Overview of the approach to survivors of epithelial ovarian, fallopian tube, or peritoneal carcinoma
- Linda R Duska, MD
Linda R Duska, MD
- Associate Professor
- Fellowship Director
- Gynecologic Oncology
- University of Virginia
- Section Editors
- Larissa Nekhlyudov, MD, MPH
Larissa Nekhlyudov, MD, MPH
- Section Editor — Cancer Survivorship
- Director of Cancer Research
- Department of Population Medicine
- Associate Professor
- Harvard Medical School
- 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
- Deputy Editors
- Sadhna R Vora, MD
Sadhna R Vora, MD
- Deputy Editor — Oncology
- Instructor in Medicine
- Harvard Medical School
- Sandy J Falk, MD, FACOG
Sandy J Falk, MD, FACOG
- Senior Deputy Editor — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Clinical Instructor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
Although epithelial carcinoma of the ovary, fallopian tube, and peritoneum (collectively called epithelial ovarian carcinoma [EOC]) is the most fatal of the gynecologic cancers, as of 2014, there are almost 200,000 survivors in the United States alone . Although nearly 80 percent enter remission following primary treatment, the majority of EOC survivors are living with disease; the recurrence rates are 25 and 80 percent for women with early stage and advanced disease, respectively [2,3]. However, there are long-term survivors of EOC with reported 5 and 10-year survival rates of 43 and 33 percent, respectively . Due to the older age at onset or the surgical treatment of EOC, most survivors will be postmenopausal.
This topic will review the approach to EOC survivors. For the purposes of this review, we will limit discussion to EOC survivors who have completed initial therapy and are without evidence of disease because these are the patients most likely to be seen by their primary care provider in a coordinated care setting. In contrast, the care and needs of women with recurrent EOC are dependent on whether they are on active treatment and are discussed separately. (See 'Coordination of care' below and "Adjuvant therapy of early stage (stage I and II) epithelial ovarian, fallopian tubal, or peritoneal cancer", section on 'Treatment of recurrent disease'.)
Further information on the diagnosis, staging, and treatment of EOC is available elsewhere. (See "Overview of epithelial carcinoma of the ovary, fallopian tube, and peritoneum".)
OVARIAN CANCER SURVIVORSHIP
Issues pertaining to survivorship in ovarian cancer are not as well studied as they are for other cancers. This may be due to the overall poor prognosis of women with EOC and smaller populations of affected individuals compared with patients with other cancers (eg, endometrial or breast cancer). However, survivorship-related issues are important because in addition to affecting quality of life (QOL), they may also influence survival outcomes [5,6]. As an example, a randomized trial by the Gynecologic Oncology Group (GOG 152) evaluated QOL at the third and sixth treatment cycles and then at 6 and 12 months after starting treatment . The study found that baseline QOL score was significantly associated with overall survival. In addition, while QOL decreased during treatment, it significantly improved after the start of treatment at both 6- and 12-month assessment points.
OVERVIEW OF PRIMARY TREATMENT
The approach to treatment is dependent on the clinical stage at presentation:
- DeSantis CE, Lin CC, Mariotto AB, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin 2014; 64:252.
- Armstrong DK, Bundy B, Wenzel L, et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med 2006; 354:34.
- Trimbos JB, Parmar M, Vergote I, et al. International Collaborative Ovarian Neoplasm trial 1 and Adjuvant ChemoTherapy In Ovarian Neoplasm trial: two parallel randomized phase III trials of adjuvant chemotherapy in patients with early-stage ovarian carcinoma. J Natl Cancer Inst 2003; 95:105.
- Ovarian Cancer National Alliance. Statistics. http://www.ovariancancer.org/about-ovarian-cancer/statistics/ (Accessed on April 23, 2013).
- Wenzel L, Huang HQ, Monk BJ, et al. Quality-of-life comparisons in a randomized trial of interval secondary cytoreduction in advanced ovarian carcinoma: a Gynecologic Oncology Group study. J Clin Oncol 2005; 23:5605.
- Mutch DG, Orlando M, Goss T, et al. Randomized phase III trial of gemcitabine compared with pegylated liposomal doxorubicin in patients with platinum-resistant ovarian cancer. J Clin Oncol 2007; 25:2811.
- Young RC, Decker DG, Wharton JT, et al. Staging laparotomy in early ovarian cancer. JAMA 1983; 250:3072.
