What do cancer "grading" and cancer "staging" mean? Why are these important?

For a complete diagnosis, your doctor will need to determine the cellular features (grade) of your cancer and also how much your cancer has grown and spread in your body (stage). Grade is important because the visible characteristics of the cells are often correlated with how these cells behave and how aggressively they will grow. Knowing the stage of your cancer is important because it provides important prognostic information. Early stage cancers may be more treatable with surgery and chemotherapy, whereas later-stage cancers may need more aggressive treatment and long-term care. Both stage and grade are assigned at the first surgical intervention and never change throughout the patient's course of disease.

What is a CA 125 test? Can it be used for diagnosis?

CA 125 is a substance shed by cancer cells that is also made by inflamed normal cells that line body parts. This substance is shed into bodily fluids and finds its way into the blood stream. A CA 125 assessment is performed on a sample of your blood. The assay measures the concentration of CA 125 in the liquid portion of your blood (serum).

CA 125 testing is best used for monitoring changes that might happen in your cancer growth over time.

Please note: Approximately 20% of women who have ovarian cancer never have elevated CA 125 levels. Also, some women have naturally elevated levels of CA 125, so this protein does not necessarily mean that cancer is present. That is why it is critical to use CA 125 only as part of a diagnostic and monitoring regimen.

Is surgery necessary for cancer assessment?

Most women with ovarian cancer will have surgery at some point during the course of their disease, and each surgery has different goals:

Initial surgery (for diagnosis and treatment)
Initial surgery: technique

  • Usually performed by laparotomy, a surgery that involves a vertical (up and down) incision in the abdomen that is large enough to allow the surgeon to look inside the body and remove cancerous tissue
  • Sometimes includes debulking, which is described as removal of all visible cancer. In addition, it also involves removal of one or both ovaries and fallopian tubes (salpingo-oopharectomy) and often the removal of the uterus (hysterectomy). It is important that a gynecologic oncologist is the leader of the surgical team, as prognosis is closely related to how much of the cancer cannot be removed during surgery.

Goal: diagnosis

  • Obtain an accurate surgical diagnosis, which is crucial for planning an appropriate treatment strategy
  • Determine how far the cancer has spread ("staging" the cancer)
  • Obtain a biopsy sample to analyze the cellular characteristics of the cancer

Goal: treatment

  • "Debulking" to remove as much of the cancer tissue as possible
  • Optimal debulking of the tumor in women with bulky disease can improve outcome

"Second-look" surgery (a follow-up for women whose cancer responds to chemotherapy; not performed routinely)
Second-look surgery: techniques

  • Laparotomy
  • Laparoscopy
    - Surgery using fiberoptic scopes and tubes
    - Less invasive (can be performed through small [ = 1 inch] incisions in the abdomen)

Goal: diagnosis

  • To investigate whether any cancer remains in the abdominal cavity and will require further treatment
    - The role of second-look surgery in disease management is evolving, and this technique might be replaced by other, less-invasive assessment methods

Additional debulking surgery
Goal: treatment

  • To reduce cancer symptoms and improve the effects of chemotherapy

Surgery for recurrent ovarian cancer

  • To remove measurable disease after a reasonable disease-free interval
  • To remove bowel or ureteral obstruction

Radiation therapy
Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumors (only rarely used in the treatment of ovarian cancer in the United States).

Chemotherapy (often referred to as "chemo") involves using chemicals (medications) that travel through the bloodstream to destroy cancer cells or stop them from growing both in and outside the ovaries. Chemotherapy is used in the majority of cases as a follow-up to surgery. However chemotherapy is sometimes used before surgery (also called neoadjuvant chemotherapy) with the aim of shrinking a tumor and making it easier to remove all of the cancer.

Currently, this is experimental and only available as part of a clinical trial (see clinical trial section in Medical Information)

Therapy for Relapsed, Resistant, or Recurrent Ovarian Cancer
After first therapy for ovarian cancer, cancer may be cured completely, return (relapsed or recurrent cancer), or continue to grow (resistant cancer). Unfortunately, the majority of patients with advanced-stage ovarian cancer experience progression of their disease, even after response to first-line therapy. However, relapsed, resistant, or recurrent disease does not mean that cancer has defeated you. There are many effective therapy options available to women whose cancer remains or returns after their first round of therapy. An important consideration when selecting a therapy plan for recurrent ovarian cancer is how well your cancer responded to previous treatments (usually platinum-based therapies). This information provides insight into how sensitive your cancer is to particular classes of chemotherapy agents. Both surgery and chemotherapy may play a role in the treatment of recurrent ovarian cancer. Surgery may be beneficial, especially if there was more than a 1-year remission after initial treatment. In addition, surgery may be needed in cases of intestinal obstruction. Cancers that are resistant to treatment with platinum-based agents are generally very aggressive, but they may still be responsive to treatment with other chemotherapy agents.

