How Ovarian Cancer Is Treated

Surgery, Chemotherapy, Radiation, and Clinical Trials

The treatment options for ovarian cancer depend on the stage of the disease as well as other factors and may include surgery, chemotherapy, targeted therapies, or clinical trials. Except in very early stage tumors, a combination of these therapies is usually used. Treatments may also vary if your cancer is a recurrence of an earlier cancer or if you are pregnant.

Your Cancer Care Team

Your first step in choosing the best treatment options is to understand your cancer care team. It's important to know which provider will play the role of managing your care and who you should call with questions.

Most often, ovarian cancer is first diagnosed, or at least suspected, by an obstetrician-gynecologist (OB/GYN) or another primary care physician. When choosing treatment options, however, it's recommended that you consult with a gynecologic oncologist before starting a regimen.

Other members of your health care team may include your primary care physician, an oncology social worker or counselor, a pathologist (who looks at any tissue removed during surgery), and possibly a palliative care physician (who focuses on relieving cancer-related symptoms) or a fertility specialist.

Treatment Options

There are two basic types of treatments for ovarian cancer:

  • Local Treatments: Treatments such as surgery and radiation therapy are local treatments. They treat cancer where it originated but do not address any cancer cells that have spread beyond the initial site of the cancer.
  • Systemic Treatments: When cancer spreads beyond its original location, systemic treatments such as chemotherapy, targeted therapies, or hormonal therapy (with non-epithelial tumors) are usually needed. These treatments address cancer cells no matter where they are located in your body.

Most people with epithelial ovarian cancer will have a combination of these treatments. Occasionally, such as with germ cell and stromal cell tumors, or early stage (such as stage IA) epithelial tumors, surgery alone, without chemotherapy, may be effective.

Surgery

Surgery is the mainstay of treatment for many people with ovarian cancer. It can vary both by the type of ovarian cancer and the stage. Studies have found that when ovarian cancer surgery is performed by a gynecologic oncologist, outcomes tend to be much better than when surgeries are performed by physicians of other specialties, as these are complex procedures.

Still, even when seeing a gynecologic oncologist, many people find it helpful (and often reassuring) to get a second opinion. If you are considering doing so, you may wish to consider one of the larger National Cancer Institute-designated cancer centers, which often have surgeons who specialize in one particular type of surgery.

Oophorectomy (for Germ and Stomal Cell Tumors)

Germ cell and stromal cell tumors are often found in the early stages. Many people with these tumors are young, and surgery to remove only the affected ovary (oophorectomy) can sometimes result in the preservation of the other ovary and uterus. Surgery alone may also be effective in very early epithelial tumors.

If both ovaries need to be removed, there are still some options for preserving fertility, such as freezing embryos. If you are interested in doing this if possible, talk with a physician who specializes in fertility preservation before your treatment begins.

Cytoreduction/Debulking Surgery (for Epithelial Ovarian Cancer)

Around 80 percent of epithelial ovarian cancers are found in the later stages of the disease (stage III and stage IV). Unlike breast and lung cancer, where surgery for stage IV disease doesn't improve life expectancy, surgery can extend life for those with stage IV ovarian cancer. It also improves the later benefit from chemotherapy.

Surgery for advanced epithelial ovarian cancer is referred to as cytoreductive surgery (debulking surgery). "Cyto" is the root word for cell and "reductive" means to reduce, so the goal of this surgery is to reduce the number of cancer cells present, rather than eliminate all cancer.

There are three possible outcomes of this surgery:

  • Complete: All visible cancer is removed.
  • Optimal: Cancer remains, but all areas are less than 1 cm in diameter (often referred to as miliary disease).
  • Sub-optimal: Nodules that are larger than 1 cm in diameter remain.

Cytoreductive surgery is a long and arduous surgery, and the risks of a longer procedure often outweigh the benefits. Therefore, an "optimal" cytoreduction is usually the goal of surgery.

In addition to removing both ovaries and fallopian tubes (a bilateral salpingo-oophorectomy) and uterus (hysterectomy), other tissue is often removed or biopsied as well. For example, the omentum, or layer of fatty tissue that overlays the ovaries and pelvis, is frequently removed (omentectomy).

Washings, a procedure in which saline is injected into the abdomen and pelvis and then withdrawn in order to look for the presence of cancer cells that are "loose" in the abdomen and pelvis, is also performed.

Lymph nodes in the abdomen and pelvis are often biopsied or removed (lymph node dissection). In addition, samples may be taken from the surface of many pelvic and abdominal organs, such as the bladder, intestines, liver, spleen, stomach, gallbladder, or pancreas. With serious epithelial tumors, the appendix is usually removed.

