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Cancer Medicine :: Ovarian Cancer Treatment

Ovarian Cancer

General treatment information

After the diagnostic tests are done, your cancer care team will recommend 1 or more treatment options. The main treatments for ovarian cancer are:

Surgery, Chemotherapy, Hormone therapy, Targeted therapy, Radiation therapy

Surgery for ovarian cancer

Surgery is the main treatment for most ovarian cancers. How much surgery you have depends on how far your cancer has spread and on your general health. For women of childbearing age who have certain kinds of tumors and whose cancer is in the earliest stage, it may be possible to treat the disease without removing both ovaries and the uterus.

For epithelial ovarian cancer, surgery has 2 main goals: staging and debulking (removing as much of a tumor as possible − this is discussed in detail further down). It’s important that this surgery is done by someone who’s experienced in ovarian cancer surgery. Many gynecologists and surgeons are not trained to do the staging and debulking procedures that are necessary in treating ovarian cancer. For this reason, experts recommend that patients see a gynecologic oncologist for surgery.

Gynecologic oncologists are specialists who have training and experience in treating staging, and debulking ovarian cancer. Cancers that are debulked properly are called optimally debulked. Women with these cancers have a better outlook for survival than cancers that are not debulked properly (called sub-optimally debulked). Women with sub-optimally debulked ovarian cancer may need to have more surgery later.

For other types of ovarian cancer (germ cell tumors and stromal tumors), the main goal of surgery is to remove the cancer.

Staging epithelial ovarian cancer

Surgery for ovarian cancer has 2 main goals. The first goal is to stage the cancer − to see how far the cancer has spread from the ovary. Usually this means removing the uterus (this operation is called a hysterectomy), along with both ovaries and fallopian tubes (this is called a bilateral salpingo-oophorectomy or BSO). In addition, the omentum is also removed (an omentectomy). The omentum is a layer of fatty tissue that covers the abdominal contents like an apron, and ovarian cancer sometimes spreads to this tissue. Some lymph nodes in the pelvis and abdomen are biopsied (taken out to see if they contain cancer spread from the ovary).

If there is fluid in the pelvis or abdominal cavity, it will also be removed for analysis. The surgeon may "wash" the abdominal cavity with salt water (saline) and send that fluid for analysis. He or she may also remove tissue samples from different areas inside the abdomen and pelvis. All the tissue and fluid samples taken during the operation are sent to a lab to be examined for cancer cells. Staging is very important because ovarian cancers at different stages are treated differently. If the staging isn't done correctly, the doctor may not be able to decide on the best treatment.

Debulking epithelial ovarian cancer

The other important goal of surgery is to remove as much of the tumor as possible − this is called debulking. Debulking is very important in any patient with ovarian cancer that has already spread widely throughout the abdomen at the time of surgery. The aim of debulking surgery is to leave behind no tumors larger than 1 cm. This is called optimally debulked. Patients whose tumors have been optimally debulked, have a better outlook than those left with larger tumors after surgery.

Sometimes the surgeon will need to remove a piece of colon to debulk the cancer properly. In some cases, a piece of colon is removed and then the 2 ends that remain are sewn back together. In other cases, though, the ends can’t be sewn back together right away. Instead, the top end of the colon is attached to an opening (stoma) in the skin of the abdomen to allow body wastes to get out. This is known as a colostomy. Most often, this is only temporary, and the ends of the colon can be reattached later in another operation.

Debulking surgery might also mean removing a piece of the bladder. If this occurs, a catheter (to empty the bladder) will be placed during surgery. This will be left in place until the bladder recovers enough to be able to empty on its own. Then, the catheter can be removed.

Debulking may also require removing the spleen and/or the gallbladder, as well as part of the stomach, liver, and/or pancreas.

If both ovaries and/or the uterus are removed, you will not be able to become pregnant. It also means that you will go into menopause if you haven’t done so already. Most women will stay in the hospital for 3 to 7 days after the operation and can resume their usual activities within 4 to 6 weeks.

Surgery for ovarian germ cell tumors and ovarian stromal tumors

Most ovarian germ cell tumors are treated with a hysterectomy and bilateral salpingo-oophorectomy. If the cancer is in only one ovary and the patient still wants to be able to have children, only the ovary containing the cancer and the fallopian tube on the same side are removed (leaving behind the other ovary and fallopian tube and the uterus).

Ovarian stromal tumors are often confined to just one ovary, so surgery may be limited to removal of that ovary. If the cancer has spread, more tissue may need to be removed. This could mean a hysterectomy and bilateral salpingo-oophorectomy and even debulking surgery.

Chemotherapy for ovarian cancer

Chemotherapy (chemo) is the use of drugs to treat cancer. Most often, chemo is a systemic treatment − the drugs are given in a way that allows them to enter the bloodstream and reach all areas of the body. Systemic chemo can be useful for cancers that have metastasized (spread). Most of the time, systemic chemo uses drugs that are injected into a vein (IV) or given by mouth. For some cases of ovarian cancer, chemotherapy may also be injected through a catheter directly into the abdominal cavity. This is called intraperitoneal (IP) chemotherapy. Drugs given this way are also absorbed into the bloodstream, so IP chemotherapy is also a type of systemic chemo. 

