Types of Ovarian Cancer

Ovarian cancer doesn’t come with just one type of tumor, one type of cell, or four general stages. There are different types of cells, types of tumors, and stages to keep in mind if your doctor gives you the dreaded news.

There are over 30 types of ovarian cancer because of the type of cell from which they start. Cancerous tumors can start from three common cell types:
Surface Epithelium - cells covering the lining of the ovaries
Germ Cells - cells that are destined to form eggs
Stromal Cells - cells that release hormones and connect the different structures of the ovaries

The most common tumors include:
Common Epithelial Tumors. They develop from cells that cover the outer surface of the ovary. Most of the tumors like this are benign (noncancerous) and include several types: serous adenomas, mucinous adenomas, and Brenner tumors.
Cancerous Epithelial Tumors. These are carcinomas, which begin in the tissue that lines the ovaries, and are the most common and most dangerous.
Borderline tumors or tumors of low malignant potential (LMP tumors). These are tumors that aren’t clearly identified as cancerous under a microscope.
Germ Cell Tumors. These develop from the cells that produce the ova or eggs. Most are benign, but some are cancerous and may be life threatening. The most common germ cell malignancies are maturing dysgerminomas, teratomas, and endodermal sinus tumors.
Stromal Tumors. These belong to a rare class of tumors that develop from connective tissue cells that hold the ovary together, in addition to cells that produce the female hormones: estrogen and progesterone. The most common types of stromal tumors are granulosa-theca and Sertoli-Leydig cell tumors and are considered to be low-grade cancers

The stages of ovarian cancer include:
Stage I – Cancer growth is limited to the ovary or ovaries.
Stage IA - Growth is limited to one ovary and the tumor is confined to the inside of the ovary. Stage IB - Growth is limited to both ovaries without any tumor on their outer surfaces.
Stage IC - The tumor is Stage IA or IB and (1) tumor is present on the outer surface of one or both ovaries; (2) the capsule has ruptured; and/or (3) there are ascites containing malignant cells or with positive peritoneal washings.
Stage II - Growth of the cancer involves one or both ovaries and has extended to the pelvis.
Stage IIA - The cancer has extended to and/or involves the uterus, fallopian tubes, or both.
Stage IIB - The cancer has extended to other pelvic organs.
Stage IIC - The tumor is Stage IIA or IIB and (1) tumor is present on the outer surface of one or both ovaries; (2) the capsule has ruptured; and/or (3) there are ascites containing malignant cells or with positive peritoneal washings.
Stage III - Growth of the cancer involves one or both ovaries, and (1) the cancer has spread beyond the pelvis to the lining of the abdomen; and/or (2) the cancer has spread to lymph nodes.
Stage IIIA - During an operation, the surgeon can see cancer on one or both of the ovaries, but not in the abdomen or lymph nodes. However, small deposits of cancer are found in the abdominal peritoneal surfaces when biopsies are checked under a microscope.
Stage IIIB - The tumor is in one or both ovaries, and deposits of cancer are visibly present in the abdomen during surgery, but not exceeding 2 cm in diameter. The cancer has not spread to the lymph nodes.
Stage IIIC - The tumor is in one or both ovaries, and (1) the cancer has spread to lymph nodes; and/or (2) the deposits of cancer exceed 2 cm in diameter and are found in the abdomen.
Stage IV - The most advanced stage. Growth involves one or both ovaries and distant metastases (spread of the cancer to organs located outside of the peritoneal cavity) have occurred. Finding ovarian cancer cells in pleural fluid (from the cavity which surrounds the lungs) is also evidence of stage IV disease.

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Factors That Could Lead to Ovarian Cancer

Some of these factors may make you more susceptible to ovarian cancer.

Ovarian cancer often goes undetected until it has spread within the pelvis and abdomen. At this late stage, ovarian cancer is more difficult to treat and is frequently fatal. Early-stage ovarian cancer, in which the disease is confined to the ovary, is more likely to be treated successfully.