- Young RC, Walton LA, Ellenberg SS, et al. Adjuvant therapy in stage I and stage II epithelial ovarian cancer. Results of two prospective randomized trials. N Engl J Med 1990; 322:1021.
- Cella DF. Measuring quality of life in palliative care. Semin Oncol 1995; 22:73.
- Dow KH. The quality of lives: 1,525 voices of cancer. Betty R. Ferrell, PhD, FAAN, 1996 Oncology Nursing Society Distinguished Researcher. Oncol Nurs Forum 1996; 23:907.
- Wenzel LB, Donnelly JP, Fowler JM, et al. Resilience, reflection, and residual stress in ovarian cancer survivorship: a gynecologic oncology group study. Psychooncology 2002; 11:142.
- Mirabeau-Beale KL, Kornblith AB, Penson RT, et al. Comparison of the quality of life of early and advanced stage ovarian cancer survivors. Gynecol Oncol 2009; 114:353.
- Ezendam NP, Pijlman B, Bhugwandass C, et al. Chemotherapy-induced peripheral neuropathy and its impact on health-related quality of life among ovarian cancer survivors: results from the population-based PROFILES registry. Gynecol Oncol 2014; 135:510.
- Huang HQ, Brady MF, Cella D, Fleming G. Validation and reduction of FACT/GOG-Ntx subscale for platinum/paclitaxel-induced neurologic symptoms: a gynecologic oncology group study. Int J Gynecol Cancer 2007; 17:387.
- Mayerhofer K, Bodner-Adler B, Bodner K, et al. A paclitaxel-containing chemotherapy does not cause central nervous adverse effects: a prospective study in patients with ovarian cancer. Anticancer Res 2000; 20:4051.
- Kudelka AP, Hasenburg A, Verschraegen CF, et al. Phase II study of i.v. CI-980 in patients with advanced platinum refractory epithelial ovarian carcinoma. Anticancer Drugs 1998; 9:405.
- Hensley ML, Correa DD, Thaler H, et al. Phase I/II study of weekly paclitaxel plus carboplatin and gemcitabine as first-line treatment of advanced-stage ovarian cancer: pathologic complete response and longitudinal assessment of impact on cognitive functioning. Gynecol Oncol 2006; 102:270.
- Hess LM, Chambers SK, Hatch K, et al. Pilot study of the prospective identification of changes in cognitive function during chemotherapy treatment for advanced ovarian cancer. J Support Oncol 2010; 8:252.
- Correa DD, Zhou Q, Thaler HT, et al. Cognitive functions in long-term survivors of ovarian cancer. Gynecol Oncol 2010; 119:366.
- Newell S, Sanson-Fisher RW, Girgis A, Ackland S. The physical and psycho-social experiences of patients attending an outpatient medical oncology department: a cross-sectional study. Eur J Cancer Care (Engl) 1999; 8:73.
- Cella D, Peterman A, Passik S, et al. Progress toward guidelines for the management of fatigue. Oncology (Williston Park) 1998; 12:369.
- Liavaag AH, Dørum A, Fosså SD, et al. Controlled study of fatigue, quality of life, and somatic and mental morbidity in epithelial ovarian cancer survivors: how lucky are the lucky ones? J Clin Oncol 2007; 25:2049.
- Payne JK. The trajectory of fatigue in adult patients with breast and ovarian cancer receiving chemotherapy. Oncol Nurs Forum 2002; 29:1334.
- Ahlberg K, Ekman T, Gaston-Johansson F. Fatigue, psychological distress, coping resources, and functional status during radiotherapy for uterine cancer. Oncol Nurs Forum 2005; 32:633.
- Donovan HS, Ward S. Representations of fatigue in women receiving chemotherapy for gynecologic cancers. Oncol Nurs Forum 2005; 32:113.
- Teng FF, Kalloger SE, Brotto L, McAlpine JN. Determinants of quality of life in ovarian cancer survivors: a pilot study. J Obstet Gynaecol Can 2014; 36:708.
- Diaz JP, Tew WP, Zivanovic O, et al. Incidence and management of bevacizumab-associated gastrointestinal perforations in patients with recurrent ovarian carcinoma. Gynecol Oncol 2010; 116:335.
- Rose PG, Piver MS. Intestinal perforation secondary to paclitaxel. Gynecol Oncol 1995; 57:270.
- Wenzel LB, Huang HQ, Armstrong DK, et al. Health-related quality of life during and after intraperitoneal versus intravenous chemotherapy for optimally debulked ovarian cancer: a Gynecologic Oncology Group Study. J Clin Oncol 2007; 25:437.
