OVARIAN CANCER

DR PRASHANT NYATI Consultant Gynecological & Robotic Onco-Surgeon, SL. Raheja Hospital, Mumbai

OVARIAN CANCER Symptom, Causes & Treatment

Women’s Health

Early symptoms • Abnormal fullness after eating (early satiety) and indigestion • Increased frequency of urination • Fatigue • Frequent acidity • Pain in the back and legs • Irregular periods • Painful intercourse

Cancer is normal cells of our body behaving abnormally, loose control on the cell division and cell death. These unrestricted cell division form Lump (Tumour) which can be Benign (does not spread to other parts of body) or Malignant (can spread to other parts of body). The female reproductive organs consist of Uterus, Fallopian Tubes, Ovaries, Cervix, and Vagina. The Ovaries are two in number and are situated on either side of the Uterus. The ovaries have a very important function of producing Egg (Ova) along with female hormones; Ovarian size varies as per age. The occurrence of Ovarian Cancer varies with demography and location in India, and ranges roughly at 8.4 per 1,00,000 women population. The age of diagnosis reaches peak between 55-64 years, but now-a-days we are seeing it in younger women between the age group of 30-35 years. Roughly, only about 10-20% of Ovarian Cancer are diagnosed in early stage. Since the Ovaries are situated in the abdominal cavity, the signs and symptoms are very vague and are masked by common day to day problems and complaints. Also, women have high level of tolerance, hence smaller problems are overlooked till they grow in magnitude. Know yourself and beware of changes in your body habit, if symptoms persist for longer durations, consult an expert. Ovaries consist of 3 types of cells, and each cell lining can develop in a different type of Ovarian Cancer. • Epithelial Tumors form 90% of Ovarian Cancers,they arise from the layer of tissue on the outer surface of the ovaries • Stromal Tumors grow in the hormone-producing cells • Germ Cell Tumors develop in ovarian cells that produce eggs There is one type of Ovarian Cancer, which is in between the ‘malignancy and benign’ stage, known as ‘Borderline Ovarian Cancer’, with low malignant potential, is less aggressive in nature and has limited spread.

DIAGNOSIS: It is much easier to treat Ovarian Cancer if diagnosed it in the early stages, but as the Ovaries are situated in pelvic region of the abdominal cavity, and the abdomen has large capacity to accommodate, hence even large size tumors go unnoticed for long time. There’s no standard diagnostic screening available for Ovarian Cancer, other than Ca125, which is not very accurate. This draws even more importance towards identification of persistent symptoms and seeking expert opinion. Detailed physical examination is followed by laboratory test and imaging studies such as: • Ultrasonography, CT scan, MRI abdomen & pelvis, 3PET Scan

Risk factors for Ovarian Cancer The exact cause of Ovarian Cancer is not known, but we know certain factors that can increase the risk: • Genetic Mutation of genes associated with Ovarian Cancer, such as BRCA1 or BRCA2 • Personal or family history of Breast Cancer • The use of certain fertility drugs or hormones for longer then recommended duration • Nulliparity (not being able to get pregnant) • Obesity

• Tumor marker levels: Ca125, CEA, Ca19.9. AFP, BhCG, HE4 • Upper and lower GI scopy • These are biomarker and proteins that are used to assess treatment response and recurrence for Ovarian Cancer, and other reproductive organ Cancer • Biopsy: This involves removing a small sample of tissue from the Ovaries or abdominal metastasis and analyzing the sample under a microscope, to confirm the diagnosis.

STAGING OF OVARIAN CANCER: There are four stages in all, and each stage has sub-stage: • Stage 1: Limited to one or both ovaries • Stage 2: Limited to the pelvis • Stage 3: Disease outside of the pelvis, but limited to the abdomen, or Lymph Nodeinvolvement, but not including the inside of the Liver • Stage 4: Disease spread to the Liver or outside of the abdomen