Certain factors may increase your risk of ovarian cancer:

Age. Ovarian cancer can occur at any age but is most common in women ages 50 to 60 years.
Inherited gene mutation. A small percentage of ovarian cancers are caused by an inherited gene mutation. The genes known to increase the risk of ovarian cancer are called breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2). These genes were originally identified in families with multiple cases of breast cancer, which is how they got their names, but women with these mutations also have a significantly increased risk of ovarian cancer.

The gene mutations that cause Lynch syndrome, which is associated with colon cancer, also increase a woman's risk of ovarian cancer.

Estrogen hormone replacement therapy, especially with long-term use and in large doses.
Age when menstruation started and ended. If you began menstruating before age 12 or underwent menopause after age 52, or both, your risk of ovarian cancer may be higher.
Never being pregnant.
Fertility treatment.
Smoking.
Use of an intrauterine device.
Polycystic ovary syndrome.
If you have a genetic predisposition to ovarian cancer, your doctor may recommend regular pelvic imaging and blood tests to screen for the disease.

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12 Questions You Should Ask If You've Been Diagnosed With Ovarian Cancer

An ovarian cancer diagnosis may be devastating, but it's important to get the answers to several important questions. This will help you ensure you know all the ins and outs of the disease, as well as how you and your family can deal with the diagnosis in the best way possible.

Are you sure?
The work-up for the diagnosis is by an imaging test – by an ultrasound, CT scan or both – and a blood test called a CA-125, explains Karen Lu, chair of gynecologic oncology at the MD Anderson Cancer Center in Houston, and “most of the time – unfortunately, about 75 percent of the time – women present with ovarian cancer with symptoms of bloating and increase in the size of their abdomen," Lu says. "And when they get imaging by their physician, they have very advanced disease.”

But other times, the diagnosis isn’t so obvious. A biopsy or surgery is needed for definite diagnosis, she says.

What type of ovarian cancer do I have?
Ovarian cancers are classified by where the tumor first developed in the ovary – in the cells of its covering layer (epithelium), in the egg-producing cells or in the hormone-producing cells – along with other subtypes. Malignant epithelial ovarian cancer is the most common.

What kind of doctor should I see?
Your doctor should be a board-certified gynecologic oncologist – a doctor who specializes in cancer of the female reproductive system, Lu says.

“We’re an unusual specialty that includes both surgery and chemotherapy,” says Leslie Randall, a gynecologic oncologist with University of California Irvine Health. “Because the disease is so complicated, and sometimes the chemo and surgery go hand in hand, it’s really important to have somebody who knows both sides of the coin to be involved in their care.”

Where do I go for care?
A big cancer center is ideal, Randall says, but if you don’t have access, then the best thing is to locate a gynecologic oncologist in the community.

Lu says it’s important to ask doctors or a medical group about their experience and approach, with questions such as: “Do you do this on a regular basis?” “Are there any innovative approaches?" “Do you offer any clinical trials?” and “Does your group have a particular focus on ovarian cancer?”

What is my treatment plan?
Most patients start with surgery followed by chemotherapy once they’ve recovered, although some women need chemotherapy first. The extent of treatment needed may not be known until the woman is actually on the operating table and the pathologist has analyzed her tumor.

What is your surgical approach?
Survival odds are better when all the cancer is removed during tumor-debulking surgery. “We have a very specific goal – which is no residual tumor,” Lu says. That’s why you want your doctor to use maximal cytoreductive effort.

With advanced ovarian cancer, instead of one big tumor, many small tumors are spread throughout the abdominal cavity, Randall explains. “'Cytoreductive’ means removing all those little tumors,” she says. “It’s a labor-intensive type of surgery, but it helps people live longer the more you remove.”

How do you give chemotherapy?
A major marker of good ovarian cancer care is whether women have access to intraperitoneal chemotherapy, Randall says. With intraperitoneal chemo, drugs are injected directly into the abdominal cavity through a thin catheter, rather than being given intravenously. While not all patients are good candidates for this method, she says, it’s considered the standard of care. “A lot of women don’t get peritoneal therapy because they’re going to a provider who doesn’t give [it],” she says. “It’s a wrong reason not to get peritoneal therapy.”