- Burger RA, Brady MF, Bookman MA, et al. Incorporation of bevacizumab in the primary treatment of ovarian cancer. N Engl J Med 2011; 365:2473.
- Fitch M, Gray RE, Franssen E. Perspectives on living with ovarian cancer: young women's views. Can Oncol Nurs J 2000; 10:101.
- Fitch MI, Gray RE, Franssen E. Perspectives on living with ovarian cancer: older women's views. Oncol Nurs Forum 2001; 28:1433.
- Lakusta CM, Atkinson MJ, Robinson JW, et al. Quality of life in ovarian cancer patients receiving chemotherapy. Gynecol Oncol 2001; 81:490.
- Duska LR, Chang YC, Flynn CE, et al. Epithelial ovarian carcinoma in the reproductive age group. Cancer 1999; 85:2623.
- Plaxe SC, Braly PS, Freddo JL, et al. Profiles of women age 30-39 and age less than 30 with epithelial ovarian cancer. Obstet Gynecol 1993; 81:651.
- Green JA. Early ovarian cancer--time for a rethink on stage? Gynecol Oncol 2003; 90:235.
- Sun CC, Ramirez PT, Bodurka DC. Quality of life for patients with epithelial ovarian cancer. Nat Clin Pract Oncol 2007; 4:18.
- Carmack Taylor CL, Basen-Engquist K, Shinn EH, Bodurka DC. Predictors of sexual functioning in ovarian cancer patients. J Clin Oncol 2004; 22:881.
- Liavaag AH, Dørum A, Bjøro T, et al. A controlled study of sexual activity and functioning in epithelial ovarian cancer survivors. A therapeutic approach. Gynecol Oncol 2008; 108:348.
- Levin AO, Carpenter KM, Fowler JM, et al. Sexual morbidity associated with poorer psychological adjustment among gynecological cancer survivors. Int J Gynecol Cancer 2010; 20:461.
- Barton D, La Vasseur B, Loprinzi C, et al. Venlafaxine for the control of hot flashes: results of a longitudinal continuation study. Oncol Nurs Forum 2002; 29:33.
- Kimmick GG, Lovato J, McQuellon R, et al. Randomized, double-blind, placebo-controlled, crossover study of sertraline (Zoloft) for the treatment of hot flashes in women with early stage breast cancer taking tamoxifen. Breast J 2006; 12:114.
- Pergialiotis V, Pitsouni E, Prodromidou A, et al. Hormone therapy for ovarian cancer survivors: systematic review and meta-analysis. Menopause 2016; 23:335.
- Eeles RA, Tan S, Wiltshaw E, et al. Hormone replacement therapy and survival after surgery for ovarian cancer. BMJ 1991; 302:259.
- Ursic-Vrscaj M, Bebar S, Zakelj MP. Hormone replacement therapy after invasive ovarian serous cystadenocarcinoma treatment: the effect on survival. Menopause 2001; 8:70.
- Mascarenhas C, Lambe M, Bellocco R, et al. Use of hormone replacement therapy before and after ovarian cancer diagnosis and ovarian cancer survival. Int J Cancer 2006; 119:2907.
- Hopkins ML, Fung MF, Le T, Shorr R. Ovarian cancer patients and hormone replacement therapy: a systematic review. Gynecol Oncol 2004; 92:827.
- Biglia N, Gadducci A, Ponzone R, et al. Hormone replacement therapy in cancer survivors. Maturitas 2004; 48:333.
- Guidozzi F, Daponte A. Estrogen replacement therapy for ovarian carcinoma survivors: A randomized controlled trial. Cancer 1999; 86:1013.
- Power L, Lefas G, Lambert P, et al. Hormone Use After Nonserous Epithelial Ovarian Cancer: Overall and Disease-Free Survival. Obstet Gynecol 2016; 127:837.
- Norton TR, Manne SL, Rubin S, et al. Prevalence and predictors of psychological distress among women with ovarian cancer. J Clin Oncol 2004; 22:919.
- Ferrell B, Smith SL, Cullinane CA, Melancon C. Psychological well being and quality of life in ovarian cancer survivors. Cancer 2003; 98:1061.
- Howell D, Fitch MI, Deane KA. Impact of ovarian cancer perceived by women. Cancer Nurs 2003; 26:1.
