Latest developments in the diagnosis and management of ovarian cancer.
In the UK, around 7,100 women are diagnosed with ovarian cancer each year. It is the fifth most common cancer among women after breast cancer, bowel cancer, lung cancer and cancer of the uterus.
Ovarian cancer is most common in women who have been through the menopause (usually over the age of 50 years), although it can affect women of any age. Of all those with ovarian cancer in England and Wales, more than 70 out of every 100 women (70%) will survive for one year or more after they are diagnosed. Almost 50 out of every 100 women (50%) will survive for five years or more. And more than 33 out of every 100 women (33%) will survive for 10 years or more.
The symptoms of ovarian cancer can be similar to symptoms caused by other, more common, conditions. NICE recommends that if a woman has the following symptoms and they last for a month or more, or occur on at least 12 days in a month, she should see her GP to be checked for ovarian cancer:
It also says that if a woman over 50 years develops symptoms similar to irritable bowel syndrome (IBS), such as bloating and changes in bowel habit, she should be offered tests by her GP to check for ovarian cancer. This is because it is unusual for a woman of this age to develop IBS if she hasn’t had it before.
Borderline tumours or early-stage ovarian cancer can usually be cured with surgery to remove the cancer. Most women, however, are treated with a combination of surgery and chemotherapy. The aim of treatment may be to cure the cancer or to keep it under control for as long as possible.
This update includes the latest news in the diagnosis and management of ovarian cancer.
New method enables the early detection of ovarian cancer
An innovative, ‘three-way’ catheter developed by Paul Speiser from the University Department of Gynaecology at the MedUni Vienna and the Molecular Oncology working group, could help diagnose ovarian cancer more effectively.
Speiser has developed a catheter that prevents irrigation liquid from draining into the abdominal cavity and which can be harvested virtually painlessly.
A study, published in the Journal of Clinical Oncology, showed that when ovarian cancer was present, tumour cells were found in the irrigation fluid in 80% of cases. For one test subject who had already decided to have prophylactic removal of her ovaries, a type of next-generation sequencing (“smart sequencing”/analysis of genetic changes in DNA) performed on the irrigation fluid obtained was able to detect an occult, or hidden, carcinoma.
This is an important development since ovarian cancer has virtually no symptoms and is only discovered very late in around three-quarter of all cases. At a late stage, ovarian cancer is associated with a very poor prognosis in terms of the patient’s life expectancy.
Around 75% of these tumours arise from the fallopian tube. There are currently no options for detecting this condition early or preventing it.
“Currently there are only two types of cancer in which the early detection methods of the American Prevention Task Force can be rated with an ‘A’ for ‘extremely’ targeted”, says Speiser, who is also a member of the Comprehensive Cancer Centre (CCC) at the MedUni Vienna and the Vienna General Hospital, “Cervical cancer and colorectal cancer. Our development could add a third type of cancer to this list. These results encourage the hope that at least early detection will soon be possible.”
The study was initiated and managed by the MedUni Vienna and organised in cooperation with centres in London, Dublin, Milan, Graz, Berlin, Hamburg, Prague, Pilsen, Leuven and Essen. This and other studies are also being carried out in close collaboration with Bert Vogelstein from the John Hopkins University in Baltimore.
The scientists’ aim is to develop the removal of irrigation fluid and its analysis so that it “can be easily used in every hospital and in every gynaecology department”, says Speiser. Other studies are also expected to show whether it is possible to detect tumours or their early stages using this method and to possibly prevent the disease from progressing at all.
Different types of ovarian cancer have different causes
The more children a woman has or whether a woman has had her fallopian tubes cut lowers the risk of different types of ovarian cancer to different levels, according to new research presented at the 2015 National Cancer Research Institute (NCRI) Cancer Conference.
Data was collected from more than 8000 women with ovarian cancer as part of the UK Million Women Study.
Researchers then examined the risk of the four most common types of ovarian cancer-serous, mucinous, endometrioid and clear cell tumours-in women with different childbearing patterns.
