Diagnosing ovarian cancer

Friday 1 April, 2016

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On this page: Physical examination | Removing fluid from the abdomen | Blood tests | Imaging and investigations | Staging and grading ovarian cancer | PrognosisWhich health professionals will I see? | Key points


The tests and scans described in this section can show if there are abnormalities, but they cannot provide a diagnosis of ovarian cancer. The only way to confirm a diagnosis is by taking a tissue sample (biopsy) and looking at the cells under a microscope. This is usually done during surgery, which means that the cancer is diagnosed and treated at the same time.

Sometimes ovarian cancer is found unexpectedly during another operation, such as a hysterectomy (when the uterus and cervix are removed). In many cases, ovarian cancer is present for some time before it is diagnosed.

Physical examination

The doctor will check for any masses or lumps by feeling your abdomen and doing an internal vaginal examination. An internal examination is not painful but may be uncomfortable.

Removing fluid from the abdomen

Sometimes swelling or bloating is due to a build-up of fluid in the abdomen. This is known as ascites.

To check the fluid for cancer cells, your doctor will inject a local anaesthetic to the abdomen area and pass a needle through your skin to take a sample. This is called paracentesis. The fluid is sent to a laboratory to be examined. To make you feel comfortable, the fluid will be removed.

Blood tests

You may have blood tests to check for proteins produced by cancer cells. These are called tumour markers. The most common tumour marker for ovarian cancer is CA125.

The level of CA125 may be higher in women with ovarian cancer. However, it can also rise for reasons other than cancer, including ovulation, menstruation, irritable bowel syndrome, liver or kidney disease, endometriosis or fibroids. The CA125 blood test is used during diagnosis and treatment and after treatment.

At diagnosis

A CA125 test is more accurate in diagnosing women who have been through menopause (postmenopausal) than those who haven’t (premenopausal). Women with early stage ovarian cancer often have normal CA125 levels. This is why doctors will often combine CA125 tests with an ultrasound (see below).

During treatment

If you are found to have ovarian cancer that produces CA125, the blood test is also used to check how well the treatment is working. Falling CA125 may mean it’s working, and rising CA125 may mean the treatment is not working effectively.

After treatment

CA125 blood tests are sometimes included in follow-up tests.

The Pap test does not diagnose ovarian cancer. It’s used to look for abnormal cells on the cervix that may develop into cervical cancer.

Imaging and investigations

Your doctor may recommend a number of imaging scans and investigations to determine the extent and stage of the disease. You may also have chest x-rays to check the lungs for cancer or fluid.

Ultrasound

An ultrasound uses echoes from soundwaves to create a picture of your organs on a computer. A technician called a sonographer performs the scan. It can be done in two ways:

Abdominal ultrasound

You will lie on an examination table while the sonographer moves a small handheld device called a transducer over your abdominal area.

Transvaginal ultrasound

The sonographer will insert a transducer about the size of a tampon into your vagina. The transducer will be covered with a gel to make it easier to insert. Some women find the transvaginal ultrasound procedure uncomfortable, but it should not be painful. Talk to your doctor and the sonographer if you feel embarrassed or concerned.

The transvaginal ultrasound is often the preferred type of ultrasound, as it provides a clearer picture of your ovaries and uterus.

"I went in to have minor surgery. Afterwards the doctor said, ‘I’m sorry, but it looks like ovarian cancer.’ It certainly changed my life." – Louisa
CT scan

A CT (computerised tomography) scan uses x-ray beams to create a detailed three-dimensional picture of the inside of the body. It is used to look for signs that the cancer has spread, but the CT scan may not be able to detect all ovarian tumours.

CT scans are usually done at a hospital or a radiology clinic. You will be asked not to eat or drink for several hours (fast) before the scan. A liquid dye, sometimes called the contrast, may be injected into one of your veins to help make the pictures clearer. The contrast makes your organs appear white on the scan, so anything unusual can be seen more clearly.

