Seminars in Oncology Nursing 35 (2019) 151 156

Contents lists available at ScienceDirect

Seminars in Oncology Nursing

journal homepage: https://www.journals.elsevier.com/seminars-in-oncology-nursing

Ovarian Cancer: An Integrated Review

Christine Stewart, BSN, RN, CMSRNa,*,
Christine Ralyea, DNP, MBA, MS-NP, RN, NE-BC, CNL, OCNÒ , CCRNb,
Suzy Lockwood, PhD, MSN, RN, OCNÒ , FAANc
a
Carolina’s Medical Center, Charlotte, NC
b
Assistant Vice President Patient Care Services, Carolina’s Medical Center, Rock Hill, SC
c
Interim Dean, Harris College of Nursing & Health Sciences, Associate Dean for Nursing & Professor, Texas Christian University, Ft Worth, TX

A R T I C L E I N F O A B S T R A C T

Key Words: Objective: To provide an overview of the risk factors, modifiable and non-modifiable, for ovarian cancer as
ovarian cancer well as prevention, diagnostic, treatment, and long-term survivorship concerns. This article will also examine
gynecologic current and future clinical trials surrounding ovarian cancer.
oncology Data Sources: A review of articles dated 2006 2018 from CINAHL, UpToDate, and National Comprehensive
prevention
Cancer Network guidelines.
BRCA
Conclusion: There is no screening test for ovarian cancer and with diagnosis often in the late stages, recur-
risk factors
rence is high in this population. Early identification can range from knowing the vague symptoms associated
with the cancer to prophylactic surgical removal of at-risk tissue. Standard treatment for ovarian cancer is
surgery followed by combination chemotherapy. Although advances are being made, ovarian cancer remains
the most fatal female gynecologic cancer.
Implications for Nursing Practice: Becoming familiar with and educating women about risk factors and the elu-
sive symptoms of ovarian cancer can increase patient autonomy and advocacy, as well as potentially improve
patient outcomes for those affected by ovarian cancer.
© 2019 Elsevier Inc. All rights reserved.

When one thinks about fatal gynecologic malignancies, breast cancer
is often the first that comes to mind. October is filled with pink ribbons
and breast cancer awareness stickers, and communities rally to partici-
pate in dedicated walks and screening events. However, most may not
know that ovarian cancer is the most fatal of all female reproductive can-
cers.1,2 Often known as the silent killer, ovarian cancer is frequently not
diagnosed until it is at an advanced stage because of its generally vague
symptoms, making it hard to treat on a curative basis.3,4 In fact, over 70%
of ovarian cancers are not diagnosed until the disease has progressed to
stage III or IV. The latest research has survival rates for ovarian cancer
after 5 years to be 47.4%.2,5 Interestingly, data suggest that ovarian cancer
does not usually start in the ovaries. Mallen et al6 note that many ovarian
cancers originate in the fallopian tube. When looking at the molecular
profile of cancers, cells in the fallopian tubes, ovaries, and peritoneum
all look the same. Because of this, they are said to represent the same
disease. Taking this into consideration has an impact on not only risk
factors, but prevention and treatment options as well. This article will
examine the pathophysiology, prevalence, risk factors, treatment options,
and what is to come in the future for this fatal cancer.
Incidence and Prognosis
Ovarian cancer rates have fallen in recent years, with increased
use of oral contraceptive pills.7,8 As of 2018, ovarian cancer was the
seventh most common cancer worldwide in women, with around
240,000 new cases.2 Ovarian cancer is the second most common
malignancy after breast cancer in women over the age of 40, particu-
larly in developed countries.9 When looking at all types of cancers,
ovarian cancer is the eleventh most common type in women, the fifth
leading cause of cancer-related death in women, and, as mentioned
before, the most fatal gynecologic cancer.2 Despite awareness of
ovarian cancer, curative and survival trends have not changed
significantly because it remains a challenge to diagnose early. This is
due in part to several factors; lack of a definitive screening tool and
vague signs and symptoms that can “masquerade” as other nonmalig-
nant conditions. In the United States alone, there are over 22,000
new cases of ovarian cancer each year, with 14,000 deaths related to
ovarian cancer.2,10
By Population/Age

* Address correspondence to: Christine Stewart, BSN, RN, CMSRN, Carolina’s Medical The Centers for Disease Control and Prevention reports that white
Center, 1000 Blythe Blvd, Charlotte, NC, 28203.
women have the highest prevalence, with 11.3 out of every 100,000
E-mail address: Christine.McDaniel@CarolinasHealthcare.org (C. Stewart).

https://doi.org/10.1016/j.soncn.2019.02.001
0749-2081/© 2019 Elsevier Inc. All rights reserved.
152 C. Stewart et al. / Seminars in Oncology Nursing 35 (2019) 151 156

women being affected.2,10 The highest incidence per ethnicity after Table 1
whites are Hispanics, Asian/Pacific Islander, African Americans, and Types of epithelial ovarian cancer.