TREATMENT OF OVARIAN CANCER: Ovarian Cancer is to be treated by multimodal approach including Surgery, Chemotherapy, Radiation, Hormones therapy, targeted drugs, along with Psychological Counselling, which us of utmost importance. The management depends on the stage(spread) and grade of the Cancer, and now-a-days age of patient, as we see many younger girls where future fertility is at risk. The team of doctors including Medical and Surgical Oncologist will plan appropriate treatment depending on your state. Surgery: Primary Staging Surgery can be done if the probability of complete removal is possible or else 2-4 cycles of Chemotherapy (Neo-adjuvant) is given, followed by Interval Debulking Cytoreductive surgery. Depending on type, grade and stage of Ovarian Cancer, the type of surgery (Radical or Conservative) is decided by the Gynaecological Onco-surgeon and his team. In case of Germ Cell Tumour, Sex Cord Stromal Tumour, Borderline Ovarian Cancer and Stage I Epithelial Ovarian Tumor, conservative surgery is possible in selected cases,so as to retain fertility and hence future chances of pregnancy. This is known as ‘fertility sparing surgery’ where only the diseased Ovary is removed along with proper staging, and uterus & the other Ovary is conserved.

Radical Staging Surgery for Ovarian Cancer normally includes: • Pan Hysterectomy with removal of bilateral Fallopian Tubes and Ovarian masses • Pelvic and Para Aortic Lymph Nodes dissection • Omentectomy (procedure designed to remove the omentum) • Metastatic Tumor excision including Splenectomy, Gallbladder removal and Liver resection • SOS Appendicectomy, Peritonectomy and Sub-Diaphragmatic resection • Resection and Anastomoses of intestines These are routinely conducted major surgeries, which requires 4-6 days of hospitalisation and certain pre-operative preparation. With advances in technology, we are able to perform some of the surgeries for Ovarian Cancer Laparoscopically or Robotics assisted.This leaves practically no scars, enables lesser hospital stay, faster return to routine activities and better quality of a life. But,this is applicable to selective few cases, which have very limited diseases and low grade. Different techniques of surgery known as HIPEC and IP Chemotherapy are also used in select cases with its due risks. Before the surgery,the treatment plan is discussed with the patient and immediate family members, the effects and side effects, risk and complications are discussed and explained in detail. Also, if needed Psychosexual or Psychological Counselling should be offered. Chemotherapy: There are various types of Chemotherapy drugs available which are normally used in combination for treating Ovarian Cancer. Either the Chemotherapy can be given prior to surgery as Neoadjuvant, or after surgery as Adjuvant Therapy. There are various effects and side effects of the chemotherapeutic agents ranging from nausea, vomiting, to fall in total Leukocyte count. But with advances in technology, we are able to tide over the adverse reactions and give a better quality of life to our patients. Chemotherapy can be administered in day-care setup, so the patient is out of hospital in few hours and can do go back to normal routine activities. Targeted Therapy: Targeted Therapy attacks the Cancer cells while doing little damage to normal cells in the body. Radiation: In Ovarian Cancer only few selected cases require Radiation Therapy

Fertility preservation In case of conservative treatment of young patients, there can be some harm to the reproductive organs and hence make future pregnancy difficult. In such cases, well trained Councellors, Medical Oncologists, Surgical Oncologists and Fertility Specialists, come together with the patient and their family to discuss options for preserving fertility with following options: • Embryo Freezing: Here the fertilized egg is frozen • Oocyte Freezing: Here the unfertilized egg is frozen • Surgery to preserve fertility: In some cases, surgery that only removes one ovary and keeps the healthy ovary can be done. This is usually only possible in early stage Ovarian Cancer • Ovarian tissue preservation: This involves removing and freezing ovarian tissue for future use. • Ovarian suppression: This involves taking hormones to suppress ovarian function temporarily.

