Click the icon to see an image of a fibroid tumor. 

• Endometriosis
• Polycystic ovaries

 Click the icon to see an image of a polycystic ovary.

• Ectopic pregnancies

 Click the icon to see an image of an ectopic pregnancy.

• Meig syndrome (a benign ovarian growth associated with fluid buildup in the abdomen and around the lungs)
• Ovarian hyperstimulation syndrome following fertility treatments.

Once a growth is detected, the additional tests described below may help the doctor evaluate the risk for it being cancerous. If ovarian cancer has been diagnosed, these tests are also used to monitor how the cancer is progressing.

Transvaginal Ultrasound and Other Imaging Tests

Ultrasound. Ultrasound is a noninvasive diagnostic tool that can evaluate tumors and masses discovered during the rectovaginal exam:

• Typically, a probe that emits sound waves (ultrasound) is placed in the vagina. The sound waves bounce off tissues, organs, and masses in the pelvic cavity. These echoes are collected and converted into a picture of the area called a sonogram. Healthy tissue, fluid-filled cysts, and solid tumors produce different sound waves.

 Click the icon to see an image of transvaginal ultrasound.

• The ultrasound probe may also be placed on abdominal walls above the ovaries (transabdominal ultrasound), but it does not provide as clear a picture of the ovaries. This technique may be needed to evaluate larger masses or cancer that has spread into the abdomen.

Other Imaging Techniques. Other imaging techniques are less common for the diagnosis or evaluation of suspected ovarian cancer but may help determine if cancer has spread to other parts of the body:

• Computed tomography (CT). Computed tomography records x-ray absorption rates of tissue and bone. These data are converted into clear images on a screen. CT scans help determine if cancer has spread to the lymph nodes, abdominal organs, abdominal fluid, and the liver.

 Click the icon to see an image of a CT scan. 

• Magnetic resonance imaging (MRI). MRI creates multiple cross-sectional images of the pelvis and abdominal organs, which are assembled into three-dimensional images. An MRI is not usually used to diagnose ovarian cancer, but may help determine if cancer has spread to the brain or spinal cord.

 Click the icon to see an image of a MRI scan. 

• Chest x-rays. Find cancer that has spread to the lungs.

 Click the icon to see an image of an x-ray machine. 

CA-125 and Other Blood Tests

CA-125 Blood Test. CA-125 is a protein that is secreted by ovarian cancer cells and is elevated in over 80% of patients with ovarian cancer. Oncologists will usually only obtain a blood test for this protein if ovarian cancer is strongly suspected or has been diagnosed. In general, a CA-125 level is considered to be normal if it is less than 35 U/mL (microns per milliliter). The test may also be useful for evaluating tumor growth and predicting survival in patients with recurrent cancer who have been treated with topotecan or paclitaxel-carboplatin chemotherapy regimens.

The test is not useful for diagnosis or early screening, however. In about half of women with very early ovarian cancer, CA-125 levels are not elevated above the normal standard. Furthermore, an elevated level can be caused by a number of other conditions including:

• Endometriosis
• Fibroids
• Noncancerous ovarian cysts
• Pregnancy
• Pelvic inflammatory disease
• Liver diseases
• Heart failure
• Other tumors, such as breast, colon, lung, and pancreatic cancers
• Age and menstrual status can also affect the levels of CA-125

OVA1 Blood Test. The OVA1 blood test helps predict whether ovarian cancer is more likely to be present in a pelvic mass. The test measures the level of CA-125 and four other proteins. The test can help doctors decide what type of surgery should be performed. The OVA1 test is used in addition to, not in place of, other diagnostic and clinical procedures. It is not used to screen for or provide a definite diagnosis of ovarian cancer, but can help doctors to determine that a malignancy is more likely to be present.

Exploratory Surgery

An exploratory surgical procedure is required to confirm a diagnosis of ovarian cancer. It is also necessary to properly stage a patient, since the imaging tests may miss small implants of ovarian tumor within the pelvis and the abdominal cavity. Surgery may be laparotomy or a less-invasive laparoscopy. A gynecologic oncologist usually performs these procedures.

