Diagnosis and Treatment of Epithelial Ovarian Cancer

Ovarian cancer represents about 25% of all female genital tract malignancies. The lifetime risk of developing spontaneous ovarian cancer is about 1.7%. Epithelial ovarian cancer was expected cause 15,520 deaths in 2008. There has been a significant improvement in the five year survival rate for patients with ovarian cancer. Most patients with this type of ovarian cancer do not have signs or symptoms until disease spreads to the upper abdomen. 70% of patients present with advanced disease. Symptoms for early stage ovarian cancer can include nonspecific pelvic discomfort, urinary frequency and constipation which are caused by an enlarging pelvic mass. With advanced disease, patients experience abdominal pain, bloating, anorexia, nausea and constipation.The best tumor marker for ovarian cancer is CA 125. The National Cancer Institute recommends screening for ovarian female cancer with known genetic syndromes associated with this disease and for women with strong family history. Routine screening of women without family history of ovarian cancer is not recommended. The known genetic syndromes include hereditary breast and ovarian cancer syndrome associated with BRCA 1, BRCA 2 and Hereditary Nonpolyposis Colorectal Cancer Syndrome (HNPCC). For patients with HNPCC syndrome, the lifetime risk of ovarian cancer is 9% to 12%.Epithelial cancer accounts for about 90% of ovarian cancers. Stromal tumors include granulose tumor or Sertoli-Leydig tumor.Upon initial presentation, surgery is used for confirmation and staging the cancer. Stage I disease is confined to one or both ovaries. Stage IV disease involves distant metastasis. The 5 year survival for stage IA disease and grade 1 or 2 histology is greater than 90%. For high risk stage I disease and stage II disease, 5 year survival is 80%. For patients with stage III disease after optimal debulking, 5 year survival is 20% to 30%. This reduces to be less than 10% for stage III patients with suboptimal debulking and stage IV disease.Stage I ovarian cancer with favorable prognostic features can be treated with surgery alone. For women with high risk, early stage cancer (Stage I grade 3 or stage II disease), adjuvant chemotherapy with platinum based agents show an 11% improvement in progression free survival and 8% improvement in overall survival. As for the standard of care in chemotherapy for advanced ovarian-type cancer, studies have shown that paclitaxel/cisplatin combination is superior to cyclophosphamide/cisplatin combination. Because of the high recurrence rate in patients with advanced ovarian cancer, the issue of whether consolidation chemotherapy may improve time to progression and overall survival was examined in a phase III trial comparing 3 and 12 cycles of taxol. Progression free survival favored the 12 cycle arm. For many patients with advanced ovarian cancer who have an initial treatment response, disease relapses at a later time. The treatment of patients with recurrent disease or resistant disease needs to be individualized. There are also a number of single agent drugs with activity in ovarian cancer. Radiation can also play a role in the palliation of some patients with recurrent ovarian cancer. The best treatment of ovarian cancer needs a team approach between the primary care physician, gynecological oncology surgeon, medical oncologists and radiation oncologists.

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