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Gynecological Cancer – 4 Ovary Etiology Evaluation

Gynecological Cancer  – 4

(All the articles published in past are available at
Question: Thank you Chiragbhai. You pointed out some very important concepts last time. Can you please reiterate them, since I think they are of great importance for all cancers in general?
Answer: Sure. 1. Solid tumors are rarely an emergency. Hence better to plan properly, before starting any treatment, even if planning takes 2-6 weeks. This is the average time taken in USA or Europe for most solid tumors. Not to undergo surgery right away thinking that urgent surgery improves results.
2. For many cancers, preferred treatment worldwide is combination of chemotherapy and radiotherapy, NOT SURGERY, such as Cervix, Larynx, Hypopharynx, Nasopharynx, Base of Tongue, Anal Canal, Esophagus, Lung.
3. Even in above noted areas, and most cancers in general, benefit from a TEAM APPROACH (known as multidisciplinary evaluation by surgeon, radiation oncologist, medical oncologist, pathologist, radiologist, and others). This allows patient to obtain current best option. Doctors and patients should ask for cancer centers where such team work is available, generally through a process known as TUMOR BOARD. But there may be other ways of having a team approach.
4. Palliative care center referral, at least once, is important in advance cases of cervix cancer (this applies to most advance cancers) for better quality of life. Patient issues in such stages are of many different types, and most doctors are not trained to provide high quality palliative care. Palliative care is not just TLC (tender loving care). There is science behind this care. In Western countries, there is a formal degree in Palliative Care, same as for medicine, surgery, pediatrics etc.
Que: Wonderful, well phrased. Now, Chiragbhai what is the next cancer we are going to cover?
Ans: Next most common gynecological cancer is cancer of the ovary. It includes many different histologies, but 90% are epithelial ovarian cancers. It is the fourth most common cancer in women of India (after Breast, Cervix, Colon), at about 26,000 new cases per year. Unfortunately about 20,000 do not survive. That means only about 20% are cured overall. This is mainly due to late diagnosis. In USA, this rate is about 40%.
Que: Oh! That means our cure rates are about half that of USA. But even there, it seems majority are not cured. What are the likely reasons? And what are the risk factors for ovary cancer?
Ans: Yes, early diagnosis, and proper treatment are both largely lacking in India. Main reasons for our lower cure rates. Symptoms of this cancer are vague, and mostly none till more advance stage in many cases. Bloating, mild pain, distension, urinary symptoms, early satiety are the common symptoms. Most women and doctors would rarely investigate such symptoms right away, as they overlap with so many other conditions and day to day issues. Hence late diagnosis is extremely common even in USA.
Risk factors are not known in every patient, with no relation to diet, alcohol. Known factors include late first pregnancy and childbirth, no pregnancy, older age, no breastfeeding, in vitro fertilization treatment, endometriosis, pelvic inflammatory disease. Some studies suggest correlation with tobacco, obesity.
About 10-15% cases are hereditary, associated with syndromes like HBOC, HNPCC. These can be diagnosed by genetic tests, and should be suspected if there is a strong family history, early age of diagnosis. Such genetic tests and experts (genetic counselors) to interpret these tests are now widely available in India as well, including in Gujarat. Detection of these syndromes helps patient and family members both. As these patients themselves, and family are at risk for other cancers, like breast, colon, prostate. So this is useful for both men and women in family.
Screening tests for early diagnosis have been extensively investigated, in many large trials as well, including thousands of women. So far NO test is recommended by any professional societies worldwide. These include CA-125, abdominal ultrasound, various biomarkers, combinations of biomarkers etc. All of these are NOT RECOMMENDED.
Que: How do you evaluate a suspected case of ovary cancer?
Ans: First basic test is ultrasound. If there is mass in adnexa, depending on the findings and age, further tests like various tumor markers, CT/MRI etc can be done. PET-CT scan is occasionally required. If patient is in early stage, and operable, a biopsy is generally avoided. As there is risk of rupturing capsule and increasing stage, it is better to operate and remove whole ovary tumor. However, if there is already intraabdominal spread, especially with significant ascites etc, a biopsy is done first to establish diagnosis, and then finalize treatment plan. In most such cases, chemotherapy is given first, followed by surgery.

March 13th 2017.

Dr. Chirag A. Shah;

M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad.

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