What doctors wish patients knew about ovarian cancer prevention

Ovarian cancer affects one or both ovaries. While it is not common, it is the top cause of deaths from any gynecologic cancer in the United States, according to the American College of Obstetrics and Gynecology. This may be because ovarian cancer often goes undetected until it is in an advanced stage. Occurring most commonly in women between the ages of 50 and 65, what is known about risk factors has not translated into practical ways to prevent ovarian cancer.

Most ovarian cancers develop from epithelial cells, which cover the surface of the ovaries. In fact, about nine in 10 cases involve epithelial tumors. These cells are widespread throughout the body and cover many surfaces, but in the case of ovarian cancer, epithelial cells lining the surface of the ovaries start to grow uncontrollably, invading and damaging other parts of the body.

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

For this installment, two physicians took time to discuss what patients need to know about reducing risk of ovarian cancer. These AMA members are:

• Nariman Heshmati, MD, an ob-gyn at the Everett Clinic in Washington and senior regional medical director for Optum Washington. He is also past chair of the Washington American College of Obstetricians and Gynecologists Section.
• Lanny F. Wilson, MD, chair of the Physician Well-Being Program at Advent Health in Hinsdale, Illinois and chair of obstetrics and gynecology at Avalon University School of Medicine in Youngstown, Ohio.

“There’s no known way to prevent ovarian cancer but there are things that have been associated with a lower chance of getting ovarian cancer,” said Dr. Heshmati. “Breastfeeding for a year or more appears to modestly reduce the risk of ovarian cancer.”

Additionally, “having given birth, using birth control pills for more than five years, and certain gynecologic surgeries … also have been associated with lower rates of ovarian cancer,” he said.

“The most important preventive thing that a person can do is have annual exams with a primary care physician,” said Dr. Wilson. “Call your doctor right away if you have symptoms and just stay in good general health.”

“I've also often said that water is your friend, and that's true,” he said, noting that “you want your circulation working like a clear mountain stream, carrying clean messages to your brain, heart, kidneys and ovaries. So, a good, hydrated diet is really important.”

“We don't really have any good screening tools for ovarian cancer. Pap smears, HPV testing for cervical cancer, mammography for breast cancer, colonoscopy for colon cancer,” said Dr. Wilson. “But we haven't figured out a good way to screen for ovarian cancer for those people who are at routine risk.”

“For those at routine risk of ovarian cancer, there isn’t a recommended screening test, and no screening strategy has been shown to reduce the risk of death from ovarian cancer,” said Dr. Heshmati. “Remember, with every screening test—whether that is an ultrasound or a blood test like a CA 125—there are risks of false positives, associated anxiety and potential harm from follow up invasive testing.” 

“Around 1.2% of women will develop ovarian cancer sometime during their life,” Dr. Heshmati said, noting “there is no way to know for sure who will get ovarian cancer. Although, some women will have a hereditary syndrome that makes them higher risk for having ovarian cancer.”

“For instance, 39–44% of women with BRCA1 mutations go on to develop ovarian cancer,” he said, adding “there are some risk factors that have been identified for ovarian cancer.

“Those include being middle aged or older, having a close relative with ovarian cancer, having had a prior breast, uterine or colon cancer, being of eastern European or Ashkenazi Jewish background, having never given birth, and having a history of endometriosis,” Dr. Heshmati added.

“Pap smears are really important to get because they are an excellent screening tool for cervical cancer, which happens to be the only gynecologic cancer we have simple and reliable screening for,” said Dr. Heshmati. “Unfortunately, it does not check for ovarian cancer.”

“How often you should get a pap smear has been changing based on testing advances that incorporate human papilloma virus—HPV—testing and a better understanding of who is at the highest risk for developing a cervical cancer,” he explained. “We now recommend pap smears start at age 21 and occur every three years. After age 30, pap smears can space out to every five years because of HPV testing.”

“One of the first things that a primary care doctor does—whether it’s an ob-gyn, internal medicine or family medicine physician—they’ll take a family history,” said Dr. Wilson. “And if a person has a strong family history of any of the cancers, then they may be a candidate for genetic testing.”

“If someone is considered high risk for ovarian cancer based on that history, additional testing can be done to identify if there is a hereditary syndrome such as BRCA or Lynch present which places someone at higher risk,” said Dr. Heshmati.

“Lynch syndrome is a genetic condition that increases a person’s risk of cancer of the colon, rectum, uterus, pancreas, and bile duct,” said Dr. Wilson

“In the cases where those syndromes are identified, additional screening or even preventative surgery may be recommended,” Dr. Heshmati said.

