Ovarian cancer is most often treated with surgery and chemotherapy.
If ovarian cancer is suspected, it is absolutely critical to have a gynecologic oncologist perform surgery. A gynecologic oncologist’s involvement can have a direct and positive impact on a patient’s survival. In recent decades, research has shown that surgery by a gynecologic oncologist is one of the top factors in increasing ovarian cancer survival rates, as well as decreasing rates of recurrence.
Your specific treatment plan will depend on several factors, including:
- Stage and grade of your cancer
- Size and location of your cancer
- Age and general health
Surgery is often the initial step in ovarian cancer and also provides the gynecologic oncologist with the definitive diagnosis. The cancer is removed during surgery. Additionally, specific organs, such as the ovaries, can be removed. Frequently, the gynecologic oncologist also removes the omentum (tissue covering the stomach and large intestine) and possibly lymph nodes. In some cases, the fallopian tubes, uterus and the cervix will also be removed.
It is critical to stage and grade the cancer appropriately, which determines the spread of the cancer and its differentiation. This procedure is typically known as “debulking” and may also involve tissue samples from various organs, the diaphragm as well as fluid (known as ascites). Tumor debulking reduces the amount of cancer substantially and allows the chemotherapy to treat the cancer which remains, such as microscopic cancer.
If a woman has not yet gone through menopause when the ovaries are removed, she will experience immediate surgical menopause due to the loss of hormones that are made by the ovaries. Soon after the surgery, the woman is likely to experience the following symptoms:
- Hot flashes
- Vaginal dryness
- Sexual problems
- Sleep disturbance
- Increased risk of heart disease
- Bone thinning (osteoporosis)
You should talk with your doctor about ways to cope with these side effects.
There are different types of surgery for ovarian cancer. The type of surgery you have depends mainly on these factors.
- Type of ovarian cancer that you have
- Whether the cancer is confined to your ovary or has spread
- Whether you plan to become pregnant
- Whether your general health is good
If your cancer was found at an early stage and has not spread, your surgeon may be able to leave your uterus and one ovary and fallopian tube intact, which may still allow you to have children. If both of your ovaries and your uterus are removed, you will no longer be able to have children. You will enter sudden menopause, if you have not already reached it. This means you will no longer have menstrual periods.
You may have more than one type of surgery. They may be done as one procedure or as separate procedures. Depending on the type and stage of the cancer, you may or may not have another type of treatment. For example, you could have chemotherapy, before or after surgery.
No matter what type of surgery you have, it is important for the cancer to be staged to see the extent of the disease. To do this, a pathologist checks the removed tissue samples (called biopsies) from your reproductive organs. In addition, the surgeon will usually remove specific lymph nodes. The surgeon will also usually take multiple biopsies in the abdomen and pelvis and remove the omentum.
These are the types of surgery used to treat ovarian cancer:
Total Abdominal Hysterectomy and Bilateral Salpingo-Oopherectomy (TAH/BSO)
This surgery is the most common in the treatment of ovarian cancer. During this procedure, the surgeon removes the following:
- Both ovaries
- Both fallopian tubes
- Cervix, which is the narrow end of the uterus
This surgery removes an ovary. The surgeon may remove one or both of the ovaries. It depends on the likelihood of the cancer spreading. Another consideration may be whether or not you want to have children. If the cancer has not spread to more than one ovary, it may be possible for the surgeon to remove only one ovary and one fallopian tube. This is called salpingo-oopherectomy. This procedure would let you attempt pregnancy. If conservative surgery is performed, it is very important that staging be done to be sure that the cancer is in an early stage.
Lymph Node Biopsy/Omentectomy
Your doctor will usually remove lymph nodes and the omentum at the same time as an oophorectomy or hysterectomy. Lymph nodes are small glands that are part of your immune system. They help your body fight infections. The surgeon removes nodes and has the pathologist check them for signs of cancer. The omentum, which is a fatty structure that hangs off of your stomach, can also frequently be involved with cancer. It also should be removed as part of the staging process.
Cytoreduction or Debulking
This surgery involves the removal of as much of the cancer as possible. Often this is a very extensive surgery and other organs such as a portion of the small intestine, colon, diaphragm, or spleen are removed. It is extremely important to have this surgery performed by a surgeon who can do cytoreduction, as ovarian cancer often spreads to multiple areas in the abdomen and pelvis at the time of diagnosis. Women in whom all of the cancer can be removed have cure rates that are twice as high as women in whom large amounts of tumor are left behind.
Chemotherapy uses drugs to kill or reduce the number of cancer cells and help to keep the cancer from coming back. Used with surgery, it has been shown to extend the lives of women with ovarian cancer.
About 1 to 4 weeks after your surgery, you will likely begin chemotherapy. Typically a woman will have it for about 6 months. How often you receive treatment will depend on the type of chemotherapy you receive, which depends on the size of the tumor and whether it is likely to spread quickly. You may have chemotherapy every day, every week, every few weeks, or even once a month. You may be treated in the doctor’s office, or you may be treated in the outpatient part of a hospital.
Chemotherapy drugs travel through the bloodstream to reach all parts of the body. This is why chemotherapy can be effective in treating ovarian cancer that has spread beyond the ovaries. The same drugs that kill cancer cells, however, may also damage healthy cells.
Chemotherapy is usually given in cycles. Periods of chemotherapy treatment are alternated with rest periods when no chemotherapy is given.
