Knocked Up Podcast - Ovarian Cancer, the 'Silent Killer' with Dr Tzippi Ben-Harim
At the start of Ovarian Cancer Awareness Month we learn more about this 'silent killer' with Dr Tzippi Ben-Harim, Specialist Gynaecologist from the WHM team.
At the start of Ovarian Cancer Awareness Month we learn more about this 'silent killer' with Dr Tzippi Ben-Harim, Specialist Gynaecologist from the WHM team.
What is ovarian cancer – where does it grow, how does it develop?
Why do we often hear ovarian cancer described as a 'silent killer'?
What makes ovarian cancer particularly challenging compared to other cancers?
Are there any key risk factors that we should be aware of?
I’ve heard there’s a myth that the contraceptive pill increases ovarian cancer risk, is there any truth to this? Where does this myth come from?
If a woman has a family history of ovarian cancer, what steps should she take to protect their health? Is there a role for genetic testing? If yes, could these results impact treatment decisions?
Are there any early symptoms that women often dismiss?
Why don't we have a reliable screening test like the smear for cervical cancer?
From a fertility perspective, what does an ovarian cancer diagnosis mean?
What are the fertility options once you have received a diagnosis of ovarian cancer?
Walk us through what happens after a woman receives an ovarian cancer diagnosis.
Has treatment evolved in recent years?
What support systems should women have in place during treatment?
What promising developments in ovarian cancer research excite you most?
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
Find us on Instagram - @knockeduppodcast
Have a question about women's health? Is there a specific topic you'd like us to cover? Email podcast@womenshealthmelbourne.com.au. We keep all requests anonymous.
TRANSCRIPT
Jordi Morrison:
You are joined as always by me, Jordi Morrison. And today, we are also joined by Doctor Tzippi Ben-Harim, specialist gynecologist from the Women's Health Melbourne team.
Welcome, Tzippi.
Dr. Tzippi Ben-Harim:
Thank you. Thank you for having me.
Jordi Morrison:
My pleasure, Tzippi. We're talking to you about a really important topic today, something we haven't covered before that isn't directly related to fertility, but it is related to ovaries, and that is ovarian cancer.
Ovarian cancer is a bit scary. It's often described as the silent killer. Why is it called that?
Dr. Tzippi Ben-Harim:
I agree that ovarian cancer is a bit scary, and I think that the reputation of a silent killer is because the symptoms are very vague and nonspecific. As opposed to other cancers like uterine cancer, where bleeding presents early and allows early diagnosis.
With ovarian cancer, the symptoms are nonspecific like bloating and abdominal pain, feeling full early, some change in bowel habits or change in weight, fatigue. So very nonspecific.
And the other thing that is contributing to gaining this silent killer title is the fact that ovarian cancer is quite often diagnosed at the late stage or a later stage.
So quite often, the diagnosis is made in what we call stage three. Stage three means that the ovarian cancer has spread within the pelvis and the abdominal cavity. And again comparing it to uterine cancer — in uterine cancer, quite often the diagnosis is made early in stage one when the cancer is limited to the uterus and that basically simplifies the treatment.
Jordi Morrison:
And that's partly because the symptoms of uterine cancer are so obvious?
Dr. Tzippi Ben-Harim:
Yep. Uterine cancer usually presents itself with vaginal bleeding. It's more prevalent in postmenopause, and women who have not had bleeding for a few years are now bleeding again. It raises their concern. They come in early and get an early diagnosis.
And, sadly, we are not at the same stage with ovarian cancer with the vague symptoms and late diagnosis.
Jordi Morrison:
It's true. I don't think many women would go to their doctors because they felt full and bloated.
Dr. Tzippi Ben-Harim:
Yeah. It's such a common nonspecific symptom. We think, oh, maybe I've eaten something. It's gonna go away. And, yeah, that contributes to the late diagnosis.