For ovarian cancer overall, women with one child had about a 20% reduction in risk compared to women without children, and about a 40% reduction of endometrioid and clear cell tumours.
Each additional birth then offered an estimated 8% reduction in the overall risk of ovarian cancer.
Researchers also compared risk between those women who had surgery to cut or clip their fallopian tubes with those who had not. This procedure-known as tubal ligation or sterilisation-is a surgical procedure for permanent contraception.
Women who had had this surgery had a 20% lower overall risk of ovarian cancer. The risk was about 20% lower for high-grade serous tumours-the most common type of ovarian cancer-and about half for endometrioid and clear cell tumours.
Dr Kezia Gaitskell, Cancer Research UK funded lead researcher and pathologist based at the Cancer Epidemiology Unit, University of Oxford, said: “In the last few years, our understanding of ovarian cancer has been revolutionised by research showing that many cases may not in fact come from the ovaries. For example, many high-grade serous tumours-the most common type-seem to start in the fallopian tubes, while some endometrioid and clear cell tumours may develop from endometriosis.
“We think that the signicant reduction in risk among women with one child compared to women without children is likely to be related to infertility, as there are some conditions-such as endometriosis-that may make it harder for a woman to become pregnant, and which may also increase her risk of these specific types of ovarian cancer.
“For the reduced risk seen among women with tubal ligation—it could be that tubal ligation acts as a barrier to help prevent the abnormal cells that might cause these tumours passing through the fallopian tubes to the ovaries. Our results are really
interesting, because they show that the associations with known risk factors for ovarian cancer, such as childbirth and fertility, vary between the different tumour types.”
Professor Charlie Swanton, Chair of the 2015 NCRI Cancer Conference, said: “We’ve known for some time that the number of children a woman has, and her use of contraception, can influence her risk of ovarian cancer, so this research provides important further detail about different types of the disease.
“Ovarian cancer, like many other cancers, is not one disease, but different diseases that are grouped together because of where they start. It’s important to know what affects the risk of different types of ovarian cancer and what factors impact this. We now need to understand the mechanisms behind these findings to develop some way to extend this lower; risk to all women, regardless of how many children they have.”
Improvement in early diagnosis of ovarian cancer in England
Public Health England have published the latest data on the routes by which women with ovarian cancer are diagnosed. The earlier women are diagnosed, the greater their chances of surviving ovarian cancer. Women who are diagnosed at a later stage are often diagnosed once the cancer has already spread, making treatment more difficult.
The data shows that less than half of women diagnosed via an emergency presentation live for a year or more following diagnosis, compared to over 80% of women diagnosed following a GP referral.
In September initial data showed that the number of women with ovarian cancer diagnosed
via an emergency presentation (through A&E or an emergency referral from a GP or consultant) had fallen to 26% in 2013. This compares to a figure of 32% in 2006.
The data also shows that there has been a dramatic increase in the number of women with
ovarian cancer who are diagnosed following a two-week wait (an urgent referral when a GP has discovered ascites or a pelvic or abdominal mass upon examining a woman). In 2006, 22% of women with ovarian cancer were diagnosed following a two-week wait referral, but in 2013 this had risen to 31%. This is again really positive news and follows the introduction of NICE guidelines in 2011, which provided the referral pathway for women with ovarian cancer.
Together with the fall in the number of women diagnosed via an emergency presentation, this suggests that more women are being diagnosed after being referred by their GP rather than following an emergency presentation.
Finally, the data shows that there has been little change in the number of women diagnosed
through a non-urgent GP referral. In 2006, 25% of women with ovarian cancer were diagnosed
following a referral by their GP and in 2013 this had risen to 26%. These are women who will be referred first for CA125 testing then an ultrasound before being referred to a specialist if these indicate the possibility of ovarian cancer. Therefore, while
women are being diagnosed earlier, this shows that there is more to be done to ensure women are diagnosed at the earliest possible opportunity.
