What makes ovarian cancer the 'silent killer' and how can women protect themselves?

Ovarian cancer's history traces back to 1809 when Jane Todd Crawford, diagnosed with a massive ovarian tumor, underwent a risky surgery by Ephraim McDowell. McDowell, a frontier surgeon, performed the first successful ovariotomy, removing 22.5 pounds of tissue, and Crawford survived another 32 years. This story is often told as a tale of heroism—McDowell’s skill and Crawford’s courage—but it also highlights the ongoing challenge of diagnosing and treating ovarian cancer. As literary critic Susan Gubar noted, the disease’s early symptoms—bloating, fatigue, pelvic pain, and constipation—are often dismissed, earning it the label of a "silent killer." In the late 19th century, advances in cancer research, surgery, and cell theory improved treatments. In the 20th century, genetics and connections between ovarian and breast cancer, such as the BRCA1 and BRCA2 genes, further shaped modern approaches. However, ovarian cancer remains difficult to detect and treat.

Why is ovarian cancer hard to diagnose in its early stages?
Ovarian cancer is often referred to as a "silent killer" because it tends to progress quietly and undetected, typically not being diagnosed until it has reached advanced stages. Common symptoms, such as abdominal discomfort, bloating, feeling full after eating small meals, loss of appetite, and a sensation of incomplete bowel emptying, are frequently mistaken for common gastric issues. As a result, many patients seek consultation with a gastroenterologist, leading to a delay in diagnosing the cancer. Hence, most patients present to us at stage 3, when the disease is more advanced. This delay, combined with the lack of reliable and consistent screening methods, is one of the primary reasons why mortality rates for ovarian cancer have not improved as much over the past 30 years compared to other cancers.Remember, when you have such symptoms in addition to seeing a gastroenterologist, it's always a good idea to consult your gynecologist as well.

Who is at risk of developing ovarian cancer?
Having one or more risk factors for ovarian cancer doesn’t guarantee you’ll develop it, and some people with the disease have no known risk factors. However, certain factors can increase the risk of epithelial ovarian cancer:
-Age: Risk increases after menopause, especially in women over 63, but ovarian cancers can also been seen in young age. Teenagers are most commonly affected by germ cell tumors.
- Obesity: Obese women may have a higher risk, though not for the most aggressive types.
- Childbearing: Having children later (after 35) or never having a full-term pregnancy raises the risk.
- Hormone therapy: Using estrogen or progesterone after menopause increases risk.
- Family history: A history of ovarian, breast, or colorectal cancer in the family raises risk, especially with inherited gene mutations like BRCA1/BRCA2.
-Inherited mutations: Conditions like BRCA1, BRCA2, Peutz-Jeghers syndrome and MUTYH-associated polyposiscan increase risk.
-Fertility treatments: IVF may increase the risk of certain ovarian tumors.
- Previous breast cancer: Women with a history of breast cancer, particularly with a family history, have a higher risk.
- Smoking: Smoking is linked to a higher risk of mucinous ovarian cancer.

Who treats ovarian cancer and how is it treated?
Your treatment team may include various specialists based on your plan:
Gynecologic oncologist: A doctor who specializes in gynecology and has advanced training in treating gynecological cancers. They perform surgeries for ovarian cancer, which may be done first, followed by chemotherapy if needed. In some cases, the treatment sequence may be chemotherapy-surgery-chemotherapy. The treatment approach will depend on your condition and the stage of the disease.

Medical oncologist: A doctor who specializes in chemotherapy and other medicinal cancer treatments.
Studies show that patients have better survival rates when treated by a gynecologic oncology surgeon instead of a general surgeon. Dr. Rani emphasizes that the first treatment must be the best treatment, highlighting the importance of choosing the right surgeon for ovarian cancer to improve survival chances.

Fertility-Sparing Surgery
Fertility-sparing surgery may be an option for women with early-stage ovarian cancer in only one ovary who wish to have children in the future. In this procedure, gynecologic oncologists remove the affected ovary and its connected fallopian tube. They also take a sample from the surface of the uterus through a procedure called dilation and curettage to ensure there is no cancer present.
To ensure the safety of fertility-sparing surgery, gynecologic oncologists carefully confirm that the cancer has not spread beyond the affected ovary. They may perform one or more biopsies to examine tissue from the pelvic and abdominal areas for signs of cancer. They might also remove lymph nodes or sample the omentum (a layer of fatty tissue in the abdomen) to check for cancer.
The uterus and the healthy ovary are preserved to maintain fertility.

Making Treatment Decisions
Your treatment plan will depend on various factors, including your overall health, personal preferences, and whether you plan to have children. Age is not the sole determining factor, as studies show that older women can tolerate ovarian cancer treatments well.
It’s essential to discuss all treatment options with your doctors, including their goals and potential side effects, to choose the plan that best suits your needs. Be sure to ask questions if anything is unclear.
If possible, seeking a second opinion can provide additional information and help you feel more confident in your treatment decision.

Getting Through Cancer Treatment
Cancer patients need support and information at every stage of their illness. Understanding all your options and accessing the resources you need will help you make informed decisions about your care.
Whether you're considering treatment, undergoing treatment, or not receiving treatment at all, supportive care is available to manage pain or other symptoms. Open communication with your cancer care team is essential to fully understand your diagnosis, recommended treatments, and ways to enhance your quality of life.

Dr. Rani A. Bhat MBBS, MS (Obs& Gyn), FRCOG (UK), Fellowship in Gynae-Oncology (Singapore), Fellowship in Gynae-Oncology & Robotic Surgery (Hong Kong), Diploma in Gynaecological Operative Endoscopy (France), Head & Senior Consultant, Division of Gynaecological Oncology, Apollo Hospital, Bannerghatta Road, Bangalore.