OVARIAN CANCER

Once doctors have determined the stage of the cancer, they will recommend a treatment strategy. In the past few years there have been significant advances in treatments, and new experimental therapies continue to be studied.

The choice of treatment depends largely on the type and stage of ovarian cancer a woman has and whether or not she plans to have children.

Surgery

Surgery is usually the first step in the treatment of all types of ovarian cancer. During surgery, physicians will try to remove as much of the cancer as possible -- a procedure commonly referred to as debulking. For women of childbearing age, doctors will also try to remove the cancer without removing both ovaries and the uterus.

A laparotomy is a surgical procedure that helps doctors further confirm a diagnosis of ovarian cancer and determine how far it has spread. A surgical incision is made through the abdominal wall to determine the stage of the cancer. This is called surgical staging. Surgical staging also involves looking at other tissues in the pelvic region and lymph nodes. The cancerous ovary is removed and examined to ensure that the cancer developed in the ovary and did not spread from another organ. Cancer cells are also collected and are used to determine the stage of the cancer and whether additional surgery is required.

Following the examination, doctors will confirm an ovarian cancer diagnosis and the stage. Those with stage I or early stage II ovarian cancer may not require any additional surgery after a laparotomy. Doctors will also confirm that the cancer originated in the ovaries and did not spread from another area of the body. If the surgery confirms a more advanced stage of ovarian cancer, doctors will remove both ovaries, both fallopian tubes and the uterus. This is called a total abdominal hysterectomy with bilaterial salpingo-oophorectomy.

Removal of the ovaries and/or the uterus means that a woman will not be able to become pregnant and may enter menopause, if she hasn’t already done so. However, if only one ovary is cancerous and removed, a woman can still become pregnant. Again, for women of childbearing age with certain types of ovarian cancer, doctors may be able to remove the cancer without removing the ovaries and the uterus.

Chemotherapy

Following surgery, most ovarian cancer patients will require chemotherapy to prevent the recurrence of the cancer. Chemotherapy kills cancer cells by stopping them from dividing and reproducing. The type of chemotherapy a woman receives is determined by her physical and mental condition, the type of ovarian cancer she has and her response to previous chemotherapy (if she had prior chemotherapy treatments).

Most chemotherapies are administered intravenously (through a vein) in a cycle every three to four weeks. In cases where the veins cannot accept drugs, a catheter (flexible tube) may be inserted in the neck or chest vein to make treatment easier. Some chemotherapies are now even available in convenient oral forms.

Chemotherapy can be given in the hospital or in an outpatient setting. Treatments that require several days to administer may require the patient to stay in the hospital. However, most patients can receive their chemotherapy treatment in an outpatient setting. Nurses specializing in the treatment of cancer assist doctors in administering chemotherapy and monitor side effects. To learn more about your health care team click here.

Since each chemotherapy drug attacks cancer in a different way, two or more different types of chemotherapy treatments are usually given at the same time to maximize the effectiveness of chemotherapy. This is referred to as combination therapy. Administering combination treatments can also help prevent cancer cells from becoming resistant to the individual drugs.

First-Line Chemotherapy

First-line chemotherapy refers to the initial chemotherapy treatment for ovarian cancer. The standard first-line treatment for ovarian cancer is paclitaxel (Taxol) combined with cisplatin (Platinol) or carboplatin (Paraplatin). In addition, other chemotherapy drugs are being studied for the first-line treatment of ovarian cancer.

Ovarian cancer patients usually receive six courses (or administrations) of a chemotherapy treatment. One course is administered every 21 days. Response may be assessed before each subsequent administration through a physical examination, measurement of the levels of a blood protein called CA125 and/or a CAT scan. Patients whose CA125 level falls below the normal value (35 U/ml) before their third course of treatment have a very good chance of remission (a decrease or disappearance of the disease).

Second-look surgery might be performed on patients who have shown a response to chemotherapy, whose CA125 levels return to normal and whose signs of ovarian cancer completely disappear based on physical examination and a CAT scan. The procedure can be performed by laparotomy or laparoscopy and allows doctors to look at tissues under a microscope.