When samples are taken from the intestines, the two ends on either side of the region removed are reattached when possible. If not, the end of the intestine before the surgical site is sewn to the skin so that the bowel can be drained to the outside (creation of a stoma).

All of this surgery may be done right away, or instead after chemotherapy is given or after a recurrence of cancer.

The most common side effects of surgery are bleeding, infections, and reactions to anesthesia. Since cytoreduction surgery tends to be a lengthy operation, it's recommended that those at risk have a thorough heart and lung evaluation prior to surgery.

Chemotherapy

With ovarian cancer, it's almost impossible to remove all of the cancer. Even when surgery removes all visible cancer cells (such as with earlier stages), the recurrence rate is very high at around 80 percent. This means that even if visible cancer is not seen, microscopic areas of cancer are left behind. Therefore, chemotherapy is usually given for all but the very earliest stages of epithelial ovarian cancer. Chemotherapy is often used for higher stages of germ cell tumors as well.

Drugs Used

The drugs commonly used include a combination of:

  • Platinum drugs: Paraplatin (carboplatin) or Platinol (cisplatin).
  • Taxanes: Taxol (paclitaxel) or Taxotere (docetaxel).

There are many other drugs that may be used as well, including Doxil (liposomal doxorubicin) and Gemzar (gemcitabine).

With germ cell tumors, chemotherapy often includes a combination of Platinol (cisplatin), VP-16 (etoposide), and bleomycin.

Methods of Administration

Chemotherapy may be given in one of two ways:

  • Intravenously (IV): IV chemotherapy is usually given every three to four weeks and is repeated for three to six cycles. This can be given through a catheter placed in your arm, or through a chemotherapy port or PICC line.
  • Intraperitoneal chemotherapy: In this procedure, chemotherapy is given through a needle inserted directly into the abdominal cavity.

IV administration is more common, but researchers now believe that intraperitoneal chemotherapy is vastly underused for ovarian cancer. You may want to inquire about it.

In a 2016 review of studies, researchers found that intraperitoneal chemotherapy increases survival with ovarian cancer more than IV chemotherapy. In this study, it was noted that intraperitoneal chemotherapy caused more digestive tract side effects, fever, pain, and infection, but was less likely than IV chemotherapy to cause hearing loss (ototoxicity).

That said, intraperitoneal chemotherapy is not tolerated as well as IV chemotherapy and cannot be used if there is kidney dysfunction or significant scar tissue in the abdomen, so it is usually reserved for women with stage IV disease and those who had a sub-optimal cytoreduction.

Side Effects

Chemotherapy drugs interfere with cell division at different points in the cycle and are effective in killing off rapidly growing cells, such as cancer cells. Unfortunately, the treatment affects normal, rapidly dividing cells too, causing undesirable effects.

The most common side effects of chemotherapy drugs used for ovarian cancer include:

  • Nausea and vomiting: The treatment of chemotherapy-induced nausea and vomiting has improved dramatically in recent years, and preventive medications now often allow people to go through chemotherapy with little or no vomiting.
  • Bone marrow suppression leading to a low level of white blood cells, red blood cells, and platelets. It is the low level of a type of white blood cell called neutrophils that predisposes people to infections during chemotherapy.
  • Fatigue
  • Hair loss

Longer-term side effects of chemotherapy can include peripheral neuropathy (tingling, pain, and numbness in the hands and feet) and hearing loss (ototoxicity). There is also a small risk of developing secondary cancers down the line.

The side effects and complication of chemotherapy, however, are usually far outweighed by the survival benefits of these treatments.

Targeted Therapies

Targeted therapies are treatments that interfere with specific steps in the growth of ​cancer. Since they are directed specifically at cancer cells, they sometimes (but not always) have fewer side effects than chemotherapy. Therapies that may be used with ovarian cancer include:

  • Angiogenesis inhibitors: Cancers need to create new blood vessels in order to grow and spread. Angiogenesis inhibitors inhibit this process, essentially starving the tumor of a new blood supply. Avastin (bevacizumab) can sometimes slow the growth of ovarian cancer but can have serious side effects such as bleeding, blood clots, and a perforated bowel.
  • PARP Inhibitors: The first PARP inhibitor was approved for ovarian cancer in 2015. Unlike chemotherapy, these medications may be given in pill form rather than via an IV. PARP inhibitors work by blocking a metabolic pathway that causes cells with a BRCA gene mutation to die. Drugs available include Lynparza (olaparib), Rubraca (rucapraib), and Zejula (niraparib).

