Ovarian Cancer

A lot of ovarian cancer patients are already at late stage when diagnosed because the symptoms of early-stage diseases are subtle.

Normal population

• Ovarian cancer screening for the general population lacks strong supporting evidence.
• The challenge in early detection lies in the subtle nature of symptoms associated with early-stage ovarian cancer, with many women experiencing mild or no symptoms at all. This often leads to delayed diagnosis as patients may not seek medical attention until the disease has progressed.
• While routine ovarian cancer screening has not been proven effective in detecting early-stage cases, regular gynaecological check-ups can occasionally lead to diagnosis before symptoms manifest. 
   

High-risk group

• High-risk individuals for ovarian cancer are those with a strong family history of the disease or known carriers of mutated genes that increase ovarian cancer risk.
• For these individuals, regular check-ups play a crucial role in potentially diagnosing ovarian cancer at an early stage.
• Patients identified as carriers of abnormal genes, such as BRCA1 and BRCA2, may consider prophylactic removal of their fallopian tubes and ovaries. This preventive measure can significantly reduce their lifetime risk of developing ovarian cancer, offering a proactive approach to managing their elevated risk.
   

Diagnosis

• Ovarian cancer often presents a diagnostic challenge, as many patients are diagnosed at advanced stages due to the subtle nature of early-stage symptoms.
• Diagnosis typically involves a combination of imaging studies, including ultrasound, CT and MRI scans.
• The decision to surgically remove ovarian tumours is generally based on their size and characteristics observed in these imaging studies.
• Tumour markers serve as a complementary tool to imaging, aiding in predicting the tumour's nature.
• Definitive confirmation of ovarian cancer can only be achieved through histological examination of the removed tumour tissue.
• In cases of confirmed ovarian cancer, a comprehensive staging process is essential.
• During surgery, frozen section analysis can be performed to determine the tumour’s nature in real-time. If non-benign pathology is detected, staging procedures can be conducted immediately, eliminating the need for a second operation.
• For patients who are not eligible for primary surgery, alternative diagnostic methods may be employed. These include imaging-guided biopsies or aspiration of body fluids to obtain tissue or cell samples for diagnosis confirmation.

Assessment

• Ovarian cancer diagnosis sometimes cannot be made before surgery, making a comprehensive pre-operative assessment necessary.
• This includes basic blood tests, tumour marker levels and imaging studies, which are crucial for informed decision-making.
• Patients should be evaluated for the most suitable surgical approach, whether open laparotomy or minimally invasive procedures with or without robotic assistance.
• The use of frozen section analysis has both advantages and disadvantages and should be discussed pre-operatively.
• It's important to note that not all patients benefit from primary surgical debulking; in such cases, neoadjuvant chemotherapy may be considered.

Early-stage disease

• Early-stage disease, surgical removal and histological confirmation are often the first steps, as diagnosis may not be confirmed pre-operatively.
• Standard treatment involves removing the uterus, both fallopian tubes and ovaries, along with a comprehensive staging operation. This can be performed via laparotomy or laparoscopy.
• For younger patients wishing to preserve fertility, fertility-sparing operations may be considered in suitable cases with favourable histology.
• Most patients require adjuvant chemotherapy post-surgery. 

Late-stage disease 

• The primary approach is debulking surgery (removal as much of the visible tumour as possible) followed by chemotherapy. However, if optimal debulking is not feasible, neoadjuvant chemotherapy may be considered before surgery.

After completion of treatment, patients should be followed up regularly to 

• Deal with the side-effects and complications arising from the treatment
• Monitor the disease status 

Side-effects and Complications from Treatment 

• Extensive operation involves the removal of and insults to normal structures, e.g. lower limb oedema after pelvic lymphadenectomy
• Chemotherapy side-effects can be long-lasting, e.g. numbness over extremities after chemotherapy using platinum agents
• Patients who have received radiotherapy can also develop post-treatment complications 

Monitoring of Disease Status 

• Physical examination
• Vaginal cytology
• Blood test for tumour markers
• Repeated imaging studies if necessary. It helps pick up recurrent diseases