Patient education: First-line medical treatment of epithelial ovarian cancer (Beyond the Basics)
- Thomas J Herzog, MD
Thomas J Herzog, MD
- Clinical Director
- University of Cincinnati Cancer Institute
- Vincent E Herrin, MD
Vincent E Herrin, MD
- Associate Professor of Medicine
- University of Mississippi School of Medicine
- Divisions of Hematology and Oncology
- Director, Medicine Residency Program
- University of Mississippi School of Medicine
OVARIAN CANCER OVERVIEW
Ovarian cancer is diagnosed in over 20,000 women in the United States each year . The average age at diagnosis of ovarian cancer is 63 years old . The lifetime risk of developing ovarian cancer is approximately 1.4 percent.
There are several different types of cancer that can arise in the ovary, although epithelial ovarian cancer (referred to as ovarian cancer in this topic) is the most common and is the subject of this review. Additionally, fallopian tube cancer and primary peritoneal cancer, which arise from the fallopian tubes or the tissues lining the abdominal and pelvic cavities, are commonly included in the discussion of ovarian cancer as they are very similar in presentation, prognosis, and treatment.
This topic review will cover chemotherapy treatment for ovarian cancer. Separate topic reviews are available that discuss the diagnosis and staging (including initial surgical staging) of ovarian cancer. (See "Patient education: Ovarian cancer diagnosis and staging (Beyond the Basics)".)
DO I NEED CHEMOTHERAPY?
After ovarian cancer is removed with surgery, there is still a risk that cancer cells remain and may return or spread to other parts of the body. Chemotherapy is given after surgery to destroy these cells and improves the chance of curing ovarian cancer and decreases the risk of dying of ovarian cancer. The need for chemotherapy depends on the disease stage and cell type, which is determined at the time of surgery. In general, chemotherapy is recommended for all newly diagnosed patients except in the case of selected women with stage IA or IB disease (also called "early-stage disease"). For women diagnosed with early-stage disease, surgery alone is effective, and no additional therapy is recommended. (See "Patient education: Ovarian cancer diagnosis and staging (Beyond the Basics)", section on 'Staging'.)
What is chemotherapy? — Chemotherapy refers to the use of medicines to stop or slow the growth of cancer cells. Chemotherapy works by interfering with the ability of rapidly growing cells (such as cancer cells) to divide or reproduce themselves. Because most of an adult's normal cells are not rapidly growing, they are not as affected by chemotherapy. Exceptions to this include rapidly dividing cells such as bone marrow (where red and white blood cells are produced), hair, and lining of the gastrointestinal tract; thus, chemotherapy results in side effects such as low blood counts and hair loss.
What types of chemotherapy are used? — Among the chemotherapy agents most commonly used in the treatment of ovarian cancer are taxanes (paclitaxel or docetaxel) and platinum agents (carboplatin or cisplatin). Studies have demonstrated that platinum- and taxane-containing chemotherapy improves the survival of women with ovarian cancer over other types of regimens. As a result, the combination of a platinum-type drug (usually carboplatin) and a taxane (typically paclitaxel) is a standard chemotherapy regimen.
How is chemotherapy administered? — Most chemotherapy drugs are given into the vein (intravenously or IV). However, for women with optimally resected stage III disease, another treatment strategy involves giving a combination of chemotherapy both IV and directly into the abdominal (peritoneal) cavity, called intraperitoneal (IP) chemotherapy (IV/IP treatment).
In general, regardless of the route administered (intravenously or intraperitoneally), chemotherapy drugs are given in a carefully defined sequence and dosed over a period of several months. Chemotherapy drugs are usually not administered daily but periodically, in cycles. A cycle of chemotherapy refers to the time it takes to give the treatment and then allow the body to recover from the effects. During this time, patients are closely monitored for signs of drug toxicity and side effects.
Influence of disease stage on the chemotherapy recommendation — As noted above, the need for chemotherapy after surgery and the type and duration of treatment that is recommended depends on the disease stage and aggressiveness of the tumor (also referred to as the "grade" of the tumor). (See "Patient education: Ovarian cancer diagnosis and staging (Beyond the Basics)", section on 'Staging'.)
Stage I — After surgery, most women with stage IA or IB ovarian cancers (ie, cancers limited to the ovary) do well without chemotherapy, and observation alone is a standard approach. Women with aggressive (grade 2 or 3) stage IA or IB ovarian cancers and all women with stage IC ovarian cancer should receive chemotherapy after surgery using paclitaxel and carboplatin. Some cell types such as clear cell cancers are automatically classified as grade 3 tumors based upon their more aggressive behavior. Treatment usually begins within two to six weeks after surgery. Each cycle of chemotherapy is given over three weeks for a total of six cycles. However, the optimal duration of chemotherapy for women with stage I ovarian cancer remains controversial. Many oncologists recommend individualizing the number of cycles (with a minimum of three) based upon patient risk factors and how well the woman is tolerating the chemotherapy.