Laparotomy is an open-surgery procedure that requires general anesthesia. The surgeon makes an incision from the pubic bone to the navel to explore the abdominal cavity. Laparoscopy does not require general anesthesia and the oncologist uses only small incisions to insert a lighted instrument to examine the organs and evaluate the spread of the tumor. With both procedures, tissue samples (biopsies) can be removed for further testing.

 Click the icon to see an image of pelvic laparoscopy. 

Prognosis

About 75% of women survive ovarian cancer at least 1 year after diagnosis. Nearly half are alive 5 years after diagnosis. This is called the 5-year survival rate.

Survival rates vary depending on different factors, including age and the stage at which it is detected. In general, women younger than age 65 have better survival rates than older women.

Unfortunately, most patients with ovarian cancer are not diagnosed until the disease is advanced. This usually means the cancer has spread to the upper abdomen. In order to establish a prognosis and determine treatment, the doctor needs to know the cell type, stage, and grade of the disease.

Prognosis by Cell Type

When examined under the microscope, there are a number of different cell types of ovarian cancer. Mucinous and clear cell tumors tend to be more difficult to treat.

Prognosis by Stage

Cancers are staged (I through IV) according to whether they are still localized (remaining in the ovary) or have spread beyond the original site.

The survival rate varies according to the cancer stage:

• Five-year survival rates are over 90% if the cancer is still confined to the ovary at diagnosis. However, only 19% of ovarian cancers are found at this stage.
• If the cancer has spread to nearby regions in the pelvis, the 5-year survival rate is about 70%.
• If the cancer has spread to sites outside the pelvis, the 5-year survival rate is about 30%.

Prognosis by Grade

Tumors are graded according to how well or poorly organized they are (their differentiation). Ovarian tumors are graded on a scale of 1, 2, or 3. Grade 1 tends to closely resemble normal tissue and has a better prognosis than grade 3, which indicates very abnormal, poorly defined tissue.

Treatment

In general, the course of treatment is determined by the stage of the cancer. Stages range from I to IV based on the cancer's specific characteristics, such as whether it has spread beyond the ovaries. Surgery is the main treatment for ovarian cancer. Following surgery, women with higher-stage tumors may receive chemotherapy. Women can also consider enrolling in clinical trials that are investigating new types of treatments.

About 10 - 15% of epithelial ovarian tumors are referred to as "borderline" because their appearance and behavior under the microscope is between benign and malignant. These tumors are also called "carcinomas of low malignant potential" because they rarely metastasize or cause death. Borderline ovarian tumors are most often seen in younger women with epithelial ovarian cancer. Surgery is usually recommended to remove these tumors. Chemotherapy may also be used to treat borderline tumors that appear to have more aggressive features (such as recurring after surgery).

Stages

Stage I. In stage I, the cancer has not spread. It is confined to one ovary (stage IA) or both ovaries (stage IB). In stages IA and IB, the ovarian capsules are intact, and there are no tumors on the surface. Stage IC can affect one or both ovaries, but the tumors are on the surface, or the capsule is ruptured, or there is evidence of tumor cells in abdominal fluid (ascites). The overall 5-year survival rate for stage IA or IB can be as high as 90%, depending on the type of tumors and whether cells are well or poorly differentiated. Stage IC has a poorer outlook than the earlier stages. It is very important that women receive an accurate staging assessment, including a pathologic review conducted by a gynecologic pathologist.

Stage II. In stage II, the cancer has spread to other areas in the pelvis. It may have advanced to the uterus or fallopian tubes (stage IIA), or other areas within the pelvis (stage IIB), but is still limited to the pelvic area. Stage IIC indicates capsular involvement, rupture, or positive washings (that is, they contain malignant cells).

Stage III. In stage III, one or both of the following are present: (1) The cancer has spread beyond the pelvis to the omentum (a layer of fatty tissue in the abdomen) and other areas within the abdomen, such as the surface of the liver or intestine. (2) The cancer has spread to the lymph nodes.

