Chemotherapy (chemo) is the use of drugs to treat cancer. Most often, chemo is a systemic treatment -- the drugs are given in a way that allows them to enter the bloodstream and reach all areas of the body. Systemic chemo can be useful for cancers that have metastasized (spread). Most of the time, systemic chemo involves using drugs that are injected into a vein (IV) or given by mouth. For some cases of ovarian cancer, chemotherapy may also be injected through a catheter directly into the abdominal cavity. This is called intraperitoneal (IP) chemotherapy. Drugs given this way are also absorbed into the bloodstream, so IP chemotherapy is also a type of systemic chemo. This is discussed in more detail later in this section.
Epithelial ovarian cancer
Chemo for ovarian cancer most often consists of a combination of 2 or more drugs, given IV every 3- to 4-weeks. Giving 2 or more drugs in combination seems to be more effective in the initial treatment of ovarian cancer than giving just one drug alone.
The standard approach is the combination of a platinum compound, such as cisplatin or carboplatin, and a taxane, such as paclitaxel (Taxol®) or docetaxel (Taxotere®). For IV chemotherapy, most doctors favor carboplatin over cisplatin because it has fewer side effects and is just as effective.
The typical course of chemo for epithelial ovarian cancer involves 3 to 6 cycles. A cycle is a schedule that allows regular doses of a drug, followed by a rest period. Different drugs have varying cycles; your doctor will let you know what kind of schedule is planned for your chemo.
Epithelial ovarian cancer often shrinks or even seems to go away with chemo, but the cancer cells may eventually begin to grow again. If the first chemo seemed to work well and the cancer stayed away for a time, this can be treated with additional cycles of the same chemotherapy used the first time. In some cases, different drugs may be are used. Some of the chemo drugs that are helpful in treating ovarian cancer include (they are not listed in the order of preference):
- Topotecan
- Liposomal doxorubicin (Doxil®)
- Gemcitabine (Gemzar®)
- Cyclophosphamide (Cytoxan®)
- Vinorelbine (Navelbine®)
- Ifosfamide (Ifex®)
- Etoposide (VP-16)
- Altretamine (Hexalen®)
- Capecitabine (Xeloda®)
- Irinotecan (CPT-11, Camptosar®)
- Melphalan
- Pemetrexed (Alimta®)
- Albumin bound paclitaxel (nab-paclitaxel, Abraxane®)
Different drug combinations are often used to treat germ cell tumors and are described in the section on treatment of germ cell tumors.
Chemotherapy drugs kill cancer cells but also damage some normal cells. Therefore, your doctor will be careful to avoid or minimize side effects, which depend on the type of drugs, the amount taken, and the length of treatment.
Common temporary side effects include:
- Nausea and vomiting
- Loss of appetite
- Loss of hair
- Hand and foot rashes
- Mouth sores
Chemotherapy can damage the blood-producing cells of the bone marrow, so patients may have low blood cell counts. This can result in:
- Increased chance of infection (caused by a shortage of white blood cells)
- Bleeding or bruising after minor cuts or injuries (caused by a shortage of blood platelets)
- Fatigue (caused by low red blood cell counts)
Most side effects disappear once treatment is stopped. Hair will grow back after treatment ends, although it may look different. There are remedies for many of the temporary side effects of chemotherapy. For example, there are very good drugs that can be given to prevent and treat nausea and vomiting. For more information about chemotherapy and its side effects, please see our document, Understanding Chemotherapy: A Guide for Patients and Families.
Some chemo drugs may have long-term or even permanent side effects. For example, cisplatin can cause kidney damage. To help prevent this, doctors give lots of IV fluid before and after this drug is given. Both cisplatin and the taxanes can cause nerve damage (called neuropathy). This can lead to problems with numbness, tingling, or even pain in the hands and feet. Cisplatin can also damage the nerves to the ear, which can lead to hearing loss (called ototoxicity). Other drugs can have other side effects, so ask your doctor what side effects to expect from the drugs that you wil receive. Most side effects improve once treatment is stopped, but can last a long time and may never go away completely.
Chemo can also cause early menopause and infertility (inability to become pregnant), which may be permanent. This is rarely an issue in the treatment of epithelial ovarian cancer, since most women have both ovaries removed as a part of treatment.
Rarely, some cancer treatment drugs may later cause a life-threatening cancer of white blood cells called acute myeloid leukemia. This is called a secondary malignancy. Your health care team knows which drugs can cause this problem and will discuss this possibility with you. Their positive effects against ovarian cancer offset the small chance that any of these drugs will cause leukemia.
Intraperitoneal chemotherapy
In intraperitoneal (IP) chemotherapy for ovarian cancer, in addition to giving the chemo drug paclitaxel IV, the drugs cisplatin and paclitaxel are injected into the abdominal cavity through a catheter (thin tube). The tube can be placed during the staging/debulking surgery, but sometimes it is placed later. If it is done later, it can be placed by a surgeon using laparoscopy, or by an interventional radiologist under x-ray guidance. The catheter is usually connected to a port, which is placed under the skin against a bony structure of the abdominal wall, such as a rib or pelvic bone. A port is a half dollar-sized disk topped with a pliable diaphragm. A needle can be placed through the skin and the diaphragm to give chemo and other drugs. Over time, problems may rarely occur with the catheter. -- it may become plugged or infected or even damage the bowel.
Giving chemo this way has the advantage of giving the most concentrated dose of the drugs to the cancer cells in the abdominal cavity. Chemo given this way also gets absorbed into the bloodstream and so can reach cancer cells outside of the abdominal cavity. IP chemotherapy works well, but the side effects are often more severe than with regular chemo. In a study of women with advanced ovarian cancer, women getting the IP chemotherapy had more abdominal pain, nausea, vomiting, and other side effects than the women getting chemo through the vein. These side effects actually made some women stop their treatment early. Still, the women getting IP chemotherapy lived longer than the women getting regular chemo.
IP chemotherapy is currently only given to some of the women with ovarian cancer that has spread to the inside of the abdomen. It was only studied in women who had no tumors larger than 1 cm after debulking (called optimally debulked) Also, because it can be so toxic, women must have normal kidney function and be in good overall shape for their doctor to be willing to try IP chemo. They also cannot have a lot of adhesions or scar tissue inside their abdomen because this can prevent the chemo from spreading around well.
Germ cell tumors
Patients with germ cell cancer often need to be treated with combination chemo. The combination used most often is called PEB (or BEP), and includes the chemotherapy drugs cisplatin (Platinol), etoposide, and bleomycin. Dysgerminomas are usually very sensitive to chemotherapy, and can sometimes be treated with the less toxic combination of carboplatin and etoposide. Other drug combinations may be used if the cancer isn’t responding to treatment or to treat cancer that has recurred (come back). These include:
- TIP: paclitaxel (Taxol), ifosfamide, and cisplatin
- VeIP: vinblastine, ifosfamide, and cisplatin
- VIP: etoposide (VP-16), ifosfamide, and cisplatin
Chemo for germ cell tumors has some of the same risks and side effects as the chemo for epithelial ovarian cancer. These include nausea/vomiting, hair loss, and low blood counts. Neuropathy, infertility, and premature menopause can also occur. The later development of leukemia occurs rarely.
Rarely, bleomycin can lead to lung damage, so some doctors order tests of lung function before using this drug. Ifosfamide can cause the bladder lining to bleed (called hemorrhagic cystitis). This can usually be prevented by giving the drug mesna with the ifosfamide.
Stromal tumors
Ovarian stromal tumors are not often treated with chemotherapy, but when they are the combination of carboplatin plus paclitaxel or PEB (see above) are most often used.
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