Diagnosing ovarian cancer

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1 This information is an extract from the booklet Understanding cancer of the ovary. You may find the full booklet helpful. We can send you a free copy see page 10. Diagnosis Contents Diagnosis Types of ovarian cancer Staging Grading Most women are diagnosed after going to see their GP when they notice symptoms. Your GP will ask about your symptoms and carry out an internal (vaginal) examination to check for any lumps or swellings. There is more information on this on the next page. They will arrange for you to have a blood test called a CA125 test (see page 2) and an ultrasound scan (see page 3) to look at your ovaries. If your GP suspects ovarian cancer, they will refer you to a gynaecologist (a specialist in women s health), or a gynaecology cancer team, within two weeks. Sometimes women are admitted directly to hospital if they have a symptom that is making them very unwell. At the hospital At the hospital, the gynaecologist will ask you about your general health, any previous health problems, and whether you have any history of cancer in your family. If you have not already had a CA125 blood test and ultrasound, they ll usually arrange for you to have these tests. They may also organise further tests, such as a CT scan (see page 4). You may be introduced to a clinical nurse specialist before or after you have your tests. They will give you information and support during and after treatment. Questions about cancer? Ask Macmillan Page 1 of 10

2 Tests Your specialist doctor will explain the tests you need to have to diagnose ovarian cancer. Some tests may also be used to find the stage of the cancer. The stage of a cancer describes its size, position and if it has spread from where it started. Internal (vaginal) examination Your doctor will do an internal examination to check for any lumps or swelling in the ovaries or womb. It takes about five minutes and shouldn t be painful but may be uncomfortable. You can ask for a female doctor to examine you if you prefer. You lie on a couch, with your feet drawn up and knees apart. The doctor places one or two gloved fingers into your vagina and gently presses on your lower tummy with their other hand. They may put a speculum (which holds the vaginal walls apart) into the vagina to check that your cervix looks normal. CA125 blood test You ll have a blood test to check for raised levels of a protein called CA125. It s normal to have some CA125 in the blood but the level may be higher in women with ovarian cancer. The level of CA125 can also be raised by non-cancerous conditions and by other types of cancer. In early ovarian cancer, CA125 levels may be normal. Ultrasound scan An ultrasound scan uses sound waves to build up a picture of the organs inside the abdomen (tummy area) and the pelvis. A computer converts the sound waves into pictures that you can see on a screen. You have the scan in the hospital scanning department. The person doing the scan (ultrasonographer) will explain more about it and help you lie down comfortably on your back. There are two types that can be used: Pelvic ultrasound You ll be asked to drink plenty of fluids before this test so that your bladder is full. They spread a gel on to your abdomen and gently go over the area with a small hand held device, which produces the sound waves. Vaginal ultrasound They gently insert the tip of an ultrasound probe (tampon size) into your vagina. The probe produces sound waves. Although this scan may sound like it will be uncomfortable, you may find it easier than a pelvic ultrasound, as you don t need a full bladder. Page 2 of 10 Questions about cancer? Ask Macmillan

3 Risk of malignancy index (RMI) Your gynaecologist may use a scoring system called the RMI to assess whether a lump or swelling on the ovary is likely to be a cancer. It takes into account: whether a woman has gone through the menopause the level of CA125 (see pages 2) in the blood the results of an ultrasound. Removing fluid from the abdomen Sometimes swelling or bloating in the tummy can be due to a build-up of fluid. This is called ascites and it can be caused by ovarian cancer or by other non-cancerous conditions. If you have ascites, your doctor may want to take a sample of this fluid to check for cancer cells. The doctor injects some local anaesthetic into the skin on your tummy (abdomen) to make it numb. They gently pass a small needle through the skin and withdraw a sample of the fluid into a syringe. The fluid is sent to the laboratory to be examined. If you have a lot of fluid in your abdomen, it can be uncomfortable so your doctor may remove it. You can have this done in the outpatient clinic or ward. The doctor puts a fine tube called a cannula through the skin. The tube attaches to a drainage bag that collects the fluid as it drains from your tummy. We can send you more information about ascites. CT (computerised tomography) scan A CT scan takes a series of x-rays, which build up a three dimensional picture of the inside of the body. The scan takes minutes and is painless. It uses a small amount of radiation, which is very unlikely to harm you and will not harm anyone you come into contact with. You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. This may make you feel hot all over for a few minutes. It s important to let your doctor know if you are allergic to iodine or have asthma, because you could have a more serious reaction to the injection. You ll probably be able to go home as soon as the scan is over. Questions about cancer? Ask Macmillan Page 3 of 10