 Click the icon to see an image of the lymph system located near the ovaries. 

Stage IV. Stage IV is the most advanced cancer stage. The cancer may have spread to the inside of the liver or spleen. There may be distant spreading of the cancer, such as ovarian cancer cells in the fluid around the lungs.

Treatment Options for Stage I and Stage II Ovarian Cancer

Treatment options for stage I and stage II ovarian epithelial cancer may include:

• Surgery: Removal of the uterus (total hysterectomy), removal of both ovaries and fallopian tubes (bilateral salpingo-oophorectomy); partial removal of the omentum (omentectomy); and surgical staging of the lymph nodes and other tissues in the pelvis and abdomen. (Carefully selected premenopausal women in Stage I with the lowest-grade tumors in one ovary may sometimes be treated only with the removal of the diseased ovary and tube in order to preserve fertility.)
• Chemotherapy: Patients with stage IA or B disease, grade 1 (or sometimes grade 2), usually do not need further therapy after surgery. However, higher risk patients (stage IC, stage I/grade 3) are usually treated with platinum-based chemotherapy to reduce their risk of subsequent relapse.
• Clinical trials with radiation therapy, chemotherapy, or new treatments

Treatment Options for Stage III and Stage IV Ovarian Cancer

Treatment options for stage III and stage IV ovarian epithelial cancer may include:

• Surgery: Removal of the tumor (debulking), total abdominal hysterectomy, bilateral salpingo-oopherectomy, and omentectomy
• Chemotherapy: Combination chemotherapy with a platinum-based drug and a taxane drug delivered intraperitoneally (through the abdominal cavity)
• Clinical trials of biologic drugs (targeted therapy) following combination chemotherapy

 Click the icon to see an illustrated series detailing hysterectomy.  

Treatment Options for Recurrent Ovarian Cancer

If ovarian cancer returns or persists after treatment, chemotherapy is the mainstay of treatment, although it is not generally curative in the setting of relapsed disease. Clinical trial options include additional surgical debulking, and biologic drug therapy combined with chemotherapy.

Surgery

Surgery for ovarian cancer uses laparotomy, a major abdominal operation. It is the primary diagnostic tool for ovarian cancer and also plays a role in treatment. Complete surgical intervention includes the following:

• Surgical staging (examining all tissues and organs in the pelvic cavity for accurate assessment of the disease stage).
• Debulking (removal of as much of the cancerous tissue as possible). This is an important component of ovarian cancer management and should be performed by a surgeon trained in cancer surgery techniques.

Patients with ovarian cancer should see a qualified gynecologic oncologist (a surgical specialist in female reproductive cancers) and a qualified medical oncologist with special expertise in the chemotherapeutic management of gynecologic cancer. Studies indicate that it is best for patients, especially those with advanced-stage ovarian cancer, to receive care at medical centers that specialize in cancer treatment and surgery.

Surgical Staging

Surgical staging includes biopsies of the following:

• The undersurface of the diaphragm
• The omentum (a layer of fatty tissue in the abdomen)
• Sometimes lymph nodes along the abdominal aorta

An abdominal wash is performed by injecting a salt solution into the abdominal cavity to facilitate microscopic detection of cancerous cells not visible to the naked eye. The surgeon then evaluates the pelvis and abdomen and removes suspected cancer tissue. The entire affected ovary is usually removed (oophorectomy) during surgical staging if the surgeon believes it might be cancerous. The tissue is sent to a laboratory for an immediate evaluation called a frozen section diagnosis. The doctor will also examine the bowel and bladder for cancer invasion.

Preservation Surgery in Premenopausal Women with Early Cancer

If the tumor is in an early stage on one ovary and a woman wants to retain her ability to have children, the surgeon may be able to remove only the affected ovary and perform surgical staging. Chemotherapy follows in select patients. Studies indicate that in carefully selected young patients, many can expect normal fertility afterward. However, most women with ovarian cancer are not candidates for this procedure.

