Ovarian Cancer: Prevention, Screening, Treatment, and Survivorship Recommendations
Even though its incidence is less common, ovarian cancer is the fifth leading cause of death from cancer in women, according to the American Cancer Society (https://www.cancer.org/cancer/ovarian-cancer/about/key-statistics.html). It also estimated more than 22,000 new cases of ovarian cancer in 2019, with a five-year survival of 47% for all stages.
Treatment and prognosis are dependent on several histologic subtypes. Epithelial ovarian cancer accounts for 90% of malignancies (https://www.cancer.org/cancer/ovarian-cancer/about/key-statistics.html), and the following information focuses on epithelial histology. Ovarian cancer typically affects women older than 45, and more than 70% of women present with advanced disease (https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/ovarian-cancer-screening1).
Prevention and Screening
Because of a lack of methods to detect ovarian cancer in the general population, U.S. Preventive Services Task Force does not recommend (https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/ovarian-cancer-screening1) regular screening in asymptomatic women. Oncology nurses have a responsibility to educate women about the signs and symptoms of ovarian cancer and the importance of discussing them with their care provider promptly.
According to the National Cancer Institute (NCI) (https://www.cancer.gov/types/ovarian/hp/ovarian-epithelial-treatment-pdq#_677), symptoms, which may include bloating, abdominal pain, early satiety, and dysuria, are often vague and attributed to other causes, which can delay diagnosis. Risk factors include (https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf) older age at first pregnancy, nulliparity, use of hormonal therapy, and history of pelvic inflammatory disease (https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/ovarian-cancer-screening1). Women diagnosed with ovarian cancer should have a genetic risk assessment (https://www.cancer.gov/types/ovarian/hp/ovarian-epithelial-treatment-pdq#_677) and may undergo germline or somatic testing, which can impact prognosis and treatment options (https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf).
The CEA antigen, identified in 1965, was the first ovarian cancer biomarker (https://doi.org/10.3390/diagnostics7010014). In 1985, researchers isolated the cancer antigen 125 (CA-125). Although the U.S. Food and Drug Administration has not approved it as a screening measure in women with elevated risk, CA-125 is used to monitor for recurrence in women with an ovarian cancer diagnosis.
Today, in addition to CA-125, the following markers are available to monitor ovarian cancer disease progression; CEA (mucinous), LDH (dysgerminoma, mixed germ cell tumors), beta HCG (choriocarcinoma and mixed germ cell tumors), inhibin B (granulosa cell tumors), alpha fetoprotein (yolk sac tumors, embryonal cell tumors), and HE4 (epithelial cell cancers).
CA-125 has a 76% sensitivity and a 94% a specificity. Panels with multiple biomarkers and single nucleotide polymorphisms are emerging to improve sensitivity (https://doi.org/10.1016/j.ygyno.2018.03.050).
Typically women receive staging and debulking surgery to remove as much disease as possible, followed by systemic chemotherapy. Women with advanced disease may also receive intraperitoneal chemotherapy. The number of cycles will vary, but they typically receive three to six cycles of carboplatin and paclitaxel or other chemotherapy. Treatment is often dependent (https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf) on performance status and comorbidities, which affect tolerability.
Additional systemic combination chemotherapy is often used for disease recurrence. Antiangiogenesis agents, such as bevacizumab, may be used in some settings. PARP inhibitors (https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf), such as olaparib, rucaparib, and niraparib, may be used for advanced disease (https://www.cancer.gov/types/ovarian/hp/ovarian-epithelial-treatment-pdq#_677), disease progression or recurrence, and maintenance. Palliative radiation may control symptoms in patients with advanced disease (https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf). Oncology nurses should review clinical trial options with patients.
Side Effects and Management
Often, women will present with menopausal symptoms and sexual dysfunction following initial debulking surgery or systemic chemotherapy. Lymphedema may occur after lymph node removal. Side effects from chemotherapy include gastrointestinal toxicity, cytopenias, peripheral neuropathy, and fatigue. Infusion and hypersensitivity reactions are common (https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf), and clinicians must be vigilant in identifying and treating signs and symptoms immediately. Patients should also be routinely screened for psychosocial distress, such as depression, anxiety, financial toxicity, fear of recurrence, or change in body image. Refer for multidisciplinary support services (https://doi.org/10.1188/17.CJON.353-361) or psychotherapy when indicated.
Palliative care and symptom management are important in patients with recurrent or advanced disease. Paracentesis may improve discomfort from ascites (https://www.cancer.org/cancer/ovarian-cancer/about/key-statistics.html). Given the many physical and psychosocial side effects associated with diagnosis and treatment of ovarian cancer, oncology nurses must perform consistent side effect assessment measures and offer resources as needed.