Chemotherapy for epithelial ovarian cancer

Chemo for ovarian cancer most often is a combination of 2 or more drugs, given IV every 3- to 4-weeks. Giving 2 or more drugs in combination seems to be more effective in the initial treatment of ovarian cancer than giving just one drug alone.

The standard approach is the combination of a platinum compound, such as cisplatin or carboplatin, and a taxane, such as paclitaxel (Taxol®) or docetaxel (Taxotere®). For IV chemotherapy, most doctors favor carboplatin over cisplatin because it has fewer side effects and is just as effective.

The typical course of chemo for epithelial ovarian cancer involves 3 to 6 cycles. A cycle is a schedule of regular doses of a drug, followed by a rest period. Different drugs have varying cycles; your doctor will let you know what kind of schedule is planned for your chemo.

Epithelial ovarian cancer often shrinks or even seems to go away with chemo, but the cancer cells may eventually begin to grow again. If the first chemo seemed to work well and the cancer stayed away for a time, it can be treated with additional cycles of the same chemotherapy used the first time. In some cases, different drugs may be are used. Some of the chemo drugs that are helpful in treating ovarian cancer include (in alphabetical order):Albumin bound paclitaxel (nab-paclitaxel, Abraxane®),Altretamine (Hexalen®), Capecitabine (Xeloda®),Cyclophosphamide (Cytoxan®),Etoposide (VP-16),Gemcitabine (Gemzar®),Ifosfamide (Ifex®),Irinotecan (CPT-11, Camptosar®),Liposomal doxorubicin (Doxil®),Melphalan,Pemetrexed (Alimta®),Topotecan,Vinorelbine (Navelbine®).

The different drug combinations used to treat germ cell tumors are described in the section treatment for germ cell tumors.

Chemotherapy drugs kill cancer cells but also damage some normal cells. Therefore, your doctor will be careful to avoid or minimize side effects, which depend on the type of drugs, the amount taken, and the length of treatment.

Common temporary side effects include:

Nausea and vomiting

Loss of appetite

Loss of hair

Hand and foot rashes

Mouth sores

Chemotherapy can damage the blood-producing cells of the bone marrow, so patients may have low blood cell counts. This can result in:

Increased chance of infection (caused by a shortage of white blood cells)

Bleeding or bruising after minor cuts or injuries (caused by a shortage of blood platelets)

Fatigue (caused by low red blood cell counts)

Most side effects disappear once treatment is stopped. Hair will grow back after treatment ends, although it may look different. There are remedies for many of the temporary side effects of chemotherapy. For example, there are very good drugs that can be given to prevent and treat nausea and vomiting. 

Some chemo drugs may have long-term or even permanent side effects. For example, cisplatin can cause kidney damage. To help prevent this, doctors give lots of IV fluid before and after this drug is given. Both cisplatin and the taxanes can cause nerve damage (called neuropathy). This can lead to problems with numbness, tingling, or even pain in the hands and feet. Cisplatin can also damage the nerves to the ear, which can lead to hearing loss (called ototoxicity). Other drugs can have other side effects, so ask your doctor what side effects to expect from the drugs that you will receive. Most side effects improve once treatment is stopped, but some can last a long time and may never go away completely.

Chemo can also cause early menopause and infertility (inability to become pregnant), which may be permanent. This is rarely an issue in the treatment of epithelial ovarian cancer, since most women have both ovaries removed as a part of treatment.

Rarely, some chemo drugs can permanently damage bone marrow. This can later cause a bone marrow problem like myelodysplastic syndrome or even acute myeloid leukemia. This is called a secondary malignancy. Your health care team knows which drugs can cause this problem and will discuss this possibility with you. Their positive effects against ovarian cancer offset the small chance that any of these drugs will cause leukemia.

Intraperitoneal chemotherapy

In intraperitoneal (IP) chemotherapy for ovarian cancer, in addition to giving the chemo drug paclitaxel IV, the drugs cisplatin and paclitaxel are injected into the abdominal cavity through a catheter (thin tube). The tube can be placed during the staging/debulking surgery, but sometimes it is placed later. If it is done later, it can be placed by a surgeon using laparoscopy, or by an interventional radiologist under x-ray guidance. The catheter is usually connected to a port, a half dollar-sized disk topped with a pliable diaphragm. The port is placed under the skin against a bony structure of the abdominal wall, such as a rib or pelvic bone. A needle can be placed through the skin and into the port to give chemo and other drugs. Over time, problems may rarely occur with the catheter. − it may become plugged or infected or even damage the bowel.

Giving chemo this way gives the most concentrated dose of the drugs to the cancer cells in the abdominal cavity. This chemo also gets absorbed into the bloodstream and so can reach cancer cells outside the abdominal cavity. IP chemotherapy works well, but the side effects are often more severe than with regular chemo. In a study of women with advanced ovarian cancer, women getting the IP chemotherapy had more abdominal pain, nausea, vomiting, and other side effects than the women getting chemo through the vein. These side effects actually made some women stop their treatment early. Still, the women getting IP chemotherapy lived longer than the women getting regular chemo.