Stage II — All women with stage II disease (ie, outside the ovary but confined to the pelvis) require chemotherapy after surgery. Most oncologists administer six cycles of IV paclitaxel plus carboplatin. Some clinicians also use a combination of IP and IV chemotherapy for women with stage II disease, but there is no evidence that IV/IP treatment in women with stage II ovarian cancer is more beneficial than standard administration of IV chemotherapy alone.
Stage III — All women with stage III disease (ie, abdominal involvement) require chemotherapy after surgery. In the United States, the standard course of chemotherapy can be given in different methods:
●Six cycles of paclitaxel plus carboplatin given on day 1 of a 21-day cycle. This treatment approach has been a standard approach for many years. Some studies suggest that adding another drug, bevacizumab (given every three weeks during chemotherapy and then for one year after), to this regimen may postpone relapse. No data to date have shown that adding bevacizumab improves overall survival in this setting.
●Six cycles of carboplatin on day 1 with paclitaxel on days 1, 8, and 15 of a 21-day cycle. This "dose-dense" treatment approach is preferred by some clinicians based upon one randomized trial that showed an improvement over time to relapse and overall survival when compared with every-21-day paclitaxel plus carboplatin. However, "dose-dense" chemotherapy is associated with greater toxicity than every-21-day administration.
●Six cycles of a combination of IV and IP chemotherapy. In this 21-day schedule, cisplatin or carboplatin is given IP on day 1, paclitaxel on day 1 or day 2 as an IV infusion, and then paclitaxel is given IP on day 8. This IV/IP regimen is preferred by some clinicians based upon several randomized trials that have shown an improvement in time to relapse and overall survival when compared with IV therapy alone. However, IV/IP chemotherapy requires placement of an IP catheter (either during the initial surgery or as a second outpatient surgical procedure) and is associated with significant toxicity, which many patients cannot tolerate. Furthermore, not all trials have confirmed superior outcomes with IP.
Stage IV — All women with stage IV disease (ie, commonly involving the lungs or liver) require chemotherapy. While the prognosis is worse for these patients compared with those with earlier-stage disease, chemotherapy is given to control the disease and reduce any symptoms that may be due to the cancer. In this case, carboplatin and paclitaxel are typically administered as long as the chemotherapy is tolerated and a benefit is seen. This may require more than six cycles of chemotherapy.
What are the side effects of treatment? — Chemotherapy can cause side effects during and after treatment. The type and severity of these side effects depends upon which chemotherapy drugs are used and how they are administered. Side effects that occur during chemotherapy are usually temporary and reversible. The most common side effects are nausea, vomiting, mouth soreness, temporary lowering of the blood counts, and hair loss.
Bevacizumab can cause side effects that are different from those caused by chemotherapy. Common side effects include new or worsening hypertension, nose bleeds, dizziness, headache, and delayed wound healing. Women with ovarian cancer who receive bevacizumab may have a slightly increased risk of bowel perforation during treatment. Patients with preexisting tumor involvement of the gastrointestinal tract (eg, bowel obstruction or bowel wall thickening) or history of inflammatory bowel disease appear to be at greatest risk for this complication. Although initial studies suggested that this was relatively common, subsequent studies suggest that the overall risk is 7 percent or less.
Neoadjuvant chemotherapy — In most cases, chemotherapy is given after surgery for ovarian cancer, but some clinicians prefer to do chemotherapy for several cycles followed by surgery to reduce operative complications and improve complete resection rates in patients with large tumor volumes. Additionally, neoadjuvant chemotherapy is used when it is deemed too risky to perform initial surgery because of the extensive nature of the cancer and/or the debilitated condition of the patient. In such cases, chemotherapy may be recommended as a first step in the treatment process; this is referred to as neoadjuvant chemotherapy. Initial or neoadjuvant chemotherapy can shrink the tumor and improve a woman's overall medical condition, making her a better candidate for later debulking surgery.
SURVEILLANCE AFTER OVARIAN CANCER TREATMENT
At the end of treatment (both surgery and chemotherapy), a woman is considered to have a "complete response" if her physical examination is normal, there is no evidence of cancer on imaging studies (such as a computed tomography [CT] scan), and the blood levels of the tumor marker cancer antigen 125 (CA-125) are normal. However, even when all of these criteria are met, microscopic amounts of residual cancer (ie, not visible on imaging studies) can still be present. Growth of these microscopic tumor cells is probably responsible for tumor recurrence at a later date.
To monitor for the possibility of recurrent ovarian cancer, follow-up blood tests, physical examinations, and imaging tests are recommended for at least five years after treatment ends. Though the optimal surveillance strategy is not defined, our approach is similar to the guidelines from the National Comprehensive Cancer Network (NCCN):
●Office visits with pelvic examination every two to four months for two years, then every six months for three years, then annually.
●Periodic blood tests for CA-125 and/or human epididymis protein 4 (HE4) at the discretion of your physician. A rise in the level of blood tumor markers such as these is often the earliest sign of an ovarian cancer recurrence. However, the benefit of detecting and treating a recurrence based on elevations in tumor makers alone, before there are any signs or symptoms of recurrence, has been questioned. (See 'Signs of recurrence' below.)
