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This page is for GPs and is not intended as patient information. For information about the treatment of ovarian cancer, read this page

 

Treatment options for ovarian cancer often involve surgery and chemotherapy. For some, it will not be curative but instead provide optimal disease management and help maintain best possible quality of life.

Surgery

Treatment optionsSurgery is the primary treatment for the majority of women first diagnosed with ovarian cancer. The surgeon will aim to carry out ‘optimal debulking’ surgery to remove as much of the tumour as possible.

Surgical management of stage 1 ovarian cancer

This will usually include:

  • Hysterectomy (including the cervix)
  • Bilateral salpingo-oophrectomy
  • Omentectomy

The surgeon will assess the liver, spleen, peritoneum, appendix and diaphragm for signs of cancer through close clinical inspection and palpation.

If signs of tumour are found in the organs of the pelvis or abdomen, the surgeon will remove as much tumour as possible in ‘optimal debulking’ surgery.

Retroperitoneal lymph node assessment, in addition to biopsies taken from the pelvis and abdomen, will give further information and facilitate accurate staging.

In women of child-bearing age who wish to preserve their fertility, and whose disease appears to be confined to the ovary, a unilateral salpingo-oopherectomy may be performed if there are no signs of malignant disease in the contralateral ovary. The uterus may also be preserved.

Surgical management of advanced ovarian cancer (stages 2, 3 and 4)

In women where the tumour has spread beyond the ovaries the surgeon will try to remove as much tumour as possible, with ‘cytoreduction’:

  • complete cytoreduction – there are no visible signs of tumour following surgery
  • optimal cytoreduction – remaining tumour is less than 1cm in diameter
  • sub-optimal cytoreduction – remaining tumour is less than 2cm in diameter

Complete cytoreduction is often not possible in patients with advanced disease. Optimal cytoreduction surgery will be the priority.

Interval debulking surgery

This is a procedure often used in women who have undergone sub-optimal cytoreductive surgery. Following the initial surgery women are given chemotherapy. If a reduction in the residual tumour mass is detected, a further surgery will be performed to remove any remaining tumour.

Current recommendations state that patients with stage 3 ovarian cancer or above should be operated on by a gynaecological oncologist to achieve best surgical results.

Chemotherapy

Ovarian cancer is a chemosensitive disease and adjuvent chemotherapy has been shown to improve prognosis for patients with advance disease.

Current guidelines recommend that chemotherapy is started no later than eight weeks after initial surgery.

Women with low risk stage I disease

Adjuvent chemotherapy is not recommended for women who have optimal surgical staging and have low-risk stage I disease i.e. grade 1 or 2, stage Ia or Ib 

Women with high risk stage I disease

Adjuvent chemotherapy is recommended for women who have high risk stage I disease i.e. grade 3 or stage Ic. 

First-line treatment

NICE currently recommends paclitaxel (Taxol®) in combination with platinum agents; carboplatin or cisplatin is for first-line treatment. Paclitaxel is known to cause more side effects than treatment with a platinum agent alone and is not recommended for women who experience allergic reaction.

Carboplatin and cisplatin have been found to be equally effective in treating ovarian cancer. However, there are some advantages to treating patients with carboplatin:

  • carboplatin is less toxic than cisplatin, reducing nephrotoxicity, ototoxicity, nausea and vomiting
  • carboplatin is easier to administer than cisplatin and can be given to the patients in the outpatients departmen

Through the Cancer Drugs Fund (CDF) in England, bevacizumab (Avastin) is available to some women as a first-line treatment for advanced stage ovarian cancer (stage 3C/4) if they meet the criteria.

Relapsed disease

Treating ovarian cancer is often hampered by the tumours intrinsic or acquired resistance to platinum based chemotherapy. Most women will show some level of response to first-line chemotherapy, but relapse and subsequent relapses are highly likely. Treatment for relapsed disease is usually regarded as a palliative measure for symptomatic recurrent tumours.

The choice of second-line treatment is determined by the tumours level of platinum sensitivity, defined by NICE as follows:

  • Platinum-sensitive ovarian cancer: disease that responds to first-line platinum-based therapy but relapses 12 months or more after completion of initial platinum-based chemotherapy.
  • Partially platinum-sensitive ovarian cancer: disease that responds to first-line platinum based therapy but relapses between six and 12 months after completion of initial platinum based chemotherapy.
  • Platinum-resistant ovarian cancer: disease that relapses within six months of completion of initial platinum-based chemotherapy.
  • Platinum-refractory ovarian cancer: disease that does not respond to initial platinum-based chemotherapy.

Second-line treatment

For platinum-sensitive recurrent tumours, a combination of paclitaxel and platinum-based therapy is recommended.

For tumours that are platinum-resistant, or platinum-refractory alternative chemotherapy drugs, PLDH - pegylated liposomal doxorubicin hydrochloride (Caelyx®), and topotecan (Hycamtin®) may be considered.

In England NICE approved Olaparib (Lynparza) as a maintenance treatment of relapsed platinum-sensitive ovarian cancer, for women with a BRCA1 or 2 mutation, who have received three or more rounds of platinum based (carboplatin/cisplatin) chemotherapy.

In Scotland bevacizumab (Avastin) is an approved treatment for women who have platinum resistant recurrent ovarian cancer and have received no more than two rounds of chemotherapy. 

Radiotherapy

Radiotherapy is mainly used as a palliative treatment to reduce pain and, occasionally, bleeding.

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