Knowledge is Key When it Comes to Ovarian Cancer


Ovarian cancer affects 1 in 70 women in the general population.


Unfortunately, symptoms of ovarian cancer are very vague. They can include:

  • Bloating
  • Nausea
  • Feeling full after only eating a small amount
  • Abdominal pain
  • Changes in bowel or bladder function

Many women have these symptoms due to other causes, such as irritable bowel syndrome or gastroesophageal reflux disease. This makes it difficult to identify ovarian cancer based on symptoms. However, in a study by Goff et al., if symptoms occur more than 12 times per month and are new in onset, ovarian cancer can be considered.


Simple cysts of the ovary develop as a normal function of the ovary in a premenopausal woman. However, it is concerning if a cyst is complex with separations or septations, solid features or papillations (clusters). Those findings in a woman who has undergone menopause are very concerning.

If a complex cyst is found, often tumor markers, such as CA-125 and sometimes HE-4 or OVA-1, are drawn to evaluate the chance of finding ovarian cancer. There is a 70-80% chance of finding ovarian cancer in a postmenopausal woman with a complex pelvic mass and an elevated CA-125. However, CA-125 can have false positive results, meaning the number can be elevated, but not necessarily due to ovarian cancer.

An elevated CA-125 is not specific for ovarian cancer. Potential causes of falsely elevated CA-125 include endometriosis, pneumonia, liver problems like cirrhosis, fibroid tumors, pelvic inflammatory disease and ovulation.

It is thought that 20% of ovarian cancers are hereditary. BRCA1 and BRCA2 are genetic mutations associated with an increased risk for breast and ovarian cancer. If there is a family history of breast or ovarian cancer, it is very helpful to undergo a blood test for genetic testing to accurately predict risk of these cancers and others.

Ovarian cancer screening has been studied extensively. If there is an increased genetic risk, serial transvaginal ultrasounds with CA-125 levels may be obtained in those desiring future fertility. However, there are no good screening tests for ovarian cancer, so knowing family history can be lifesaving in identifying families at risk.


For patients who have an increased genetic risk, there is benefit for preventative removal of the fallopian tubes and ovaries to decrease risks of gynecologic cancers. This is referred to as a “risk-reducing” surgery.

If a patient is found to have a complex cyst or mass of the ovary, it is very important that this is managed surgically in a very specific way. Pelvic washings may be performed at the beginning of surgery. The mass will be removed for pathologic evaluation. If this evaluation is done at the time of the surgery, this is known as a “frozen section.”

A frozen section is when the pathologist takes one or more pieces of the mass, quickly freezes them and looks at them under the microscope while the patient is still in the operating room. If an ovarian cancer is found, a staging procedure may be performed. This includes completing the hysterectomy, with removal of the uterus and cervix, removing both ovaries and fallopian tubes.

Additionally, biopsies may be collected, including biopsies of the lining of the abdomen known as the peritoneum and removal of the omentum (a piece of fat that lays over the bowel). A pelvic and paraaortic lymph node dissection (removal of lymph nodes in the ovaries and other pelvic organs) may be performed to adequately determine the stage of the cancer.

Staging of cancer allows the physician to determine the chance of cure and accurately decide on postoperative therapy, such as amount and number of chemotherapy treatments. In all patients who are thought to have cancer confined to the ovary based on appearance at surgery, 30% have spread of disease or increase in stage at the time of final pathology reports. If staging is not done, a patient could be overtreated or undertreated, which could impact chance of a cure and increase negative outcomes from treatment.

Typically, staging is performed by a gynecologic oncologist. Patients with early-stage epithelial ovarian cancer, meaning the cancer began in the layer that covers the ovary, sometimes do not need chemotherapy or only need three cycles of chemotherapy, whereas patients with more advanced stage of disease require at least six cycles of chemotherapy. Therefore, it is very important for a patient to have thorough staging to accurately determine the appropriate postoperative care.

A patient may present with spread of disease at initial diagnosis, which could include ascites (fluid produced by the tumor that can cause increased swelling of the abdomen or shortness of breath) or carcinomatosis (tumor nodules or masses felt or seen on CT scans). Options for treatment include a debulking surgery (removal of as much tumor as possible at time of surgery) or a biopsy with treatment with chemotherapy first, followed by surgery.

If a debulking surgery is performed, there is benefit from “optimal tumor reduction,” which means that all bulky tumors are removed and any tumor that is left is less than one centimeter in size. The main goal of these surgeries is to not have any visible disease left at the end of the surgery. There is a difference in survival of 22 months in patients who have an “optimal debulking” versus a “suboptimal debulking,” which means there is still a tumor greater than one centimeter present at the end of the surgery.

Some patients may receive chemotherapy both intravenously (through an IV) and intraperitoneally (directly in their abdomen). In patients who have optimal debulking, there is marked improvement in survival by 16 months for patients who receive intraperitoneal chemotherapy versus intravenous chemotherapy alone. Intraperitoneal chemotherapy is given by a catheter being placed at the time of surgery. Chemotherapy after surgery is then given not just in the vein, but also directly into the abdomen. It allows the chemotherapy to reach places not easily accessible to intravenous chemotherapy.

Unfortunately, most patients with ovarian cancer present with advanced stage disease, most often at stage III disease, with spread already outside of the ovary. Patients with advanced stage of disease can require six or more cycles of chemotherapy for treatment. In some women, additional agents may be combined with chemotherapy to aid the chance of cure, such as bevacizumab.

Additionally, poly (ADP-ribose) polymerase (PARP) inhibitors may be given. These agents have been shown to decrease the risk of recurrence up to 70% in women with certain tumor or genetic mutations. These agents may be continued even after the six cycles of chemotherapy are completed.

It is now standard of care to test for these mutations in all women newly diagnosed with ovarian cancer. In this way, we can tailor treatment to maximize the benefits for those women.

It is very important that patients with suspected ovarian cancer see a gynecologic oncologist and undergo the appropriate surgical management and chemotherapy. There have been great strides in the fight against ovarian cancer. Our hope is that by identifying patients who have increased risk and performing prophylactic surgery as well as aggressively treating patients diagnosed with the disease, that we will decrease the incidence as well as continue to improve survival of patients affected.

If you’ve been diagnosed with ovarian cancer, ask for a second opinion with UofL Physicians – Gynecologic Oncology, a part of UofL Health – Brown Cancer Center. Call 502-561-7220.

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Article by: Whitney Goldsberry, M.D.

Whitney Goldsberry, M.D., is a gynecologic oncologist with UofL Physicians – Gynecologic Oncology and UofL Health – Brown Cancer Center. She joined the team in 2021 and sees patients at Brown Cancer Center, UofL Health – Medical Center Northeast and UofL Health – Center for Women's Health at UofL Health – Mary & Elizabeth Hospital. She is an assistant professor in the Department of Obstetrics, Gynecology and Women's Health at University of Louisville School of Medicine. She graduated from University of Louisville where she completed residency in obstetrics and gynecology. She completed a fellowship in gynecologic oncology at University of Alabama at Birmingham.

All posts by Whitney Goldsberry, M.D.
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