IP chemotherapy currently is only given to some of the women with ovarian cancer that has spread to the inside of the abdomen. It was only studied in women who had no areas of cancer spread outside the abdomen (stage III) and who had no tumors larger than 1 cm after surgery (optimally debulked). Also, because it can be so toxic, women must have normal kidney function and be in good overall shape for their doctor to be willing to try IP chemo. They also cannot have a lot of adhesions or scar tissue inside their abdomen because this can prevent the chemo from spreading well.

Germ cell tumors

Patients with germ cell cancer often need to be treated with combination chemo. The combination used most often is called PEB (or BEP), and includes the chemotherapy drugs cisplatin (Platinol), etoposide, and bleomycin. Dysgerminomas are usually very sensitive to chemotherapy, and can sometimes be treated with the less toxic combination of carboplatin and etoposide. Other drug combinations may be used if the cancer isn’t responding to treatment or to treat cancer that has recurred (come back). These include:

TIP: paclitaxel (Taxol), ifosfamide, and cisplatin

VeIP: vinblastine, ifosfamide, and cisplatin

VIP: etoposide (VP-16), ifosfamide, and cisplatin

Chemo for germ cell tumors has some of the same risks and side effects as the chemo for epithelial ovarian cancer. These include nausea/vomiting, hair loss, and low blood counts. Neuropathy, infertility, and premature menopause can also occur. The later development of leukemia occurs rarely.

Rarely, bleomycin can lead to lung damage, so some doctors order tests of lung function before using this drug. Ifosfamide can cause hemorrhagic cystitis (irritation and bleeding of the bladder lining). This can usually be prevented by giving the drug mesna with the ifosfamide.

Stromal tumors

Ovarian stromal tumors are not often treated with chemotherapy, but when they are, the combination of carboplatin plus paclitaxel or PEB (see above) is most often used.

Targeted therapy for ovarian cancer

Targeted therapy is a newer type of cancer treatment that uses drugs or other substances to identify and attack cancer cells while doing little damage to normal cells. These therapies attack the cancer cells' inner workings − the programming that makes them different from normal, healthy cells. Each type of targeted therapy works differently, but all alter the way a cancer cell grows, divides, repairs itself, or interacts with other cells.

The targeted therapy drug that has been studied the most in ovarian cancer is bevacizumab (Avastin®). This drug helps block the signal that cancer cells send out to cause new blood vessels to form to nourish new tumors. In studies, bevacizumab has been shown to shrink or slow the growth of advanced ovarian cancers. Trials to see if bevacizumab works even better when given along with chemotherapy have shown good results in terms of shrinking (or stopping the growth of) tumors. But it has not yet been shown to help women live longer. Also, there have been problems with patients developing holes in the bowel wall (perforations) during treatment. Although this complication is rare, it can be fatal.

Bevacizumab isn’t yet approved by the US Food and Drug Administration to treat ovarian cancer, but it has been approved to treat other cancers. It may be a treatment option for some women.

Other targeted therapy drugs are being studied.

Hormone therapy for ovarian cancer

Hormone therapy is the use of hormones or hormone-blocking drugs to fight cancer. This type of systemic therapy is rarely used to treat epithelial ovarian cancer, but is more often used to treat ovarian stromal tumors.

Luteinizing-hormone-releasing hormone (LHRH) agonists

LHRH agonists (sometimes called GnRH agonists) switch off estrogen production by the ovaries. These drugs are used to lower estrogen levels in women who are premenopausal. Examples of LHRH agonists include goserelin (Zoladex®) and leuprolide (Lupron®). These drugs are injected every 1 to 3 months. Side effects can include any of the symptoms of menopause, such as hot flashes and vaginal dryness. If they are taken for a long time (years), these drugs can weaken bones (sometimes leading to osteoporosis).

Tamoxifen: Tamoxifen is a drug that is often used to treat breast cancer. It can also be used to treat ovarian stromal tumors and is rarely used to treat advanced epithelial ovarian cancer. Tamoxifen acts as an anti-estrogen in many tissues in the body, but as a weak estrogen in others. The goal of tamoxifen therapy is to keep any estrogens circulating in the woman’s body from stimulating cancer cell growth. The anti-estrogen activity of this drug can lead to hot flashes and vaginal dryness. Because tamoxifen acts like a weak estrogen in some areas of the body, it does not cause bone loss and can increase the risk of serious blood clots in the legs.

Radiation therapy for ovarian cancer: Radiation therapy uses high energy x-rays or particles to kill cancer cells. These x-rays may be given in a procedure that is much like having a regular (diagnostic) x-ray. In the past radiation was used more often for ovarian cancer, but now radiation therapy is only rarely used in this country as the main treatment for this cancer.

External beam radiation therapy: In this procedure, radiation from a machine outside the body is focused on the cancer. This is the main type of radiation therapy used to treat ovarian cancer. Treatments are given 5 days a week for several weeks. Each treatment lasts only a few minutes and is similar to having a regular x-ray. As with a regular x-ray, the radiation passes through the skin and other tissues before it reaches the tumor. The actual time of exposure to radiation is very short, and most of the visit is spent getting the patient precisely positioned so that the radiation is aimed accurately at the cancer.

Some common side effects include:Skin changes – the skin in the treated area may look and feel sunburned or even blister and peel,Fatigue,Nausea,Diarrhea,Vaginal irritation, sometimes with a discharge

These side effects improve after treatment is stopped. Skin changes gradually fade, and the skin returns to normal in 6 to 12 months.