What about chemo side effects?
Side effects depend on the type of drugs you receive, and you should have an idea what to expect. Figueras was surprised at how debilitating her side effects were. At first, “I was gung-ho to go to my chemotherapy,” she says. “In my mind, I was going to have it on [each] Friday; I was going to be sick all weekend – and then I was going to be fine again. And nothing could be further from the truth.”

Do you offer clinical trials?
It “absolutely” is important to be at a place that offers clinical trials, Lu says. Even if you don’t choose to be in one, you may want to hear about those research studies, which can give you a chance to receive the newest treatments for your condition.

What if I don’t have access to care?
Patients can connect to resources and specialists nationwide through the Society of Gynecologic Oncology website, Randall suggests. “There’s a lot of patient information – good information, because a lot of information on the Web is not good,” she says. The society also has a patient advocate to help women find providers.

What about emotional and social support?
“You need to find those people who are going to be there for you,” Figueras says, and she’s lucky to have a “fantastic” support system in her family, her blog community and her Facebook friends.

“I have a friend who is a chef who called me and couldn’t really offer anything but food. So he would provide my lunch for me on chemo days,” she says. “My very first chemo … he actually sent over a lobster tail.” For peer support and information, she turns to the Ovarian Cancer National Alliance.

Do I need to make decisions right away?
When you’re diagnosed, Lu says, “It’s very scary, and you feel like ‘I have to deal with this thing tomorrow.’” But it’s worth taking your time to make sure you find a doctor “who is experienced and also someone that you trust, that you have a good relationship with,” she says, rather than feeling you have to rush into something.

Within a month is a reasonable time frame to pick a provider and get started, both experts agree. However, Randall adds, “You really don’t want to spend a whole lot of time in that process. The sooner you get to treatment, the better the outcome will be in the long term.” 

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4 Things You Didn't Know About Ovarian Cancer

Here are four things you probably don't know, but should know about ovarian cancer:

It's Known as the Silent Killer

Prolonged bloating, pelvic abdominal pain, and feeling the need to urinate frequently are all things that the average women might feel on the average day. They’re also symptoms of ovarian cancer. Since symptoms are so vague, the cancer can be tough to catch. It’s easy to chalk those symptoms up to hormonal changes, a UTI, or just a big Chinese dinner, Avner says. “That’s why it’s so important for women to know the symptoms and be empowered to go to their doctor if the symptoms persist or worsen,” Avner says.

It’s the Deadliest Gynecological Disease

Two-thirds of women who are diagnosed with ovarian cancer will die as a result, Avner says. That’s why you need to be proactive. To ensure your symptoms aren't overlooked, ask your doctor questions like, ‘Could it be my ovaries?’

A Pap Smear Doesn’t Check for It

Many of us think that after heading to the lady doctor, we’re covered. But in reality, your ob-gyn is testing for cervical cancer, a far less pervasive and far less deadly cancer, Avner says. This year, 12,360 women will be diagnosed with cervical cancer versus 21,980 new diagnoses of ovarian cancer, according to the American Cancer Society.

Oral Contraceptives Reduce Your Risk

Popping the Pill every day has its benefits: hormone control, cramp killer, unplanned pregnancy prevention, and protection from cancer. “Five years of oral contraceptives for a woman in her 20s or 30s can have the power to reduce the risk for ovarian cancer by 50 percent,” Avner says. These five years can be non-consecutive, so if you go on the pill for a few years in your early 20s and go off again until you’re 30, you’ll still reap the benefits. One study found that the risk for ovarian cancer decreases by 36 percent for every 10 years taking oral contraceptives. Another found that the protection continues long after you stop.

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Getting a Jump on Ovarian Cancer

Learn the story behind this young woman's fight with ovarian cancer.

In July 2013, Ivanna Vidal learned she carried a mutation in one of her genes, the BRCA2 gene, that increases the risk of breast and ovarian cancers. About a year later, she was found to have a mass in her right ovary just months after an ovarian cancer screening came back negative.

Last month, during what she thought would be a preventative surgery to remove her ovaries, fallopian tubes and uterus, the mass in her ovary was biopsied. Doctors diagnosed her with advanced-stage ovarian cancer.

