Ovarian Cancer

Question 1

What is the pathophysiology of breast cancer?

Answer 1

Ovarian cancer is the leading cause of gynecologic cancer death, and the second most common type of gynecologic cancer. Most ovarian cancers are epithelial tumors that grow on the surface of the ovaries. These tumors grow rapidly, spread quickly, and are often bilateral. Tumor cells spread by direct extension into nearby organs and through blood and lymph circulation to distant sites. Free-floating cancer cells also spread through the abdomen to seed new sites, usually accompanied by ascites (abdominal fluid).
Ovarian cancer seems to be disordered growth in response to excessive exposure to estrogen. This would explain the protective effects of pregnancies and oral contraceptive use, both of which interrupt the monthly estrogen exposure.

Question 2

What risk factors are associated with ovarian cancer?

Answer 2

• Middle to older age
• BRCA1 or BRCA2 gene mutations
• Infertility
• Difficulty getting pregnant
• Nulliparity
• History of endometriosis
• History of breast, uterine, or colorectal (colon) cancer (especially Lynch syndrome, hereditary nonpolyposis colorectal cancer [HNPCC])
• Of Eastern European or Ashkenazi Jewish background

Question 3

What is associated in the assessment?

Answer 3

As a matter of prevention, it is important for nurses to teach women to “think ovarian” even at the onset of vague abdominal and GI symptoms. Most women with ovarian cancer have had mild symptoms for several months but may have thought they were caused by normal perimenopausal changes or stress. They may report abdominal pain or swelling or have vague GI disturbances such as indigestion and gas. Ask the patient if she has had urinary frequency or incontinence, unexpected weight loss, and/or vaginal bleeding.

Complications of advanced metastatic cancer include:
- Pleural effusion
- Venous thromboembolism (VTE)
- Bowel obstruction

On pelvic examination, an abdominal mass may not be palpable until it reaches a size of 4 to 6 inches (10 to 15 cm). Any enlarged ovary found after menopause should be evaluated as though it were malignant.

Question 4

What diagnostics can be done?

Answer 4

• A cancer antigen test, CA 125, measures the presence of damaged endometrial and uterine tissue in the blood. It may be elevated if ovarian cancer is present, but it can also be elevated in patients with endometriosis, fibroids, pelvic inflammatory disease, pregnancy, and even menses. It is also useful for monitoring a patient’s progress during and after treatment.
• Abdominal and pelvic CT scans or MRI is most commonly used to evaluate for metastasis.
• A chest x-ray is obtained to evaluate for the presence of pleural effusion, metastases, and mediastinal lymphadenopathy.
• A liver profile may be ordered if there is ascites.

Question 5

What interventions can be done?

Answer 5

• Nursing care of the patient with ovarian cancer is similar to that for the patient with endometrial or cervical cancer. The options for treatment depend on the extent of the cancer and usually include surgery first, followed by chemotherapy.
• Radiation may be used for treatment of metastasis, but is not used often for ovarian cancer alone as a treatment method.
• Diagnosis depends on findings during surgical exploration and diagnostic testing. A total abdominal hysterectomy, bilateral salpingo-oophorectomy (BSO; removal of the ovaries and fallopian tubes), and pelvic and para-aortic lymph node dissection are usually performed. Tumors are staged during surgery. Very large tumors that cannot be removed are debulked (reduced). These procedures can be performed via laparoscopic technique or robotic-assisted laparoscopy to decrease recovery time, minimize pain, and reduce postoperative complications.
• Nursing care of the patient is similar to that for any patient having abdominal surgery. As for any patient after abdominal surgery, assess vital signs and pain and maintain catheters and drains. Teach her the importance of antiembolism stockings, incentive spirometry, and early ambulation.
• Evaluate for respiratory or urinary infection. Assess vital signs and monitor the quantity and quality of urine output.
• After removing and staging ovarian cancer, chemotherapy is used often. Chemotherapeutic agents may be given IV and/or intraperitoneally.

Question 6

What is a part of the care coordination and transition management?

Answer 6

• Teach patients discharged to home to avoid tampons, douches, and sexual intercourse for at least 6 weeks or as instructed by the surgeon. Remind them to keep their follow-up surgical appointment and to follow the surgeon’s other recommendations about resuming usual activities.
• Refer patients and their families to Gilda’s Club within their local demographic for support groups.
• Ovarian cancer has a high recurrence rate. After recurrence, the cancer is treatable but no longer curable. A once-daily oral pill, Zejula (niraparib), is now approved for maintenance therapy, which is a type of treatment given after a favorable response to chemotherapy to keep ovarian cancer from recurring. If the patient refuses maintenance therapy, or if maintenance therapy is unsuccessful, the patient may deny symptoms at first or express feelings of anger and grief. The patient and family are often fearful of the outcome. Provide encouragement and support during this difficult time and refer to grief counseling, spiritual leaders (if desired), and community support groups. For patients with advanced metastatic disease, collaborate with members of the interprofessional team for possible referral to hospice.