The dye used in a CT scan usually contains iodine. If you have had an allergic reaction to iodine or dyes during a previous scan, tell the medical team beforehand. You should also let them know if you’re diabetic, have kidney disease or are pregnant.

The dye may make you feel hot all over, leave a bitter taste in your mouth, and you may feel the need to pass urine. Symptoms usually ease quickly, but tell the person carrying out the scan if they don’t.

The CT scanner is a large, doughnut-shaped machine. You will lie on a table that moves in and out of the scanner. The scan takes 10–20 minutes, but it may take extra time to prepare and then wait for the scan. While a CT scan can be noisy, it is painless. Most women can go home as soon as the CT scan is over.

PET scan

A PET (positron emission tomography) scan highlights abnormal tissues in the body, and it can be more accurate than a CT scan.

The results are often used to decide what combination of treatment is most likely to work, to help with planning before surgery, and to check on how the treatment is working.

Before the scan, you will be injected with a small amount of radioactive glucose solution. This makes cancer cells show up brighter on the scan because they take up more of the glucose solution than normal cells do. You will be asked to sit quietly for 30–90 minutes while the glucose solution moves around your body, then you will be scanned for high levels of radioactive glucose.

The radiation will leave your body within a few hours. Let your doctor know beforehand if you are diabetic, pregnant, think you might be pregnant, or are breastfeeding.

PET scans may not be available at your local hospital. Some women have to travel to a hospital or treatment centre where a PET scanner is located.

Resilience is a free information kit for women with ovarian cancer. It has been produced by Ovarian Cancer Australia and includes information on diagnosis, treatment and support. To order a copy, visit their website call 1300 660 334.

Colonoscopy

Some women have a bowel examination (colonoscopy) to make sure that symptoms are not due to a bowel problem. The doctor will insert a thin, flexible tube with a small camera and a light (colonoscope) into your bowel.

The day before the test, you may have to fast (no eating or drinking). On the day, you will probably be given an anaesthetic so you don’t feel any discomfort. This will make you feel drowsy. Your doctor will talk to you about what to expect.

Staging and grading ovarian cancer

The tests described above help the doctors decide how far the cancer has spread. This is called staging.

Knowing the stage helps your health care team recommend the best treatment for you. If you have difficulty understanding the stage of the cancer, ask your doctor to explain the stage in simple terms. It is often not possible to work out the stage of the ovarian cancer until after surgery.

The staging system most commonly used for ovarian cancer is the International Federation of Gynecology and Obstetrics (FIGO) system. It divides ovarian cancer into four stages. Each stage is further divided into sub-stages, such as A, B, C. Stage I means it is early ovarian cancer. Stages II–IV mean the cancer has spread from the ovary and is advanced. About 7 out of 10 (70%) women with ovarian cancer are stage III or stage IV at diagnosis.

Staging: FIGO system

Each stage has a number of sub-stages.

  • Stage I
    Cancer is in one or both ovaries only.
  • Stage II
    Cancer is in one or both ovaries and has spread to other organs in the pelvis (uterus, fallopian tubes, bladder or bowel).
  • Stage III
    Cancer is in one or both ovaries and has spread beyond the pelvis to the lining of the abdomen (peritoneum), the bowel or lymph nodes.
  • Stage IV
    The cancer has spread further to distant organs such as the lung or liver.
Grading

The grade of ovarian cancer describes how similar the cancer cells are to normal cells. There are three grades of epithelial ovarian cancer. Treatment has a greater chance of success if the grade is lower.

  • Grade 1
    The cancer cells look similar to normal cells and are probably growing slowly.
  • Grade 2
    The cancer cells appear slightly abnormal and might grow more rapidly.
  • Grade 3
    The cancer cells look very different from normal cells and may grow quickly.

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of the disease.

Epithelial cancer

The stage and grade of the cancer will influence the outcome. If epithelial ovarian cancer is diagnosed and treated before the cancer has spread outside the ovary (stage I), it has a good prognosis. Many women with more advanced cancer may respond well to treatment, but the cancer often comes back (recurs) and further treatment is needed.