American Indian/Alaska natives, whose incident rates are 9.8, 9.0, 8.5, Type I v type II tumor types
and 7.9 per 100,000, respectively.11,12 Ovarian cancer is rare in young Type I
women, particularly under the age of 30; risk increases with age, Less lethal than type II
with the occurrence spiking drastically after the age of 50, and aver- Causes are continued ovulation cycles, inflammation, and endometriosis
Typically present as low-stage disease
age diagnosis between the ages of 50 and 70 years.2,12 Ovary origin
Type II
Associated with fatal outcomes
Prognosis
Diagnosed later
Linked to genetic mutations
Prognosis for those women that develop ovarian cancer is directly Fallopian tube origin
related to the stage of disease at the time of diagnosis.4,5 Those diag- High-grade v low-grade serous tumors
nosed at stage I, have a 5-year survival rate of 90%.2,9 In those with High-grade serous tumors
90% of all tumor types
regional disease (meaning the disease has spread to adjacent tissues),
More fatal prognosis
5-year survival rates drop to around 80%, and 25% in those with meta- 10-year mortality rate of 70%
static disease. Over the last 30 years, mortality rates from ovarian Low-grade serous tumors
cancer have narrowly dropped.2,9 10% of all tumor types
Diagnosed at younger age
Better prognosis than high-grade serous tumors
Classifications and Histopathology Endometrioid carcinomas
Originate from endometriosis
Good prognosis
Ovarian cancer has three main types: epithelial (most common),
Clear cell carcinomas
germ cell, and sex-cord-stromal, with the latter two comprising only 10% of epithelial ovarian cancers
about 5% of all ovarian cancers.4,11 There are four primary histologic Often diagnosed in early stages
subtypes of epithelial ovarian cancer; serous, endometrioid, mucin- If diagnosed late has poor prognosis
ous, and clear cell.3,4 Serous tumors are categorized into two classifi- Mucinous carcinoma
Least common type of epithelial ovarian cancer
cations: high-grade serous carcinomas (HGSC) or low-grade serious Associated with metastasis from gastrointestinal tract
carcinomas (LGSC).4,13 HGSCs account for 70% to 80% of all subtypes Germ cell ovarian cancer
of epithelial ovarian cancer, while LGSCs account for less than 5%. Rare
Endometrioid, mucinous, and clear cell subtypes account for 10%, 3%, Make up only 3% of all ovarian cancers
Frequently diagnosed in younger women
and 10%, respectively.13 Table 1 highlights key aspects of the types of
Histologic type similar to that of germ cell tumors in the testes of men
epithelia ovarian cancers. Sex cord-stromal ovarian cancer
Least common ovarian cancer
Epithelial Ovarian Cancer Less than 2% of all primary ovarian cancers
Rarely malignant
Usually diagnosed early
When one reads about epithelial malignancies, these will typically Smoking can decrease risk
have three point-of-origin sites: ovarian, tubal, or other epithelial sites
in the pelvis.14 Epithelial ovarian malignancies (which account for the
majority of ovarian cancers) are divided into two categories: type I and
presenting with later stages of disease and a 10-year mortality rate
type II tumors.5,14,15 Type I tumors, which are not as lethal as type II
of 70%.15
tumors, are thought to be caused from continual ovulation cycles,
inflammation, and endometriosis. Having endometriosis is believed to
increase a woman’s risk of ovarian cancer and is associated with 5% to Endometrioid Carcinomas
15% of all epithelial ovarian cancers.4,6,16 Many of these cancers present Endometrioid carcinomas are believed to originate from endome-
as low-stage diseases and usually have a more favorable outcome than triosis and are often diagnosed at earlier stages, resulting in a better
types that are not associated with endometriosis. Unfortunately, type prognosis for women affected by this histologic type.9 One reason for
II tumors are commonly associated with fatal outcomes.16 These can- this may be because this type of histology is chemosensitive, making
cers are usually diagnosed later and are often linked to the genetic treatment more successful.
mutations of the BRCA genes and p53 mutations, another tumor-
suppressing gene. One theory is that these tumors have migrated from Clear Cell Carcinoma
the fallopian tubes, the point of origin for these cancers.6 Clear cell carcinomas account for 10% of epithelial ovarian cancers
and are similar to endometrioid cancers in that they have a relatively
LGSC Versus HGSC good prognosis. This is because they too are often diagnosed in the
When speaking about the serous subtype of epithelial ovarian earlier stages.14 If diagnosed late or once the disease has advanced,
cancers specifically, percentages can be further broken down the prognosis will be similar to that of the serous or endometrioid
between HGSC and LGSC, with HGSCs making up 90% of all serous type. This is partially because of the cells being less sensitivity to plat-
tumor types, and LGSCs making up 10%.17 These two types of serous inum-based chemotherapy, as well as associated complications that
