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OVARIAN CANCER OVERVIEW — Ovarian cancer is the second most common cancer of the reproductive organs among women in the United States. It most commonly occurs in women between the ages of 50 and 65. A woman's lifetime risk of developing ovarian cancer is approximately 1.4 percent.
There are several different types of cancer that can start in the ovary; the most common is called "epithelial" ovarian cancer. This topic review will discuss the treatment of epithelial ovarian cancer, with a focus on chemotherapy after initial surgery. The diagnosis and staging of ovarian cancer is discussed separately. (See "Patient education: Ovarian cancer diagnosis and staging (Beyond the Basics)".)
CANCER CARE DURING THE COVID-19 PANDEMIC — COVID-19 stands for "coronavirus disease 2019." It is an infection caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and has since spread throughout the world. Getting vaccinated lowers the risk of severe illness; experts recommend COVID-19 vaccination for anyone with cancer or a history of cancer.
In some cases, if you live in an area with a lot of cases of COVID-19, your doctor might suggest rescheduling or delaying medical appointments. But this decision must be balanced against the importance of getting care to screen for, monitor, and treat cancer. Your doctor can talk to you about whether to make any changes to your appointment schedule. They can also advise you on what to do if you test positive or were exposed to the virus.
SURGICAL TREATMENT — Ovarian cancer is diagnosed (and the stage determined) through exploratory surgery (see "Patient education: Ovarian cancer diagnosis and staging (Beyond the Basics)", section on 'Initial surgery'). The surgeon will also remove all visible cancer. In most cases, this involves removing the uterus, fallopian tubes, and ovaries (figure 1). This is done to ensure that as much of the cancer as possible is removed, and to help prevent the cancer from spreading further. Sometimes, no further treatment is needed; however, most of the time, additional (or "adjuvant") treatment with chemotherapy is recommended.
Sometimes, doctors suggest treatment with chemotherapy before surgery. Your health care providers will talk to you about your options. (See 'Chemotherapy before surgery' below.)
DO I NEED CHEMOTHERAPY? — Most women with ovarian cancer do get treatment with chemotherapy (in addition to surgery). After the cancer is removed with surgery to the extent possible, there is still a risk that cancer cells remain and may return or spread to other parts of the body. Chemotherapy is given after and sometimes before surgery to destroy these cells; it improves the chance that the cancer will not recur and decreases the risk of dying of ovarian cancer.
Whether or not you are a candidate for chemotherapy depends on your disease stage and how aggressive the tumor is (also referred to as the "grade" and cell type of the tumor); this is determined during or usually after surgery by a pathologist who looks at the tissues under a microscope. In general, chemotherapy is recommended for all women who are newly diagnosed with ovarian cancer, except in the case of selected women with stage IA or IB disease (also called "early-stage disease"), in which case surgery alone is often effective. Women with later-stage disease are offered chemotherapy. Although advanced-stage cancer is associated with a poorer prognosis, chemotherapy can help relieve symptoms and slow the progression of disease. The stage and grade of your disease will also affect which chemotherapy drugs your doctor suggests.
For women diagnosed with early-stage and low-grade disease, surgery alone is usually effective, and no additional therapy is needed. (See "Patient education: Ovarian cancer diagnosis and staging (Beyond the Basics)", section on 'Ovarian cancer staging'.)
What is chemotherapy? — Chemotherapy refers to the use of medicines to stop or slow the growth of cancer cells. Chemotherapy targets growing cells, interfering with their ability to divide or multiply. Because most of an adult's normal cells are not actively growing, they are not as affected by chemotherapy as the cancer cells. However, the cells in the bone marrow (where the blood cells are produced), the hair follicles, and the lining of the gastrointestinal (GI) tract are all growing; the side effects of chemotherapy drugs (such as hair loss or nausea) are related to effects on these and other normal tissues.
What types of chemotherapy are used? — Among the chemotherapy agents most commonly used in the treatment of ovarian cancer are taxanes (paclitaxel or docetaxel) and platinum agents (carboplatin or cisplatin). Studies have demonstrated that platinum- and taxane-containing chemotherapy improves the survival of women with ovarian cancer over other types of regimens. As a result, the combination of a platinum-type drug (usually carboplatin) and a taxane (usually paclitaxel) is the standard chemotherapy regimen.
