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02.10 Ovarian Cancer

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Overview

  1. Cancer of ovaries and/or Fallopian tubes
    1. Non-specific symptoms
    2. Abdominal metastases common
    3. Hormone-related
    4. Affects older women
  2. Treatment modalities
    1. Current research and clinical trials are promising
    2. Often requires surgery
    3. No routine screening exists

Nursing Points

General

  1. Three main types
    1. Epithelial – majority
    2. Germ cell – egg production
    3. Stromal – hormone producing
  2. Genetic Risk
    1. BRCA-1, BRCA-2
      1. Same genes linked to breast cancer risk
    2. Genetic counseling

Assessment

  1. Non-specific symptoms
    1. Abdominal pain
    2. Fatigue
    3. Difficulty urinating
    4. Bloating
    5. Constipation
    6. Reflux
    7. Early fullness
  2. Diagnosis
    1. Radiology
      1. Pelvic ultrasound
      2. Abdominal CT
      3. Chest CT
      4. Mammogram
        1. Remember: hormonal component
        2. Breast Ca to Ovarian Mets
    2. Ovarian biopsy
      1. Often requires oopherectomy
      2. Fertility concerns
    3. Advanced stage
      1. Malignant ascites
      2. Malignant pleural effusion
    4. No specific tumor marker
      1. CA-125 “recognizes” most female reproductive cancers
      2. Does not differentiate between cancers

Therapeutic Management

  1. Initial Treatment
    1. Surgery
      1. Early stage: radical hysterectomy & oopherectomy
      2. Later stage: pelvic exoneration, HIPEC
      3. May require colostomy, ileostomy, and/or urostomy
      4. May require ureteral stents
    2. Chemotherapy
      1. Required for all patients except low-risk stage I
    3. Radiation uncommon
  2. Goals of care
    1. Not always treating for cure
      1. Abdominal metastases are difficult to treat
      2. Often palliative focus
        1. Relieve GI symptoms
        2. Decrease pain
    2. Crucial conversations
      1. Encourage questions from patient
      2. Advocate to team

Nursing Concepts

  1. Coping
    1. Cancer diagnosis
    2. Family history
    3. Genetic counseling
  2. Hormone Regulation
    1. Some tumors fed by hormones
    2. Risk/benefits of hormone therapy post-treatment
  3. Reproduction
    1. Occurs within female reproductive system
    2. Fertility impact

Patient Education

  1. Genetic component
    1. Family history
    2. Familial risk
    3. Counseling recommended
  2. Symptom management
    1. Treatment related
      1. Chemotherapy
      2. Post-surgical
    2. Disease-related
      1. Pain
      2. GI symptoms
  3. Survivorship
    1. Survivor at time of diagnosis
    2. Support groups
    3. Fertility impact

Reference Links

Video Transcript

All right. Today, we are going to be talking about ovarian cancer, and let’s just review the female anatomy real quick. So we remember what we’re talking about here. There we go. So we have the vagina, the cervix, the uterus, the fallopian tubes, and the ovaries, right. We’re talking about ovarian cancer and ovarian cancer is actually a group of three cancers that develop in the three types of ovarian cells and also in the fallopian tubes. So, it’s a group of cancers and I just want to make note of where this is in our body, right in our pelvic area here. And that’s close to our abdominal cavity. That’s a really commonplace for ovarian cancer to spread. So let’s talk about the risk factors for ovarian cancer. This is really important for this cancer. It is hormone-related just like breast cancer. 

So it puts you at an increased risk if you’re on estrogen replacement therapy, like if you had a hysterectomy or hormone replacement, post-menopause that puts you at risk for ovarian cancer and breast cancer. And there is a hereditary genetic mutation. This is that BRACA gene, right? BRACA one and two are related to ovarian cancer again, and breast cancer. So this is a mutation that Angelina Jolie had, right. And had the preventative surgery. So people who want to have preventative surgery have a bilateral salpingo-oophorectomy. So they have their ovaries and their fallopian tubes removed often also the breasts are removed with that surgery too because they’re linked so closely. I actually have a friend who’s only 29 and had both surgeries. She actually had a hysterectomy with it. So they removed her uterus and her cervix also, and her fallopian tubes and her breasts, and she had them reconstructed and she never looked back. She feels so confident that she did everything she possibly could to prevent cancer that has been devastating to her family. People often feel really empowered by having that surgery.

They have found that actually there’s a decreased risk of ovarian cancer with being young for your first pregnancy and also with breastfeeding. So a theory is that the less menstrual cycles you have, you have a less likely chance of having ovarian cancer.

Ovarian cancer is actually the most fatal gynecologic malignancy. It is a devastating diagnosis, usually, although it does have a good prognosis, if it’s caught early, like up to a 90%, five-year survival, if it’s caught early, it is a very poor prognosis if not caught early and oftentimes it’s caught late because there is no routine screening for ovarian cancer. Pap smears do not check for ovarian cancer. And that’s something that patients get really upset about. I hear people say, “Oh man, I, how could this be? How could this already be in the late stages? I get my routine screenings like I’m supposed to”, It’s not related to pap smears, pap smears are screening for cervical cancer. That’s an important education point for our patients. 