carcinomas have different molecular profiles, clinical presentations, are seen with this diagnosis (ie, blood clots and paraneoplastic
and even prognosis.13,17 LGSCs have a better prognosis, with the hypercalcemia).9,14
expected survival time being significantly longer compared with
those with HGSCs (as well as clear cell or mucinous types).17,18 Addi- Mucinous Carcinoma
tionally, in comparison to HGSCs, women are usually diagnosed at a The least common type of epithelial cancer, mucinous carcinomas,
younger age with LGSCs.18 LGSCs tend to originate in the ovaries, are most often diagnosed at stage I.14 Mucinous histology can be asso-
while HGSCs tend to originate in the fallopian tubes with ensuing ciated with metastasis from the gastrointestinal tract. Women are
spread to the ovaries or peritoneum.15 HGSCs are associated with a strongly recommended to have a gastrointestinal evaluation com-
more fatal prognosis, with more than 85% of women with this type pleted to rule out mucinous carcinoma.9,14
 C. Stewart et al. / Seminars in Oncology Nursing 35 (2019) 151 156
Germ Cell Ovarian Cancer Tumors
Germ cell tumors are rare, making up only 3% of all ovarian cancer
cases. They are typically diagnosed at a young age, with the average
age between 10 and 30 years.12,19 Ovarian germ cell tumors have been
known to produce certain tumor markers, which can be beneficial in
treatment planning.20,21 Because this type of ovarian cancer is fre-
quently diagnosed in younger women, it is important to develop a
plan, surgical or otherwise, that includes a focus on the fertility wishes
and potential of the patient. Interestingly, the histologic types of ovar-
ian germ cell tumors are comparable to histologic types of germ cell
tumors that arise in the testes of men.20 Of note, germ cell tumors pres-
ent with the same generally vague symptoms as other types of ovarian
cancer, such as abdominal swelling and irregular vaginal bleeding.19,20
Sex Cord Ovarian Cancer Tumors
Sex cord-stromal malignancies are the least common when speak-
ing of ovarian neoplasms, encompassing less than 2% of all primary
ovarian cancers.22 Unlike the larger variety of epithelial ovarian can-
cers, sex cord-stromal tumors are rarely malignant and are usually
diagnosed early.22 This type of ovarian cancer is higher in African
American women as opposed to white women, and the average age
of diagnosis is around 50 years.22 Remarkably, smoking has been
shown to decrease the risk of this type of ovarian cancer, as well as
clear cell carcinomas.12,22
Risk Factors
It is important to educate women and health care providers about
the risk factors for ovarian cancer. Signs and symptoms of ovarian
cancer historically have been nonspecific and vague. For most
women, they are not out of the norm for symptoms they may feel on
any given day: abdominal bloating, abdominal pain, urinary fre-
quency, early satiety or feeling full, or changes in bowel habits.1,4,15
For this reason, women may not seek medical care, resulting in a late
diagnosis. In fact, most women recall having these symptoms prior to
their diagnosis, and even some who presented with such symptoms
were treated without their health care providers looking further into
the cause of their symptoms.23,24 As health care providers, it is imper-
ative to consider these nonspecific symptoms when evaluating
women who are at increased risk for ovarian cancer. Ovarian cancer
can occur sporadically in any woman, even those who have no nota-
ble risk factors. Table 2 provides an overview of risk factors and their
relative risk probability for ovarian cancer.12
Family History/Genetic Predisposition
Having a family history of ovarian and breast cancer has been
shown to increase a woman’s risk of ovarian cancer. Mutations of the
BRCA1 and BRCA2 (tumor suppressing genes), and MMR gene are pri-
marily associated with a genetic risk of ovarian cancer, and can
Table 2
Risk factors for ovarian cancer.
Modifiable Nonmodifiable
Smoking BRCA1 mutation carrier
Hormonal replacement therapy BRCA2 mutation carrier
Dietary factors (see text) Family history
Lynch syndrome
Uninterrupted ovulation cycles
Endometriosis
Ethnicity/race
Data from the American Cancer Society. Cancer facts and figures 2018. Special Section:
Ovarian Cancer.12
153
increase the risk of ovarian cancer from 1.6% to 40%, 18%, and 10%,
respectively.1,21 This genetic link, known as hereditary breast and
ovarian cancer syndrome (HBOC), should be considered if a woman
has an immediate relative with a diagnosis of ovarian or breast cancer
before the age of 50. By the age of 70, 10% to 40% of carriers of these
genetic mutations will develop ovarian malignancies. Also linked to
ovarian cancer is Lynch syndrome, although this is less common.25
Lynch syndrome is an autosomal dominant genetic disorder in which
there is a genetic mutation that puts one at risk for certain cancers,
specifically colorectal cancer, but also increases the risk for other
malignancies, including ovarian cancer.25
Ovulation
Ovulation also has a direct link to the risk of ovarian cancer. Stud-
ies have shown that the more ovulatory cycles a woman completes,