4 Image-guided biopsy This test removes a sample of the tumour (biopsy) so that it can be tested to confirm the diagnosis of ovarian cancer. Your doctor may recommend this if other test results strongly suggest you have ovarian cancer and they think you should have chemotherapy before surgery. Your doctor numbs the skin over the ovary using a local anaesthetic injection. You may also be given a sedative to help you relax. The doctor passes a needle through the skin into the tumour using a CT or ultrasound scan to guide them to the right place. They remove a small sample of tissue (a biopsy) from the tumour. This is then sent to the laboratory for checking. You need to stay in hospital for a couple of hours after a biopsy, and possibly overnight because of the risk of bleeding afterwards. Surgery to diagnose the cancer Often the only way to be certain whether a lump on the ovary is cancer is to do an operation to look at the ovaries and the surrounding area. This is usually done with an operation called a laparoscopy (or keyhole surgery see below). Sometimes an operation called a laparotomy using one larger cut to open the abdomen and look inside is done instead. Doctors can take samples of tissue during surgery to check for ovarian cancer cells. Laparoscopy This operation allows the doctor to look at the ovaries the surrounding area and other organs and take small samples of tissue (biopsies). It s done under a general anaesthetic. You can usually go home the same day, but some women may have to stay in hospital overnight. The surgeon makes 3 4 small cuts (1cm long) in the skin and muscle of the lower abdomen. They pump some carbon dioxide gas into the abdomen to lift up the tummy wall, so the organs can be seen clearly. The doctor then puts a thin fibre-optic tube with a tiny camera on the end (called a laparoscope) into the abdomen. They examine the area and take biopsies that are checked for cancer cells. Page 4 of 10 Questions about cancer? Ask Macmillan

5 You should be able to get up as soon as the effects of the anaesthetic have worn off. You may have discomfort in your neck and/or shoulder afterwards but this will go away after a day or two. Walking about can help relieve it. Some women have uncomfortable wind in the tummy after surgery. Taking sips of peppermint water and moving around can help. Laparotomy If a laparoscopy isn t suitable for you, your surgeon may carry out a laparotomy. You have this under a general anaesthetic. The surgeon makes a vertical ( up and down ) cut from your bikini line to your belly button or just above it. They examine your ovaries and the organs nearby and take small samples of tissue (biopsies). Sometimes if cancer is found, the surgeon may then operate to remove the cancer. This is only done if you and your doctor have discussed it and you have agreed (consented) to it before the operation. Waiting for test results Waiting for test results can be a difficult time. It may take from a few days to a couple of weeks for the results of your tests to be ready. You may find it helpful to talk with your partner, your family or a close friend. Your specialist nurse or organisations, such as Ovacome (visit ovacome.org.uk or call ), can also provide support. You can also talk things over with one of our cancer support specialists on As soon as I was diagnosed I was able to say I have ovarian cancer. I think you ve got to be able to admit it to yourself and not be afraid of it because it s just part of life. I think because I was able to talk about it I didn t feel shame or embarrassment or anything. It s just part of the journey. Clara Questions about cancer? Ask Macmillan Page 5 of 10

6 Types of ovarian cancer Most ovarian cancers start in the cells that cover the surface of the ovary (the epithelium) and are called epithelial ovarian cancers. There are several types of epithelial ovarian cancer. They include: serous the most common type mucinous endometrioid clear cell undifferentiated or unclassifiable. It s now thought that high-grade serous ovarian cancer may start in the fallopian tube (page 7) and then spread to the ovary. But all epithelial ovarian cancers and cancers of the fallopian tube are treated in a similar way. Borderline tumours Borderline tumours are made up of abnormal epithelial cells, but they aren t true cancers. They can sometimes turn into cancer, but most don t. Borderline tumours usually grow slowly and are unlikely to spread. They are staged in the same way as ovarian cancers and are always stage 1. Non-epithelial ovarian cancers There are non-epithelial cancers that can affect the ovaries. We have separate information about germ cell ovarian tumours of the ovary. These non-epithelial tumours start in the ovarian cells that produce eggs. They usually affect young women. Page 6 of 10 Questions about cancer? Ask Macmillan

