Ovarian Cancer Metastatic

Metastatic ovarian cancer is cancer that has spread from the ovaries or fallopian tubes to distant parts of the body, making it one of the most challenging forms of gynecologic cancer to treat.

Table of contents

• What is metastatic ovarian cancer?
• How ovarian cancer spreads
• Where ovarian cancer spreads
• Symptoms and complications
• Diagnosis and staging
• Survival rates and prognosis
• Treatment approaches
• Living with metastatic ovarian cancer

What is metastatic ovarian cancer?

Metastatic ovarian cancer is cancer that has spread from the ovaries, or the fallopian tubes, to parts of the body outside the site of origin^[1]. When ovarian cancer has metastasized, it is classified as Stage IV^[1].

When cancer is found outside the site of origin — outside the ovary — it may be considered locally advanced (when it is in other parts of the pelvis) or metastatic (when it has spread to more distant sites)^[1]. Metastatic ovarian cancer is associated with stage IV or more advanced cancer stages^[4]. If cancer spreads from one site, such as the ovary, to other parts of the body, it is still considered ovarian cancer^[4].

Due to the challenges of diagnosing ovarian cancer, when patients finally receive a diagnosis, more than 70% of people will have metastasized ovarian cancer^[6]. The high mortality of this tumor is largely explained by the fact that the majority (75%) of patients present at an advanced stage, with widely metastatic disease within the peritoneal cavity^[3].

• Ovaries
• Fallopian tubes
• Peritoneum
• Liver
• Lungs
• Spleen
• Lymph nodes

How ovarian cancer spreads

Ovarian cancer has a unique pattern of metastasis (the spread of cancer from its original site to other parts of the body). Ovarian cancer can spread through the body in a few different ways^[6]. Cancer cells may break off from the original tumor and travel directly through your pelvis and abdomen to nearby organs, through your lymphatic system (part of your immune system), or through your bloodstream^[6].

Ovarian cancer metastasizes either by direct extension from the ovarian or fallopian tumor to neighboring organs (bladder or colon) or when cancer cells detach from the primary tumor^[3]. Exfoliated tumor cells are transported throughout the peritoneum (the tissue lining the abdominal cavity) by physiological peritoneal fluid and disseminate within the abdominal cavity^[3].

Ovarian cancer has a unique pattern of metastasis in which cancer cells metastasize directly to the peritoneal cavity, without entering the blood vessels, because of the lack of anatomical barrier of the primary ovarian tumor^[4]. This peritoneal metastasis then increases the chance of ovarian cancer cells spreading to more distant organs^[4].

Unlike most other cancers, ovarian cancer rarely disseminates through the vasculature. However, pelvic and/or para-aortic lymph nodes can be involved^[3].

Where ovarian cancer spreads

There is no single trajectory for where ovarian cancer will spread. However, if not caught in early stages, most cases of ovarian cancer will follow a similar path: from the pelvis, to more distant parts of the abdomen and peritoneal cavity, to the lymph nodes, and the liver^[1].

How ovarian cancer spreads through the body varies from person to person, but the disease usually follows a similar pattern moving to your pelvis, then to further areas of your abdomen, your lymph nodes and then to your liver^[6].

When the cancer has spread outside the ovary into the pelvis (the area between your hip bones), the cancer may be affecting tissues and organs in the pelvis, such as the womb, bladder or bowel^[6]. In the early stages of ovarian cancer, the growing tumor can press on your bladder making it feel fuller and giving you the feeling that you need to urinate (wee) more often^[6].

If not treated successfully, ovarian cancer will continue to metastasize to more distant areas of the body, such as the lungs, fluid in the lungs, or tissue inside the liver^[1]. Stage 4 ovarian cancer has spread to distant body parts such as the liver or lungs^[7].

Stage 4 is divided into 2 groups^[7]:

• Stage 4a means the cancer has caused a build up of fluid in the lining of the lungs (the pleura). This is called a malignant pleural effusion.
• Stage 4b means the cancer has spread to the inside of the liver or spleen, lymph nodes outside the tummy (abdomen), or other organs such as the lungs.