the higher her risk of ovarian cancer.7 This may be because of the
proinflammatory response of the distal fallopian tubes during ovula-
tion, which promotes malignant ovarian tendencies.6 It is then cor-
rect to assume that factors that interrupt ovulation, such as birth
control use, early onset of menses, pregnancy, breastfeeding, and
early menopause, can decrease a woman’s risk of ovarian cancer.1,3,5
Knowing this can guide health care providers in the right direction
when assessing women for nonspecific symptoms, allowing us to
investigate whether a woman has had any of these protective factors,
and encourage them when possible in women who have the afore-
mentioned risk factors.
Endometriosis
Endometriosis has been linked to some epithelial ovarian can-
cers. Endometriosis-associated epithelial ovarian cancers tend to
develop in younger women and have a better overall prognosis.26
However, there is no evidence that shows that removal of endo-
metriosis lesions will decrease a woman’s chances of developing
ovarian cancer.26
Dietary Factors
Smaller studies have shown a link between dietary fiber intake
and its correlation with the prevalence of ovarian cancers.27
Huang et al27 conducted a study that showed increased intake of
dietary fiber led to a significant reduction in the incidence of
ovarian cancer. A decrease in the risk of epithelial ovarian cancer
is linked to a diet high in soy.16 Additionally, low levels of vita-
min D have been associated with an increased risk of developing
ovarian cancer.28
Ethnicity/Race
Certain ethnic backgrounds have also been shown to have an
increased genetic risk of developing ovarian cancer, specifically Jew-
ish, French Canadian, Dutch, and those of Icelandic descent.1,2
Prevention
When looking at risk factors for ovarian cancer, they can be cate-
gorized as modifiable and non-modifiable. A key to prevention is first
to educate women and health care providers about the risk factors,
signs and symptoms, and prevalence of ovarian cancers. In one study
it was noted that women in the general population could not cor-
rectly identify signs and symptoms of ovarian cancer, and even sug-
gested that some factors (such as abnormal pap smear results) were
incorrectly associated with ovarian cancer. Only about 40% of the
women in this study were considered at least “slightly familiar” with
signs and symptoms.29 In any health care setting there is always an
154 C. Stewart et al. / Seminars in Oncology Nursing 35 (2019) 151 156
opportunity to teach. Teaching at-risk patients, or even the general
population, about risk factors and symptoms can help promote self-
advocacy and health awareness. If women knew what signs to look
for, maybe it could prevent late diagnosis. Women should also be
encouraged, if and when appropriate, to discuss methods of ovulatory
regulation with their providers.
Interruption of Ovulation
Oral contraceptive use has been shown to decrease the risk of
ovarian cancer in average-risk women by 40% to 50%. The longer the
use of oral contraceptives the greater the benefit of risk reduction.5,30
As mentioned earlier, disruption of ovulation has been shown to sig-
nificantly decrease a woman’s risk for ovarian cancer. This can hap-
pen in multiple ways, including multiple pregnancies, breastfeeding,
having a hysterectomy, and removal of fallopian tubes or ovaries.16
Taking these methods into consideration, oral contraceptives seem to
be a promising and noninvasive method for reducing one’s risk of
ovarian cancer. Furthermore, having one’s first pregnancy under the
age of 25 has been shown to decrease the risk of ovarian cancer.4,13
Surgical Prevention
There are surgical prevention options for ovarian and breast can-
cers, although these options must be accompanied with thorough
education and patient autonomy. One such option is a risk-reducing
bilateral salpingo-oophorectomy in patients who have been deemed
high risk because of identified genetic mutations, such as a BRCA1
mutation. Risk-reducing bilateral salpingo-oophorectomy is a mini-
mal risk surgery, but does come with post-surgery side effects: vagi-
nal dryness, decreased sexual function, and even decreased ability to
have an orgasm.6,7 These prophylactic surgeries have substantially
reduced the incidence of cancer in BRCA mutation carriers by up to
80%.3 Removing at-risk tissue, while a very effective strategy in
reducing cancer and mortality rates, must come with considerations
of the woman’s age, fertility, and comorbidities. Tubal ligation is also
an option for women to significantly reduce the risk of ovarian can-
cer, with results being comparable to the use of oral contraceptives.7
Because most high-grade ovarian cancers originate in the fallopian
tubes, it is now under consideration to remove fallopian tubes during
routine hysterectomies to reduce the risk of ovarian cancer.6
Pharmacologic Prophylaxis
Although there is no definite recommended regimen of pharmaco-
logic prophylaxis, there have been conflicting studies on the use of aspi-
rin (low dose and standard dose).16 While some studies have shown no
