ cell, and stromal cell tumors. Epithelial ovarian cancer is the most prevalent, accounting for about 90% of cases. In India, the incidence of ovarian cancer is on the rise, with approximately 40,000 cases diagnosed annually, a number expected to increase to nearly 50,000 in the coming year. It ranks as the third most common cancer among women in the country, following breast and cervical cancers.
However, the challenge with ovarian cancer is its late detection. Seven out of one lakh women in India stands to develop ovarian cancer, a number that underscores the importance of awareness and early intervention.
Who is at Risk?
Age remains one of the most significant risk factors. As women get older, particularly beyond the age of 50, the risk of developing ovarian cancer increases. But it's not just older women at risk. There’s an increasing incidence of the disease among younger women, which can be attributed to lifestyle and reproductive choices.
Delayed childbearing or not having children at all significantly elevates the risk. Women who have their first pregnancy after the age of 35 or never become pregnant have a higher likelihood of developing ovarian cancer. Other contributing factors include obesity, high-fat diets, lack of exercise, and conditions like endometriosis, a condition where uterine tissue grows outside the uterus. Genetic factors also play a role, particularly mutations in the BRCA1 and BRCA2 genes, which greatly increase the risk of ovarian and breast cancers.
The Challenge of Early Detection
One of the most pressing concerns with ovarian cancer is its tendency to be diagnosed late. It often presents with vague symptoms that are easily mistaken for other conditions. Symptoms like abdominal bloating, pain, loss of appetite, and urinary disturbances are common but nonspecific, often leading to delays in seeking medical attention.
Adding to the complexity is the lack of effective screening programs. Unlike cervical cancer, which can be detected early through regular Pap smears, ovarian cancer has no reliable screening test. Even regular ultrasounds may not catch the disease in its early stages, as it can progress rapidly between tests. By the time symptoms become pronounced, many women are diagnosed in stage 3 or 4, where the disease has spread to the abdominal cavity, making treatment more challenging.
Diagnosis and Genetic Markers
While early detection remains difficult, advancements in genetic testing have opened new avenues for assessing risk. BRCA testing, once an expensive procedure, has now become more accessible. BRCA1 and BRCA2 mutations increase the risk of not just ovarian cancer but also breast, pancreatic, and prostate cancers. Testing family members for these mutations, especially if a close relative has been diagnosed with ovarian cancer, can help identify those at high risk and enable preventative measures, such as enhanced surveillance or even preventive surgery.
Also important are HBOC (Hereditary Breast and Ovarian Cancer) panels, which test for a broader range of genetic mutations linked to ovarian cancer. These panels help determine whether patients may benefit from specific treatments, such as PARP inhibitors, which target cancers with certain genetic mutations.
Treatment Options: Tailored to the Stage
Treatment for ovarian cancer varies based on the stage at diagnosis. For early-stage cancers (stages 1 and 2), surgery to remove the tumor is often the first line of defense, sometimes followed by chemotherapy. In more advanced stages, chemotherapy may be used before surgery to shrink the tumor and make surgical removal safer and more effective.
The gold standard for chemotherapy in ovarian cancer remains platinum-based drugs, which have been used for decades. However, newer treatments such as targeted therapies are now being incorporated into the treatment plan. Bevacizumab, a drug that inhibits blood vessel growth in tumors, is one such therapy that has shown promise, particularly in preventing cancer recurrence when used in combination with chemotherapy.
Advancements in Treatment: Targeted Therapies and Precision Medicine
In recent years, significant strides have been made in treating ovarian cancer. One of the most exciting developments is the use of PARP inhibitors, a class of drugs that target cancer cells with defects in their DNA repair mechanisms, particularly those with BRCA mutations.
There has also been progress in surgical techniques, with robotic surgery now allowing for more precise and less invasive tumor removal. "Cytoreductive surgery—the removal of as much of the tumor as possible—combined with hyperthermic intraperitoneal chemotherapy (HIPEC) during surgery, is showing promising results in reducing recurrence," says Dr. Srinivasan.
However, while treatments have improved, ovarian cancer remains challenging to treat, particularly in its advanced stages. Immunotherapy, a breakthrough in many cancers, has not shown the same level of success in ovarian cancer, although research is ongoing.
Managing Side Effects and Preserving Fertility
The physical toll of ovarian cancer treatment is significant. Chemotherapy, while effective, is associated with side effects such as fatigue, neuropathy, and hair loss. Managing these side effects requires a comprehensive care plan, which includes supportive therapies and counseling.
For younger patients, fertility preservation is a major concern. Dr. Srinivasan explains that in cases where only one ovary is affected, it's sometimes possible to preserve the other ovary and delay complete surgery until after childbearing is complete. For others, egg or embryo freezing offers a chance to preserve fertility before treatment begins.
The Importance of Awareness and Support
Awareness of the symptoms and risk factors is crucial. Regular checkups with a gynecologist, especially for women with a family history of ovarian cancer, can help catch potential issues early. Genetic testing for families with BRCA mutations or a history of ovarian cancer is also essential in managing and reducing risk.
Support systems are equally important. In Chennai, cancer support groups, often led by survivors, provide emotional and psychological support for patients and their families. These groups, along with counseling services, play a vital role in helping patients cope with the challenges of cancer treatment.
"Ovarian cancer remains a formidable opponent," concludes Dr. Srinivasan, "but with the advancements in treatment and a greater focus on genetic testing, we are gradually improving outcomes for women facing this disease."
Senior Consultant, Medical Oncology and Hematology
Apollo Cancer Centre, Chennai.