●Chest X-ray and chest/abdomen/pelvic CT scan are reserved for patients with any abnormalities on history, exam, or blood test.
Signs of recurrence — Even women with a complete response to initial therapy can have a recurrence of ovarian cancer at a later time. The likelihood of a tumor recurrence is highest in women with more advanced-stage disease at diagnosis, particularly if the initial debulking surgery was unable to remove all visible tumor. The earliest evidence of recurrent ovarian cancer can be indicated by a rising blood level of one of the tumor markers (CA-125 or HE4), symptoms (often abdominal pain or bloating with or without back pain), or clinical signs (bloating or a pelvic mass).
In the past, treatment for recurrent ovarian cancer was sometimes recommended based on rising levels of tumor markers alone, instead of waiting until symptoms developed. However, a large study showed no survival benefit of starting chemotherapy based on rising CA-125 values alone and that quality of life may be improved by waiting until there are symptoms or signs of ovarian cancer recurrence. You should talk to your healthcare provider for more information about this issue.
DIAGNOSIS OF RECURRENT OVARIAN CANCER
Women with recurrent ovarian cancer following an initial complete response and those who do not respond well to initial chemotherapy are candidates for further chemotherapy, often called second-line chemotherapy. The choice of chemotherapy agents for second-line treatment depends upon whether and how well the patient responded to first-line treatment, current symptoms, time elapsed from last treatment, and long-term side effects from previous chemotherapies.
Platinum-sensitive ovarian cancer — If the initial treatment with chemotherapy worked, and the response lasted for at least six months, a woman is considered to have "platinum-sensitive" cancer. For such patients, at the time of relapse, retreatment with another round of platinum-based chemotherapy is usually recommended. Studies show that a repeat response to chemotherapy is possible with platinum-based retreatment. In fact, if the initial response lasted longer than 24 months, up to one-fourth of patients will have a complete response to retreatment with platinum. In general, combination platinum-based therapy (with more than one drug) is preferred to single-agent therapy. In particular, the addition of bevacizumab to the chemotherapy regimen, with subsequent continuation of bevacizumab as "maintenance treatment" (treatment intended to prolong the duration of time that a cancer doesn’t grow), was associated with an improvement in both response rate and time to progression. Women who can’t take bevacizumab can get chemotherapy followed by maintenance treatment with a drug called niraparib. Niraparib is one of a group of drugs called poly-ADP ribose polymerase (PARP) inhibitors.
In women with a BRCA mutation (a genetic mutation that is associated with increased risks for breast and ovarian cancer), PARP inhibitors (eg, olaparib or rucaparib) may be used as an alternative to another line of chemotherapy after progression on multiple lines of chemotherapy.
Studies in carefully selected patients have also demonstrated a benefit to repeat surgical treatment, particularly if the tissue can be easily removed and the woman has been free of disease recurrence for more than 6 to 12 months. Thus, repeat surgical treatment may be an option.
Platinum-resistant ovarian cancer — If a woman has persistent or nonresponsive ovarian cancer despite first-line therapy with paclitaxel and a platinum agent, or if she relapses within six months of completing such therapy, she is considered to have "platinum-resistant" cancer. Most women in this situation are treated with a course of chemotherapy with a single agent. Select women with platinum-resistant ovarian cancer may benefit from chemotherapy plus bevacizumab. In addition, for women with a BRCA mutation, a PARP inhibitor is also a treatment option, particularly for women who have progressed after multiple prior lines of treatment. You and your doctor should review which treatment options are best for you.
Progress in treating cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. We strongly encourage patients to enroll in well-designed clinical trials evaluating new treatments for epithelial ovarian cancer. These trials generally provide the highest level of care while providing access to the newest and potentially most active regimens. Further information regarding clinical trials can be found at the following websites:
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Ovarian cancer (The Basics)
Patient education: Ovarian cysts (The Basics)
Patient education: Ovarian cancer screening (The Basics)
Patient education: Preserving fertility after cancer treatment in women (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis
Serum biomarkers for evaluation of an adnexal mass for epithelial carcinoma of the ovary, fallopian tube, or peritoneum
Screening for ovarian cancer
Medical treatment for relapsed epithelial ovarian, fallopian tubal, or peritoneal cancer: Platinum-resistant disease
Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Histopathology
First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer
Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management
Early detection of epithelial ovarian cancer: Role of symptom recognition
Adjuvant therapy of early stage (stage I and II) epithelial ovarian, fallopian tubal, or peritoneal cancer
Cancer of the ovary, fallopian tube, and peritoneum: Surgery for recurrent cancer
The following organizations also provide reliable health information:
●National Cancer Institute
●American Cancer Society
- Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017; 67:7.
- http://seer.cancer.gov/statfacts/html/ovary.html (Accessed on May 31, 2013).
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.