Germ cell and stromal cell tumours

Can usually be treated successfully.

Borderline tumour

Usually has a good prognosis.

Discussing your prognosis and thinking about the future can be challenging and stressful. It may help to talk with family and friends. You can also call Cancer Council 13 11 20 if you need more information or emotional support.

There are many important factors in assessing your prognosis. These include: test results; the type of ovarian cancer you have; the grade; how well you respond to treatment; and other factors such as your age, fitness and overall health.

Which health professionals will I see?

Your GP will probably arrange the first tests to assess your symptoms. If these tests do not rule out cancer, you will usually be referred to a gynaecological oncologist, who specialises in treating women with ovarian cancer.

The gynaecological oncologist may arrange further tests and advise you about treatment options.

You will be cared for by a range of health professionals who specialise in different aspects of your treatment. This is often referred to as a multidisciplinary team (MDT).

MDT Health professional
gynaecological oncologist* treats women with cancers of the reproductive system, e.g. ovarian, cervical, uterine, vulvar and vaginal cancers
gynaecological pathologist* examines tissue removed from the abdomen or ovaries under a microscope
medical oncologist*
prescribes and coordinates the course of chemotherapy
radiation oncologist* prescribes and coordinates the course of radiotherapy
radiologist* reads and interprets diagnostic scans (e.g. CT and PET scans)
oncology nurses
administer drugs, including chemotherapy, and provide care and support throughout treatment
cancer nurse coordinator or cancer care coordinator
coordinates your care, liaises with other members of the MDT and supports your family throughout treatment
dietitian
recommends an eating plan to follow during treatment and recovery
physiotherapist and occupational therapist
help with physical or practical issues, including any rehabilitation you may need
social worker links you to support services
counsellor, clinical psychologist
provide emotional support and help manage anxiety and depression
palliative care specialists* and nurses
work closely with GP and oncologists to help control symptoms and manage quality of life when cancer is advanced

*Specialist doctor

Key points

  • Most ovarian cancers are present for some time before they are diagnosed.
  • You will have many tests to check your health, but the only way to definitively diagnose ovarian cancer is by taking a tissue sample (biopsy) during surgery.
  • The doctor will feel your abdomen and do an internal vaginal examination to check for masses or lumps.
  • Blood tests may be done to look for tumour marker proteins made by cancer cells. The most common tumour marker for ovarian cancer is CA125.
  • An ultrasound scan uses soundwaves to create a picture of the ovaries. The sonographer may pass a small device called a transducer over the abdomen or insert it into the vagina.
  • A CT scan uses x-ray beams to take pictures of the inside of your body. It may not detect all tumours.
  • Some women have other tests, such as a PET scan or a bowel examination (colonoscopy).
  • Results of the diagnostic tests and biopsy help the doctors work out how far the cancer has spread. This is called staging. The grade describes how similar the cancer cells are to normal cells.
  • Prognosis means the likely outcome of the disease. Women with early stage cancer have the best chance of long-term survival. Most women are diagnosed at a later stage.
  • You will see a team of health professionals, including a gynaecological oncologist and oncology nurses, who will provide care and advice.

Reviewed by: Prof Martin K Oehler, Director Gynaecological Oncology, Royal Adelaide Hospital, SA; Dr Serene Foo, Medical Oncologist, Mercy Hospital for Women, Austin Health and Epworth Eastern Hospitals, VIC; Maira Kentwell, Senior Genetic Counsellor and Manager, Department of Genetic Medicine and Familial Cancer Centre, The Royal Melbourne Hospital, VIC; Jane Lucas, Consumer; Cindy Morgan, Consumer; Shannon Philp, Nurse Practitioner – Gynaecological Oncology, Chris O’Brien Lifehouse, NSW; Lea Rawlings, Perth Support Coordinator, Ovarian Cancer Australia; Deb Roffe, 13 11 20 Consultant, Cancer Council SA, SA; and Merran Williams, Clinical Nurse, Bloomhill Cancer Care, QLD.