Cumulative toxicities are long-term effects on your body from exposure to chemotherapy agents. Because the cumulative toxicity of chemotherapy agents is an important consideration for women with relapsed or recurrent disease, you might want to discuss the concept of long-term treatment planning with your doctor. You should discuss the differences between acute (intense and short-term) and cumulative toxicities with your health care team. Many women with ovarian cancer experience multiple relapses and receive several rounds of chemotherapy. It is important to work with your health care team to minimize the effects of cumulative toxicities on your quality of life and your future treatment options.

Is there a link between ovarian cysts and ovarian cancer?

The normal ovary produces a normal physiologic cyst with each menstrual cycle in women during the reproductive years (ages 12-52). During menarche, as well as during the peri-menopause period, this normal process occurs less frequently. The normal cyst or follicle contains the egg or ovum and usually is less than 3 cm. in size. After ovulation, this cyst persists in the form of a corpus luteum and is also normal and physiologic. These cysts are rarely greater than 5 cm., resolve with each menstrual cycle, are simple in appearance, and are not suggestive of ovarian cancer. Cysts that persist throughout multiple cycles, are 6 cm. or larger, are complex, or are formed during childhood or after menopause are considered abnormal. However, the vast majority of these are benign. Further diagnostic evaluation of this group of cysts is warranted, as a very small fraction may be ovarian cancer.

How common is ovarian cancer?

According to the American Cancer Society, ovarian cancer ranks fifth in cancer deaths among women, but accounts for more deaths than any other cancer of the female reproductive system. It is estimated that there will be about 15,000 deaths from ovarian cancer in the United States annually, a rate that has changed little in the last 50 years. It is estimated that about 22,000 new cases of ovarian cancer will be diagnosed in the United States annually.

What is a low malignant potential tumor?

A Low Malignant Potential Tumor is a tumor of intermediate capacity to recur and to metastasize (spread). Usually if these tumors recur, they recur very late in time and usually in only one or a few sites as opposed to multiple and early metastatic disease.

Why does chemotherapy often cause unpleasant side effects?

Because chemotherapy agents typically circulate throughout the body in the blood stream, your entire body is exposed to them. Chemotherapy agents are targeted poisons that affect cells that are rapidly growing and dividing, two important characteristics of cancer cells. However, some normal cells, such as those that line your digestive tract and those that generate your blood cells, need to grow and divide rapidly for your body to function normally, fight infections, and recover from injuries. These rapidly dividing normal cells can also be adversely affected by chemotherapy agents. Therefore, many chemotherapy agents can cause unpleasant side effects. It is important to speak with your oncologist because there are treatments and strategies to minimize these side effects.

What are the common side effects of chemotherapy?

Chemotherapy agents typically target cells that are growing and dividing rapidly. The cells that line your digestive system, make your hair, and fight viruses and bacteria typically grow at a very rapid rate and are often affected by chemotherapy agents. Therefore, patients who are receiving chemotherapy often experience digestive problems (nausea, indigestion, and diarrhea), hair loss and changes in the color and thickness of their hair, and decreases in immune system function (increased rate of infections). Other common effects include slower wound healing, anemia (reduction in the number of red blood cells, which transport oxygen throughout the body), and fatigue.

What steps can be taken to minimize side effects and maximize safety?

The most important safety instructions are to closely follow the directions given to you by your health care team and to ask them questions whenever something is not clear. Take all medication as directed, and consult with your health care team or pharmacist for direction if you miss a dose. Report all symptoms to your team, and update them if you have any changes in your other health conditions or prescription medications.

How were the standard chemotherapy regimens developed?

The standard therapies for ovarian cancer were isolated from plant extracts or are synthetic chemicals that were developed by pharmaceutical companies. These medications were tested in clinical trials in women with ovarian cancer, and only agents that displayed safety and anticancer activity received approval from the United States Food and Drug Administration. Once treatments receive approval, societies of clinical oncologists review the safety and activity information and develop recommended treatment guidelines.

Why are there many different therapies for ovarian cancer?

Because all women and all cancers are different, there are many different therapies for ovarian cancer. Except for identical twins, every person is genetically different. Everyone also has a different health history and diet and different sets of habits, allergies, and outlooks, so different people may react differently to available therapies. For example, women with kidney or liver disease may be less able to tolerate the standard first-line therapy for ovarian cancer. Alternate therapies may be needed to ensure safety. In addition, because ovarian cancers develop from a woman's normal ovarian tissue, everyone's cancer is as unique and different as they are. Therefore, not all of these cancers are expected to respond to the standard therapy.

How could participation in a clinical trial be beneficial for me?

Through participation in clinical trials, you may receive access to new and investigational therapy options that are not available to women outside the clinical trial setting. Clinical trial designs are all screened, approved, and monitored by national health authorities, and patients who enroll in clinical trials must be treated with the best available care. Participation in a clinical trial might also empower you by letting you know that your treatment experiences may pave the way to better care for women with ovarian cancer in the future.
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