Ovarian Tumours
The ovaries are the female reproductive organs, which contain the ova (eggs). Ovaries also release the female hormone estrogen, which helps support pregnancy and contributes to female sexual characteristics. A gradual decline in estrogen production normally takes place in women between the ages of 48 and 52. At the same time, the monthly release of eggs decreases and the menstrual cycle becomes irregular and eventually stops. This is called menopause.
The ovaries, like other body parts, are made of tiny structures called cells. When these cells grow abnormally, a tissue mass or tumour forms. Tumours can be benign - that is, neither spreading nor interfering with ovarian tissue function - or they can spread (metastasize) and become cancerous, compressing or invading normal tissues. Tumour cells can spread directly into nearby tissues, through lymphatic (drainage) channels, or through the bloodstream. When ovarian cancer spreads, it is usually by direct extension into nearby tissues or through the lymphatic system.
Ovarian cancer is difficult to diagnose because the symptoms are vague. There may be abdominal enlargement, usually due to fluid accumulation. Some women experience a change in bowel function, urinary frequency, and / or nausea. In some cases, ovarian cancer initially causes no symptoms and is discovered incidentally during a pelvic examination.
The Pap smear (a microscopic examination of cells shed into the vagina from the uterus) is not a reliable means of detecting ovarian cancer.
Inital Evaluation
When you are referred to the Gynaecological Cancer Centre (GCC) at KK Hospital, your care is coordinated by one of our attending doctors. They are specialists in gynaecological oncology and staff members of the Gynaecological Oncology Unit.
Your attending doctor will review your medical history and do a physical examination. He will review your laboratory results, as well as pertinent past medical records.
Ultrasound or CT (computerised tomography) scans of the abdominal organs may be done to help identify changes caused by pressure from the suspected tumour. You may be asked to have X-ray studies of the bowel (barium enema) or kidneys and bladder (intravenous urogram - IVU). You may have a chest X-ray to determine whether the tumour has affected the lungs. You may also have blood tests for tumour markers - substances in the blood, which may be related to the presence of the tumour.
Treatment
Surgery is often the initial treatment for suspected ovarian cancer. An operation called Staging Laparotomy is performed. This surgery involves making an abdominal incision to reach the ovaries. If cancer is found, as much of the tumour as possible is removed.
The extent of the surgery depends upon the type of cancer found and how much it has spread. In some cases, only one ovary is removed. More commonly, however, both ovaries, the fallopian tubes, uterus, pelvic and some para-aortic lymph nodes, and the omentum (tissue that covers the bowels) are removed because they are the most common sites for tumour spread.
Planning For Hospital Admission
Our GCC manager and nurses will schedule the time of admission on the day of surgery, and any further tests requested by your doctor. The GCC staff can answer many of your questions about hospital routines, ward and surgical charges, or other services you might want.
The Gynaecological Oncology Team
Our GCC staff and ward nurses are trained in caring for women with gynaecological cancer. They will look after you throughout your hospitalization and recovery from surgery.
Our social worker is available to meet with you to discuss a variety of topics, including social and psychological support and financial concerns.
You will become acquainted with several doctors during your hospital stay. In addition to your attending doctor, who will perform the surgery, the resident medical officers (doctors receiving advanced training), house officers, anaesthetists, physiotherapists and medical students will comprise the team involved in your care.
Preparing For Surgery
The day before surgery, our resident doctors will meet with you to review the plans initiated by your attending doctor and answer any questions.
You may have routine urine and blood studies, as well as a chest X-ray and ECG (electrocardiogram), at this time. The anaesthetist will examine you and discuss the surgical anaesthetic. He or she will order medications for sedation before surgery, including sleeping medicines for the night before, if you wish.
You may be prescribed a drink to clear your bowels the day before surgery. This is to avoid contamination during surgery. You may have a regular dinner (unless special instructions are given), but nothing to eat or drink after midnight, not even water.
If you normally take important medicines (for example, heart, blood pressure, or diabetic medications) in the morning, ask your doctor whether or not to take them (with a sip of water) on the day of your surgery.
The physiotherapist will also teach you breathing exercises that prevent lung congestion and leg exercises that improve blood circulation while you are less active. You will be encouraged to walk soon after surgery because early activity stimulates the body’s return to normal function.
Surgical Risk
With any surgery there are risks of bleeding, infection, and unusual anaesthetic reactions. You may require blood transfusions during or after surgery.
There are risks related to surgery in the abdomen. These include damage to bowel, bladder, ureters (tubes that drain urine from the kidneys to the bladder), or the large blood vessels and nerves in the surgical area. Blood clot formation, nerve damage, or prolonged leg swelling may occur, but are quite rare. Your doctor will discuss these risks with you.
The Post-Operative Period
Following the staging laparotomy you may require two or three hours for recovery from the anaesthetic. Patients after major surgery may be transferred to the intensive care ward (Women’s ICU) or post-operative area (POA) for the first one or two days for close monitoring.
As you awaken, you will become aware of the nurse checking your condition frequently. Your blood pressure, pulse and temperature will be monitored, and you will have an intravenous (IV) line until you are able to drink and eat normally. You will also have a urinary bladder catheter.
Do not be alarmed if you have a nasogastric tube in your nose (to drain secretions from your stomach or bowel) or are receiving oxygen or a blood transfusion upon awakening - these therapies are common following surgery.
Back In Your Hospital Room
You will be encouraged to take deep breaths and to cough deeply every two or three hours. Nurses will help you to turn periodically in bed and to exercise your feet and legs gently to encourage good circulation.
