We help answer your questions about ovarian cancer recurrence, and look at treatment options. Knowing what questions to ask ahead of treatment can help you get clear answers.
- Why has the cancer come back?
- What can be done and can it be cured?
- I need to start treatment now, don’t I?
- Treatment options
Some women have a normal CT scan and a normal CA125 after successfully being treated for their initial ovarian cancer diagnosis. However, sometimes the cancer can still come back, even years after finishing your initial or ‘first-line’ treatment for ovarian cancer.
CT scans and CA125 cannot always detect invisible deposits of ovarian cancer that may remain. We need to develop highly sensitive and reliable methods to detect those tiny groups of cancer cells.
We still don’t fully understand why some cancers return, and why some return five years after finishing chemotherapy and others just months after.
There are lots of options for women with recurrent ovarian cancer. There are new and potentially promising treatments becoming available.
Unfortunately, it is rare that treatments for recurrent ovarian cancer make the disease disappear forever – it almost always comes back again at some point. The aim of treatment is to keep the disease under control and keep you feeling well for as long as possible in between treatments.
Many women first discover that their cancer has returned when their CA125 blood test starts to rise – yet they often feel completely well. If your cancer has returned but you feel fine, most oncologists will suggest that you can delay starting treatment.
However, some women may reasonably want to start treatment straight away – this is a natural reaction. If you want to start treatment sooner, discuss this with your oncologist. Your CNS will also be able to help you at this time.
There can be some benefits to waiting:
- It prolongs the interval between platinum-based chemotherapy treatments, which may help the response to the drug, and reduce the chances of developing resistance to it.
- It may improve your quality of life, because over the course of time if there are a number of recurrences, there would be less time spent having treatment and dealing with the side effects.
Discuss your preferences with your CNS or oncologist, as you may have a reason for wanting to start treatment as soon as possible (for instance to attend and be well for an important event).
Once you begin treatment it is likely that CA125 will be used to assess your response to treatment, unless you are amongst the small proportion of women whose CA125 has never registered as abnormal.
CT scans and ultrasounds may also be used to assess your response to treatment.
Chemotherapy is most commonly offered, and sometimes surgery may be considered.
There are a number of chemotherapy treatments available on the NHS for recurrent ovarian cancer. Your oncologist or CNS will discuss the available treatments and how they might be suitable for you. Increasingly new types of drugs (targeted agents) are being used or trialled, to limit the blood supply to tumours and affect their ability to grow.
- want to be more involved in making decisions about your treatment and care than you were before
- have opinions about whether a treatment option is right for you based on how you responded to it previously
- consider the pros and cons of participating in a clinical trial
- explore the possibility of accessing drugs other than those approved for recurrent ovarian cancer in the NHS
Types of chemotherapy
Oncologists divide recurrent ovarian cancer into two groups, depending on how long it has been since you finished your last platinum based chemotherapy (containing either carboplatin or cisplatin):
- platinum sensitive
- platinum resistant
If it has been six months or more since your last treatment with carboplatin or cisplatin. This means that there is a greater chance it will respond to more platinum.
Your oncologist will suggest giving you more carboplatin, usually in combination with another drug, such as paclitaxel (Taxol®), liposomal doxorubicin (Caelyx®), or gemcitabine.
The term ‘partially platinum sensitive’ can be used, when recurrence occurs between six and twelve months after the last treatment.
Occasionally (in approximately 10 per cent of cases), women can become allergic to carboplatin – this most commonly appears during the second or third cycle of chemotherapy for recurrent disease.
If this happens, you may be able to continue with carboplatin at a later date, using ‘desensitisation regimes’, where the carboplatin is re-started at a very low dose and gradually increased. Or you might be able to switch to cisplatin, which is very similar to carboplatin. However, if the allergy is severe, you may have to stop platinum chemotherapy altogether.
The cancer has returned within six months of your last treatment with platinum (either carboplatin or cisplatin).
