Any form of cancer that begins or develops in the ovary or ovaries is called as ovarian cancer. Ovaries are reproductive organs found in females that are responsible for the production of ova (eggs) for reproduction.

Ovarian cancer is different from benign forms of ovarian tumours that generally do not spread beyond the ovaries. Ovarian cancer is one of the most common types of gynaecological cancers and is associated with the highest rate of deaths amongst gynaecological cancers.

What are the chances of a woman getting pregnant if she has ovarian cancer?

Ovarian cancer, as well as the treatment for ovarian cancer (surgical or medical), can affect the chances of getting pregnant. This may be because of surgical removal of ovaries and/or uterus (womb) or the side effects of chemotherapy & radiation (early menopause). Fertility after ovarian cancer depends on a few factors such as the stage of cancer and the age of the woman at the time of treatment.

Those women who are diagnosed with early-stage ovarian cancer where only one ovary is affected the other ovary continues to produce eggs. However, this ovary can be damaged by chemotherapy medications leading to early menopause. Such individuals can get their eggs frozen and opt for getting pregnant on treatment completion. Hence, it is important that the individual discusses fertility options with the treating doctor once she’s diagnosed with ovarian cancer.

What are the chances of getting pregnant with single ovary?

Removal of ovaries, also known as oophorectomy in women may be done for a variety of reasons. Some of the common reasons being, the presence of a tumour, infections not amenable to conservative options, cysts, endometriosis or sometimes cancer. Sometimes only one ovary is removed (unilateral oophorectomy) leaving behind the other one. A woman may become pregnant even with a single ovary in place, though conception in such a case may happen with some challenges. Further, in such cases, underlying factors like maternal age, blockage of a fallopian tube, hormonal disturbances, ovarian reserve etc may add to the existing challenges. The chances of conception after unilateral oophorectomy may range from 42-88% in case of women who may have undergone a constructive surgery for ovarian cancer or tumour removal. In case you have undergone or would be undergoing an oophorectomy and have plans to conceive later, do consult your gynaecologist about your options for increasing future chances of pregnancy like prescription medicines, egg or embryo freezing techniques

What causes ovarian cancer?

Although the exact cause of ovarian cancer may not be known in many cases, there are a few factors that are identified with a higher risk for ovarian cancer

Genetics and family history: Women who have close relatives that were diagnosed with breast cancer or ovarian cancer are at high risk. Furthermore, certain genes are associated with a high risk of ovarian cancer (BRCA gene).
Age: Women above the age of 40 years are at high risk for ovarian cancer. Postmenopausal women over the age of 60 have the highest risk.
Obesity: Being overweight or obese carries a high risk of ovarian cancer.
Medications: Fertility medications may be linked with a higher risk for ovarian cancer especially in women who have used them for more than a year without getting pregnant. Certain androgenic drugs also increase the risk of ovarian cancer. Hence women on these medications should be evaluated throughout the treatment.
Smoking: Certain types of ovarian cancer are associated with smoking

Of note, pregnancy lowers the risk of breast cancer, especially in women who have had full-term pregnancy at or below 30 years of age. Risk reduces with each full-term pregnancy. Breastfeeding lowers the risk of ovarian cancer even more. Similarly, birth control pills and some gynaecological surgeries (tubal ligation and hysterectomy) reduce the risk of ovarian cancer.

causes ovarian cancer

Is a pregnant woman more susceptible to ovarian cancer?

Ovarian cancer is reported to occur more frequently in post-menopausal women between the age group of 55 and 64 years. Although the chances are less, it can occur during the childbearing years and it’s rare to be diagnosed with ovarian cancer during pregnancy. Conversely, pregnancy before 35 years of age lowers the risk of breast cancer, especially in women who have had full term pregnancy. Risk lessens with each full-term pregnancy.

Ovarian cancerous growths are easily detectable by routine ultrasound during pregnancy in otherwise asymptomatic pregnant women. But this does not mean that pregnancy is a causative factor for ovarian cancer as many times the finding may be coincidental.

What are the symptoms of ovarian cancer, how is it differentiated from pregnancy?