How is chemotherapy administered? — Most chemotherapy drugs are given intravenously (by IV). However, in certain situations, doctors may use another treatment strategy that involves giving chemotherapy both by IV and directly into the abdominal (peritoneal) cavity. This approach is called intravenous/intraperitoneal (IV/IP) therapy.
In general, regardless of the way therapy is administered (IV or IV/IP), chemotherapy drugs are given in a carefully defined sequence over a period of several months. Chemotherapy sessions typically happen weekly or every three weeks. A "cycle" of chemotherapy refers to the time it takes to give the treatment and then allow the body to recover from the effects. During this time, you will be closely monitored for signs of drug toxicity and side effects.
What are the side effects of treatment? — Chemotherapy can cause side effects during and after treatment. The type and severity of these side effects depends upon which chemotherapy drugs are used and how they are administered. Side effects that occur during chemotherapy are usually temporary and reversible. The most common side effects are nausea, vomiting, mouth soreness, temporary lowering of the blood counts, and hair loss.
Another drug, bevacizumab, is sometimes given in addition to chemotherapy medicines. Bevacizumab can cause different side effects, including new or worsening hypertension (high blood pressure), nose bleeds, dizziness, headache, and delayed wound healing. Women with ovarian cancer who receive bevacizumab may have a slightly increased risk of bowel perforation (a tear in the large intestine) during treatment. Your doctors can talk to you about this risk.
CHEMOTHERAPY BEFORE SURGERY — In most cases, chemotherapy is given after surgery for ovarian cancer. However, some clinicians prefer to give several cycles of chemotherapy before surgery, for certain patients (called "neoadjuvant" chemotherapy). The goal is to reduce the size of the tumor and improve the chances that the surgeon will be able to remove all of the cancer. Neoadjuvant chemotherapy may also be used in situations in which the cancer is extensive (making initial surgery risky) or the person is not healthy enough for surgery.
MAINTENANCE THERAPY — Your doctor may recommend that once your surgery and chemotherapy are completed, you receive additional treatments. The rationale is to prevent potential microscopic disease from growing and to prolong the time to tumor growth. This could involve a continuation of targeted agents such as bevacizumab or a different agent such as a poly(ADP-ribose) polymerase (PARP) inhibitor. Some people receive both a PARP inhibitor and bevacizumab together. These maintenance treatments are given for approximately an additional year or up to three years depending upon the agent used and other factors.
MONITORING AFTER OVARIAN CANCER TREATMENT — After completing treatment (surgery and/or chemotherapy), your doctor will do a physical exam, imaging tests (such as a computed tomography [CT] scan), and blood tests to see if any cancer remains in the body. A "complete response" means these tests do not suggest evidence of cancer. However, it is possible for tiny, undetectable amounts of cancer to still be present, even in the case of a complete response. When this happens, the cancer can grow again later and require additional treatment.
To monitor for the possibility of recurrent ovarian cancer, experts recommend continuing to get follow-up blood tests and exams for at least five years after treatment ends. Imaging tests may also be done depending on the results of your physical exam and blood tests, as well as whether you have any symptoms. Below is one approach for ongoing monitoring, which is similar to the guidelines from the National Comprehensive Cancer Network (NCCN):
●Office visits with pelvic examination every two to four months for two years, then every six months for three years, then annually.
●Periodic blood tests for cancer antigen 125 (CA-125) and/or human epididymis protein 4 (HE4) as recommended by your health care provider. A rise in the level of "tumor markers" such as these is often the earliest sign of an ovarian cancer recurrence. However, it's not clear whether there is a benefit to detecting and treating a recurrence based on elevations in tumor makers alone (in the absence of signs or symptoms). (See 'Signs of recurrence' below.)
●Chest X-ray and chest/abdomen/pelvic CT scan are typically done only if your provider finds any abnormalities on your history, exam, or blood test(s).
Signs of recurrence — Even women with a complete response to initial therapy can have a recurrence of ovarian cancer at a later time. The likelihood of a tumor recurrence is highest in women with more advanced-stage disease at diagnosis, particularly if initial surgery was unable to remove all of the cancer. The earliest evidence of recurrent ovarian cancer may be a rising blood level of one of the tumor markers (CA-125 or HE4), symptoms (often abdominal pain or bloating with or without back pain), or clinical signs (such as a pelvic mass).
In the past, treatment for recurrent ovarian cancer was sometimes recommended based on rising levels of tumor markers alone, instead of waiting until symptoms developed. However, a large study showed no survival benefit of starting chemotherapy based on rising CA-125 values alone and that quality of life may be improved by waiting until there are symptoms or signs of ovarian cancer recurrence. If your CA-125 level is rising but you do not have symptoms, your health care provider can talk with you about what this means and what your options are.
TREATMENT OF RELAPSED OR RECURRENT OVARIAN CANCER — Women with relapsed (recurrent) ovarian cancer following an initial complete response, and those who do not respond well to initial chemotherapy, are candidates for further chemotherapy. This is often called "second-line" chemotherapy. The choice of which drugs to use for second-line treatment depends upon several different factors, including whether and how well you responded to first-line treatment, your current symptoms, how long it has been since your last treatment, and whether you have any long-term side effects from previous cycles of chemotherapy.
Platinum-sensitive ovarian cancer — If the initial treatment with chemotherapy worked, and the response lasted for at least six months, a woman is considered to have "platinum-sensitive" cancer. For these women, at the time of relapse, retreatment with another cycle of platinum-based chemotherapy is usually recommended. Studies show that a repeat response to chemotherapy is possible with platinum-based retreatment. In general, combination platinum-based therapy (with more than one drug) is preferred to single-drug therapy. Other drugs, such as bevacizumab or a poly(ADP-ribose) polymerase (PARP) inhibitor, may be used with and/or following chemotherapy to improve outcomes such as response rates and time to tumor progression as done in front-line treatment. Niraparib, olaparib, and veliparib are examples of PARP inhibitors. PARP inhibitors work particularly well in women with advanced ovarian cancer who carry a mutation in breast cancer susceptibility gene 1 or 2 (BRCA1 or BRCA2; a genetic mutation that is associated with increased risks for breast and ovarian cancer).
In certain situations, if the cancer can be removed and the woman has been free of disease for at least six months, repeat surgery may be an option.
Platinum-resistant ovarian cancer — If a woman has persistent or nonresponsive ovarian cancer despite first-line therapy with paclitaxel and a platinum agent, or if she relapses within six months of completing such therapy, she is considered to have "platinum-resistant" cancer. Most women in this situation are treated with a course of chemotherapy with a single drug. Select women with platinum-resistant ovarian cancer may benefit from chemotherapy plus bevacizumab. In addition, for women who carry a mutation in the BRCA1 or BRCA2 gene, a PARP inhibitor is also a treatment option, particularly if they have progressed after multiple prior lines of treatment. Your health care provider can talk to you about your options in order to help you decide which approach to take.
CLINICAL TRIALS — Progress in treating cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. We strongly encourage patients to enroll in well-designed clinical trials evaluating new treatments for epithelial ovarian cancer. These trials generally provide the highest level of care while providing access to the newest and potentially most active regimens. Further information regarding clinical trials can be found at the following websites:
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Ovarian cancer (The Basics)
Patient education: Ovarian cysts (The Basics)
Patient education: Ovarian cancer screening (The Basics)
Patient education: Preserving fertility after cancer treatment in women (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis
Adnexal mass: Role of serum biomarkers in diagnosing epithelial carcinoma of the ovary, fallopian tube, or peritoneum
Screening for ovarian cancer
Medical treatment for relapsed epithelial ovarian, fallopian tube, or peritoneal cancer: Platinum-resistant disease
Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Histopathology
First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer
Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Surgical staging
Early detection of epithelial ovarian cancer: Role of symptom recognition
Adjuvant therapy of early-stage (stage I and II) epithelial ovarian, fallopian tube, or peritoneal cancer
Cancer of the ovary, fallopian tube, and peritoneum: Surgical options for recurrent cancer
The following organizations also provide reliable health information:
●National Cancer Institute
●American Cancer Society
●National Ovarian Cancer Coalition
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Vincent E. Herrin, MD, who contributed to an earlier version of this topic review.
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