Treatment Options

At the Ovarian Cancer Center, surgery is the mainstay of initial diagnosis and treatment of ovarian cancer. It is critical for women with suspected ovarian cancer to find an experienced gynecologic oncologist capable of performing the full range of surgical procedures for ovarian cancer.

The initial surgical approach may be either minimally invasive, such as with laparoscopy or robotic surgery, or through a traditional laparotomy, which requires a midline incision through the abdomen.

• To obtain tissue for the pathologist to study and establish a definitive diagnosis of ovarian cancer and the specific subtype of cancer
• To remove all or most of the disease through cytoreductive surgery in women whose cancer has spread

In most cases, this staging surgery includes a total hysterectomy (removal of the uterus) and bilateral salpingo-oophorectomy (removal of both ovaries and fallopian tubes), removal of the omentum (a fatty apron that hangs off the colon), and biopsies of lymph nodes and other peritoneal structures. The gynecologic oncologist can then determine the stage of disease, which will guide additional treatment decisions and usually includes chemotherapy.

Young women with Stage I ovarian cancer who want to preserve their fertility may have a more conservative operation. If there has been no evidence of spread beyond the primary ovary, only the diseased ovary would be removed.

• Part of the intestine or colon (which can almost always be reattached)
• Sections of the abdominal peritoneum
• The spleen or a portion of the diaphragm

The goal of cytoreductive surgery is to remove all or most of any visible disease, which means that many areas within the abdomen may require surgery to accomplish this goal. It is not uncommon for the surgeon to remove part of the intestine or colon, which are then reattached. In experienced hands, the need for a colostomy is unlikely (3 percent) even when part of the colon is removed.

Cytoreductive surgery may also include removal of enlarged lymph nodes, resection of the peritoneum over the diaphragm and removal of the spleen — all of which are common sites for the spread of ovarian cancer.

Where a woman undergoes surgery for advanced-stage ovarian cancer is critically important, extensive scientific literature shows. Women treated by an experienced gynecologic oncologist who performs cytoreductive operations frequently have long-term survival rates that are two to three times higher than for women treated by less experienced surgeons. Surgeons experienced in cytoreductive surgery are significantly more likely to remove all or most of the disease, with a resulting improvement in survival outcomes.

In addition, medical centers that perform a high-volume of ovarian cancer surgeries have the necessary resources to make sure that the surgery is performed both safely and effectively. Ideally, this type of surgery should be performed by a qualified and experienced gynecologic oncologist in a tertiary medical center that treats more than 20 ovarian cancer surgery cases a year.

For a minority of patients, surgical cytoreduction may not be appropriate either because their medical condition does not permit the surgery to be performed safely or because the location of the disease does not readily lend itself to surgical removal.

In this case, treatment begins with neoadjuvant chemotherapy (usually three to four treatments or cycles) to allow the patient’s medical condition to improve or to reduce the extent of the disease.

Cytoreductive surgery is then performed three to four months after the start of chemotherapy. It is usually followed by another three to four months of chemotherapy.

Except for women with very early Stage I ovarian cancer, most patients will receive some type of chemotherapy to either treat the visible disease or eradicate any lingering tumor cells that cannot be seen with the naked eye.

Standard chemotherapy for the most common types of ovarian cancer consists of two drugs—carboplatin and paclitaxel—administered intravenously every three weeks for three to six cycles as an outpatient. (A cycle is a 21-day treatment period.)

These drugs work by interfering with the cancer cells’ ability to divide and reproduce, but they can also damage healthy cells resulting in such common side effects as temporary hair loss, fatigue, nausea and suppression of the bone marrow and blood cells.

For selected patients with Stage III ovarian cancer, intra-peritoneal chemotherapy—with drugs administered directly into the abdominal cavity–may also accompany intravenous administration. Scientific studies show that for appropriately selected patients, intra-peritoneal chemotherapy can substantially improve the chances of long-term survival.

Recently, researchers have focused on the use of angiogenesis inhibitors in the treatment of ovarian cancer. These drugs block the growth of new blood vessels and interfere with the proteins and enzymes that ovarian cancer needs to grow.

Avastin, the most widely studied angiogenesis inhibitor for ovarian cancer, appears to enhance the effectiveness of standard chemotherapy with the drugs carboplatin and paclitaxel.

Researchers also are studying the effectiveness of hyperthermic intra-peritoneal chemotherapy (HIPEC). In this treatment approach, the peritoneal cavity is bathed directly with heated chemotherapy drugs immediately after cytoreductive surgery.

For women with advanced-stage cancer of the ovary, fallopian tube or peritoneum, one of the strongest determinants of survival is how much of the cancer is removed in the initial cytoreductive surgery. Research studies have shown that women who have all or most of the cancer removed at the time of diagnosis have a long-term survival rate two to three times longer than women unable to have this type of surgery.

Women with Stage III ovarian cancer are now surviving more than five years, provided that all visible cancer is removed before beginning chemotherapy.

For selected women with recurrent ovarian cancer, a repeat attempt at cytoreductive surgery may be recommended prior to re-treatment with chemotherapy. Patients most likely to benefit from repeat tumor "debulking" (secondary cytoreductive surgery) are those who have completed their initial chemotherapy at least 12 months earlier, who have no more than three sites of recurrence and are healthy enough to withstand another major operation.

The decision to proceed with secondary cytoreductive surgery should be made by an experienced gynecologic oncologist.

Radiation therapy is infrequently used to treat ovarian cancer, mostly because the disease tends to be metastatic at the time of diagnosis and would require a very large area of radiation.

For certain patients with isolated ovarian cancer recurrence, radiation therapy can be a very effective treatment either alone or in combination with standard chemotherapy.

Patients at the Ovarian Cancer Center receive extensive follow-up care and support from our multidisciplinary team of physicians, nurses, social workers and other experts.

Unfortunately, many women with ovarian cancer eventually experience a recurrence of their disease. A typical follow-up program include blood tests to monitor CA125 levels along with a physical exam every three months for the first two or three years. CT scans are usually performed at six-month intervals. Follow-up tests and physical exams then begin to occur less frequently because the risk of recurrence diminishes with time.

When ovarian cancer recurs, effective management of the disease requires a treatment plan tailored to the individual woman. This usually begins either a CT scan or combined PET/CT scans to determine the location and extent of disease.

About 40 percent of patients who experience a recurrence will be candidates for a repeat attempt at cytoreductive surgery to remove all visible tumor cells before beginning re-treatment with chemotherapy. The selection of chemotherapy treatment for recurrent disease will depend on prior treatments, the time between completion of initial therapy and recurrence and the individual patient’s previous experience with toxicity.

For certain patients, tissue may be obtained and sent for a commercially available chemotherapy sensitivity/resistance assay to help direct the choice treatments.