Treating Ovarian Cancer

Initial treatment with surgery

The initial treatment for stage I epithelial 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).

Treatment options after surgery

The treatment after surgery depends on findings from the surgery, which will help determine the cancer’s exact stage or sub stage.

Stages IA and IB: The treatment after surgery depends on how the cancer cells look in the lab (the tumor grade).

• For grade 1 (low grade) tumors, usually no more treatment is needed after surgery. If preserving fertility is a goal, the initial treatment might involve removing only the affected ovary and fallopian tube.
• Those with grade 2 (high grade) tumors are either watched closely after surgery without further treatment, or treated with chemotherapy (chemo). The chemo used most often is carboplatin and paclitaxel for 3-6 cycles, but cisplatin can be used instead of carboplatin, and docetaxel can be used instead of paclitaxel.
• For grade 3 (high grade) tumors, chemo after surgery is usually recommended.

Stage IC:  After surgery, chemo is recommended, usually with carboplatin and paclitaxel.

Fallopian tube and primary peritoneal cancers

Stage I fallopian tube and primary peritoneal cancers are treated the same way as stage I ovarian cancer.

Initial treatment

For stage II epithelial ovarian cancers, treatment starts with surgery for staging and debulking. This includes a hysterectomy and bilateral salpingo-oophorectomy. The surgeon will try to remove as much of the tumor as possible.

Treatment options after surgery

After surgery, chemo is recommended for 3- 6 cycles. The combination of carboplatin and paclitaxel is used most often. Some women with stage II ovarian cancer are treated with intraperitoneal (IP) chemotherapy with or without intravenous (IV) chemotherapy.

Fallopian tube and primary peritoneal cancers

Stage II fallopian tube and primary peritoneal cancers are also treated with surgery for staging and debulking, followed by chemo.

Initial treatment

Stage III cancers are generally treated similarly to 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 tumor as possible.

The goal is to leave behind no visible tumor or no tumor larger than 1 cm. When this goal is reached, the cancer is said to have been optimally debulked.

If the tumor has grown into the intestines or to other organs like the bladder or liver, some of these may be removed to take out as much of the tumor as possible. The smaller the remaining tumor, the better the outlook will be.

Treatment after surgery

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 3- 6 cycles. The targeted drug bevacizumab (Avastin) might be given along with chemo as well.

Another option is to give intra-abdominal (intraperitoneal or IP) chemo along with intravenous (IV) chemo, after surgery. 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.

After surgery, and during and after chemo, blood tests checking for the CA-125 tumor marker will be done to see how well the treatment is working. A CT scan, PET-CT scan, or MRI might also be done.

If initial surgery is not possible

For women who are not healthy enough to have full staging and debulking surgery, chemo might be given as the first treatment. If the chemo works and the woman 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 6 cycles).

Maintenance therapy

If the cancer shrinks or appears to be gone after treating with chemo that includes a platinum drug (cisplatin or carboplatin), doctors might recommend continued treatment for some women. The goal of maintenance therapy is to kill any cancer cells left behind after treatment and to keep the cancer from coming back. Drugs that might be used include bevacizumab, niraparib, rucaparib, and olaparib.

In stage IV, the cancer has spread to distant sites, like the liver, the lungs, or bones. These cancers are very hard to cure with current treatments, but they can still be treated. The goals are to help the person feel better and live longer.

Primary treatment

Stage IV can be treated like stage III, with surgery to remove the tumor and debulk the cancer, followed by chemo (and possibly the targeted drug).

Another option is to treat with chemo first. Then, if the tumors shrink from the chemo, surgery may be done, followed by more chemo. Most often, 3 cycles of chemo are given before surgery, with at least 3 more after surgery.

Maintenance therapy

If the cancer shrinks or appears to be gone after treating with chemo that includes a platinum drug (cisplatin or carboplatin), doctors might recommend continued treatment for some women. The goal of maintenance therapy is to kill any cancer cells left behind after treatment and to keep the cancer from coming back. Drugs that might be used include bevacizumab, niraparib, rucaparib, and olaparib.

Palliative care

Palliative care involves treatments focused on improving quality of life. People with any stage of cancer may get palliative therapy. It often plays a bigger role in treating stage IV cancer, when the focus of treatment to extend a person’s quality of life. 

Cancer is called recurrent when it come backs after treatment. Recurrence can be:

• Local (in or near the same place it started)
• Distant (spread to organs like the lungs or bone)

Advanced epithelial ovarian cancer often comes back months or years after the initial treatment.

Surgery

Sometimes, more surgery is recommended.

Chemotherapy

Most women with recurrent ovarian cancer are treated with 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 chemo was not used before, the same drugs used for newly diagnosed cancer (usually carboplatin and paclitaxel) are used.
• If it has been at least 6 months since any chemo, treating with a similar chemo combination may still be effective.
• If the cancer comes back in less than 6 months or never went away, different chemo drugs are usually tried.