If you are having side effects from radiation, discuss them with your cancer care team. There may be things you can do to obtain relief.

Brachytherapy: Radiation therapy also may be given as an implant of radioactive materials, called brachytherapy, placed near the cancer. This is rarely done for ovarian cancer.

Radioactive phosphorus: Radioactive phosphorus was used in the past, but is no longer part of the standard treatment for ovarian cancer. For this treatment, a solution of radioactive phosphorus is instilled into the abdomen. The solution gets into cancer cells lining the surface of the abdomen and kills them. It has few immediate side effects but can cause scarring of the intestine and lead to digestive problems, including bowel blockage.

Treatment of invasive epithelial ovarian cancers, by stage

The first step in treating most stages of ovarian cancer is surgery to remove and stage the cancer. Debulking is also done as needed (see the section about surgery for details).

Stage I:The initial treatment for stage I ovarian cancer is surgery to remove the tumor. Most often the uterus, both fallopian tubes, and both ovaries are removed (a hysterectomy with bilateral salpingo-oophorectomy) (this is discussed in the surgery section).

In stages IA and IB (T1a or T1b, N0, M0), cancer was found inside one or both ovaries, without spread to lymph nodes or other organs. The treatment after surgery depends on the way the cancer looks under the microscope (called the tumor grade).

The tumor is grade 1 when the cancer cells look a lot like normal ovarian cells. The outlook is good for grade 1 tumors, and most patients require no treatment after surgery. If someone with a grade 1, Stage IA ovarian cancer wants to be able to have children after treatment, the initial surgery may be changed. Instead of removing the uterus, both ovaries, and both fallopian tubes, the surgeon may offer the option of removing only the ovary containing the cancer along with the fallopian tube on the same side.

For a grade 2 cancer (meaning the cancer looks something like normal ovarian cells), patients are either watched closely after surgery without further treatment, or they are treated with chemotherapy (chemo). The chemo used most commonly is carboplatin and paclitaxel (Taxol) for 3-6 cycles, but cisplatin can be used instead of carboplatin, and docetaxel (Taxotere) can be used instead of paclitaxel.

Grade 3 cancers don’t look very much like normal ovarian tissue under the microscope. The treatment of these tumors usually includes chemotherapy (like the chemo that is given for grade 2).

Stage IC (T1c, N0, M0): For stage IC ovarian cancer, standard surgery to remove the cancer is still the first treatment. After surgery, chemo is recommended, usually 3 to 6 cycles of treatment with carboplatin and paclitaxel.

Stage II (including IIA, IIB, IIC):For all stage II cancers, treatment starts with surgery for staging and debulking. This includes a hysterectomy and bilateral salpingo-oophorectomy (see the section about surgery for details). The surgeon will try to remove as much of the tumor as is possible.

After surgery, chemo is recommended for at least 6 cycles. The combination of carboplatin and paclitaxel is most often used. Some women with stage II ovarian cancer are treated with intraperitoneal (IP) chemotherapy instead of intravenous (IV) chemotherapy. This was discussed in more detail in the section about chemotherapy

Stage III:Stages IIIA, IIIB, and IIIC are given the same treatments as stage II cancers. First, the cancer is surgically staged and the tumor is debulked (like stage II). The uterus, both fallopian tubes, both ovaries, and omentum (fatty tissue from the upper abdomen near the stomach and intestines) are removed. The surgeon will also try to remove as much of the tumor as possible. The goal is to leave behind no tumor larger than 1 cm. When this goal is reached, the cancer is said to have been optimally debulked.

Sometimes tumor is growing on the intestines, and in order to remove the cancer, part of the intestine will have to be removed. Sometimes pieces of other organs (like the bladder or liver) may have to be removed to remove the cancer (this was discussed in the section about surgery). The smaller the remaining tumor, the better the outlook will be.

After recovery from surgery, combination chemo is given. The combination used most often is carboplatin (or cisplatin) and a taxane, such as paclitaxel (Taxol), given IV (into a vein) for 6 cycles.

Another option is to give intra-abdominal (intraperitoneal or IP) chemo after surgery. This was discussed in more detail in the section about chemotherapy. Since IP chemo means giving the drug paclitaxel IV along with the drugs cisplatin and paclitaxel into the abdomen (IP), women who get IP chemo are actually getting both IV and IP chemo. IP chemo is usually only considered if the cancer was optimally debulked − it may not work as well if a lot of tumor is left in the abdomen. IP chemo seems to work better than IV chemo, but it also causes worse side effects. These side effects can make it hard for someone to continue their treatment. For that reason, IP chemo may not be for everyone. Still, it is an option for women with advanced ovarian cancer to consider.

After surgery, and during and after chemo, blood tests will be done to determine if you have normal levels of a tumor marker called CA-125. A CT scan, PET-CT scan, or MRI could also be done to evaluate your response to treatment.

Patients who are too weak to have full staging and debulking surgery are sometimes treated with chemo as the first treatment. If the chemo works and the patient becomes stronger, surgery to debulk the cancer may be done, often followed by more chemo. Most often, 3 cycles of chemo are given before surgery, with at least 3 more after surgery (for a total of at least 6 cycles).