7 Staging The stage of a cancer describes its size, position and if it has spread from where it started. Knowing the stage helps your doctors advise you on the best treatment for you. Your doctor will not usually be able tell the exact stage of the cancer until after it has been removed with surgery. If an operation isn t appropriate, they use the results of your tests to decide on the stage of the cancer. Doctors usually stage ovarian cancer using the FIGO staging system. It divides ovarian cancers into four number stages that are also subdivided. It may help to look at the diagrams below and on page 8 when reading this staging section. Organs close to the ovaries Kidney Ureter Lymph node Fallopian tube Omentum Lymphatic vessel Rectum Ovary Bladder Urethra Womb Vagina Questions about cancer? Ask Macmillan Page 7 of 10

8 Side view of the body Liver Peritoneum Stomach Omentum Bowel Spine Peritoneal space Womb Ovary Bladder Rectum (back passage) Stage 1 This is early ovarian cancer. Stage 1a The cancer is only in one ovary. Stage 1b The cancer is in both ovaries. Stage 1c The cancer is in one or both ovaries with any of the following: The tissue surrounding the ovary (capsule) has broken during surgery, which could have let cancer cells leak into the abdomen or pelvis. There are cancer cells on the surface of one or both ovaries or the tissue surrounding the ovary (capsule) has broken before surgery, which could have let cancer cells leak into the abdomen or pelvis. There are cancer cells in the fluid taken from the abdomen during surgery. Page 8 of 10 Questions about cancer? Ask Macmillan

9 Stage 2 The cancer has spread outside the ovary or ovaries to other areas inside the pelvis. Stage 2a The cancer has spread to the womb and/or fallopian tubes. Stage 2b The cancer has spread to other structures within the pelvis, such as the bowel or bladder. Stage 3 The cancer may have spread outside the pelvis to the peritoneum and/or to the lymph nodes at the back of the tummy (retroperitoneal lymph nodes). Stage 3a1 The cancer has spread but only to the retroperitoneal lymph nodes. Stage 3a2 The cancer has spread outside the pelvis but doctors can only see this under a microscope. The cancer may have spread to the retroperitoneal lymph nodes. Stage 3b The cancer has spread outside the pelvis but the tumour is less than 2cm in size. It may have spread to the retroperitoneal lymph nodes. There may be cancer cells on the surface of the liver and spleen but not inside these organs. Stage 3c The same as stage 3b but the tumour is 2cm or larger. Stage 4 The cancer has spread to organs outside the abdomen. Stage 4a The cancer has caused a build up of fluid in the lining of the lungs (called the pleura). This is called a pleural effusion. Stage 4b The cancer has spread to the inside of the liver or spleen, to lymph nodes in the groin or outside the abdomen and/or to other organs, such as the lungs. Questions about cancer? Ask Macmillan Page 9 of 10

10 Grading Grading is about how the cancer cells look under the microscope compared with normal cells. Knowing the grade helps your doctor decide whether you need further treatment after surgery. This is how ovarian cancers are graded: Borderline tumours are made up of abnormal cells rather than cancer cells. Low-grade or well-differentiated (grade 1) The cancer cells look similar to normal cells and usually grow slowly and are less likely to spread. Moderate- or intermediate-grade (grade 2) The cancer cells look more abnormal and are slightly faster-growing. High-grade or poorly-differentiated (grade 3) The cancer cells look very different from normal cells and may grow more quickly. More information and support More than one in three of us will get cancer. For most of us it will be the toughest fight we ever face. And the feelings of isolation and loneliness that so many people experience make it even harder. But you don t have to go through it alone. The Macmillan team is with you every step of the way. To order a copy of Understanding cancer of the ovary, or any other cancer information, visit be.macmillan.org.uk or call We make every effort to ensure that the information we provide is accurate and up to date but it should not be relied upon as a substitute for specialist professional advice tailored to your situation. So far as is permitted by law, Macmillan does not accept liability in relation to the use of any information contained in this publication, or thirdparty information or websites included or referred to in it. Macmillan Cancer Support Registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). Registered office 89 Albert Embankment, London, SE1 7UQ REVISED IN MAY 2015 Planned review in 2017 Page 10 of 10 Questions about cancer? Ask Macmillan