The typical signs and symptoms of ovarian cancer in relation to pregnancy are:

Bloating
Frequent urination
Pain in the lower part of the stomach
Menstrual abnormalities
Felling of fullness and problems while eating
Constipation
Fatigue
Back pain
Pain during sex

Since most of these symptoms occur during a normal pregnancy as well, it is difficult to differentiate those from those of ovarian cancer. Also, the symptoms of ovarian cancer can be more severe or persistent than the usual symptoms of pregnancy. The timing of these symptoms also could give a clue to the individual that there might be some other issue than pregnancy in causing these symptoms. For example, excessive weight gain during the first trimester of pregnancy might occur in a pregnant woman with ovarian cancer. Normally, weight gain is not much in normal pregnant women. This makes it very important to discuss these symptoms with your doctor or gynaecologist as soon as you notice them, especially when there is a family history of ovarian or breast cancer.

In many cases, the doctors detect abnormal growth on the ovaries during routine ultrasound examination in pregnancy. Many times, the pregnant woman might not have experienced any symptoms.

Does ovarian cancer change the way a woman will deliver a baby?

Most of the time, the woman can continue through the pregnancy and deliver the baby normally. The way by which the baby is delivered, either normally or through a C-section will depend on the stage and grade of ovarian cancer. Many women can have a full-term, normal vaginal delivery. However, other indications for a C-section cannot be overlooked. Sometimes, the surgeon may schedule a C-section for delivery as well as debulking of cancer or tumour at the same time

How do doctors diagnose ovarian cancer?

Before running any tests, the doctors will take a detailed medical history to learn about any possible symptoms that could be liked to ovarian cancer. This will also include a family history to understand if any of the close relatives of an individual have had breast or ovarian cancer.

The doctor will also perform a physical exam to check for any signs of ovarian tumours like enlarged ovaries or free fluid in the abdomen (ascites).

If the doctor finds anything suspicious in your medical history and/or physical exam, the doctor will recommend some tests to ascertain the cause. Diagnostic tests that doctors use to detect ovarian cancer are:

Blood tests for detection of the CA-125 tumour marker in the blood.
Ultrasound examination
Pelvic computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) scan
Genetic testing: This is done to look for any inherited genetic changes (mutations) which are linked to ovarian cancer.
Biopsy of ovarian tissue: This is a definitive way of diagnosing ovarian cancer. In this test, a piece of the tumour is removed either through a needle or a CT guided needle or during laparoscopy. This tissue is then analysed to diagnose ovarian cancer.

Other tests: Some additional tests can be done to understand whether cancer has spread to other parts of the body. This helps in the staging of the disease as well as deciding the treatment approach.

diagnose ovarian cancer

What are the fertility-sparing treatments for ovarian cancer?

Fertility sparing treatments are of interest for women of child-bearing age (upto 45 years) with any gynecologic cancers including ovarian cancer, cervical cancer & endometrial cancer. These patients are reffered to oncofertility specialist for a consultation. Considering the medical and fertility history, age and suppression medicines, the oncologist and oncofertility specialists plan treatments which are either conservative or traditional. It is possible to spare fertility by conservative surgery in case the cancer is found at an early stage. This surgery generally includes removal of the ovary and fallopian tube of the affected side.

Fertility-sparing surgery (FSS) is indicated for patients with stage 1 epithelial ovarian cancer. FSS has proven efficacy in preserving fertility without apparent adverse impact on cancer outcomes. Advances in Assisted Reproductive Technologies (ART) have provided patients with more fertility options. Fertility preservation options such as ovarian tissue or oocyte retrival & storage is recommended for young women as the survival rates continue to improve.

Treating ovarian cancer – does pregnancy affect the way ovarian cancer is treated?

Treatment options for ovarian cancer depend on the stage and severity of the disease. Currently, due to routine use of ultrasound early in pregnancy, it is possible to diagnosis the ovarian cancer early thus leading to effective management of asymptomatic ovarian cancers. Certain factors that affect treatment for ovarian cancer during pregnancy include:

Safety of the growing fetus
Risk of death due to ovarian cancer for the pregnant woman

Is there any risk for the developing baby due to ovarian cancer during pregnancy?