link to the use of aspirin and a decrease in the risk of ovarian cancer,
others have shown significant reduction in risk in patients taking a daily
low-dose aspirin compared with those taking no aspirin.16 Regarding
anti-inflammatory medications, if endometriosis causes an inflamma-
tory response that promotes carcinogenesis, it is also reasonable to con-
clude that an anti-inflammatory regimen would provide positive
benefits as an adjuvant therapy to discourage further tumor formation.6
Screening and Diagnosis
Screening for ovarian cancers is difficult because of the notori-
ously vague and nonspecific symptoms. Historically, the cancer anti-
gen 125 (CA125) has been used as a tumor marker for ovarian cancer,
with some desire for it to be used as a “screening” tool. It was discov-
ered that this marker lacked specificity and sensitivity. Not only has
CA125 been elevated in benign scenarios and even during pregnancy,
it was discovered not to be elevated in up to 50% of patients in the
earlier stages of ovarian cancer. As such, the CA125 marker is no lon-
ger a recommended method of screening for ovarian cancer.
Because genetic mutations can significantly increase one’s risk for
the development of gynecologic cancer, genetic screening is an option
to discover risk status. Providers have struggled to develop an effec-
tive screening tool for ovarian cancer, but a combination of different
tools can be somewhat effective. A transvaginal sonography, which is
beneficial in screening for pelvic masses, is not specific to ovarian
cancer and is not solely used for this purpose. However, when com-
bined with testing for the CA125 marker and a newer biomarker
called the human epididymis protein 4, transvaginal sonography may
aid in screening for some ovarian cancers. Further research is needed
for this to be effective because federal regulations currently limit the
use of monitoring with the human epididymis protein 4 biomarker.1
As with any cancer, a true diagnosis comes from a biopsy of sam-
ple tissue. Ovarian cancer is diagnosed through a core-needle biopsy,
where tissue is aspirated and examined closer to discover possible
malignancies. While this used to come with the risk of abdominal
wall metastasis, this risk has been reduced with the use of transvagi-
nal ultrasound-guided biopsies that carry only a small chance of nee-
dle site metastasis.31 Staging ovarian cancer is similar to staging
other cancers, being classified as stages I to IV using the International
Federation of Gynecology and Obstetrics scale as well as the American
Joint Committee on Cancer’s staging system.13 As a note, most
patients present with stage III carcinoma.13
Treatment
If preventative surgery is not an option and a woman is diagnosed
with ovarian cancer, there are multiple treatment options. Treatment
of ovarian cancer has traditionally been a combination of chemother-
apy and surgery, primarily with surgical staging of affected tissue,
tumor debulking surgery, and subsequent chemotherapy.4,13
Debulking Surgery
In patients who present with advanced stage ovarian cancer, it is
recommended to perform debulking surgery, which is considered
optimal if residual tumor nodules are less than 1 cm in maximum
diameter or thickness (per National Comprehensive Cancer Network
guidelines).13,32 Debulking surgery performed in appropriate patients
after further treatment by gynecologic oncologists has been associ-
ated with better outcomes.13,22,23 Likewise, large tumors or residual
tumors after an initial exploratory operation have been shown to
have negative side effects on effectiveness of treatment.13,22,23 They
can block perfusion to the area, which can lead to damaged tissue,
increased chance of cellular damage, as well as leaving opportunity
for the growth of multidrug-resistant clones.32 It may be suitable to
determine if a patient would benefit from debulking surgery by per-
forming an exploratory laparoscopic surgery to determine futility of
treatment. Laparoscopic surgeries are less invasive and are commonly
associated with decreased recovery time and improved quality of life.
While performing debulking surgeries, additional intraoperative pro-
cedures (ie, hysterectomy and bilateral salpingo-oophorectomy)
should be performed if extensive disease is obvious.4,13 Maximizing
the opportunity to remove affected tissue during debulking surgeries
is important; this can include bowel resection, hepatectomy, splenec-
tomy, cystectomy, and removal of any masses if at all possible.4,13 It is
also recommended that for subsequent interval debulking surgeries,
there should be a minimum of six cycles of treatment, including three
cycles of adjuvant therapy after each surgery.4,13
Neoadjuvant Therapy and Chemotherapeutic Agents
Before surgery, it may be necessary to decompress the size of the
tumor with what is called neoadjuvant therapy to reduce tumor bur-
den before surgery is performed.13 Current National Comprehensive
Cancer Network guidelines recommend intravenous taxane/
 C. Stewart et al. / Seminars in Oncology Nursing 35 (2019) 151 156 155