Total Hysterectomy and Bilateral Salpingo-Oophorectomy and Debulking

The goal of surgery is to remove as much of the tumor as possible for improving symptoms and increasing the effectiveness of chemotherapy. The surgery itself is typically performed as follows:

• In premenopausal women in later stages of ovarian cancer, and in all postmenopausal women, the surgeon usually removes the uterus (a hysterectomy) and both ovaries and fallopian tubes (a bilateral salpingo-oophorectomy).
• In addition, the surgeon usually removes the omentum (omentectomy), any growths on the diaphragm and intestine, and possibly certain lymph nodes (lymphadenectomy).

If surgical staging reveals that the cancer has invaded the bowel, a portion of the intestine may have to be removed as well.

Treating Menopausal Symptoms and Premature Menopause. The ovaries produce estrogen. Removing the ovaries results in menopause. After removal of the ovaries, premenopausal women usually have hot flashes, a symptom of menopause. Symptoms come on abruptly and may be more intense than those of natural menopause. Symptoms include hot flashes, vaginal dryness and irritation, and insomnia. A significant number of women gain weight.

The most important complications that occur in women who have had their ovaries removed are due to estrogen loss, which places women at risk for osteoporosis (loss of bone density) and a possible increase in risks for heart disease. In the past, women were typically prescribed estrogen-only hormone replacement therapy (HRT) after surgery if their ovaries were removed. There have been concerns however about health risks, including the risk for breast cancer and stroke, which have now limited its use.

The decision to use estrogen replacement therapy (ERT) depends in part on a woman's age as well as other medical factors. For younger women (in their 20s, 30s, or 40s), the benefits of ERT for bone and heart health may outweigh the risks. For women closer to the age of menopause, risks may outweigh benefits. Women who have had an oopherectomy should discuss with their doctors whether ERT is appropriate for them.

[For more information on hysterectomy, see In-Depth Report #73: Uterine fibroids and hysterectomy. For information on hormone replacement therapy, see In-Depth Report #40: Menopause.]

Surgery for Bowel Obstruction

Bowel obstruction is common in ovarian cancer. Surgery can be very helpful for select patients with this problem.

Chemotherapy

Following surgery, patients (other than those with early-stage, low-grade disease) usually have chemotherapy. Unlike surgery and radiation, which treat the cancerous tumor and the area surrounding it, drug therapy destroys rapidly dividing cells throughout the body, so it is a systemic therapy.

Ovarian cancers are very sensitive to chemotherapy and often respond well initially. Unfortunately, in most cases, ovarian cancer recurs. With treatment advances, however, more than half of women now survive 5 years or longer. Doctors are now approaching this disease as a chronic and potentially long-term illness that requires the following:

• Identifying the disease recurrence as soon as possible
• Administering treatments that are as effective as possible without causing suffering
• Partnering with the patient in determining her own best course

Drugs Used in Chemotherapy

Standard Chemotherapy. The standard initial chemotherapy uses a combination of:

• A platinum-based drug such as carboplatin (Paraplatin, generic) or cisplatin (Platinol, generic). Carboplatin is preferred over cisplatin in the combination. Carboplatin works as well as cisplatin but is less toxic and can be administered in a more convenient, outpatient regimen.
• A taxane such as paclitaxel (Taxol, generic) or docetaxel (Taxotere, generic). Currently, paclitaxel is the drug most often used as initial therapy in combination with a platinum drug.

Chemotherapy for Relapsed or Refractory Cancer. Unfortunately, even in patients who respond, the disease eventually becomes resistant to the first-line drugs, and the cancer returns. Some ovarian tumors are resistant to platinum drugs.

Once cancer recurs or continues to progress, the patient may be treated with more cycles of carboplatin and a taxane drug, or a different type of chemotherapy drug may be used in combination treatment.