Many different chemo drugs can be used to treat ovarian cancer, so some women may receive several different chemo regimens over time.

Other treatments

Treatment with targeted therapy might also be helpful. Options might include:

• Bevacizumab (Avastin), often combined with chemo
• A PARP inhibitor drug such as olaparib (Lynparza), rucaparib (Rubraca), or niraparib (Zejula)
• The antibody-drug conjugate mirvetuximab soravtansine (Elahere)

Some women benefit from hormonal treatment with drugs like anastrozole, letrozole, or tamoxifen.

Considering a clinical trial

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.

Stage I

All stage I stromal tumors are treated with surgery to remove the ovary with the tumor. Most women with stage I tumors are watched closely after the operation and don’t require further treatment. However, some stage I tumors are more likely to come back after surgery, for example:

• Very large tumors
• Tumors where the cyst broke open (ruptured)
• Poorly differentiated tumors (also called high grade − the cancer cells don’t look like normal tissue when examined in the lab).

These cancers are said to be at high risk for recurrence. Women with high-risk stage I stromal cancers have 2 options after surgery: observation (being watched closely) or chemotherapy (chemo).

Stages II, III, and IV

These cancers are treated initially with surgery to remove the ovary with the tumor and to stage and debulk the cancer.

This is usually followed by chemo or hormone therapy. Often, the chemo used is the same type used to treat germ cell tumors (BEP: bleomycin, etoposide, and cisplatin). The combination of carboplatin and paclitaxel (Taxol) may also be used.

Hormone treatment is most often used to treat advanced stromal tumors in women who cannot tolerate chemo, but who want to try treatment. This may mean treatment with a drug such as leuprolide (Lupron), goserelin (Zoladex), tamoxifen, or an aromatase inhibitor.

Radiation therapy may be an option but is not commonly recommended.

Recurrent stromal tumors

A recurrent cancer is one that comes back after treatment. For tumors that produce hormones, certain hormone blood levels may be checked regularly after surgery to check for increased levels that could suggest the tumor has returned. This can happen many years later for stromal tumors. Even so, the prognosis (outlook) might still be good because they grow relatively slowly.

• Surgery may be repeated.
• Any of the chemo regimens used initially can also be used to treat a relapse.
• Hormone therapy is also an option to treat recurrence.
• Radiation therapy might also sometimes be helpful to help with symptoms.

There isn't a standard treatment for recurrent stromal cancer, so treatment as part of a clinical trial is also a good option.

Borderline epithelial tumors used to be called low malignant potential tumors. These tumors look the same as invasive epithelial ovarian cancers when seen on an ultrasound or CT scan. Doctors can't be sure whether a tumor is invasive or borderline until a biopsy sample has been taken (usually during surgery) and checked in a lab.

Initial surgery

Surgery for borderline tumors is similar to surgery for invasive ovarian cancer, with the goals of removing the tumor along with full staging and debulking.

• If preserving fertility is not a concern, the uterus, both fallopian tubes, and both ovaries are removed. Surgical staging is done to see if the tumor has spread outside the ovary or pelvis. This may include removing the omentum and some lymph nodes and taking fluid samples (washings) from the abdomen and pelvis.
• If preserving fertility is important, only the ovary with the tumor and the fallopian tube on that side are removed. Rarely, only the part of the ovary containing the tumor is removed. Surgical staging is still needed to see if the tumor has spread. If the tumor is limited to 1 ovary, further treatment may not be needed. Instead, regular ultrasound exams will be done to monitor for cancer.

Treatment options after surgery

Treatment after surgery depends on whether the tumor is a low-grade serous carcinoma. If it is, chemotherapy (usually carboplatin and paclitaxel) or hormonal therapy may be offered.

Recurrent cancer

If the tumor comes back after initial surgery, further debulking surgery might be considered. Chemo and, rarely, radiation therapy are also options.

Ovarian germ cell tumors, including benign teratomas and malignant cancers, are rare but treatable. Treatment depends on the tumor type and stage. It often involves surgery, chemotherapy, or both. In many cases, fertility-preserving options are available.

Learn more in Treating Ovarian Teratomas and Germ Cell Tumors.

Palliative treatments are used to relieve the symptoms of ovarian cancer.

Relieving fluid buildup (ascites)

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. The fluid may build 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. These treatments can relieve symptoms for some women and, rarely, might help some women live longer. Often, however, their effects are temporary, and the cancer returns or persists.

Managing intestinal obstructions

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. There are several procedures that might be done, depending on the type of obstruction and your overall health:

• 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.
• 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.
• For some women, surgery can be done to relieve intestinal obstruction. This is usually only done if you are well enough to get additional treatments (like chemo) after surgery. Often, however, the cancer has grown so much in the abdomen that surgery to unblock the intestine doesn't work.