carboplatin and liposomal doxorubicin/carboplatin regimens as adju- Recurrence and Advanced Ovarian Disease
vant and neoadjuvant therapy after debulking surgery.13 A combina-
tion of carboplatin and paclitaxel remain the primary chemotherapy Removing the source of the cancer, the ovaries and fallopian tubes,
treatment for ovarian cancer.33 For 15 years, carboplatin has been the remains the primary first step in the treatment of ovarian cancer.
first choice adjuvant therapy after debulking surgery.33 Median progression-free survival for ovarian cancer is 18 months.2,4
One fairly new treatment for ovarian cancer is the use of poly Greatest risk of recurrence occurs because of advanced presentation
(ADP-ribose) polymerase (PARP) inhibitors.34,35 PARP proteins aid in of the disease and a need to educate the survivor and caregivers on
self-regeneration of cells once they are damaged. Cancer cells also symptoms to be aware of.
use these proteins to repair the damage caused by chemotherapy in
the treatment of ovarian cancer. These inhibitors stop the process of Short- and Long-Term Sequelae
regeneration in the cancer cells, prohibiting growth and larger tumor
formation. New drugs in this category, such as olaparib and rucaparib, The earliest indication of recurrent disease is an increase in
have started gaining traction in their usefulness in treating ovarian CA125.4 Most patients will receive second-line chemotherapy, but a
cancer when used in conjunction with chemotherapy.35 Because of small sub-set will be considered for surgery; however, in most
their recent discovery, research is continuing to identify which drug instances the surgery will be for palliative purposes only.3 With
is appropriate depending on the patient, tumor type, and situation. ovarian cancer, the gastrointestinal and urinary systems are fre-
Additionally, although these drugs are beneficial in the treatment of quently impacted because of their location. Short- and long-term
ovarian cancer, these medications are very expensive.34 Table 3 pro- sequelae can include abdominal distension, bloating, changes in
vides a list of chemotherapeutic agents frequently used for the treat- urinary (bleeding or blockage) and bowel habits (diarrhea or consti-
ment of ovarian cancer.13 pation), unexplained weight loss or gain, change or loss of appetite,
and/or rectal bleeding because of bowel obstruction. Often back or
abdominal pain secondary to tumor size or metastasis can also
Intraperitoneal Chemotherapy
occur.1 These symptoms can be both short- and long-term and the
woman should be educated on when to report to the care provider.
Some patients with advanced epithelial cancers and peritoneal can-
If they are recurrent, happening more than 12 times per month
cers with low-volume residual disease after debulking surgeries are eli-
over a 12-month timeframe, as referenced by the American Cancer
gible for intraperitoneal therapy.13 Intraperitoneal therapy has shown
Society, this should be of heightened concern for the provider and
promise in recent years by improving patient survival rates.36 In this
followed-up with testing and development of appropriate treat-
therapy, a small incision is made in the abdominal wall and a catheter
ment plans.
is threaded through subcutaneous tissue where it is inserted into the
The greatest impact of the sequelae both short- and long-term is
peritoneal cavity. The catheter acts as an infusion port where chemo-
the psychological impact on the patient. Ovarian cancer is often