The diagnosis didn’t devastate her, though. She recently sat up in bed at UM’s Sylvester Comprehensive Cancer Center in Miami, eagerly sharing her story, even after a fourth round of chemotherapy. Vidal was one of the patients at Sylvester’s newly opened Ovarian Cancer Early Detection Clinic.

The clinic wants to identify women at a high risk for developing ovarian cancer by screening family and personal cancer histories and to provide preventive strategies to the women. Vidal, 41, for example, has an extensive family history of breast cancer, but not ovarian cancer.

“It’s all good,” she said. “I’m learning a lot from this and I’m appreciating the experience.”

As with most other cancers, the risk of being diagnosed with ovarian cancer increases with age. One preventative strategy for post-menopausal women, or for women who are finished with childbearing, is to remove the ovaries and fallopian tubes.

Other women, like Vidal, who have strong family histories of certain types of cancers need to be made aware of their risks and what they can to minimize them.

Dr. Brian Slomovitz, division director of gynecologic oncology at Sylvester, said women with BRCA mutations have a 20- to 40-percent chance of getting ovarian cancer and up to an 80-percent chance of getting breast cancer.

BRCA is not the only gene that, when mutated, can cause cancer.

Talia Donenberg, senior cancer genetics counselor for the University of Miami/Jackson Memorial Hospital, said the percentage of women with hereditary ovarian cancer has jumped from 10 percent of all cases to between 15 and 20 percent because of the discovery of more genes involved in causing inherited cancers.

Slomovitz said Vidal’s cancer was caught early enough to give her a good prognosis. But that’s not usually the case for ovarian cancer patients.

Ovarian cancers are the deadliest of all gynecologic cancers, Slomovitz said.

“Most women with ovarian cancer are diagnosed with an advanced-stage disease,” he said. “In the past, we thought it was a silent disease. We know now that that’s not the case.”

Ovarian cancer does, in fact, show symptoms: abdominal pain, bloating or swelling; frequent urination; constipation and pelvic pain. But those symptoms are not specific to women and can mimic other common problems individuals may have, like gastritis or urinary tract infections.

Vidal experienced some bloating, but she attributed it to whatever she had for lunch. Slomovitz said the key is for women to be cognizant of their symptoms and to pay attention to how long they last. It should be no longer than 10 to 14 days.

Another problem faced in treating ovarian cancer is identifying it at earlier stages.

“Currently, there is no good screening test for ovarian cancer,” Slomovitz said.

Donenberg said high-risk women are those with a first-degree relative with ovarian cancer, a first-degree relative with breast cancer under the age of 50 and/or a personal history of breast cancer.

A woman visiting the clinic can see a gynecologic oncologist, genetic counselor and a radiologist trained in identifying gynecologic cancers all in the same visit. She will get blood work done and have the results of her ultrasound read to her instead of waiting weeks for the results.

“Life is difficult. People are busy. We as healthcare providers realize that we can’t just focus on the treatment of really bad diseases, we need to focus on the prevention of some of those diseases. If we’re going to offer preventive strategies and be successful at it, we need to make sure it’s convenient for our patients,” Slomovitz said.

The clinic will also have a nurse navigator who will help patients navigate through the health care system and get them the appointments they need.

“A lot of these women feel lost,” said Donenberg. “They won’t know where to go, where to get care, who to talk to.’’

Vidal tries not to let the cancer get to her. The thing she thought would devastate her the most, losing her hair, has not impacted her.

“I’m surprised about my attitude toward my hair,” she said. “I had to shave it. It gets to the point where you just have to grab the shaver G.I. Jane-style and take it off.”

Vidal does miss her previously active lifestyle, the energy she used to have and her favorite foods. She loves sushi, ceviche and medium-rare meat, but because of the risk of infection, everything she eats now has to be well-cooked.

As a licensed clinical social worker, she hopes to help women going through something similar.

“People talk about waiting for the storm to pass to see the rainbow,” Vidal said. “I remember hearing someone say it’s not about waiting for storm to pass, it’s about learning to dance in the rain. I’m trying to dance in the rain.”

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