Symptoms of ovarian cancer are vague in silent, only 15% are diagnosed in the early stages, which is why it’s so detrimental. We have very nonspecific symptoms with ovarian cancer, abdominal or pelvic discomfort, bloating feeling full of constipation, and changes to urination kind of happen a little bit later, But these are kind of vague, right? A patient could just think, “Oh, I’m on my period”. People also confuse symptoms like this with IBS. So because it’s just kind of vague symptoms, they don’t come in until late.  These symptoms do happen because of where this tumor is growing. It’s in that pelvic area, right, pushing on the abdomen. And then it often does spread to the abdomen. So in the later stage, this bloating is gonna turn into ascites. The cancer goes to the peritoneal cavity often, and then you’re going to have a firm abdomen, often ascites. And we tap that fluid and find out that it’s from ovarian cancer and then other pelvic organs. So if it’s spread to the urinary system, we might have some bleeding with urination, that sort of thing, or pain, tumors just kind of in the abdominal cavity can cause constipation or a full feeling. So they’re just really nonspecific and that leads to why it’s diagnosed so late. When it is diagnosed we do a pelvic ultrasound, CT chest abdomen, and then also we’re going to do a mammogram and that’s because it’s linked with breast cancer, right. And ovarian biopsy is done but, not always, sometimes they know that it’s ovarian cancer, even without doing the biopsy, but if they do this, they do remove an ovary to biopsy it. And then that all comes with fertility issues, although you can get pregnant with one ovary, there are changes there. And for ascites, a paracentesis is done for that. If the cancer spreads to that peritoneal cavity in the abdomen and causes fluid to build up they’ll test them that peritoneal fluid and they’ll find that there’s cancer in it. There is no specific tumor marker, like with some cancers, however, many tumors do produce CA-125. That’s a protein that can be found in the blood. It’s not specific to ovarian cancer, but if it’s elevated, we can kind of trend how the treatment is working with the CA-125. There are many different treatments, we’ll start with radical hysterectomy with salpingo-oophorectomy. So this is taking out these organs. If we’re going to remove the uterus, the cervix, and of course the ovaries, right, the fallopian tubes and the ovaries it is called a pelvic exoneration. This is an extreme surgery. 

And that’s what this picture is of. So we’re moving tracing this blue line here, all of these organs are removed from the pelvic cavity. So the vagina, the bladder, the womb, the cervix, the ovaries and, the anus. And obviously this also comes with reconstruction for passage of stool and urine with an ostomy or that sort of thing.

HIPEC is specific to ovarian cancer, and this is hot to chemo. It’s actually heated to 103 degrees and instilled in the abdominal cavity. The patient is in the OR and they’re turned for two hours and then the chemo is removed. So it’s direct chemo. The HIPEC stands for hyperthermic intraperitoneal chemotherapy. Chemotherapy also can be given systemically. Almost all ovarian cancers do get systemic chemotherapy before or after surgery. The only exception is very early stages, which we know often people are not diagnosed in those early stages. Radiation is uncommon, but it is used sometimes, especially for palliative reasons. And just remember any of these interventions can actually be for a palliative reason, it might not be not for a cure, but for improved quality of life, improve comfort and that sort of thing. So we always want to make sure we’re open to talking to our patients about that.

So patient education, we want to talk about the genetic component, right? If they have it, they probably want to be tested and make sure that their other families are not at risk, or if they have other family members who have had lots of these cancers they should be tested, right.

 Symptom management. So these symptoms can be pain, GI, discomfort, constipation, that sort of thing. Just kind of how to manage those. If they have ascites talk to them about position changes, that sort of thing. And then survivorship, this is very important. This is one of my favorites here. They are a survivor on day one of diagnosis. They are a survivor at day one of diagnosis. Even if they are surviving two weeks, two months, two years, they are a survivor. And that’s really empowering for patients and family to hear. And also we want to recommend them that they talk to support groups for patients and families with this devastating cancer for help with coping. Not only are they coping with it or the patients coping with it, the cancer diagnosis, but also their family might be a high risk for this cancer.

Hormone regulation is huge with this one. This cancer is related to hormones and hormone replacement therapy is something to consider with these patients also, they’re often getting a hysterectomy at a young age. So there’s kind of a risk-benefit discussion with using hormone replacement therapies at risk of a cancer coming back and then reproduction.  This can be in young childbearing age women. So we want to refer them to an oncofertility specialist and they can talk to them about preserving their eggs because if they have surgeries or some treatments will not allow them to have children.

So key points about ovarian cancer, there are nonspecific symptoms, it’s often diagnosed late. It goes to the abdomen, ascites is a common metastasis site or the peritoneal cavity, also genetic and hormonal involvement. And there is no routine screening, pap smears do not screen for ovarian cancer.

All right, guys, that’s all I have today for you. Go out and be your best selves today. And as always happy nursing.

 

 

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