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Detection and Symptoms
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In this section of the Ovarian Cancer Resource Center you'll find the answers to your questions about detection, diagnosis, and staging.
About 25% of ovarian cancers are found at an early stage. Early detection improves the chances that ovarian cancer can be treated successfully. When ovarian cancer is found early at a localized stage, about 90% of patients live longer than 5 years after diagnosis.
Routine pelvic examination: Annual pelvic examinations and Pap smears to check the pelvic area both internally and externally should begin at age 18 or when a women becomes sexually active, whichever is earlier. During this exam, the health care professional feels the ovaries and uterus for size, shape, and consistency. Although the Pap test is effective in early detection of cervical cancer, it cannot detect most ovarian cancers. Most of the ovarian cancers that are detected through Pap smears are already advanced. Although a pelvic examination is routinely recommended because it can find some reproductive system cancers at an early stage, most early ovarian tumors are difficult or impossible for even the most skilled examiner to feel.
Seek medical attention if symptoms appear: The ovaries are deep inside the pelvis and cannot be seen directly without surgery. Small ovarian tumors are difficult for even the most skilled examiner to feel. Early cancers of the ovaries tend to cause symptoms that are relatively nonspecific. These symptoms include swelling of the abdomen (due to a mass or accumulation of fluid), unusual vaginal bleeding, pelvic pressure, back pain, leg pain, and digestive problems such as gas, bloating, indigestion, or long-term stomach pain. Most of these symptoms can also be caused by other less serious conditions. By the time ovarian cancer is considered as a possible cause of these symptoms, it may have already spread beyond the ovaries. Also, some types of ovarian cancer can rapidly spread to the surface of nearby organs. Nonetheless, prompt attention to symptoms can improve the odds of early diagnosis and successful treatment. If you have symptoms of ovarian cancer, report them to your health care provider right away.
Screening tests for ovarian cancer: Screening refers to tests and examinations used to detect a disease, such as cancer, in people who do not have any symptoms. Women with a high risk of developing epithelial ovarian cancer, such as those with a very strong family history of this disease, may be screened with transvaginal sonography (an ultrasound test performed with a small instrument placed in the vagina) and blood tests. Transvaginal sonography is helpful in finding a mass in the ovary, but it does not accurately predict which masses are cancers and which are due to benign diseases of the ovary. Blood tests for ovarian cancer may include measuring the amount of CA-125 (also known as OC-125). The amount of this protein is increased in the blood of many women with ovarian cancer. However, some noncancerous diseases of the ovaries can also increase the blood levels of CA-125 and some ovarian cancers may not produce enough CA-125 to cause a positive test. When these tests are positive, it may be necessary to do more x-ray studies or to take samples of fluid from the abdomen or tissue from the ovaries to find out if a cancer is really present.
In preliminary studies of women at average risk of ovarian cancer, these tests did not make any difference in the number of deaths caused by ovarian cancer. For this reason, transvaginal sonography and the CA-125 blood test are not recommended for ovarian cancer screening of women without known strong risk factors. However, some recent studies found that cancers detected by these tests tend to be somewhat less advanced than cancers of women who did not have any screening tests. Additional research is in progress to improve ovarian cancer screening tests. It is hoped that further improvements will make these tests effective enough to lower the ovarian cancer death rate.
There are no tests recommended for screening women for germ cell tumors or stromal tumors. Some germ cell cancers release certain markers (proteins) such as human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) into the blood. After these tumors have been treated by surgery and chemotherapy, blood tests for these markers can be used as a sign that the cancer may be coming back.
HOW IS OVARIAN CANCER DIAGNOSED?
Signs and Symptoms of Ovarian Cancer
There are several signs and symptoms that may be caused by ovarian cancer. However, most of these may also be caused by benign (noncancerous) diseases and by cancers of other organs.
If there is reason to suspect you may have ovarian cancer, your doctor will use one or more methods to be absolutely certain that the disease is present and to determine the stage of the cancer.
Consultation with a Specialist
If your pelvic examination or other tests suggest that you may have ovarian cancer, you will need a doctor or surgeon who specializes in treating women with this type of cancer. A gynecologic oncologist is an obstetrician/gynecologist who is specially trained in treating cancers of the female reproductive system.
Imaging methods such as computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and ultrasound studies can confirm whether a pelvic mass is present. Although these studies cannot confirm if the mass is a cancer, they are useful in looking for spread of ovarian cancer to other tissues and organs.
Ultrasound: Ultrasound or ultrasonography uses sound waves to create an image on a video screen. Sound waves are released from a small probe placed in the woman's vagina or on the surface of her abdomen. The sound waves create echoes as they enter the ovaries and other organs. The same probe detects the echoes that bounce back and a computer translates the pattern of echoes into a picture. Because ovarian tumors and normal ovarian tissue often reflect sound waves differently, this test may be useful in detecting tumors and in determining whether a mass is solid or a fluid-filled cyst.
Color-flow Doppler: This procedure uses a special type of ultrasound instrument to assess blood flow to the ovaries. In ovarian cancer there is usually an increase in blood flow. However, several benign conditions can also increase blood flow to the ovaries.