Jordi Morrison:
So maybe tell us a little bit about what is ovarian cancer? So where does it grow? How does it develop? And what does stages one, two, three look like?
Dr. Tzippi Ben-Harim:
So ovarian cancer starts either at the ovary or the tube, which sounds a bit confusing because now we know that many ovarian cancers actually originate at the tube.
And obviously, with the late diagnosis where it's quite spread, it's hard to decipher whether it's starting at the ovary or at the tube.
If we go back, it starts at the ovary usually with the lining of the ovary, though a small proportion starts within the ovarian tissue inside and it gradually grows to basically involve the ovaries, the tubes, the uterus, some fat around the abdominal area, and also there will be some fluid accumulating in the abdomen.
So when we do staging, the staging in ovarian cancer is surgical staging, which means that the decision on the actual staging is done during surgery.
Though, we do know what to expect in advance because many women will get a CT, so a CAT scan of the abdomen and pelvis. So it's not that we're going in blinded, we go in with an anticipation of how much involvement there would be.
In all cancers, stage one is when the cancer is limited to the affected organ — so limited to the ovary without any evidence of spread.
So what it means is that when we go in, we take samples from the fat around, from some washing that we do in the pelvis and from lymph nodes, and if everything comes back negative and everything else looks pristine in the pelvis and the abdomen, that would be stage one.
Stage three is when there is involvement in the abdomen and the pelvis. So there will be involvement of the fat around the abdomen and pelvis. There will be fluid in the abdomen which tests positive for cancer.
And we need to remember there is also a stage four. Stage four is when the cancer has spread outside of the abdomen and pelvis.
So for example, with some fluids around the lungs.
Jordi Morrison:
And are there any key risk factors that we could be aware of?
Dr. Tzippi Ben-Harim:
So we have the more minor risk factors and the major risk factor.
So if we look at women that are at very high risk of ovarian cancer, that would be women that are carrying a specific gene that increases the risk.
Genes that are very well known — BRCA1 and 2 — and they dramatically increase the risk of women to have breast or ovarian cancer.
In those women, there will be a strategy of surveillance to try and diagnose early for breast cancer and a recommendation for risk reductive surgery, so to remove the ovaries and tubes before the age of 40.
Bearing in mind that if we remove the ovary and tubes before the age of 40, we basically bring premature menopause.
So the decision is not taken lightly. However, when we weigh the risks and benefits for these particular women taking the ovaries out, the benefits outweigh the risks of premature menopause.
If we go back to the general population, the general population, the lifelong risk of ovarian cancer is probably one in a hundred.
Jordi Morrison:
That's not small.
Dr. Tzippi Ben-Harim:
It's not small. This is the second most common gynecological cancer. So uterine cancer is the most common one and ovary is second in line and this is in developed countries.
So in developing countries, cervical cancer is more prevalent.
Going back to the risk factors — so the risk increases with age. The average age of ovarian cancer is 63.
Other risk factors are infertility, endometriosis, polycystic ovarian syndrome, and cigarette smoking.
We also have some protective factors. So the important one to mention would be pregnancy, breastfeeding, oral contraceptives, which we can further discuss.
Jordi Morrison:
Yeah. I've got a question about that.
Dr. Tzippi Ben-Harim:
Yeah. IUD and tubal ligation.
Now we need to remember that the fact that we're saying these are risk factors, correlation is not causation, which means that we have these large observational studies that have shown that these things increase the risk. It doesn't mean that it's causing it.
Jordi Morrison:
Okay. So you did mention about the BRCA gene. We have an episode with Dr Lironne Wein coming up soon about the BRCA gene specifically.
I wanna talk a little bit about family history and the role that this takes, and what is there in terms of genetic testing available?
Dr. Tzippi Ben-Harim:
We do have genetic testing for BRCA for women that are high risk. High risk could be either a family history or a personal history. And there are quite clear criterias for genetic testing and it's covered by Medicare.