Second look surgery: In the past, many experts recommended another operation (laparoscopy/laparotomy) to see if the cancer was gone after chemo. This is known as a second look surgery. These operations haven’t been shown to have any real benefit, and so are no longer a standard part of ovarian cancer care. Still, they may be done as part of a clinical trial. In a clinical trial of new treatments, the second-look operation may be worthwhile to help determine how effective the new treatment is.

For laparoscopy, a small opening is made below the navel and a slender tube with a light is placed so the doctor can inspect the abdominal cavity to see how successful treatment has been.

Laparotomy requires an incision or surgical opening long enough to allow the surgeon to look inside the pelvis and abdomen and take biopsy samples. Your cancer care team can decide if you need more chemo based on the results of the second-look surgery,.

Consolidation therapy: For some patients, the doctor will recommend giving additional chemo after the cancer appears to be gone after the initial treatment. This is called maintenance or consolidation therapy. It is aimed at killing any cancer cells that were left behind after treatment but are too small to be seen with medical tests. The goal of consolidation therapy is to keep the cancer from coming back after treatment. One study showed that giving paclitaxel (every 4 weeks) for a year lengthened the time before the cancers came back, but didn't help the women live longer. Another study found no benefit, but it gave the drug on a different schedule. This is still being studied in clinical trials.

Stage IV:In stage IV, the cancer has spread to distant sites, like the inside of the liver, the lungs, or bone. This stage isn’t able to be cured with current treatment, but it can still be treated. The goals of treatment are to help patients feel better and live longer. Stage IV can be treated like stage III − with surgery to remove the tumor and debulk the cancer, followed by chemo. Another option is to treat with chemo first. Then, if the tumors shrink from the chemo, surgery may be done, which is followed by more chemo. Most often, 3 cycles of chemo are given before surgery, with at least 3 more after surgery. Another option is to limit treatment to those aimed at improving comfort (but aren’t aimed at fighting the cancer). This type of treatment is called palliative, and is discussed in more detail in the next section.

Recurrent or persistent ovarian cancer

Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs like the lungs or bone). Persistent tumors are those that never went away completely after treatment. Advanced epithelial ovarian cancer often comes back months or years after the initial treatment.

Sometimes, more surgery is recommended. Most patients with recurrent or persistent ovarian cancer are treated with some form of chemo. Which chemo drugs are used depends on what was used the first time and how well it worked (how long the cancer stayed away). The longer it takes for the cancer to come back after treatment, the better the chance that additional chemo will work. If it has been at least 6 months since any chemo, the patient may be treated with carboplatin and paclitaxel (even if these drugs were given before). Giving carboplatin with another drug is also an option.

If the cancer comes back in less than 6 months (or if it never went away at all), different chemo drugs usually will be tried. Some women may receive several different chemo regimens over several years. Many chemo drugs can be used to treat ovarian cancer (see the section about chemotherapy). In addition, some patients benefit from hormonal treatment with drugs like anastrozole, letrozole, or tamoxifen. Someone who didn't initially receive chemo can be treated with the same drugs that are used for newly diagnosed cancer − usually carboplatin and paclitaxel.

A clinical trial for new treatments might provide important advantages for women with recurrent or persistent ovarian cancer. Ask your cancer care team for information about suitable clinical trials for your type of cancer.

High-dose chemotherapy with stem cell rescue (sometimes known as stem cell transplant) has been used for women with recurrent or persistent ovarian cancer. This treatment has very serious side effects, however, and has not been proven to help patients live longer. It is best done as part of a clinical trial that is studying improvements to this procedure. 

Palliative treatments: A common problem that can occur in women with ovarian cancer is the build up of fluid in the abdomen. This is called ascites. It can be very uncomfortable but can be treated with a procedure called paracentesis. After the skin is numbed, a needle is used to withdraw the fluid, usually about 2 to 4 quarts, into a bottle. This will often need to be repeated from time to time. Sometimes chemo injected directly into the abdomen will be recommended. Treatment with bevacizumab (Avastin) may also be an option. These treatments can relieve symptoms for some patients and, rarely, might extend life. Often, however, their effects are temporary, and the cancer returns or persists.

Ovarian cancer can also block the intestinal tract. This is called obstruction, and can cause abdominal pain, nausea, and vomiting. Dealing with an intestinal blockage can be difficult. Often, the cancer has grown so much in the abdomen that surgery to unblock the intestine doesn't work. To help make the patient comfortable, doctors may place a tube through the skin and into the stomach to allow the stomach juices to drain, so that the digestive tract isn’t completely blocked. This can help with pain, nausea, and vomiting.

Sometimes a stent (a stiff tube) can be put into the large intestine to relieve a blockage. Since this option has a high risk of complications, you should discuss the risks and benefits with your doctor first.

In some patients, surgery can be done to relieve intestinal obstruction. This is often only offered to patients who are well enough to get additional treatments (like chemo) after surgery.

Treatment for epithelial tumors of low malignant potential

These tumors are also called LMP tumors, atypical proliferating tumors, or borderline tumors. When seen on ultrasound and CT scan, these tumors look the same as invasive epithelial ovarian cancers. To know for certain that the tumor isn’t an invasive epithelial ovarian cancer, a biopsy must be done. A biopsy sample is usually taken during surgery. Surgery for LMP tumors is similar to the surgery for invasive ovarian cancer, with the goals of removing the tumor along with full staging and debulking.