PREVENTION There is no definitive way to prevent Ovarian Cancer, but certain steps can help us to prevent, and have an early diagnosis, for better survival and excellent quality of life: • Judicious use of oral birth contraceptive pills • Breastfeeding the baby • Having pregnancy • Healthy lifestyle with good exercise In case of family history of Ovarian, Breast, or Intestinal cancer in close family members, you must meet a doctor. We recommend following plan of action for early diagnosis: • Ultrasonography (Transvaginal), once or twice weekly after 35 years of age • Ca-125 • Clinical examination by expert • Genetic Counselling and Gene Study such as BRCA 1 & 2 and risk reduction surgery in genetic tested high-risk group. Consult Gynaecological Onco-surgeon if following symptoms last for 2-4 weeks: • In case of sudden change in bowel or bladder habits • Changes in menstrual cycle • Early satiety • Abdominal distension, fullness, bloating SURVIVAL Survival depends on the stage and grade of the Ovarian Cancer. Early stage at time of detection, improves chances of survival and quality of life. Once the treatment is complete, the person has to be on recommend following-up schedule, as advised by the Gynaecological Onco-Surgeon.

Health Tips

drink 8 glasses of Water a day No need to count cups. Research shows people who gulp a glass of H2O when they’re thirsty get enough to stay healthy and hydrated. You might need to drink more water if your urine is dark yellow, you don’t go regularly, you're very active, or you live in a hot climate.

eggs are Bad for your heart Eating an egg or two a day doesn’t raise the risk of heart disease in healthy people. Yes, the yolks have cholesterol, but for most of us, the amount found in any one food isn’t as bad for you as the mix of fats from everything you eat. What’s more, eggs have nutrients, like omega-3s, that may lower the risk of heart disease.

antiperspirant Causes Breast CanCer Don’t sweat it! Some scientists think the chemicals found in antiperspirants and deodorants can be absorbed through your underarm. The idea is they end up in breast tissue and make tumors more likely. But the National Cancer Institute says there’s no evidence connecting either product with breast cancer.

eat Breakfast to lose Weight Eating breakfast does help some people lose weight. It can stave off hunger, and it might prevent random eating later in the day. If you’re not a breakfast fan, you can still slim down. A Cornell University study found that the nonbreakfast crowd didn’t overeat at lunch and dinner, and they ate about 400 fewer calories a day. The bottom line: Skipping breakfast may help some healthy people shed pounds.

green MuCus Means infeCtion The contents of your tissue can’t take the place of a lab test. Studies show that green or yellow mucus is slightly more common in certain bacterial infections. But it’s not a sure sign that you have one or that you need antibiotics. A sinus infection can cause clear mucus, and a common cold can turn it green.

HEALTH MYTHS Debunked

sugar Makes kids hyper Sugar isn’t good for kids, but research shows the sweet stuff won’t cause them to act out, hurt their schoolwork, or make them unable to focus.

CraCking Joints Causes arthritis The sound might annoy people around you, but that’s about all the harm it does. You may think bones or joints rub together to cause the noise, but that’s not so. It results from a gas bubble that forms between the bones and “pops.” If you enjoy doing it, keep on. Studies show it doesn’t cause or play a role in arthritis. If you feel regular or severe pain when you do it, see your doctor.

Being Cold gives you a Cold No matter what your grandma might've told you, spending too much time in the cold air doesn’t make you sick. One study found that healthy men who spent several hours in temperatures just above freezing had an increase in healthy, virus-fighting activity in their immune systems. In fact, you’re more likely to get sick indoors, where germs are easily passed.

you need a daily MultivitaMin You may have heard that a multivitamin can make up for nutrients that aren't in your diet. Researchers don’t all agree on that point. But if your doctor tells you to take vitamin, do it. And if you’re pregnant, you need to take folic acid to lower the risk of birth defects.

a toilet seat Can Make you siCk Don’t stress if you can’t cover the seat. Toilet seats are usually pretty clean - it’s bathroom doors, door handles, and floors that tend to be covered with bugs like E. coli, norovirus (a.k.a. “stomach flu”), and the flu. Cover your hand with a paper towel before you touch doors or handles, and use hand sanitizer or wash afterward.

Fertility Tips

DR RUPAL N. SHAH Infertility & ART consultant and Medical Director of Blossom Fertility & IVF Centre, Rupal Hospital for Women & Vama - Wellness Centre for Women, Surat.

Obesity is a known risk factor for ovulation problems, but it also contributes to infertility in women who ovulate normally. Research shows that excess weight can reduce your chances of becoming pregnant. Obesity has a number of adverse effects on a woman or man’s fertility.