Rebecca Rennison, Director of Public Affairs at the charity Target Ovarian Cancer, said: “This latest data is good news in our work to improve early diagnosis, and something we have worked very hard to achieve. Going forward we need to work to further bring down the number of women diagnosed via an emergency presentation and see more women diagnosed at the earliest stage through their GP. We will continue to invest in our work with GPs and our training modules, as we know these are having an impact. We know that increased awareness and earlier diagnosis will save lives, and it is vital we maintain the momentum achieved so far.”
A fifth of women with ovarian cancer do not receive any information or advice
A new analysis by the charity Target Ovarian Cancer has revealed that women with ovarian cancer are facing a severe lack of support.
Research, from Public Health England, shows that a fifth (19%) of women with ovarian cancer are not receiving any information or advice on the physical or emotional impact of living with a cancer diagnosis. This is despite the fact that at the point of completing the survey, over half of women reported having difficulties with anxiety or depression and a similar number reported experiencing pain or discomfort.
When asked, a third of women said they would have found more advice or information on the physical (32%) and psychological or emotional (34%) aspects of living with or after ovarian cancer helpful.
A cancer diagnosis can leave women and their families feeling powerless. Good quality, timely advice and information can help them take charge of their treatment and put in place some of the practical and emotional support they need.
Every year 7,000 women are diagnosed with ovarian cancer and 4,300 lose their lives to the disease. 1,200 women under 50 are diagnosed.
Katherine Pinder, Head of Supportive Services for Target Ovarian Cancer, said: “It’s really alarming that so many women are not getting the information and advice they need when they are diagnosed with ovarian cancer. Providing this sort of advice can make a huge difference to how a woman faces her cancer diagnosis. Being diagnosed with ovarian cancer can be incredibly isolating. Many women will face issues such as isolation, fear of recurrence and death, loss of meaning in life, financial hardship, and family and relationship problems. These are serious, and women need practical and emotional support to help them cope. Yet the time available from clinical nurse specialists is limited and many women are left feeling alone and hopeless.”
Genetic testing and counselling for women with ovarian cancer
The findings from the Genetic Testing in Epithelial Ovarian Cancer study (GTEOC) were presented at the recent NCRI Cancer Conference, making recommendations that are already being rolled out to benefit women with ovarian cancer across East Anglia.
The GTEOC study has been assessing the acceptability, feasibility and cost effectiveness of streamlining genetic testing and counselling, whilst maintaining the oversight of specialist genetic services. Some 232 women have taken part in the clinical trial, funded by Target Ovarian Cancer, which tests a new way for women with ovarian cancer to access genetic testing. A major advantage of the approach trialled is the use of the regional ‘hub and spoke’ model of genetic services across the UK, giving women with ovarian cancer dramatically wider access to genetic testing.
Testing women who are diagnosed with ovarian cancer for gene mutations will allow the women themselves and their family members to seek vital help and information in a timely manner and will become essential if the promise of personalised medicine is to be fulfilled in the future. With this increased demand for testing it is essential that women have access to qualified genetic counselling throughout the process to ensure they are fully supported through a decision that can have far-reaching implications.
Chief Executive of Target Ovarian Cancer, Annwen Jones, said: “Target Ovarian Cancer awarded the funding to allow this ground-breaking clinical trial to go ahead in 2012. It’s vital that all women diagnosed with ovarian cancer have access to genetic counselling and testing. I am pleased that these preliminary findings demonstrate how this can be achieved in practice.”
Dr Marc Tischkowitz, Consultant Clinical Geneticist at Cambridge University Hospitals Trust and study author said: “The GTEOC Study has piloted a new way for women with ovarian cancer to access genetic testing. A real strength was to use the existing network of hospitals in East Anglia to provide comprehensive access to all women in the region. Based on our findings, we have already adopted this new approach into our regional NHS genetics service and are sharing our experience with other centres in the UK. This type of transnational research takes advantage of the excellent research-clinical interface in Cambridge and East Anglia, which means that new developments can be rapidly and introduced into routine care.”
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