The omentum, normally a soft 20 × 15 × 2-cm fat pad covering the bowel and the abdominal cavity, is almost always transformed by tumor^[3].

Symptoms and complications

When ovarian cancer first develops, it might not cause any noticeable symptoms^[5]. When ovarian cancer symptoms happen, they’re usually attributed to other, more common conditions^[5].

Signs and symptoms of ovarian cancer may include^[5]:

• Abdominal bloating or swelling
• Quickly feeling full when eating
• Weight loss
• Discomfort in the pelvic area
• Fatigue
• Back pain
• Changes in bowel habits, such as constipation
• A frequent need to urinate

Extensive seeding of the peritoneal cavity by tumor cells is often associated with ascites (fluid buildup in the abdomen), particularly in advanced, high-grade serous carcinomas^[3]. These cancers grow rapidly, metastasize early, and have a very aggressive disease course^[3].

The symptoms of advanced cancer can be difficult to cope with^[13]. Ovarian cancer and its treatment can also affect the bowels. The cancer often sits on the outside of the bowels, so bowel issues are the most common thing to deal with^[16]. Some patients have diarrhea or constipation, but probably the most serious side effect is bowel obstruction^[16].

People with stage 4 ovarian cancer are vulnerable to several complications that may include^[20]:

• Failure of the heart, lungs, kidneys, or liver
• Hemorrhage (heavy bleeding in a short time)
• Infections
• Loss of consciousness

Diagnosis and staging

The stage of a cancer tells you how big it is and if it has spread^[7]. The tests and scans you have to diagnose your cancer will give some information about the stage. But your doctor might not be able to tell you the exact stage until you have surgery^[7].

Doctors use the International Federation of Gynecology and Obstetrics (FIGO) staging system to stage cancers in the ovaries, fallopian tubes, and peritoneum^[7]. There are four stages, numbered 1 to 4^[7].

Stage 4 ovarian cancer has spread to other parts of your body organs such as the liver or lungs^[7]. Your healthcare team consider several factors when deciding what treatment you need, including where the cancer has spread to, whether the specialist surgeon thinks they can remove all the cancer, and your general health^[7].

Survival rates and prognosis

Your life expectancy with metastatic ovarian cancer depends on factors individual to you^[21]. Your age, overall health, how well your cancer responds to treatment, and what treatment options are available to you all make a difference in your outcome^[21].

Patients who are diagnosed with Stage I and Stage II ovarian cancer have a 5-year survival rate of 90% and 70%, respectively. Patients diagnosed with Stage III ovarian cancer have a 5-year survival rate of 39%^[1]. When looking at statistics, it is important to remember that these numbers are representative of a large swath of patients, and are not indicative of any one individual’s prognosis^[1].

Five-year relative survival rates compare the chances that someone with a certain type and stage of cancer will survive for 5 years, compared with the general population^[21]. In people who are initially diagnosed with ovarian cancer at stage IV, the 5-year relative survival rates are: for germ cell tumors of the ovary: 71%, for ovarian stromal tumors: 70%, and for invasive epithelial ovarian cancer: 31%^[21].

Survival rates often improve over time as better treatments become available^[21]. While it’s not common, it’s possible in some cases to cure ovarian cancer even in its advanced stages. Some 20% of those with late-stage ovarian cancer survive more than 12 years after treatment. In medical terms, they’re considered cured^[21].

Unfortunately, cancers that have come back can’t usually be cured. But treatment can often control the cancer and relieve symptoms. This can be for many months and sometimes years, depending on your situation^[19].

Treatment approaches

Having stage IV ovarian cancer doesn’t necessarily mean you should give up on treatment^[21]. Treatment can often help you feel better and possibly live longer^[21].

Treatments for stage 4 ovarian cancer include surgery, chemotherapy, targeted cancer drugs, and radiotherapy^[7]. The main treatments are chemotherapy and surgery^[7].

Surgery

Your specialist surgeon (gynaecological oncologist) will remove both ovaries, fallopian tubes, your womb (including the cervix)^[7]. They will also check where the cancer has spread to in your pelvis and if it is in your lymph nodes^[7]. Your gynaecological oncologist will aim to remove as much of the cancer as possible^[7]. This is called cytoreductive surgery (surgery to remove as much tumor as possible). You may also hear it called debulking surgery^[7].