Computed tomography: Commonly referred to as a CT or CAT scan, this test uses a rotating x-ray beam to create a series of pictures of the body from many angles. A computer combines the information from these pictures, producing a detailed cross-sectional image. Contrast material is usually injected into a vein before CT scanning to help produce clearer pictures.
Chest x-ray: This test may be done to determine whether ovarian cancer has spread to the lungs. This spread may cause one or more tumors in the lungs and often causes fluid to collect around the lungs. This fluid, called a pleural effusion, can be seen with chest x-rays.
Magnetic resonance imaging (MRI): Like computed tomography, MRI displays a cross-section of the body. However, MRI uses powerful magnetic fields instead of radiation. The procedure can present cross-sectional views from several angles.
The only way to determine for certain if a growth in the pelvic region is cancer is to biopsy (removing a sample of tissue) the suspicious area and examine the tissue sample under a microscope. In patients with ascites (collection of fluid inside the abdomen), samples of fluid can also be used to diagnose the cancer. A biopsy is usually done at the time of surgery. Depending on the extent of disease, the surgical procedure may be a laparotomy (surgery through an abdominal incision) or laparoscopy (surgery done through a lighted tube inserted into a very small incision in the pelvis ). The goal of surgery for ovarian cancer is to obtain tissue samples for diagnosis and staging, and to remove all deposits of cancer larger than 1 cm (about one-half inch). Another diagnostic method is to obtain small samples of the cancer using CT scanning or ultrasound to guide a thin biopsy needle. This method might be used if the patient cannot have surgery because of advanced cancer or some other serious medical condition.
HOW IS OVARIAN CANCER STAGED?
Staging is the process of finding out how widespread a cancer is. Most ovarian cancers that are not obviously widespread are staged at the time of surgery. This is done by sampling tissues from different parts of the pelvis and abdomen to be examined under the microscope. Staging is very important because ovarian cancers of different stages have a different prognosis and are treated differently. The accuracy of the staging may determine whether or not a patient will be cured. If the cancer is not properly staged, then cancer that has spread outside the ovary may be missed and not treated. Once a stage has been assigned, it does not change, even when the cancer recurs or spreads to new locations in the body.
Ask your cancer care team to explain the staging procedure. Also ask them if they will perform a thorough staging procedure. After surgery, ask what your cancer's stage is. In this way, you will be able to take part in making informed decisions about your treatment.
What the Stages of Ovarian Cancer Mean
Staging of ovarian cancer is described using the FIGO system. FIGO stands for International Federation of Gynecologists and Obstetricians.
Stage I: The cancer is still contained within the ovary (or ovaries).
Stage IB: Cancer has developed within both ovaries without any tumor on their outer surfaces. Laboratory examination of washings from the abdomen and pelvis did not find any cancer cells.
Stage IC: The tumor is present in one or both ovaries and one or more of the following are present: (1) cancer on the outer surface of at least one of the ovaries, (2) in the case of cystic tumors (fluid-filled tumors), the capsule (outer wall of the tumor) has ruptured (burst), (3) laboratory examination found cancer cells in fluid or washings from the abdomen.
Stage II: The cancer involves one or both ovaries and has involved other organs (such as the uterus, fallopian tubes, bladder, the sigmoid colon, or the rectum) within the pelvis.
Stage IIA: The cancer has extended to, or has actually invaded the uterus or the fallopian tubes, or both. Laboratory examination of washings from the abdomen did not find any cancer cells.
Stage IIB: The cancer has extended to other nearby pelvic organs such as the bladder, the sigmoid colon, or the rectum. Laboratory examination of fluid from the abdomen did not find any cancer cells.
Stage IIC: The cancer involves pelvic organs as in stages IIA or IIB and one or more of the following are present: (1) cancer on the outer surface of at least one of the ovaries, (2) in the case of cystic tumors (fluid-filled tumors), the capsule (outer wall of the tumor) has ruptured (burst), (3) laboratory examination found cancer cells in fluid or washings from the abdomen.
Stage III: The cancer involves one or both ovaries, and one or both of the following are present: (1) cancer has spread beyond the pelvis to the lining of the abdomen, (2) cancer has spread to lymph nodes (glands that fight infection and produce some types of blood cells.)
Stage IIIA: During the staging operation, the surgeon can see cancer involving the ovary or ovaries, but no cancer is grossly visible (can be seen without using a microscope) in the abdomen and the cancer has not spread to lymph nodes. However, when biopsies are checked under a microscope, tiny deposits of cancer are found in the lining of the upper abdomen.
Stage IIIB: There is cancer in one or both ovaries, and deposits of cancer are present in the abdomen which are large enough for the surgeon to see but smaller than 2 cm (about 3/4 inch) across. Cancer has not spread to the lymph nodes.
Stage IIIC: The tumor is in one or both ovaries, and one or both of the following is present: (1) cancer has spread to lymph nodes, (2) deposits of cancer larger than 2 cm (about 3/4 inch) across are seen in the abdomen.
Stage IV: This is the most advanced stage of ovarian cancer. The tumor is in one or both ovaries. Distant metastasis (spread of the cancer to the inside of the liver, the lungs, or to other organs located outside of the peritoneal cavity) has occurred. Finding ovarian cancer cells in pleural fluid (from the cavity that surrounds the lungs) is also evidence of stage IV disease.
Recurrent ovarian cancer: This means that the disease has recurred (come back) after completion of treatment.