Recurrent ovarian cancer may be treated with gemcitabine (Gemzar, generic), a drug used in combination with carboplatin for women with advanced ovarian cancer that has relapsed at least 6 months after initial therapy. Other drugs used for recurrent ovarian cancer include doxorubicin (Adriamycin, Doxil, generic), etoposide (Vepesid, generic), and vinorelbine (Navelbine, generic).

Hormonal therapy is also an option for patients who cannot tolerate or who have not been helped by chemotherapy. Hormonal therapy drugs include tamoxifen (Nolvadex, generic), and aromatase inhibitors such as letrozole (Femara, generic), anastrozole (Arimidex, generic), and exemestane (Aromasin, generic).

Administration of Chemotherapy

In general, the typical initial chemotherapy regimen is:

• Paclitaxel and carboplatin are administered in an outpatient clinic within several weeks of the surgery.
• Each treatment takes about 4 - 5 hours to complete.
• It is repeated every 3 weeks for a total of six times. (Each 3-week interval is known as a cycle of chemotherapy.)

Chemotherapy is either administered intravenously (by vein) or intraperitoneally (through the abdominal cavity). Recent research has indicated that patients with stage III ovarian cancer who receive intraperitoneal chemotherapy have a significant survival advantage compared with patients who receive standard intravenous chemotherapy. However, intraperitoneal chemotherapy can cause more severe side effects, including abdominal pain and bowel damage. Some patients cannot tolerate intraperitoneal chemotherapy. Intraperitoneal chemotherapy requires careful catheter insertion and maintenance, and doctors need to be well trained to perform this procedure.

Side Effects of Chemotherapy

Side effects occur with all chemotherapy drugs. They are more severe with higher doses and increase over the course of treatment. Some may be long-lasting.

Common side effects may include:

• Nausea and vomiting. Drugs known as serotonin antagonists, especially ondansetron (Zofran, generic), can relieve these side effects in nearly all patients given moderate drugs and most patients who take more powerful drugs.
• Diarrhea
• Temporary hair loss
• Weight loss
• Fatigue
• Depression

Serious short- and long-term complications can also occur and may vary depending on the specific drugs used. These complications may include:

• Anemia (low red blood cell count)
• Increased chance for infection from severe reduction in white blood cells (neutropenia)
• Abnormal bleeding (thrombocytopenia)
• Problems with concentration, motor function, and memory

Follow-Up Recommendations

After surgery and chemotherapy, patients should have:

• A physical exam (including pelvic exam) every 2 - 4 months for the first 2 years, followed by every 6 months for 3 years, and then annually.
• A CA-125 blood test at each office visit if the level was initially elevated. Falling CA-125 levels indicate effective treatment while persistently elevated levels indicate resistance to the chemotherapy.
• Your doctor may also order a computed tomography (CT) scan of your chest, abdominal, and pelvic areas and a chest x-ray.
• If your family history suggests a genetic component, genetic counseling may be recommended.

Investigational Drugs

Any patient with ovarian cancer is a candidate for clinical trials. In addition to testing high-dose or combinations of chemotherapy, biologic drugs that target specific proteins are being investigated. These drugs are primarily being studied for treatment of advanced or recurrent ovarian cancer, in combination with standard chemotherapy drugs.

Radiation Therapy

Radiation therapy is not typically used in ovarian cancer. This is because radiation would need to be given to the entire abdomen and pelvis, increasing its toxicity. Radiation is sometimes useful to treat isolated areas of tumor that are causing pain and are no longer responsive to chemotherapy, and to kill cancer cells that still remain after other treatments.

Resources

• www.cancer.gov -- National Cancer Institute
• www.cancer.org -- American Cancer Society
• www.cancer.net -- Cancer.Net
• www.ovarian.org -- National Ovarian Cancer Coalition
• www.ovariancancer.org -- Ovarian Cancer National Alliance
• www.sgo.org -- Society of Gynecologic Oncologists
• www.foundationforwomenscancer.org  -- Foundation for Women's Cancer
• www.ovariancancer.com -- The Gilda Radner Familial Ovarian Cancer Registry
• www.cancer.gov/clinicaltrials -- Find clinical trials

References

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol. 2007; 110(1): 201-14.