Chemotherapy can be delivered by two routes: intravenous (IV) or intraperitoneal (IP) chemotherapy. With IP chemotherapy, the medications are injected directly into the abdominal cavity. The goal is to deliver a large dose directly to the tumor location. The National Cancer Institute recommends that, for select ovarian cancer patients, chemotherapy can be given by both IV and IP. This combination has been found to increase survival for women with advanced stage ovarian cancer.
IP chemotherapy has more short term toxicity, but recent studies have shown that it is associated with a longer survival rate. It is important for you to talk with your team about the pros and cons of this approach.
Some cancers will be advanced at initial diagnosis or your doctor may think immediate surgery will be too difficult for you to tolerate. If that’s the case, your gynecologic oncologist may feel that surgery is unlikely to have the desired effect and may prescribe chemotherapy treatments first to shrink the tumor. Once the tumor has shrunk and your physical condition improves, surgery will be performed. Usually this surgery is followed by more chemotherapy.
Chemotherapy Drugs for Ovarian Cancer
There are several chemotherapy drugs used to treat ovarian cancer. Your doctor may recommend more than one at the same time. This is called combination chemotherapy. The following drugs are typically used to treat ovarian cancer. They may be used alone or in combination.
- Platinum agents such as Paraplatin (carboplatin and cisplatin). These are the drugs doctors most often use to treat ovarian cancer. They work by creating breaks in the genetic material—DNA—inside each cell. This leads to cell death.
- Taxanes such as Taxol (paclitaxel) and Taxotere (docetaxel). These keep cells from dividing. This class of drugs is used in combination with cisplatin or carboplatin.
- Anthracyclines such as Adriamycin (doxorubicin) and Doxil (liposomal doxorubicin). These drugs are often used if cancer comes back. When cancer comes back, it is called recurrence.
- Additional drugs. Other drugs often used at the time of recurrence are gemcitabine and topotecan.
Side Effects of Chemotherapy
The side effects of chemotherapy are different for everyone. They depend on the following:
- The type of drug you’re taking
- How often you take it
- How long your treatment lasts
Your gynecologic or medical oncologist, healthcare provider, or chemotherapy nurse will talk with you about possible side effects. Here are some typical side effects for the most commonly used chemotherapy drugs for ovarian cancer. Ask your treatment team members about which ones you are most likely to experience.
- Allergic reactions
- Anemia from reduced red blood cells, as noticed from a blood test
- Bleeding after normal cuts, from reduced platelet counts
- Dry skin
- Fluid retention
- Hair loss
- Infections, from reduced white blood cells
- Joint pain
- Mouth sores
- Muscle aches
- Nausea and vomiting
- Rashes on the hands or feet
- Tingling or numbness in hands and feet
These side effects usually go away during rest periods between treatments. They also usually go away after your treatment ends. Ask your doctor for ways to ease these side effects. For instance, you may take certain drugs to ease nausea and vomiting. If these side effects do not go away, it is important to bring this to your health care team’s attention. Some side effects, like cognitive issues, neuropathy and lymphedema, can be long-term. Be sure to talk with your heath care team if you are experiencing any of these.
Ask Your Doctor: Common Treatment Questions
Before beginning treatment, it is important to learn about the possible side effects. It’s also important to talk with your treatment team members about your feelings or concerns. They can prepare you for what to expect. They can also tell you which side effects should be reported to them immediately, and they can help you find ways to manage the side effects you experience.
You may find it helpful to make a list of your questions before seeing your doctor. Use the list of questions below as a starting place.
- Which treatments do you think are best for me, and why?
- Which treatments are not for me, and why?
- What is the success rate of this particular treatment for my type and stage of ovarian cancer?
- Can I take my other medicines during the treatment period?
- How long is the treatment period?
- How long will each treatment take?
- Where do I have to go for the treatment?
- Who is involved in giving me the treatment?
- Does someone need to go with me during treatments?
- How will I feel after the treatment?
- What side effects can I expect to have?
- Will this treatment make me unable to bear children?
- Will this treatment put me into menopause?
- How long will side effects last?
- Are there symptoms or side effects that I need to call you about?
- What can I do to ease the side effects?
- Will I be able to go to work and be around my family?
- Should I change my diet? What foods can’t I eat?
- Are there any clinical trials I should look into?
- Are there support groups nearby that I can join?
To make it easier to remember what your doctor says, take notes during meetings, or ask if you can use a tape recorder. It may also help to have a family member or friend with you to take part in the discussion, take notes, or just listen.
What Happens After Treatment
In general, women treated for ovarian cancer have follow-up exams (including a pelvic exam) every 3 to 4 months for 3 years. Then the exams go to every 6 months. In addition, imaging studies such as x-rays, CT scans or MRIs are periodically performed.
If the CA-125 was elevated before treatment, it is important to have it checked at each visit. Recurrences are often diagnosed when the CA-125 begins to rise. They may also be diagnosed when new masses are found on imaging studies or by examination.
If ovarian cancer recurs, there are several options for treatment. These include:
- Repeat surgery
- Re-treatment with the same chemotherapy given initially
- Treatment with a different type of agent (chemotherapy, hormonal or targeted therapy)
- Radiation (sometimes)
Each recurrence will be different. It is important to discuss your individual situation with your team. It is also important to investigate whether there is a clinical trial that is appropriate for you. Don’t be afraid to seek a second opinion.
For a comprehensive overview of treatment options for ovarian cancer, the Foundation for Women’s Cancer also provides in-depth resources on many topics, including surgery, side effects, chemotherapy, radiation therapy and targeted therapies.
Foundation for Women’s Cancer