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In the United States, ovarian cancer accounts for more deaths than all other gynecologic malignancies combined. Worldwide each year, more than 225,000 women are diagnosed, and 140,000 women die from this disease (Jemal, 2011). Of these, epithelial ovarian carcinomas make up 90 to 95 percent of all cases, including the more indolent low-malignant-potential (borderline) tumors (Quirk, 2005). The remainder includes germ cell and sex cord-stromal tumors, which are described in Chapter 36. Due to the similarities of primary peritoneal carcinomas and fallopian tube cancers, they are included within this section for simplicity.
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Approximately one quarter of patients will have stage I disease and an excellent long-term survival rate. However, there are no effective screening tests for ovarian cancer and few notable early symptoms. As a result, two thirds of patients have advanced disease when they are diagnosed. Aggressive debulking surgery, followed by platinum-based chemotherapy, usually results in clinical remission. However, up to 80 percent of these women will develop a relapse that eventually leads to disease progression and death.
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EPIDEMIOLOGY AND RISK FACTORS
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One in 78 American women (1.3 percent) will develop ovarian cancer during her lifetime. Because the incidence has slowly declined since the early 1990s, ovarian cancer is now the ninth leading cause of cancer in women. In 2015, 21, 290 new cases and 14,180 deaths are expected, and ovarian cancer remains the fifth leading cause of cancer-related death (Siegel, 2015). Overall, the average age at diagnosis is in the early 60s.
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Numerous reproductive, environmental, and genetic risk factors have been associated with ovarian cancer (Table 35-1). The most important is a family history of breast or ovarian cancer, and approximately 10 percent of patients have an inherited genetic predisposition. For the other 90 percent with no identifiable genetic link for their ovarian cancer, most risks are related to a pattern of uninterrupted ovulatory cycles during the reproductive years (Pelucchi, 2007). Repeated stimulation of the ovarian surface epithelium is hypothesized to lead to malignant transformation (Schildkraut, 1997).
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Nulliparity is associated with long periods of repetitive ovulation, and patients without children have double the risk of developing ovarian cancer (Purdie, 2003). Among nulliparous women, those with a history of infertility have an even higher risk. Although the ...