Obesity & Infertility

WHAT IS OBESITY? Obesity is defined as excess adipose tissue (fat). There are several different methods for determining excess adipose (fat) tissue; the most common being the Body Mass Index (BMI) . BMI is calculated by dividing a person's body weight in kilograms by their height in meters squared. The BMI cutoffs are: Below 18.5 Underweight 18.5-24.9 Normal weight 24.5-29.9 Overweight 30 and greater Obese 40 and greater Morbid or extreme obesity If BMI is above 30, capacity of conception in female decreases . According to one research,a woman with a BMI of 35 was found to be 26% less likely to achieve a spontaneous pregnancy than women who were normal weight or overweight but not obese. A woman with a BMI of 40 or more was 43% less likely to get pregnant. HOW OBESITY AFFECTS FERTILITY? 1. Obesity affects your hormones When your body mass index goes past the overweight category (BMI of 25–29.9) into the obese category (BMI of 30 and above), hormonal changes may occur in your body. When your levels of natural hormones change, your chances of conception decrease.

2. Obesity leads to insulin resistance The hormonal imbalance that comes with obesity often leads to insulin resistance. That is a major risk factor on the road to diabetes - but it also affects your fertility and can create abnormal menstrual cycles. Insulin resistance can lead to anovulation, in which your body does not produce eggs properly. 3. Obesity affects natural and assisted pregnancies Obesity makes it more challenging to become pregnant, no matter whether you’re using natural means or by reproductive technologies such as in vitro fertilization (IVF). It also increases your risk for a miscarriage. This issue may be caused by the hormonal issues or because of your body is producing poor quality eggs. 4. Obesity decreases your partner’s fertility, too Although much of the focus on obesity and infertility is on women, it absolutely affects men too. For men, obesity leads to a drop in testosterone hormone level which can lead to infertility. On top of that, erectile dysfunction occurs at a higher rate among obese men. Most of the time obesity is associated with hormonal disturbances in infertile women, in the form of Polycystic ovaries associated with anovulation, other pitutary or thyroid gland dysfunction or it can be due to genetic problems or problems

related to unhealthy life style and eating habits. HOW TO COPE WITH THIS PROBLEM? When you visit a doctor, in the first visit, doctor will advise you to reduce your weight. And you start dieting, and exercise immediately, but this will not give any magical result in a short time. Sometimes because of crash dieting also there are severe hormonal disturbances leading to anovulation, worsening your infertility problem. Sometimes, weight is reduced, but it will not help your infertility problem. To keep your ovary fit, add healthy food in your diet: • Eat fresh food (Please avoid re-cooked food). • Eat fruits and vegetables raw. (By making soups or juices of vegetables and fruits, the nutrients of vegetables and fruits are destroyed). • Do not decrease carbohydrates in your food. But eat the same without any process. Use wheat, juwar or bajra by making roti, thepla, bhakri etc. In place of polished rice, use red rice (Brown Rice), so the content of fiber is high in your food. • Protein is required for maintenance of all hormones in ovary. So, increase protein level in your diet. Pulses, eggs, fish, paneer are rich sources of protein. • Wherever fat is used, use the ones containing essential fatty acids like Omega-3, and Omega-6. These are available from groundnut oil, sesame oil, olive oil, dry fruits mainly from almonds and walnut. • Walnut gives you Alfa Lipoic Acid, which works like insulin which also helps to reduce fat. • Micro-nutrients like selenium, zinc, and chromium increases effectiveness of insulin, which are easily available from green vegetables, fish, eggs, full grains, and cereals. Zinc and Chromium effectively improve pimples and wrinkles over the skin. • Vitamin B12 is available from Fresh Curd, Paneer, Sprouted Beans and fermented food items like dosa, idli, dhokla etc. • In problems like PCO, requirement of calcium increases. Have more calcium content in your diet. Food like chocolate, cakes, sweets, processed food, aerated drinks reduce calcium and chromium in the body. This effectively reduces insulin production and increases fats. So please avoid such items in your diet. • You may take tablets of Vitamin A, E, D, and B12 and Calcium in your diet supplement. EXERCISE Regular exercise is a key for regular menstrual cycle. And regular menstrual cycle means regular ovulation and increase in chances of pregnancies. It is necessary that to reduce your weight, exercise is equally important as your diet. Over enthusiastics do excess exercises, but it is not necessary. Regularity in exercise is important. • 30 - 40 minutes aerobic exercise per day for 3 to 5 days in the form of walking, jogging, cycling, swimming, dancing will also help you to keep your goals. • To balance your weight, at least twice a week practice muscle strengthening exercises. This is done with dumbbells, or using various machines in a gym. • You can do yoga at least 10 to 15 minutes per day, which will include muscle stretching in your exercise schedule. Meditation may also be included into your workout plans. • To reduce your weight, contact a dietician and gym/yoga trainers, who will guide you to appropriate exercise and proper food. Exercise boosts up functions of almost all the body parts including ovaries. It will enhance insulin, which will control your sugar levels. This helps you in balancing sugar levels in your blood, which will improve your ovulation. While trying to reduce your weight, it is important that you have proper sleep and a stress-free mind also. Extracted from: ‘Joy of Getting Pregnant’ by Rupal N. Shah