Ovarian cancer generally would not affect the developing baby. There is a substantial risk for the baby only when the cancer is advanced, blocking blood flow to the baby, or causing abnormal hormone production. In many cases, the cancer treatments may pose risk than the cancer itself.

Is it possible to breastfeed while on chemotherapy or radiation therapy?

Chemotherapy as well as radiotherapy medication can be transmitted to the baby/child via breast milk and can cause serious side effects. So as a rule, breastfeeding is best avoided if an individual is receiving chemotherapy or radiation therapy.

Is it recommended for a pregnant woman with ovarian cancer to undergo debulking surgery and chemotherapy during pregnancy?

Extensive debulking surgery can cause harm to the developing baby. Thus, it is recommended that the pregnant woman undergo a conservative surgery at 16-20 weeks of pregnancy as there is a high rate of miscarriage if performed in the first trimester (first 3 months) of pregnancy. This surgery generally includes removal of the ovary and fallopian tube of the affected side.

Chemotherapy in the first trimester (first 3 months) may cause birth defects & miscarriages. So, chemotherapy is contraindicated in the first trimester of pregnancy and may be considered thereafter. However, the safest approach is to start chemotherapy after birth.

Thus, debulking surgery and chemotherapy can be performed after childbirth.

Radiation therapy is dangerous at any trimester of pregnancy as the X-rays can cause harm to the developing baby at any stage of pregnancy.

In the scenario where the ovarian cancer is so advanced that it poses a serious threat to the mother to the point of being life-threatening, the risks of not doing the treatment outweigh those risks to the pregnancy. In this case, debulking surgery as well as chemotherapy will go on as it would in a non-pregnant woman.

Is HIPEC right for ovarian cancer?

HIPEC is shown to be effective in treating advanced or metastatic cancer of the ovaries. When done in carefully selected individuals by an experienced surgeon in a facility employing a multidisciplinary approach, the outcome can be greatly improved. HIPEC is generally a part of a surgical procedure which is commonly referred to as Cytoreductive Surgery (CRS), the surgical removal of visible cancer or tumor/s in the abdominal cavity. HIPEC is delivered after completion of CRS to target the microscopic cancer cells that remain in the body. CRS and HIPEC combined provide an effective treatment approach for ovarian cancer by both, increasing the survival rate as well as the quality of life parameters. Thus, HIPEC can be an effective treatment option for individuals where other forms of treatment have not worked or not available or not suitable.

Conclusion:

Ovarian cancer is a rare occurrence during pregnancy. Although the symptoms of ovarian cancer are difficult to differentiate from those of normal pregnancy, it is still possible to detect the disease in the early stage by way of routine ultrasound examination during pregnancy. The treatment of ovarian cancer during pregnancy depends on the stage and severity of the cancer. It is possible to preserve fertility in early stages through conservative surgery. The woman can continue the pregnancy with conservative treatment measures. However, this depends on the stage of the disease and the judgment of the treating doctor. Ultimately, if the risk to the pregnant woman is high due to the underlying cancer, the treatment protocol will follow that of a non-pregnant woman.

References:

Mayo Clinic. Ovarian cancer. Available at https://www.mayoclinic.org/diseases-conditions/ovarian-cancer/diagnosis-treatment/drc-20375946. Accessed on 18^thJanuary 2019.
American Pregnancy Association. Ovarian Cancer During Pregnancy. Available at http://americanpregnancy.org/pregnancy-complications/ovarian-cancer-pregnancy. Accessed on 18^th January 2019.
US National Library of Medicine. Ovarian Cancer during Pregnancy: Clinical and Pregnancy Outcome. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811289/. Accessed on 18^thJanuary 2019.
US National Library of Medicine. Ovarian Cancer During Pregnancy: A Case Report and Literature Review. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500872/. Accessed on 18^thJanuary 2019.
American Cancer Society. Ovarian Cancer Risk Factors. Available at: https://www.cancer.org/cancer/ovarian-cancer/causes-risks-prevention/risk-factors.html/. Accessed on 18^thJanuary 2019.
US National Library of Medicine. US National Library of Medicine. Diagnosis and Management of Adnexal Masses in Pregnancy. Available at: Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3673365/. Accessed on 18th January 2019.
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