So if someone has a family history of ovarian cancer, there are two things that I think would be a good idea.
One would be to get genetic counseling because it's not just BRCA. There are other genes as well, and there are other cancers that can be linked like bowel cancer.
So I think one thing would be to get genetic advice about what tests need to be run. And then if the tests show a predisposition, that's one thing. And if it doesn't, that's another thing.
Now the other thing — even in women with a family history that do not carry a genetic predisposition, we don't have good screening for ovarian cancer at this stage.
Again, maybe there will be a breakthrough in the future.
We know that there are some cancers that we can screen for like cervical cancer, bowel cancer, and breast cancer.
So in order for screening to be effective, we need to have a tool that is very sensitive, which means it will diagnose most women and also not over-diagnose.
Because if we now achieve Bloods and Ultrasound for every woman, we'll get lots of what we call false positives.
So lots of women with cysts or with an elevated tumor marker, which actually there is nothing wrong with them.
So then we increase the anxiety, increase the intervention and do unnecessary operations.
So at this stage, I would say that we don't have a good screening tool for ovarian cancer, but hopefully, there is lots of effort put into that and that's gonna change.
Jordi Morrison:
We'll have another conversation with different information.
Dr. Tzippi Ben-Harim:
Can't wait for that. Love how things change and develop.
Jordi Morrison:
I wanna go back to the contraceptive pill, which you briefly touched on because I've heard there's a myth that it can increase the chance of ovarian cancer.
Is there any truth to this?
Dr. Tzippi Ben-Harim:
Well, the truth is contrary, actually. So one of the theories for ovarian cancer is what we call incessant ovulation.
So we know that ovulation basically causes a small damage in the wall of the ovary. This is how the egg is being released.
And women who are on the contraceptive pill — the ovulation is suppressed.
Like the combined contraceptive pill suppresses ovulation and that has been shown to significantly reduce the risk of ovarian cancer.
Jordi Morrison:
Are there any early symptoms that women often dismiss?
Dr. Tzippi Ben-Harim:
So the common theory is that the symptoms are not early and they're nonspecific.
Jordi Morrison:
Like you mentioned earlier.
Dr. Tzippi Ben-Harim:
Yeah. Women will complain of vague symptoms that retrospectively, they would say, oh, this has been going on for a while.
Jordi Morrison:
And why don't we have a reliable screening test like we do the smear for cervical cancer?
Dr. Tzippi Ben-Harim:
So with cervical cancer, we have better understanding of the development in the sense that we know that HPV, the Human Papillomavirus, is causing it, and we know how it progresses from normal tissue, from precancer cells to cancer, and then how cancer progresses.
We don't have that for ovarian cancer.
And the other thing is that we've got easy access for cervical cancer. So cervix can be easily visualized on a normal examination, which makes getting the test very easy and part of routine.
Now the screening for cervical cancer has changed. Until December 2017 in Australia, we used to do what we call a Pap smear, which is testing the cells that the cervix is shedding and we used to do it every two years.
With the understanding that HPV is actually causing cervical cancer, now the system has changed to testing for HPV and that allows earlier diagnosis with the hope that cervical cancer is going to be eventually eliminated.
The other thing that has contributed to the reduction in cervical cancer is the HPV vaccine, which now is part of the vaccination program in schools.
So these are two things. Also, cervical cancer will cause early symptoms and the common one would be bleeding after intercourse, again, because of where it's sitting.
Jordi Morrison:
And from a fertility perspective, what does an ovarian cancer diagnosis mean?
Dr. Tzippi Ben-Harim:
Luckily, usually, it does not have an impact on fertility because, again, the average age of diagnosis is 63 and most women diagnosed with ovarian cancer would be after they've completed their family.
However, there is an option for fertility sparing in young women with early stage ovarian cancer.
So if only one ovary is affected and everything else looks pristine, there is an option for fertility sparing.
Also, once we complete the treatment, there is also an option to do an egg freezing cycle or cycles and have eggs stored.