You will be urged to sit on the edge of the bed within 24 hours after your surgery and to begin walking as soon as possible. Walking will be encouraged throughout your hospital stay.
Your doctors will order pain relief medications for you, as these activities may be uncomfortable after surgery. Your nurse will work with you to schedule medications for adequate pain control balanced with rest and increasing activity.
- Bowel Function: After abdominal surgery, bowel function is normally sluggish, due to the anaesthetic and the surgical exploration. You may have a nasogastric (NG) in place to drain secretions from your stomach or bowel. Placed while you are in surgery, this narrow, flexible tube is inserted through your nose, down your throat, and into either the stomach or small intestine. The tube will be removed when bowel function returns to normal. Your doctors and nurses will use a stethoscope to listen to your abdomen for bowel sounds, which will indicate return of function. For the same reason, you will be asked to report passing gas or having bowel movements. As bowel function returns, you will gradually adjust to drinking and eating. As you advance to a regular diet, intravenous fluids will be discontinued. Dietary management (daily prune juice, high fiber or high bulk diets) or other medication (stool softener medications or mild laxatives) and an increased daily fluid intake help prevent difficulties associated with persistent slowed bowel function. You may need to continue these measures at home. Once your normal diet and activity are re-established, bowel function usually returns to normal.
- Incision: Stitches or staples closing the surgical incision are usually removed seven to ten days after surgery. There may be a reddish to brown discharge from the vagina for several days. This is part of the normal healing process.
- Emotions: Any major surgical procedure consumes a great deal of physical and emotional energy. Increased fatigue, hospital confinement, and temporary physical limitations may lead to feelings of nervousness, frustration, and even anger. Although these reactions are normal and temporary, they may distress you. It often helps to share your concerns with a close family member, friend or one of our staff.
Recovering At Home
Before leaving the hospital, you will be told what to expect in the coming days. Although it is unusual to experience complications after you leave the hospital, do inform your doctor if you have any of the following:
- Excessive bleeding
- Fever above 37.5°C
- Shaking chills
- Unusual pain or swelling
- Unusual vaginal or wound discharge
- Disturbing emotional reactions
- Any other related problems that concern you
We recommend that you get adequate rest and nutrition, as well as mild physical and light activities, during your recovery from surgery. A balanced diet with an emphasis on high protein foods will help to build your strength and aid healing.
Light activity is encouraged in the first two weeks after surgery or until you are seen in the GCC Clinic for the first time after your surgery.
Delay driving or prolonged sitting for three or four weeks. You may begin isometric (tightening) exercises of the abdomen after three or four weeks. Avoid heavy lifting and strenuous exercise for two to three months after surgery.
Ovarian cancer is a stressful disease and the treatment can be complicated. Each woman reacts to the diagnosis and treatment differently. You may feel anxious, worried, depressed or bewildered about the way your life and the lives of those close to you will be affected. Allow yourself some time to adjust. Talking to your nurses, doctor, family or close friend can provide answers and emotional support.
Sexuality
Removal of the uterus causes cessation of menstrual periods and loss of childbearing function. In younger women, removal of the ovaries may bring on menopausal (change of life) symptoms such as hot flushes, night sweats, or mood changes. Sometimes these symptoms can he alleviated by taking a hormonal medication, which may be prescribed by your doctor.
Sexual feeling need not be altered as a result of surgery for ovarian cancer. However, sexual intercourse, as well as vaginal douching or use of tampons, should be delayed for up to three weeks after surgery, depending on wound healing. Feel free to discuss concerns you or your partner have about sexual activity with your doctor or nurse at any time.
Further Treatment
The final pathology report is usually known about 1 - 2 weeks after surgery. The pathology slides will be reviewed by a panel of gynaecological cancer experts including the medical oncologist at the GCC's weekly Tumor Board Meeting and recommendations for any further treatment, if felt necessary, will be made. Your attending doctor will discuss this with you and your family.
Most ovarian cancer patients require additional therapy after they have recovered from surgery. Chemotherapy (treatment with anti-cancer drugs) may be given to kill any remaining cancer cells.
Chemotherapy
These medicines kill cancer cells regardless of their location in the body. The intravenous route is the most common way to give chemotherapy for ovarian cancer.
Once in the blood, the drug is distributed to parts of the body. The cells that divide most rapidly, such as cancer cells, take up most of the drug. Chemotherapy drugs act by interfering with growth and duplication of the cell, and the cell is eventually destroyed.
Chemotherapy can also affect normal, actively dividing cells. Normal cells, however, have a tremendous capacity to repair themselves. Such normal cells that might be affected include those in the bone marrow (where blood cells are formed), gastrointestinal tract (lining of mouth, stomach and bowels), and hair follicles.
Chemotherapy is usually given in cycles. This allows normal cells to recover from the effect of the medication. The cancer cells cannot repair themselves.
Drug frequency and dose are determined by the body's response to, and recovery from, the chemotherapy. You will have periodic blood counts to determine the recovery rate of blood cells (red blood cells, white blood cells, and platelets) in the bone marrow. Examinations are done to determine if any remaining tumour is shrinking. Your doctor will discuss with you over what period chemotherapy treatments will be given.
Follow-up Care
Even after completing treatment, follow-up examinations are recommended every three months for the first 2 years and then at four- to six-month intervals during subsequent years.
Despite treatment, there is a risk that cancer may recur and further treatment may be required. Our staff and facilities at the Gynaecological Cancer Centre in KK Women's and Children's Hospital are always available as a resource to you.