First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer
- Thomas J Herzog, MD
Thomas J Herzog, MD
- Clinical Director
- University of Cincinnati Cancer Institute
- Deborah K Armstrong, MD
Deborah K Armstrong, MD
- Professor of Oncology
- Professor of Gynecology & Obstetrics
- Johns Hopkins Kimmel Cancer Center
- Section Editors
- Barbara Goff, MD
Barbara Goff, MD
- Section Editor — Gynecologic Oncology
- Professor of Gynecologic Oncology
- University of Washington
- Don S Dizon, MD, FACP
Don S Dizon, MD, FACP
- Section Editor – Gynecologic Oncology
- Clinical Co-Director, Gynecologic Oncology
- Founder and Director, The Oncology Sexual Health Clinic
- Massachusetts General Hospital Cancer Center
- Associate Professor of Medicine
- Harvard Medical School
Epithelial cancers of ovarian, fallopian tubal, and peritoneal origin exhibit similar clinical characteristics and behavior. As such, these are often combined together and define epithelial ovarian cancer (EOC) in clinical trials and clinical practice. This topic will consider all three histologies under the heading EOC. EOC is the most common cause of death among women with gynecologic malignancies and the fifth leading cause of cancer death in women in the United States. Approximately 75 percent of women have stage III (disease that has spread throughout the peritoneal cavity or that involves lymph nodes) or stage IV (disease spread to more distant sites) disease at diagnosis. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)
Historically, the Gynecologic Oncology Group (GOG) has performed separate clinical trials for women with early (stages I and II disease) versus advanced (stages III and IV) disease. However, this separation of patient populations has not been consistent. Studies done in Canada, Europe, and elsewhere may have included patients with stage II disease or any patients who received systemic therapy (regardless of stage) as having advanced EOC. While ongoing and future GOG trials will include women with stage II disease as having advanced EOC, the GOG trials reported to date include only stage III and IV EOC patients and are discussed below. (See "Overview of epithelial carcinoma of the ovary, fallopian tube, and peritoneum", section on 'Prognosis'.)
Primary surgical cytoreduction followed by systemic chemotherapy is the preferred initial management for women with stage III or IV EOC. Patients who are not good candidates for surgery due to the location and volume of disease involvement or medical comorbidities at the time of diagnosis may be considered for neoadjuvant chemotherapy. (See "Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management" and 'Neoadjuvant chemotherapy' below.)
First-line systemic chemotherapy for women with advanced EOC involving the abdomen (stage III) or extra-abdominal sites (eg, parenchymal liver or lung, stage IV) and posttreatment surveillance of EOC will be reviewed here. Initial surgical management, first-line therapy for women with early-stage (stage I or II) disease, and the treatment of patients with relapsed or refractory EOC are discussed separately.
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- TIMING OF TREATMENT INITIATION
- TREATMENT SELECTION AND METHOD OF ADMINISTRATION
- Women with suboptimally cytoreduced disease
- - Choice of agents
- - Dose-dense IV therapy
- Women with optimally cytoreduced disease
- - Choice of agents
- - IV/IP therapy versus IV therapy alone
- Incorporation of angiogenesis inhibitors
- SPECIAL CONSIDERATIONS
- Neoadjuvant chemotherapy
- In vitro chemosensitivity and resistance assays
- EVALUATION AFTER ADJUVANT CHEMOTHERAPY
- MAINTENANCE THERAPY
- Angiogenesis inhibition
- - Bevacizumab
- - Pazopanib
- - Nintedanib
- POSTTREATMENT SURVEILLANCE
- TREATMENT OF RECURRENT DISEASE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS