Treatment of Invasive Epithelial Ovarian Cancers, by Stage
The initial treatment for stage I ovarian cancer is surgery to remove the tumor. Most often the uterus, both fallopian tubes, and both ovaries are removed (a hysterectomy with bilateral salpingo-oophorectomy) (this is discussed in the surgery section).
In stages IA and IB (T1a or T1b, N0, M0), cancer was found inside one or both ovaries, without spread to lymph nodes or other organs. The treatment after surgery depends on the way the cancer cells look under the microscope (called the tumor grade).
The tumor is grade 1 when the cancer cells look a lot like normal ovarian cells. The outlook is good for grade 1 tumors, and most patients require no treatment after surgery. If someone with a grade 1, Stage IA ovarian cancer wants to be able to have children after treatment, the initial surgery may be changed. Instead of removing the uterus, both ovaries, and both fallopian tubes, the surgeon may offer the option of removing only the ovary containing the cancer along with the fallopian tube on the same side.
For a grade 2 cancer (meaning the cancer looks something like normal ovarian cells), patients are either watched closely after surgery without further treatment, or they are treated with chemotherapy (chemo). The chemo used most commonly is carboplatin and paclitaxel (Taxol) for 3-6 cycles, but cisplatin can be used instead of carboplatin, and docetaxel (Taxotere) can be used instead of paclitaxel.
Grade 3 cancers don’t look very much like normal ovarian tissue under the microscope. The treatment of these tumors usually includes chemotherapy (like the chemo that is given for grade 2).
Stage IC (T1c, N0, M0): For stage IC ovarian cancer (including stage IC1, IC2, and IC3), standard surgery to remove the cancer is still the first treatment. After surgery, chemo is recommended, usually 3 to 6 cycles of treatment with carboplatin and paclitaxel.
Stage I fallopian tube cancer is treated the same way as stage I ovarian cancer.
Stage II (including IIA and IIB)
For all stage II cancers, treatment starts with surgery for staging and debulking. This includes a hysterectomy and bilateral salpingo-oophorectomy (see the section about surgery for details). The surgeon will try to remove as much of the tumor as is possible.
After surgery, chemo is recommended for at least 6 cycles. The combination of carboplatin and paclitaxel is most often used. Some women with stage II ovarian cancer are treated with intraperitoneal (IP) chemotherapy instead of intravenous (IV) chemotherapy. This was discussed in more detail in the section about chemotherapy.
Stage II fallopian tube cancers are also treated with surgery for staging and debulking, followed by chemo.
Stage III ovarian, fallopian tube, and primary peritoneal cancers
Stage III cancers (includes IIIA1, IIIA2, IIIB, and IIIC) are given similar treatments as stage II cancers. First, the cancer is surgically staged and the tumor is debulked (like stage II). The uterus, both fallopian tubes, both ovaries, and omentum (fatty tissue from the upper abdomen near the stomach and intestines) are removed. The surgeon will also try to remove as much of the tumor as possible. The goal is to leave behind no tumor larger than 1 cm. When this goal is reached, the cancer is said to have been optimally debulked.
Sometimes tumor is growing on the intestines, and in order to remove the cancer, part of the intestine will have to be removed. Sometimes pieces of other organs (like the bladder or liver) may have to be removed to remove the cancer (this was discussed in the section about surgery). The smaller the remaining tumor, the better the outlook will be.
After recovery from surgery, combination chemo is given. The combination used most often is carboplatin (or cisplatin) and a taxane, such as paclitaxel (Taxol), given IV (into a vein) for 6 cycles.
Another option is to give intra-abdominal (intraperitoneal or IP) chemo after surgery. This was discussed in more detail in the section about chemotherapy. Since IP chemo means giving the drug paclitaxel IV along with the drugs cisplatin and paclitaxel into the abdomen (IP), women who get IP chemo are actually getting both IV and IP chemo. IP chemo is usually only considered if the cancer was optimally debulked − it may not work as well if a lot of tumor is left in the abdomen. IP chemo seems to work better than IV chemo, but it also causes worse side effects. These side effects can make it hard for someone to continue their treatment. For that reason, IP chemo may not be for everyone. Still, it is an option for women with advanced ovarian cancer to consider.
After surgery, and during and after chemo, blood tests will be done to determine if you have normal levels of a tumor marker called CA-125. A CT scan, PET-CT scan, or MRI could also be done to evaluate your response to treatment.
Patients who are too weak or ill to have full staging and debulking surgery sometimes get chemo as the first treatment. If the chemo works and the patient becomes stronger, surgery to debulk the cancer may be done, often followed by more chemo. Most often, 3 cycles of chemo are given before surgery, with at least 3 more after surgery (for a total of at least 6 cycles). Giving chemo before surgery is also sometimes an option for some women with advanced cancers that aren’t likely to be able to be optimally debulked if the surgery is done first.
Second look surgery: In the past, many experts recommended another operation (laparoscopy/laparotomy) to see if the cancer was gone after chemo. This is known as a second look surgery. These operations haven’t been shown to have any real benefit, and so are no longer a standard part of ovarian cancer care. Still, they may be done as part of a clinical trial. In a clinical trial of new treatments, the second-look operation may be worthwhile to help determine how effective the new treatment is.
For laparoscopy, a small opening is made below the navel and a slender tube with a light is placed so the doctor can inspect the abdominal cavity to see how successful treatment has been.
Laparotomy requires an incision (cut) or surgical opening long enough for the surgeon to look inside the pelvis and abdomen and take biopsy samples. Your cancer care team can decide if you need more chemo based on the results of the second-look surgery.
Consolidation therapy: For some patients, the doctor will recommend additional chemo after the cancer appears to be gone after the initial treatment. This is called maintenance or consolidation therapy. It is aimed at killing any cancer cells that were left behind after treatment but are too small to be seen with medical tests. The goal of consolidation therapy is to keep the cancer from coming back after treatment. One study showed that giving paclitaxel (every 4 weeks) for a year lengthened the time before the cancers came back, but didn't help the women live longer. Another study found no benefit, but the drug was given on a different schedule. This is still being studied in clinical trials.
Stage IV ovarian, fallopian tube, and primary peritoneal cancers
In stage IV, the cancer has spread to distant sites, like the inside the liver, the lungs, or bones. This stage isn’t able to be cured with current treatment, but it can still be treated. The goals of treatment are to help patients feel better and live longer. Stage IV can be treated like stage III − with surgery to remove the tumor and debulk the cancer, followed by chemo. Another option is to treat with chemo first. Then, if the tumors shrink from the chemo, surgery may be done, which is followed by more chemo. Most often, 3 cycles of chemo are given before surgery, with at least 3 more after surgery. Another option is to limit treatment to those aimed at improving comfort (but not at fighting the cancer). This type of treatment is called palliative, and is discussed later in more detail.
Recurrent or persistent ovarian cancer
Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs like the lungs or bone). Persistent tumors are those that never went away completely after treatment. Advanced epithelial ovarian cancer often comes back months or years after the initial treatment.
Sometimes, more surgery is recommended. Most patients with recurrent or persistent ovarian cancer are treated with some form of chemo. Which chemo drugs are used depends on what was used the first time and how well it worked (how long the cancer stayed away). The longer it takes for the cancer to come back after treatment, the better the chance that additional chemo will work. If it has been at least 6 months since any chemo, the patient may be treated with carboplatin and paclitaxel (even if these drugs were given before). Giving carboplatin with another drug is also an option.
If the cancer comes back in less than 6 months (or if it never went away at all), different chemo drugs usually will be tried. The targeted drug bevacizumab (Avastin) may be given with chemo. For women with mutations in the BRCA1 or BRCA2 genes, olaparib (Lynparza) may be an option at some point. Some women may receive several different chemo regimens over several years. Many chemo drugs can be used to treat ovarian cancer (see the section about chemotherapy). In addition, some patients benefit from hormonal treatment with drugs like anastrozole, letrozole, or tamoxifen. Someone who didn't initially receive chemo can be treated with the same drugs that are used for newly diagnosed cancer − usually carboplatin and paclitaxel.
A clinical trial for new treatments might provide important advantages for women with recurrent or persistent ovarian cancer. Ask your cancer care team for information about suitable clinical trials for your type of cancer.
High-dose chemotherapy with stem cell rescue (sometimes known as stem cell transplant) has been used for women with recurrent or persistent ovarian cancer. This treatment has very serious side effects, however, and has not been proven to help patients live longer. It is best done as part of a clinical trial that is studying improvements to this procedure. More information about stem cell transplants is available on our website, or you can call 1-800-227-2345 for our document Stem Cell Transplant for Cancer.
Palliative treatments: Women with ovarian cancer can have a buildup of fluid in the abdomen. This is called ascites. It can be very uncomfortable but can be treated with a procedure called paracentesis. After the skin is numbed, a needle is used to withdraw the fluid, often several quarts, into a bottle. Often, ultrasound is used to guide the needle. Often the fluid builds up again, and this procedure needs to be repeated. Sometimes a catheter (a thin flexible tube) is placed into the abdomen and left there so that fluid can be removed as often as is needed without using a needle. Another option is to inject chemo directly into the abdomen to slow the buildup of fluid. Treatment with bevacizumab (Avastin) may also help slow fluid buildup. These treatments can relieve symptoms for some patients and, rarely, might extend life. Often, however, their effects are temporary, and the cancer returns or persists.
Ovarian cancer can also block the intestinal tract. This is called obstruction, and can cause abdominal pain, nausea, and vomiting. Dealing with an intestinal blockage can be difficult. Often, the cancer has grown so much in the abdomen that surgery to unblock the intestine doesn't work. To help make the patient comfortable, doctors may place a tube through the skin and into the stomach to allow the stomach juices to drain, so that the digestive tract isn’t completely blocked. This can help with pain, nausea, and vomiting.
Sometimes a stent (a stiff tube) can be put into the large intestine to relieve a blockage. Since this option has a high risk of complications, you should discuss the risks and benefits with your doctor first.
In some patients, surgery can be done to relieve intestinal obstruction. This is often only offered to patients who are well enough to get additional treatments (like chemo) after surgery.
Last Medical Review: August 5, 2014 Last Revised: February 4, 2016
- Surgery for Ovarian Cancer
- Chemotherapy for Ovarian Cancer
- Targeted Therapy for Ovarian Cancer
- Hormone Therapy for Ovarian Cancer
- Radiation Therapy for Ovarian Cancer
- Treatment of Invasive Epithelial Ovarian Cancers, by Stage
- Treatment for Epithelial Tumors of Low Malignant Potential
- Treatment for Germ Cell Tumors of the Ovary
- Treatment for Stromal Tumors of the Ovary, by Stage