For women who have finished having children, the uterus, both fallopian tubes, and both ovaries are removed. Surgical staging is done to see if the tumor has spread outside of the ovary or pelvis. This means removing the omentum and some lymph nodes, and doing washings of the abdomen and pelvis. If the patient wants to be able to become pregnant in the future, only the ovary with the tumor and the fallopian tube on that side is removed. Rarely, just the ovarian cyst containing the tumor is removed. These patients still should have surgical staging to see if the tumor has spread. If the tumor is only in one ovary, the patient is usually observed without further treatment. Experts recommend follow-up visits at least every 6 months for the first 5 years after diagnosis. Chemotherapy (chemo) and radiation therapy are not generally the first treatments used for tumors that haven’t spread outside the ovary.

If the tumor has spread outside of the ovary when it is first diagnosed, the surgeon will remove as much of it as possible (debulk it). Treatment after surgery depends on something called invasion (when one kind of cell grows into organs or tissues where it doesn't belong). Part of what makes a cancer cell dangerous is its ability to invade other tissues. When LMP tumors spread, they can form tumor implants (deposits) on the lining of the abdomen (the peritoneum) and on the surface of organs in the abdomen and pelvis. Most often, these implants are non-invasive, meaning they haven't grown into the abdominal lining or organs. When they are growing into the peritoneum or the organs, they are said to be invasive.

Patients with non-invasive spread from an LMP tumor are usually observed without further treatment after debulking surgery. If the tumor implants are invasive, chemo may be offered. The chemo given is usually the same as that used for invasive ovarian cancer. Observation is often recommended for LMP tumors because they grow very slowly and even when they spread they are rarely fatal.

If the tumor comes back after initial surgery, further debulking surgery may be considered. Chemo and, rarely, radiation therapy are also options for recurrent LMP tumors.

Treatment for germ cell tumors of the ovary

Benign germ cell tumors: Women with benign (non-cancerous) germ cell tumors such as mature teratomas (dermoid cysts) are cured by removing the part of the ovary that contains the tumor (ovarian cystectomy) or by removing the entire ovary.

Malignant germ cell tumors: As with epithelial ovarian cancers, it is a good idea to consult with a gynecologic oncologist for treating malignant germ cell tumors, especially because these are so uncommon. Less than 2% of all ovarian cancers are germ cell tumors.

Most types and stages of germ cell cancers of the ovary are treated the same way, with surgery and chemotherapy (chemo). The exceptions are stage I, grade 1, immature teratoma and stage IA dysgerminoma. Their treatment is discussed in detail later in this section.

Surgery: In general, all patients with malignant germ cell tumors will have the same staging surgery that is done for epithelial ovarian cancer. If the patient is still interested in having children, the cancerous ovary and the fallopian tube on the same side are removed, but the uterus, the ovary, and the fallopian tube on the opposite side can be left behind. This isn’t an option when the cancer is in both ovaries. If the patient has finished having children, complete staging including removing both ovaries, both fallopian tubes, and the uterus is generally recommended.

Sometimes, the doctor might consider removing only a part of one ovary to allow a woman to keep her ovarian function. Even when both ovaries need to be removed, a patient may wish to keep her uterus to allow future pregnancy through the use of in-vitro fertilization. Consulting a gynecologic oncologist is advised in these cases.

If cancer has spread beyond the ovaries (stage IC and higher), debulking may be done as a part of the initial surgery. This removes as much cancer as possible without damaging or removing essential organs.

For stage IA dysgerminoma and stage I, grade 1, immature teratoma, surgery is usually the only treatment needed. Patients with these germ cell cancers are watched closely after surgery. If the cancer comes back later, the patient is usually given chemo.

Chemotherapy: Most patients with germ cell cancer will need to be treated with combination chemo for at least 3 cycles. The combination used most often is PEB (or BEP), and includes the chemo drugs cisplatin, etoposide, and bleomycin. Dysgerminomas are usually very sensitive to chemo, and can sometimes be treated with the less toxic combination of carboplatin and etoposide. Other drug combinations may be used to treat cancer that has recurred (come back) or hasn't responded to treatment.

Germ cell cancers can cause elevated blood levels of the tumor markers human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and/or LDH. If the blood levels of these are elevated before treatment starts, they are rechecked during chemo (usually before each cycle). If the chemo is working, the levels will go down to normal. If the levels stay up, it can be a sign that a different treatment is needed.

Stage IA dysgerminoma:If dysgerminoma is limited to one ovary, the patient may be treated by removing only that ovary and the fallopian tube on the same side, without chemo after surgery. This approach requires close follow-up so that if the cancer comes back it can be found early and treated. Most patients in this stage are cured with surgery and never need chemo.

Grade 1 immature teratoma:A grade 1 immature teratoma is made up mostly of non-cancerous tissue, and only a few cancerous areas seen under the microscope look immature (look like fetal organs). These tumors rarely come back after being removed. If careful staging has determined that a grade 1 immature teratoma is limited to one or both ovaries, the patient may be treated by removing the ovary or ovaries containing the cancer and the fallopian tube or tubes. If implants (tumor deposits) are found outside the ovary but they appear mature under a microscope (look like adult tissues), no chemo is needed after surgery.