American College of Obstetricians and Gynecologists Committee on GynecologicPractice. Committee Opinion No. 477: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer. Obstet Gynecol. 2011 Mar;117(3):742-6.

Berek JS, Chalas E, Edelson M, Moore DH, Burke WM, Cliby WA, et al. Prophylactic and risk-reducing bilateral salpingo-oophorectomy: recommendations based on risk of ovarian cancer. Obstet Gynecol. 2010 Sep;116(3):733-43.

Buys SS, Partridge E, Black A, Johnson CC, Lamerato L, Isaacs C, et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA. 2011 Jun 8;305(22):2295-303..

Chan JK, Tian C, Monk BJ, Herzog T, Kapp DS, Bell J, et al. Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study. Cancer. 2008; 112(10): 2202-10.

Collaborative Group on Epidemiological Studies of Ovarian Cancer, Beral V, Doll R, Hermon C, Peto R and Reeves G. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls. Lancet. 2008; 371(9609): 303-14.

Daly MB, Axilbund JE, Buys S, Crawford B, Farrell CD, Friedman S, et al. Genetic/familial high-risk assessment: breast and ovarian. J Natl Compr Canc Netw. 2010 May;8(5):562-94.

Domchek SM, Friebel TM, Singer CF, Evans DG, Lynch HT, Isaacs C, et al. Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality. JAMA. 2010 Sep 1;304(9):967-75..

Elit L, Oliver TK, Covens A, Kwon J, Fung MF, Hirte HW, et al. Intraperitoneal chemotherapy in the first-line treatment of women with stage III epithelial ovarian cancer: a systematic review with metaanalyses. Cancer. 2007; 109(4): 692-702.

Goff BA, Mandel LS, Drescher CW, Urban N, Gough S, Schurman KM, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2007 Jan 15;109(2):221-7.

Goff BA, Matthews BJ, Larson EH, Andrilla CH, Wynn M, Lishner DM, et al. Predictors of comprehensive surgical treatment in patients with ovarian cancer. Cancer. 2007 May 15;109(10):2031-42.

Jensen A, Sharif H, Frederiksen K, Kjaer SK. Use of fertility drugs and risk of ovarian cancer: Danish Population Based Cohort Study. BMJ. 2009 Feb 5;338:b249. doi: 10.1136/bmj.b249.

Morch LS, Lokkegaard E, Andreasen AH, Kruger-Kjaer, Lidegaard O. Hormone therapy and ovarian cancer. JAMA. 2009 Jul 15;302(3):298-305.

Pearce CL, Templeman C, Rossing MA, Lee A, Near AM, Webb PM, et al. Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case-control studies. Lancet Oncol. 2012 Apr;13(4):385-94. Epub 2012 Feb 22.

Prentice RL, Thomson CA, Caan B, Hubbell FA, Anderson GL, Beresford SA, et al. Low-fat dietary pattern and cancer incidence in the Women's Health Initiative Dietary Modification Randomized Controlled Trial. J Natl Cancer Inst. 2007; 99(20): 1534-43.

Rivera CM, Grossardt BR, Rhodes DJ, Brown RD Jr, Roger VL, Melton LJ 3rd, Rocca WA. Increased cardiovascular mortality after early bilateral oophorectomy. Menopause. 2009 Jan-Feb;16(1):15-23.

Tangjitgamol S, Manusirivithaya S, Laopaiboon M, Lumbiganon P. Interval debulking surgery for advanced epithelial ovarian cancer. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006014

U.S. Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement. Ann Intern Med. 2005 Sep 6;143(5):355-61.

U.S. Preventive Services Task Force. Screening for Ovarian Cancer: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Intern Med. 2012 Sep 11. [Epub ahead of print]

Winter-Roach BA, Kitchener HC, Dickinson HO. Adjuvant (post-surgery) chemotherapy for early stage epithelial ovarian cancer. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD004706.

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