So should there be a recurrence or something that requires to get everything else out, we'll still have an option for using the eggs in storage, for example, with a surrogate.
Jordi Morrison:
After a woman receives an ovarian cancer diagnosis, what is the treatment process? What will happen next?
Dr. Tzippi Ben-Harim:
So the treatment depends on the staging.
Commonly, the treatment will be a combination of surgery and chemotherapy.
If the assumption or the estimation earlier on is that everything can be taken out safely, then it's first surgery and then chemotherapy.
However, if the assessment is that the cancer has spread profusely or the woman is not well enough to go through surgery, there will be chemotherapy first to try and shrink the volume of the tumor and then interval surgery.
With surgery, the tissue that is being removed typically would be the uterus, the ovaries, the tubes, the fat around the bowel, and lymph nodes, as well as every cancerous tissue that can be removed.
Jordi Morrison:
This is major surgery.
Dr. Tzippi Ben-Harim:
I was gonna say it's major surgery and it sounds like some of it is a bit preventative as well?
Yes. So it is major surgery and this involves like a multidisciplinary gynecologist, an oncologist, radiologist who is reviewing all the images from ultrasound and CT, pathologist who is reviewing the specimens, the tissue that we're retrieving.
So it's quite a team effort. And after we have all the tissue reports back, we sit down with the patient, with the woman, and then there is a plan for what we call adjuvant chemotherapy.
This is supplementary treatment that is aimed at reducing whatever small cancer cells that were left behind that were microscopically — risk of the cancer coming back.
Jordi Morrison:
And has treatment evolved in recent years?
Dr. Tzippi Ben-Harim:
Yeah. So we do have some breakthrough, but they're not yet for everyone.
So for some women, there is a new treatment, which is PARP inhibitor.
PARP is a protein that is involved in repairing cell damage and DNA damage.
And we have PARP inhibitors that can improve the outcome for some women with ovarian cancer.
Jordi Morrison:
Are there any developments in ovarian cancer research that are exciting you at the moment?
Dr. Tzippi Ben-Harim:
I think genetic testing will further evolve and hopefully will allow us to predict who is at risk and who is not at risk.
And the other thing would be if we will be able eventually to have a screening system, I think that would be a game changer.
Jordi Morrison:
Definitely. And do you have any advice to give our listeners about protecting their ovarian health?
Dr. Tzippi Ben-Harim:
In terms of early diagnosis, whilst we know that we don't have a good screening system, if you're concerned about something, go and see your doctor.
That's as simple as that.
And in terms of the reservations that women have about the contraceptive pill, this is a known proven benefit of the contraceptive pill.
Jordi Morrison:
And so that would be the same for the Mirena as well?
Dr. Tzippi Ben-Harim:
Mirena does not have that much of an effect.
So Mirena is an IUD that releases progesterone.
And because of the small dose, on one hand, it has less side effects, but on the other hand, it does not suppress ovulation.
So women with the Mirena, the contraceptive effect is mainly with thinning of the lining of the uterus, as opposed to the contraceptive pill that the major contraceptive effect is by suppressing ovulation.
Jordi Morrison:
And just before we go, do you wanna reiterate those symptoms that women might be experiencing just so they know what to look out for?
Dr. Tzippi Ben-Harim:
Symptoms include bloating, abdominal pain, abdominal pain, feeling full quite early, reduction in appetite, unexplained change in weight, fatigue.
So very vague and nonspecific symptoms. But if you get them all, please see your doctor.
Jordi Morrison:
Absolutely. Thank you, Tzippi, for joining us today. So interesting.
Dr. Tzippi Ben-Harim:
My pleasure.
Jordi Morrison:
To support Knocked Up, leave us a review or recommend to a friend. Join us on Instagram at @knockeduppodcast, and join Raelia at @drraelialew, and email us your questions to podcast@womenshealthmelbourne.com.au.