Recurrent or persistent germ cell tumors: Recurrent tumors are those that come back after initial treatment. Persistent tumors are those that never disappeared even after treatment. Sometimes increased blood levels of the tumor markers HCG and AFP will be the only sign that a germ cell cancer is still there (or has come back).

Treatment for recurrent or persistent germ cell tumors may include chemo or, rarely, radiation therapy. For chemo, a combination of drugs is used most often. PEB (cisplatin, etoposide, and bleomycin) may be used if the patient did not receive this combination of drugs before. For patients who had already been treated with PEB, other combinations are used (see the section about chemotherapy).

For recurrent or persistent germ cell cancer, a clinical trial for new treatments may provide important advantages. Ask your cancer care team for information about clinical trials for your type of cancer.

Treatment for stromal tumors of the ovary, by stage

Stage I:All stage I tumors are treated with surgery to remove the ovary with the tumor. Most patients with stage I tumors are watched closely after the operation and don’t require further treatment. Some stage I tumors are more likely to come back after surgery. These cancers are said to be at high-risk for recurrence. Features that make a stage I tumor high-risk include very large tumors, tumors where the cyst broke open (ruptured), and poorly-differentiated tumors (also called high grade − the cancer cells don’t look very much like normal tissue when examined under the microscope). Patients with high-risk stage I stromal cancers have 3 options after surgery: observation (being watched closely), chemotherapy (chemo), or (rarely) radiation therapy

Stages II, III, and IV:These cancers are treated with surgery to remove the ovary with the tumor. Surgery is also used to stage and debulk the cancer, as needed (this is discussed in the section about surgery). This may be followed by chemo or hormone therapy. Often, the chemo used is what’s used in the treatment of germ cell tumors (PEB: cisplatin, etoposide, and bleomycin). The combination of carboplatin and paclitaxel (Taxol) may also be used. Hormone treatment is most often used to treat advanced stromal tumors in women who cannot tolerate chemo, but who want to try treatment. This can mean treatment with a drug such as leuprolide (Lupron) and goserelin (Zoladex), the drug tamoxifen, or an aromatase inhibitor. Rarely, radiation therapy is an option as well.

Recurrence

Cancer that comes back after treatment is said to be recurrent. This can happen years later for stromal tumors. Even so, the prognosis (outlook) may still be good because they grow so slowly. Surgery may be repeated. Any of the chemo regimens used initially can also be used to treat a relapse. Hormone therapy is also an option to treat recurrence. There really isn't a standard treatment for recurrent stromal cancer, so treatment as part of a clinical trial is also a good option. Radiation therapy may sometimes be helpful for recurrent cancer.

For tumors that produce hormones, the hormone blood levels may be checked at regular intervals after surgery to check for increased levels that could suggest the tumor has returned. The level of inhibin can also go up with some stromal tumors and may be useful to in finding a recurrence

What will happen after treatment for ovarian cancer?

For some people with ovarian cancer, treatment may remove or destroy the cancer. Completing treatment can be both stressful and exciting. You will be relieved to finish treatment, yet it is hard not to worry about cancer coming back. (When cancer returns, it is called recurrence.) This is a very common concern for those who have had cancer.

It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are leading full lives. 

For other people, the cancer never goes away completely. These women may be treated with chemotherapy on and off for years. Learning to live with cancer that does not go away can be difficult and very stressful. It has its own type of uncertainty. 

Follow-up care

When treatment ends, your doctors will still want to watch you closely. It is very important to go to all of your follow-up appointments. During these visits, your doctors will ask questions about any problems you may have and may do exams and lab tests or x-rays and scans to look for signs of cancer or treatment side effects. Almost any cancer treatment can have side effects. Some may last for a few weeks to months, but others can last the rest of your life. This is the time for you to talk to your cancer care team about any changes or problems you notice and any questions or concerns you have.

Follow-up for ovarian cancer usually includes a careful general physical exam and blood tests for tumor markers that help recognize recurrence. For epithelial ovarian cancer, it is not clear if checking for CA-125 levels and treating you before you have symptoms will help you live longer. Treatment based only on CA-125 levels and not symptoms can increase side effects, so it is important to discuss the pros and cons of CA-125 monitoring and quality of life with your doctor.

The choice of which tumor marker blood tests to check depends on the type of cancer a woman has. CA-125 is the tumor marker used most often to follow-up women with epithelial ovarian cancers. Others, such as CA 19-9, CEA, and HE-4, are used most often in patients whose CA-125 levels never went up.

For women with germ cell tumors, blood is tested for alpha-fetoprotein (AFP) and/or human chorionic gonadotropin (HCG). Checking levels of hormones like estrogen, testosterone, and inhibin is sometimes helpful for women with stromal cancers.

After your cancer treatment is finished, you will probably need to still see your cancer doctor for many years. So, ask what kind of follow-up schedule you can expect.

It is important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

If ovarian cancer treatment stops working

If cancer keeps growing or comes back after one kind of treatment, it is possible that another treatment plan might still cure the cancer, or at least shrink it enough to help you live longer and feel better. But when a person has tried many different treatments and the cancer has not gotten any better, the cancer tends to become resistant to all treatment. If this happens, it's important to weigh the possible limited benefits of a new treatment against the possible downsides. Everyone has their own way of looking at this.