You’re going soft more than you care to admit Limping into the bedroom more than twice a month may mean your heart’s just not into it: An Austrian study found that the risk of developing heart disease within 10 years was 65 percent higher in men with moderate or severe erectile dysfunction than in men without ED. Blood vessels in the penis are significantly smaller and start to narrow long before those in the heart or brain. Talk to your doc, who can refer you to a cardiologist.

You see that the tip is red and swollen No, not that type of swollen. We mean inflammation, redness, and pain at the head of your smokestack. It’s called balanitis, and it’s typically caused by bacteria, viruses, or fungi, often as a result of less-than-stellar hygiene. And get checked for diabetes. Research from Bristol-Myers Squibb shows that people with diabetes are nearly three times as likely as nondiabetics to develop balanitis.

You have to urinate more often than usual The likely cause of your plumbing problem is benign prostatic hyperplasia, or BPH, a condition that rarely causes symptoms before age 40 but affects up to 90 percent of men in their 70s and 80s.

You produce less ejaculate or can’t orgasm Low testosterone could be the culprit. Testosterone helps produce semen, and the more semen you have, the more force you ejaculate with. About one-third of men who take depression medication experience difficulty reaching orgasm, according to researchers in Iran.

Your pee has gone from yellow to red A pink bowl is a red flag. Blood can be a sign of prostate, bladder, or kidney disease, so you need to find out where the blood is coming from. On the other hand, bloody semen during sexual activity is less likely to signal deadly danger. Still, ask your doctor to check it out. Your sex drive has been stuck in neutral If the fire is dying in bed, your partner isn’t necessarily to blame. Obstructive sleep apnea (OSA), a sleep disorder in which your airway becomes blocked, might be reducing your sex drive. German researchers found that men with the lowest levels of nighttime blood oxygen reported sexual desire levels that were 11 percent lower than men who breathed easily. OSA can reduce testosterone, affecting your erections as a result.

You notice it doesn’t feel as sensitive as before A numb knob could be a sign of poor diet. Each day, make sure you consume at least 2.4 micrograms of vitamin B12, from such sources as clams, milk etc, and 400 micrograms of folate, found in leafy greens and black-eyed peas. A deficiency in these vitamins can prevent nerve fibers in your penis from carrying signals to your brain. Next, have your blood sugar tested to rule out diabetes. Even a mildly high level—above 100 mg/dL after eight hours of fasting—can impact penile sensitivity.

Your erection is curving at a strange angle You might be one of the up to 23 percent of men ages 40 and over who will get Peyronie’s disease, a condition that makes an erect penis bend in any direction at an angle of 30 degrees or more. It strikes when collagen plaques form on the connective tissue surrounding the spongy interior of the penis. The cause may be genetic or a sign of too much or too little sexual activity. Seek treatment within 24 hours and consider a blood sugar test. High glucose levels alter stem cells in your penis, encouraging plaque to form.

Health Issues Your ‘Manhood’

Is Indicating

Believe it or not, your favorite organ can be really informative.