These medications are most often used for women who have BRCA mutations, but both Lynparza and Zejula can be used for women without BRCA mutations to treat ovarian cancer recurrences after chemotherapy. Side effects may include joint and muscle pain, nausea, and anemia among others, but tend to be tolerated better than chemotherapy. There is also a small risk (as with chemotherapy) of secondary cancers such as leukemia.

Other Treatments

Other types of treatment may be used with different types of ovarian cancer or for widespread disease. Hormonal therapy drugs are more commonly used for breast cancer. But drugs such as ovarian suppression drugs, tamoxifen, and aromatase inhibitors may be used for stromal cell tumors, and uncommonly, epithelial cell tumors. Radiation therapy isn't commonly used for ovarian cancer but may be utilized when there are extensive metastases in the abdomen.

Clinical Trials

There are many in-progress clinical trials looking at combinations of the above therapies, as well as newer treatments, both for the initial diagnosis of ovarian cancer and for recurrences. The National Cancer Institute recommends talking to your doctor about those that may be appropriate for you.

Sometimes the only way to use a newer treatment option is to be part of one of these studies. There are many myths about clinical trials, but the truth is that every treatment we now have for cancer was once first studied in this way.

Complementary Medicine (CAM)

To date, there are no studies that show that CAM therapies can treat ovarian cancer. Foregoing conventional treatments in favor of such options could actually be detrimental.

That said, some can help with the symptoms of cancer and its treatments, improving quality of life. For this reason, many cancer centers now offer various alternative therapies. Options that have shown some benefit in at least a few research studies include acupuncture, meditationyoga, music therapy, and pet therapy.

Supplements and Foods

Speak with your oncologist before trying any vitamin or mineral supplements. All are metabolized by either the liver or kidneys and could theoretically slow down or speed up the metabolism of chemotherapy drugs, affecting treatment. Some, in particular, warrant special caution: Vitamin E (as well as the herb Ginkgo biloba) can increase bleeding during and after surgery, and other supplements may increase the risk of abnormal heart rhythms or seizures related to anesthesia.

Furthermore, antioxidant preparations could actually end up protecting the very cells chemotherapy and radiation therapy aim to destroy; these treatments work by causing oxidative damage to the genetic material in cancer cells. Most oncologists believe that eating an antioxidant-rich diet is not a problem during treatment, however.

Omega-3 fatty acids, however, may be helpful to some. These supplements may help retain muscle mass in those with cancer cachexia, a condition involving weight loss, loss of muscle mass, and loss of appetite that affects about 80 percent of people with advanced cancer. 

There is some interest in turmeric (and its compound, curcumin), a common ingredient in curry and mustards that give these foods their yellow color. Some lab studies hint that turmeric may stimulate death of ovarian cancer cells, but not normal ones, and that ovarian cancer cells "fed" turmeric may be less likely to become resistant to chemotherapy. This research is not conclusive in terms of its application in humans, but there's no harm in using the spice.

Treatment for Recurrence

Unfortunately, around 80 percent of ovarian cancers that are treated with the standard therapies above will recur. The treatment approach for a recurrence depends on its timing:

  • Recurrence immediately after treatment: Such cases are considered platinum refractory, or resistant to platinum chemotherapy. Options include repeating chemotherapy with same drugs (although this usually results in a poor response), using a different chemotherapy regimen (there are several different options), or considering a clinical trial. 
  • Recurrence within six months of treatment: Such cases are considered platinum resistant. Options at this point might be a different chemotherapy drug or regimen, or a clinical trial. Surgery is not usually recommended.
  • Recurrence six months or more after treatment has been completed: If the original chemotherapy included the use of a platinum chemotherapy drug (Platinol or Paraplatin), the tumor is considered platinum sensitive. Treatment recommendations vary but may include cytoreduction surgery plus treatment with the original chemotherapy drugs.

Treatment in Pregnancy

Most ovarian cancers that occur during pregnancy are germ cell tumors or stromal cells tumors. These tumors often involve only one ovary, and surgery to remove the ovary is possible during pregnancy, though waiting until the second trimester is preferred.

For pregnant women with epithelial ovarian cancers and more advanced stage stromal cell or germ cell tumors, cytoreduction surgery is possible. Waiting until after the first trimester is ideal, but surgery may be considered earlier. Chemotherapy is relatively safe after the first trimester and can usually be started at around 16 weeks. For epithelial ovarian cancers, a combination of Paraplatin (carboplatin) and Taxol (paclitaxel) is usually used, with a combination of Platinol (cisplatin), Velban (vinblastine), and bleomycin used for non-epithelial tumors.

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