“If people take care of themselves, keeping their stresses and their weight under control, there's a lot to be said for just general good health,” said Dr. Wilson. “People who are healthy in mind, body and spirit are less likely to develop any of the cancers, including ovarian cancer.”

“However, you can be the healthiest person in the world, but have genetics which predispose you to cancer, then you need to really be on guard,” he said. “For example, if you have the BRCA gene and are healthy, those genes will still do what genes do, which is set up a predisposition for cancer.”

“If you want to have the tubal ligation be a form of prevention, you must remove the entire fallopian tubes bilaterally,” said Dr. Wilson. “Removing both fallopian tubes may be preventative and certainly removing the ovaries is preventative.”

“If someone's really concerned about having ovarian cancer, the sooner they remove the tubes and ovaries, the less likely they're going to have ovarian cancer,” he said. “However, you don't want to do that too early because although hormone replacement therapy is available,  there's nothing quite as good as the natural hormones that ovaries provide.

“We don't have designer hormones that are as good. They replace them reasonably well, but as long as a person can keep their ovaries, we want them to,” Dr. Wilson added. “If you do have the BRCA gene, though, you want to have your children as soon as possible and then remove the ovaries at a reasonable time—you want to remove them before cancer breaks out.”

“Interestingly, it's like if you keep those ovaries quiet, they won't be percolating and doing negative things,” said Dr. Wilson. “So, the birth control pills—the combination oral estrogen-progestin pills—essentially put the ovaries on hold during the time period in which they are being used.

“You can't get pregnant, but the pill has been shown to decrease the risk of ovarian cancer,” he added. “We must always weigh the risks against the benefits. For example, birth control pills are not a good choice for a person who’s at risk of forming blood clots.”

“Birth control pills have also been shown to help treat another gynecologic condition, endometriosis,” Dr. Wilson said. “It helps keep endometriosis under control, using the same mechanism that prevents the endometrium from enlarging and shedding as much while on the pill.”

“Endometriosis, which is endometrium outside of the uterus, is prevented from enlarging and shedding as much in a similar manner,” he explained.  “People on the pill quite often have really mild menstrual periods because there’s not much endometrium to shed. There are certainly positives to the pill.”

“A simple hysterectomy—removal of the uterus—is not preventive because even though they are in the same anatomic region, the uterus is not related to ovarian cancers—they're different organs,” Dr. Wilson said. “However, if you do a total hysterectomy, which adds removal of tubes and ovaries, called a total vaginal or total abdominal hysterectomy—removing uterus, tubes and ovaries—that is preventative.”

“Giving birth and breastfeeding both decrease the risk of ovarian cancer,” said Dr. Wilson. “And it's not just the fact that a person has given birth, which in and of itself reduces the risk of ovarian cancer.

“But breastfeeding, independent of getting pregnant, reduces the risk as well,” he added.

“The HPV vaccine doesn’t increase or decrease your risk of ovarian cancer,” said Dr. Heshmati. “On the other hand, the HPV vaccine does reduce your risk of cervical cancer and other HPV related cancers such as certain oral, anal and vaginal cancers.

“It also reduces your risk of genital warts which are caused by HPV,” he added. “Remember, HPV is estimated to cause over 36,500 cases of cancer in men and women every year in the U.S. All girls and boys should get the HPV vaccine and can start the series as early as age 9 with general recommendations for routine vaccination at age 11–12.” 

“It is recommended that anyone up to age 26 receive an HPV vaccine and some older than that may want to get it after discussing it with their physician,” Dr. Heshmati explained, noting “the benefit of getting the HPV vaccine later in life is lower since many people have already been exposed to HPV by then.” 

“The only reasons not to get the HPV vaccine are if you have had a severe allergic reaction to the vaccine or a component of it before or if you are currently pregnant,” he said.

“In general, whenever you are noticing new symptoms that are concerning to you and not improving, it’s a good idea to touch base with your doctor,” said Dr. Heshmati. “Together you can determine if something needs to be worked up further and what that work up should look like.”

“Also, if you find out you have a strong family history of certain cancers like ovarian or breast cancer, this is something you should let your doctor know,” he said, noting “there’s more and more research going on every year to help identify and treat cancers like ovarian cancer.”

“Until we have a reliable screening test, one of the most important things to know is that it’s OK to bring up concerns and symptoms that worry you to your physician,” Dr. Heshmati said. “What you are noticing may not be signs of a cancer and may not need anything more than a discussion and reassurance, but they could also be signs of other things that need to be evaluated further.”