In these circumstances, it is unlikely that it will respond to platinum chemotherapy again, and different drugs are used. These include paclitaxel (often given once per week rather than every three weeks), liposomal doxorubicin (Caelyx®), topotecan and gemcitabine. In platinum resistant ovarian cancer, these drugs are usually given alone (as ‘single agents’).
Remember you and your cancer are unique. Your oncologist will suggest using the drugs that will have the best impact on your ovarian cancer.
Surgery is not usually used for treating recurrence. You might be offered surgery if:
- it has been three years or more since you finished your first treatment, and during this time you have not experienced symptoms
- your clinical team has not detected any signs of cancer until this point
- your clinical team are confident that all tumours could be removed, usually when it is confined to one place
There is currently a UK trial called DESKTOP III, designed to see if surgery for recurrent ovarian cancer, in addition to chemotherapy, is better than chemotherapy alone. You can find out if this trial is running at a centre near you by visiting our Clinical Trials Information Centre. Just enter your postcode and keyword ‘DESKTOP’, call Target Ovarian Cancer on 020 7923 5470, or speak to your oncologist.
Surgery may also be recommended in certain circumstances to deal directly with certain symptoms such as a blocked bowel, or bowel obstruction.
You can always ask for a second opinion on whether surgery is an option, or not.
Radiotherapy is not often used for treating ovarian cancer because of how it develops. However it can sometimes be used to control symptoms in certain circumstances.
Hormone therapy, using drugs such as tamoxifen and letrozole, is best known as a treatment for breast cancer. However, it can also be useful in recurrent ovarian cancer, especially if the cancer is growing very slowly or you do not wish to receive more chemotherapy.
There have not been any large scale trials to see how hormone therapy compares to standard treatments, and who might benefit most from such an approach.
Other drugs for recurrent ovarian cancer
You will usually be offered standard treatments by your oncologists. This means drugs that are licensed for treating women with ovarian cancer in Europe/UK and approved for use within the NHS on the grounds of clinical and cost effectiveness.
Alternatively, you may be offered or want to ask about taking part in a clinical trial of a new drug, or a new combination of existing drugs.
Some women may wish to ask about accessing other ‘non-standard’ drugs.
Sometimes oncologists prescribe drugs that are either not yet licensed for ovarian cancer and/or approved for use in the NHS, to women with ovarian cancer outside the clinical trial setting. This is referred to as prescribing ‘off license’. An oncologist may, but is not obliged to, prescribe a drug ‘off license’ if they believe the patient may benefit, and they have confidence that the drug is safe because it is licensed for treating other types of cancer. This happens more commonly in Europe than the UK at present.
An oncologist may also choose to prescribe a drug, which is licensed but not yet approved for use in the NHS.
In either case the oncologist may have to apply for special funding, which may or may not be accepted.
Accessing funds for non-standard drugs
Within England, certain cancer drugs that are not available for routine use on the NHS can be accessed via a special fund called the Cancer Drugs Fund [CDF] designed to improve access to cancer drugs. Currently, only Avastin® (bevacizumab) is included on the CDF listings for women with recurrent ovarian cancer who meet the criteria.
In other UK countries, and for other drugs, Individual Patient Treatment Requests (IPTRs) or Exceptional Funding Requests (EFRs) have to be made by your oncologist. The rates of successful applications vary widely across the UK and within individual countries.
Occasionally drug manufacturers will run a compassionate access scheme for patients who meet certain criteria, meaning the drug company meet the cost. Your oncologist would need to approach the drug company.
If you are interested in accessing new drugs:
- Talk to your oncologist about any drugs beyond the standard ones that might be accessible.
- Find out about the suitability, potential risks and benefits of any of the drugs in question.
Not all drugs benefit all women. The funding and application process can be quite stressful at a time when you are unwell.
If your oncologist is reluctant or unsure about discussing other drugs, but you are still interested, you can always ask for a second opinion. You will need the support of an oncologist, as they have to make the applications for funding on your behalf.
This content is primarily taken from our guide, Back here again
Our expert guide offers practical advice and information to help you cope with an ovarian cancer recurrence.