therapeutic drugs can be inserted to dwell in the peritoneal cavity.13,36
lethal if not detected and treated as early as possible. Given the
nature of the emotional impact on the patient and family, genetic,
Vitamin D spiritual, and psychological counseling should be incorporated into
the treatment plans for patients with ovarian cancer.37 Ongoing
Another possible development in the treatment of ovarian cancer is fears of passing the BRCA1 and 2 gene mutation to a daughter and
the combination of the active form of vitamin D3 (1,25(OH)2D3): low assurance of “a cancer-free survival” can become overwhelming.
levels of vitamin D are associated with an increased risk of ovarian can- Support far greater than the brief follow-up appointments is often
cer.28 A factor that makes ovarian cancer difficult to treat is the envi- required to improve patient outcomes and ensure a focus on qual-
ronment provided by the omentum of the ovaries. In that type of ity of life.
setting, there are adipocytes, immune cells, microvascular cells, and
fibroblasts, all which create a futile breeding ground for cancer growth.
Implications for Nursing Practice
When administered in combination with chemotherapy, 1,25(OH)2D3
has been shown to significantly enhance antitumor properties, espe-
Nursing care should be holistic and patient-centered. With anyone
cially in the cancer cells of the omentum.28
going through cancer, the surgeries, treatments, and sometimes long-
lasting consequences, physical and psychosocial, can be a significant
Table 3 burden. Oncology nurses are asked to wear many hats: educator,
Commonly used chemotherapy agents for ovarian cancer. risk-anticipator, skilled provider, critical thinker, empathizer, and
advocate for safe and high-quality care. Ovarian cancer is a frighten-
Medication Route of Stage Duration
ing diagnosis and it is important for nurses to educate patients on
administration treated
expected outcomes and treatment plans. It is also important for
Paclitaxel and carboplatin Intravenous I 21 days nurses to involve a designated support person and/or team to also act
Paclitaxel and carboplatin Intravenous I 7 days
Docetaxel and carboplatin Intravenous I 21 days
as an advocate for the patient and help them cope with this poten-
Paclitaxel and cisplatin Intravenous or II, III, IV 21 days tially life-altering diagnosis.
intraperitoneal
Paclitaxel and carboplatin Intravenous or II, III, IV 21 days
intraperitoneal Conclusion
Dose-dense paclitaxel and Intravenous II, III, IV 21 days
carboplatin Ovarian cancer can be a terrifying diagnosis, but with the proper
Paclitaxel and carboplatin Intravenous II, III, IV 7 days
prevention methods and the development of screening tools there is
Docetaxel and carboplatin Intravenous II, III, IV 21 days
Carboplatin and liposomal Intravenous II, III, IV 28 days some anticipation that it may begin to decline as the most fatal gyne-
doxorubicin cologic cancer. Until that time, nurses and health care providers have
Bevacizumab with paclitaxel Intravenous II, III, IV 21 days an obligation to promote awareness and provide education to at-risk
and carboplatin populations. Education about risk factors, signs and symptoms, and
Data from the National Comprehensive Cancer Network. Ovarian cancer: including fal- use of evidence-based recommendations to reduce mortality to all
lopian tube cancer and primary peritoneal cancer.13 populations will help to reduce ovarian cancer mortality.
156 C. Stewart et al. / Seminars in Oncology Nursing 35 (2019) 151 156
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