During second-look surgery, a physician will perform a biopsy in the areas where the tumor previously existed. If the biopsy shows no evidence of cancer cells, the patient’s chemotherapy will be stopped. However, in approximately half of patients who exhibit normal CA125 levels and no evidence of cancer upon physical examination or CAT scan, ovarian cancer will be found during second-look surgery. These patients will either continue the same chemotherapy or begin a different combination of drugs. The NCI recommends that second-look surgery only be performed in conjunction with a clinical trial, as there is no current data to support it as a standard treatment.

Second-Line Chemotherapy

Ovarian cancer is considered recurrent if the disease reappears at least six months after initial treatment. Persistent tumors never disappear even after treatment. For both recurrent and persistent ovarian cancer, doctors may recommend second-line chemotherapy or additional surgery. Clinical trials (where new and promising drugs and combinations of drugs are tested) may also be an option for someone with recurrent or persistent tumors. Click here for more information on clinical trials.

There are currently a number of different chemotherapies used in the second-line treatment of recurrent ovarian cancer. One newer treatment is Hycamtin® (topotecan), the first of a new class of topoisomerase I inhibitors, which is approved for use in the second-line treatment of ovarian cancer.

Radiation Therapy

Radiation therapy plays a smaller role in the treatment of ovarian cancer. Since ovarian cancer cells spread widely, radiation therapy requires treatment of the entire abdominal area. Unfortunately, organs such as the liver and kidney cannot tolerate high levels of radiation needed to kill cancer cells, and as a result a patient undergoing radiation therapy may experience unpleasant side effects. These side effects may include severe abdominal cramps, diarrhea, and bowel obstruction. See next section for coping with side effects. However, for patients whose ovarian cancer is limited to the pelvis region, less radiation can be used.

Coping with Treatment Side Effects

Chemotherapy and Radiation

Unfortunately, chemotherapy treatments affect not only cancer cells but also normal cells, such as red blood cells, white blood cells, platelets, hair cells, and cells lining the digestive tract from the mouth to the anus. Almost all chemotherapy treatments are associated with some uncomfortable side effects.

Many cancer patients suffer from nausea and vomiting during chemotherapy; however, there are effective anti-nausea and vomiting drugs called antiemetics to prevent and treat these side effects. Some of these antiemetics are also available in convenient oral forms. For more information on coping with nausea and vomiting click here.

Other side effects of chemotherapy may include fatigue, change in appetite, mouth or vaginal sores and menstrual cycle irregularities. Temporary hair loss is also common. Click here for tips on managing hair loss. Because they are in an immunocompromised state (weakened immune system), patients undergoing chemotherapy also have an increased risk of developing infections, experiencing excessive bleeding or becoming anemic. Click here to learn more about coping with the side effects of chemotherapy.

If you have had radiation therapy for ovarian cancer, you may also experience some side effects. Radiation can cause abdominal cramping and diarrhea Click here for information on coping with side effects from radiation treatment.

Fatigue

Fatigue, a temporary condition for most people that occurs after strenuous activity, is a common medical condition for cancer patients. If you have ovarian cancer and are undergoing chemotherapy, your fatigue may be chronic- that is it won't go away. Fatigue can severely affect your health and limit your activity.

Signs of fatigue include:

Weakness
Exhaustion
Leg pain
Difficulty climbing stairs or walking short distances
Shortness of breath after light activity
Difficulty concentrating
Losing patience easily
Losing interest in hobbies or pastimes

Fatigue is a medical condition and that should be reported to your doctor. For more information about treatments and what you can do for yourself to help fatigue, click here.

Pain

Not everyone experiences cancer pain, however for those who do, there are many ways to treat it. Pain can be caused from cancer treatments or the cancer itself. Today, there is no reason that cancer pain should go untreated or ignored. Early treatment of pain is almost always more effective than waiting until the pain is severe or unbearable. If left unattended, cancer pain can lead to disruption in a person's ability to work, their relationships, and their view of the world. Above all, under-and untreated cancer pain can lead to unnecessary suffering and despair.