This is likely to be the hardest part of your battle with cancer −- when you have been through many medical treatments and nothing's working anymore. Your doctor may offer you new options, but at some point you may need to consider that treatment isn’t likely to improve your health or change your outcome or survival.

If you want to continue to get treatment for as long as you can, you need to think about the odds of treatment having any benefit and how this compares to the possible risks and side effects. In many cases, your doctor can estimate how likely it is the cancer will respond to treatment you are considering. For instance, the doctor may say that more chemo or radiation might have about a 1% chance of working. Some people are still tempted to try this. But it is important to think about and understand your reasons for choosing this plan.

No matter what you decide to do, you need to feel as good as you can. Make sure you are asking for and getting treatment for any symptoms you might have, such as nausea or pain. This type of treatment is called palliative care.

Palliative care helps relieve symptoms, but isn’t expected to cure the disease. It can be given along with cancer treatment, or can even be cancer treatment. The difference is its purpose - the main purpose of palliative care is to improve the quality of your life, or help you feel as good as you can for as long as you can. Sometimes this means using drugs to help with symptoms like pain or nausea. Sometimes, though, the treatments used to control your symptoms are the same as those used to treat cancer. For instance, radiation might be used to help relieve bone pain caused by cancer that has spread to the bones. Or chemo might be used to help shrink a tumor and keep it from blocking the bowels. But this isn’t the same as treatment to try to cure the cancer.

At some point, you may benefit from hospice care. This is special care that treats the person rather than the disease; it focuses on quality rather than length of life. Most of the time, it is given at home. Your cancer may be causing problems that need to be managed, and hospice focuses on your comfort. You should know that while getting hospice care often means the end of treatments such as chemo and radiation, it doesn't mean you can't have treatment for the problems caused by your cancer or other health conditions. In hospice the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult time. You can learn more about hospice in our documents Hospice Care and Nearing the End of Life. They can be read online, or call us to have free copies mailed to you.

Staying hopeful is important, too. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends − times that are filled with happiness and meaning. Pausing at this time in your cancer treatment gives you a chance to refocus on the most important things in your life. Now is the time to do some things you've always wanted to do and to stop doing the things you no longer want to do. Though the cancer may be beyond your control, there are still choices you can make.

What`s new in ovarian cancer research and treatment?

Risk factors and causes

Scientists continue to study the genes responsible for familial ovarian cancer. This research is beginning to yield clues about how these genes normally work and how disrupting their action can lead to cancer. This information eventually is expected to lead to new drugs for preventing and treating familial ovarian cancer.

Early detection: Accurate ways to detect ovarian cancer early could have a great impact on the cure rate. Researchers are testing new ways to screen women for ovarian cancer, and a national repository for blood and tissue samples from ovarian cancer patients is being established to aid in these studies. One method being tested is looking at the pattern of proteins in the blood (called proteomics) to find ovarian cancer early.

Diagnosis: A test called OVA1 is meant to be used in women who have an ovarian tumor. It measures the levels of 4 proteins in the blood. The levels of these proteins, when looked at together, are used to put women with tumors into 2 categories − low risk and high risk. The women labeled low risk are not likely to have cancer. The women called high risk are more likely to have a cancer, and so should have surgery by a specialist (a gynecologic oncologist). This test is NOT a screening test − it is only meant for use in women who have an ovarian tumor.

Chemotherapy
New chemotherapy (chemo) drugs and drug combinations are being tested. The drugs trabectedin (Yondelis®) and belotecan have shown promise in some studies.
When the drugs cisplatin and carboplatin stop working, the cancer is said to be platinum resistant. Studies are looking for ways (like other drugs) to make these cancers sensitive to these drugs again.
Although carboplatin is preferred over cisplatin in treating ovarian cancer if the drug is to be given IV, cisplatin is used in intraperitoneal (IP) chemotherapy. Studies are looking at giving carboplatin for IP chemo.
Another approach is to give IP chemo during surgery using heated drugs. This, known as heated intraperitoneal chemotherapy or HIPEC, can be effective, but is very toxic. It still needs to be studied and compared with standard IP chemo to see if it actually works better.
 
Targeted therapy
Targeted therapy is a newer type of cancer treatment that uses drugs or other substances to identify and attack cancer cells while doing little damage to normal cells. Each type of targeted therapy works differently, but they all attack the cancer cells' inner workings − the programming that makes them different from normal, healthy cells. Bevacizumab (Avastin) is the targeted therapy that has been studied best in ovarian cancer, but other drugs are also being looked at, as well.
 
Immunotherapy
Another approach is to develop tumor vaccines that program the immune system to better recognize cancer cells. Also, monoclonal antibodies that specifically recognize and attack ovarian cancer cells are being developed. These antibodies are man-made versions of the antibodies our bodies make to fight infection. They can be designed to home in on certain sites on the cancer cell. Farletuzumab is a monoclonal antibody that is directed against a protein on the surface of ovarian cancer cells. It has shown promise in treating ovarian cancer in early studies. Another monoclonal antibody being studied in ovarian cancer is called catumaxomab. It binds to a protein that is in some cancer cells and some immune system cells. When it is administered into the abdominal cavity, it can help treat fluid build up (ascites) that can occur when cancer is present.
 

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