Ovarian cancer symptoms often mistaken for other ailments

By Vicky Wandawa

Last month, on June 28, Irish actor Pierce Brosnan, famous for his role in a number of James Bond movies, lost his 41-year-old daughter Charlotte, to ovarian cancer — the same disease that killed her mother more than 20 years ago. She left behind a husband and two children. Charlotte’s mother, Cassandra Harris, died of the same type of cancer at the age of 43.

What is ovarian cancer

Almost silent in its initial stages, ovarian cancer presents on-and-off symptoms that a patient could easily brush off as minor. For example, rarely would one consider abdominal discomfort a danger sign of a grave health condition. Consequently, ovarian cancer causes more deaths than cancers of the female reproductive system.

Older women more prone

All women, according to Dr. Partha Mukhopadhyay, a consultant clinical oncologist at Nakasero Hospital, are at risk for ovarian cancer, but older women are more likely to get the disease than their younger counterparts.

“About 90% of women who get ovarian cancer are over the age of 40, with the greatest number of ovarian cancers occurring in women aged 60 years or older,” Mukhopadhyay explains.

The older a woman gets, especially past menopause, the higher the chances of developing ovarian cancer.

According to Dr. Martin Origa, a gynaecologist at the Uganda Cancer Institute (UCI): “Most of the cases of ovarian cancer we receive at the cancer institute are after menopause. However, it can also present in the much younger age group. In the younger age group, ovarian cancer is the sporadic kind, while in the older age group; it is either genetic or sporadic.”

Uganda does not have clear statistics regarding ovarian cancer, but in the US, each year, approximately 20,000 women suffer from the cancer. Among women in the US, ovarian cancer is the eighth most common cancer and the fifth leading cause of cancer death.

Types of ovarian cancer

There are two kinds of ovarian cancer; hereditary and sporadic. Origa explains: “The sporadic simply strikes, while the hereditary ovarian cancer is common in those with relatives who have suffered the cancer.”

Screening

Screening for ovarian cancer is under study and there are screening clinical trials taking place worldwide. However, a doctor may carry out a pelvic exam to feel the size, shape and position of the uterus and ovaries. The vagina, cervix, fallopian tubes and rectum are also checked.

Risk factors

There is no way to know for sure if you will get ovarian cancer. However, there are factors, which may increase a woman’s risk for ovarian cancer. Origa notes that having close family members, such as a mother, sister, aunt, or grandmother who have had ovarian cancer increases your risk by 10% to 40%.

Furthermore, research has found that a woman with one child or none is more likely to develop ovarian cancer.

“Each time a woman ovulates, an egg is released. The changes that occur on the ovarian surface tend to favour the development of ovarian cancer. Pregnancy suspends the period for nine months,” Origa explains. Consequently, women who use contraception, especially the pill, have less chances of developing ovarian cancer because contraception suspends the menstrual cycle.

Mukhopadhyay notes that using birth control pills for more than five years reduces the risk of developing ovarian cancer.

Other risk factors

• Having had breast, uterine, or colorectal cancer
• Having an eastern European (Ashkenazi) Jewish background
• Having endometriosis, a condition where tissue from the lining of the uterus grows elsewhere in the body, Mukhopadhyay explains.

How can one prevent ovarian cancer?

There is no known way to prevent ovarian cancer. But these factors may lower the risks of getting ovarian cancer:

• Having used birth control pills for more than five years
• Having had a tubal ligation (getting your tubes tied), both ovaries removed, or hysterectomy (an operation in which the uterus, and sometimes the cervix, is removed)
• Having given birth.

Prevalence in Uganda

Origa notes that monthly, the UCI receives about 15 new cases of ovarian cancer, 80% of who are in the advanced stages.

According to Origa, the numbers are subject to change. “Until more women are educated about ovarian cancer, we will have many dying without knowing it. There may be more dying in the villages because they don’t know that it is ovarian cancer and it kills. They think it is witchcraft and do not go to the hospital.”

Health awareness is the only way out

Origa notes that considering the cost of treatment, health awareness is vital because it leads to better health-seeking behaviour; the earlier the diagnosis, the higher the chances of cure.

Furthermore, Mukhopadhyay advises: “If you have abnormal vaginal bleeding, see a doctor right away. If you have any of the other signs for two weeks or longer, see a doctor.” These symptoms may be caused by something other than cancer, but the only way to know is to see your doctor. Treatment is most effective when ovarian cancer is found and treated early.

Health ministry official speaks out

Dr. Jackson Amone, the assistant commissioner for integrated curative services, says although the health ministry does not have a specific department for ovarian cancer, it has the non-communicable diseases’ department, under which cancer is handled.

“Ovarian cancer is difficult to diagnose, and the diagnosis can only be done at  the cancer institute, making it difficult for those upcountry to access the services.”

He adds that nonetheless, the ministry has plans to open up radiotherapy and screening services upcountry, in the northern, western and eastern regions.

Amone further notes that the ministry has the cancer awareness month, October, whereby, in conjunction with non-governmental organisations, screening and awareness camps are set up in hard-to-reach areas.