It might not be possible to have surgery if your cancer has spread widely or you are not well enough^[7]. You may have chemotherapy on its own to shrink the cancer as much as possible and to slow its growth^[7].

Chemotherapy

You might have^[7]:

• Chemotherapy after surgery – this is called adjuvant chemotherapy (additional treatment given after surgery) with cytoreductive surgery
• Chemotherapy before and after surgery – this is called neoadjuvant chemotherapy (treatment given before surgery) with interval cytoreductive surgery
• Chemotherapy into your abdomen during surgery – this is called hyperthermic intraperitoneal chemotherapy or HIPEC

Your healthcare team will discuss the best treatment for you. When you have chemotherapy will depend on your individual case^[7].

Targeted cancer drugs

Some people may have treatment with a targeted cancer drug^[7]. This will depend on your situation. You might have a targeted cancer drug with chemotherapy, on its own, or after chemotherapy^[7].

Monoclonal antibodies (molecules engineered in the laboratory to find and attach to specific proteins associated with cancer cells) are used with chemotherapy. Bevacizumab (a type of monoclonal antibody) is used with chemotherapy to treat ovarian cancer recurrence by preventing the growth of new blood vessels that tumors need to grow^[11].

PARP inhibitors (drugs that block DNA repair, which may cause cancer cells to die) are given to patients after chemotherapy for about two years to try to keep them in remission^[16]. In patients with BRCA mutations, maintenance therapy with olaparib, with or without bevacizumab, after surgery and/or chemotherapy may significantly improve survival^[14].

Radiotherapy

Occasionally doctors suggest radiotherapy for advanced ovarian cancer^[13]. Radiotherapy can shrink cancers and reduce symptoms. Your doctor might also use radiotherapy to treat cancer that has spread outside the abdomen^[13].

Living with metastatic ovarian cancer

An ovarian cancer diagnosis may change every aspect of life, from the choices you make about diet and exercise to treatment and intimacy^[23].

Managing side effects

Chemotherapy comes with side effects that vary from person to person^[16]. Short-term side effects include muscle and joint aches, weak legs, peripheral neuropathy (numbness and tingling in the fingers and toes), nausea, vomiting, fatigue, and lack of appetite^[16].

Most long-term side effects begin in the short term and become long-term^[16]. Peripheral neuropathy is sometimes permanent, and the bowels and bladder may not normalize for a year^[16]. It can take a full year to recover from chemotherapy. You’re not going to have your typical energy level right away^[16].

When patients struggle with bowel issues, healthcare providers set them up with an individualized bowel regimen, including using stool softeners daily, anti-diarrheal medications, and bowel obstruction precautions^[16].

Emotional and mental health

Finding out that you can’t be cured is distressing and can be a shock^[19]. It’s common to feel uncertain and anxious. It’s normal to not be able to think about anything else^[19].

A diagnosis of ovarian cancer may bring on overwhelming emotions, ranging from fear to confusion to grief^[22]. Talking about these emotions and the issues you face, such as body image and sexuality, can be helpful. Your doctor can recommend support groups or counselors to help guide you through this challenging time^[22].

Returning to the life you lived before ovarian cancer can be challenging^[16]. You also may find yourself worrying about ovarian cancer’s high recurrence rate. Recurrence occurs for approximately 70% of people diagnosed with ovarian cancer^[4].

Planning and decision-making

Thinking about your priorities and planning what you want to do can help you to feel more in control^[19]. You might want to talk about how you want to spend your time and what is and isn’t important to you^[19].

If you can talk with your loved ones about the future, it’s helpful to have those conversations and avoid putting them off^[20]. During this time, you might face decisions about end-of-life care, including advance directives and setting up your will^[20].

Talk to your doctor and loved ones about your wishes regarding aggressive interventions if your condition worsens suddenly^[20]. For individuals who have advanced ovarian cancer, deciding in advance whether you’d prefer to be admitted to the intensive care unit or remain at home will help guide the care you receive^[20].