He notes, however, that before and after the cancer awareness month awareness and screening takes place all-year-round by health stakeholders such as NGOs.true

Signs and symptoms

Despite the high risk in particular groups, the signs and symptoms of ovarian cancer are nonspecific and could be mistaken for other conditions. Ovarian cancer may cause one or more of these symptoms:
 

• Vaginal bleeding (particularly if you are past menopause) or an abnormal vaginal discharge.
• Pain or pressure in the pelvic or abdominal area (below the stomach and between the hip bones).
• Back pain.
• Bloating, whereby the lower area of the stomach swells or feels full.
• Feeling full quickly while eating.
• A change in your bathroom habits, such as having to pass urine very badly or very often, constipation, or diarrhoea.

What does the treatment entail?

Surgery is done and abnormal tissue removed. However, when the cancer is in advanced stages, surgery only prepares the patient for chemotherapy.

“Chemotherapy works better when most of the cancerous cells have been surgically removed,” says Uganda Cancer Institute’s Dr. Martin Origa. He adds that younger women respond faster to treatment and that the prognosis (the number of years a patient will live after treatment) is higher than it is for older women.

“Prognosis is measured by a five-year survival rate. The five-year survival rate for women aged below 40 is much higher, at 80%, meaning if 10 women presented with cancer now, five years from now, in 2018, eight will still be around, while perhaps only one among 10 of older women will be alive.”

Unfortunately, when the cancer is advanced (in three years’ time), most of these women lose the battle. The treatment is more of palliative care (focusing on relieving and preventing the suffering of patients), as it only adds a few years.

Treatment involves expensive procedures and the drugs may have severe side-effects such as hair and weight loss as well as heart problems. Origa says the commonest combination comprises six cycles, with one cycle given every three weeks.

Two drugs are given in each cycle. Each cycle costs about sh450,000 to sh500,000. This amounts to shs6,000,000. This excludes the necessary fluids and injections, among others. Yet if it has advanced, within two years’ time, it reoccurs. In spite of spending this much, you are not curing, but only postponing the inevitable.

How the cancer is diagnosed

Worldwide, when it comes to diagnosis, the signs and symptoms pose a problem because of their similarity to other conditions. Uganda Cancer Institute’s Dr. Martin Origa notes that, for example, when a patient presents with abdominal pain, it could also be a result of ulcers, or an infl amed appendix, among other causes

Similarly, swelling of the stomach could be a result of weight gain. Origa adds that ovarian cancer may present with menstrual disturbances, especially in the younger age group, where a female may bleed in between their menstrual periods. That, however, can also happen, as a result of diet change or stress.

Neither the patient nor doctor would immediately suspect ovarian cancer. Consequently, 80% of the patients of ovarian cancer in Uganda present late, when it has advanced and the pain is excessive.

Origa further clarifies: “Cancer of the cervix is still the commonest cancer, but ovarian cancer has the highest mortality rate because of its vague symptoms. For cervical cancer, abnormal vaginal discharge and bleeding after or during sex might be an indication. But with ovarian cancer, the symptoms are on and off and are similar to those of other conditions. So, for a year or two, it goes on and by the time the pain is excessive, the cancer is in advanced stages.”

Up to 80% of the patients seek medical intervention too late. Consequently, in comparison, fi ve out of 10 women presenting with cervical cancer will die, while eight out of 10 women suffering from ovarian cancer will die.

However, he also attributes the high mortality rate on the poor health-seeking behaviour. Many only go to the hospital when in too much pain.

Mukhopadhyay says there is no simple and reliable way to test for ovarian cancer in women who do not have any signs or symptoms.

However, he urges women to pay attention to their bodies and if one notices any changes that are not normal and could be a sign of ovarian cancer, one should talk to a doctor.

Ask your doctor if you should have a test, such as a rectovaginal pelvic exam, a transvaginal ultrasound, or a CA- 125 blood test if:

• You have any unexplained signs or symptoms of ovarian cancer. These tests can help fi nd or rule out ovarian cancer.
   
• You have had breast, uterine, or colorectal cancer, or a close relative has had ovarian cancer.

Furthermore, although internationally, diagnosis is a problem, developed countries like in Europe have better facilities for risk assessment, unlike third world countries like Uganda.

For example, they can carry out genetic testing on those whose relatives have suffered ovarian cancer.

Origa adds: “Genetic testing can be done to identify the genes (BRAC1 and BRCA2) that are affected by the cancer. When changes are noticed in these genes, it does not mean one has ovarian cancer, but it may signal that the risks of developing it are high.”

Consequently, from that information, a patient is advised about the options they have. For instance, one may be advised to have the ovaries removed as soon as they are done with childbearing.

For instance, Origa says, actor Angelina Jolie, whose mother died of breast cancer, underwent genetic testing to ascertain her chances of developing breast cancer.

It had been realised that she had a 50% chance of developing breast cancer, hence she underwent a mastectomy (surgical removal of a breast to remove a malignant tumour).

“Similarly, when one is found to have a high chance of developing ovarian cancer, their ovaries can be removed as soon as possible.

This prevention is only possible for genetic and not sporadic cancer.  However, removal of the ovaries can lead to the onset of menopause.

Origa adds that globally, research is being done about what chemicals can be found in the blood for risk assessment of sporadic cancer. He notes that considering the cost of treatment, health awareness is vital because it will lead to better health-seeking behaviour; the earlier than diagnosis, the higher the chances of cure.