- Shinn EH, Taylor CL, Kilgore K, et al. Associations with worry about dying and hopelessness in ambulatory ovarian cancer patients. Palliat Support Care 2009; 7:299.
- Cain EN, Kohorn EI, Quinlan DM, et al. Psychosocial reactions to the diagnosis of gynecologic cancer. Obstet Gynecol 1983; 62:635.
- Bodurka-Bevers D, Basen-Engquist K, Carmack CL, et al. Depression, anxiety, and quality of life in patients with epithelial ovarian cancer. Gynecol Oncol 2000; 78:302.
- Clevenger L, Schrepf A, Degeest K, et al. Sleep disturbance, distress, and quality of life in ovarian cancer patients during the first year after diagnosis. Cancer 2013; 119:3234.
- von Gruenigen VE, Huang HQ, Gil KM, et al. Assessment of factors that contribute to decreased quality of life in Gynecologic Oncology Group ovarian cancer trials. Cancer 2009; 115:4857.
- Hipkins J, Whitworth M, Tarrier N, Jayson G. Social support, anxiety and depression after chemotherapy for ovarian cancer: a prospective study. Br J Health Psychol 2004; 9:569.
- Hodgkinson K, Butow P, Fuchs A, et al. Long-term survival from gynecologic cancer: psychosocial outcomes, supportive care needs and positive outcomes. Gynecol Oncol 2007; 104:381.
- Gonçalves V, Jayson G, Tarrier N. A longitudinal investigation of posttraumatic stress disorder in patients with ovarian cancer. J Psychosom Res 2011; 70:422.
- McKenzie H, Crouch M. Discordant feelings in the lifeworld of cancer survivors. Health (London) 2004; 8:139.
- Shand LK, Brooker JE, Burney S, et al. Symptoms of posttraumatic stress in Australian women with ovarian cancer. Psychooncology 2015; 24:190.
- Lutgendorf SK, Slavich GM, Degeest K, et al. Non-cancer life stressors contribute to impaired quality of life in ovarian cancer patients. Gynecol Oncol 2013; 131:667.
- Fitch MI, Steele R. Identifying supportive care needs of women with ovarian cancer. Can Oncol Nurs J 2010; 20:66.
- Browall M, Carlsson M, Horvath GG. Information needs of women with recently diagnosed ovarian cancer--a longitudinal study. Eur J Oncol Nurs 2004; 8:200.
- Harries M, Gore M. Part I: chemotherapy for epithelial ovarian cancer-treatment at first diagnosis. Lancet Oncol 2002; 3:529.
- Penson RT, Dignan F, Seiden MV, et al. Attitudes to chemotherapy in patients with ovarian cancer. Gynecol Oncol 2004; 94:427.
- Lockwood-Rayermann S. Survivorship issues in ovarian cancer: a review. Oncol Nurs Forum 2006; 33:553.
- Schaefer KM, Ladd EC, Lammers SE, Echenberg RJ. In your skin you are different: women living with ovarian cancer during childbearing years. Qual Health Res 1999; 9:227.
- Salani R, Backes FJ, Fung MF, et al. Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncologists recommendations. Am J Obstet Gynecol 2011; 204:466.
- Brady MJ, Peterman AH, Fitchett G, et al. A case for including spirituality in quality of life measurement in oncology. Psychooncology 1999; 8:417.
- Carpenter JS, Brockopp DY, Andrykowski MA. Self-transformation as a factor in the self-esteem and well-being of breast cancer survivors. J Adv Nurs 1999; 29:1402.
- Canada AL, Parker PA, de Moor JS, et al. Active coping mediates the association between religion/spirituality and quality of life in ovarian cancer. Gynecol Oncol 2006; 101:102.
- Hammer K, Mogensen O, Hall EO. Hope as experienced in women newly diagnosed with gynaecological cancer. Eur J Oncol Nurs 2009; 13:274.
- Howell D, Fitch MI, Deane KA. Women's experiences with recurrent ovarian cancer. Cancer Nurs 2003; 26:10.
- Beesley VL, Price MA, Butow PN, et al. Physical activity in women with ovarian cancer and its association with decreased distress and improved quality of life. Psychooncology 2011; 20:1161.
- NCCN Clinical Practice Guidelines in Oncology: Ovarian Cancer, Including Fallopian Tube and Primary Peritoneal Cancer. Version 1.2013. http://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf (Accessed on May 06, 2013).
- Rustin G, van der Burg M, Griffin C, et al. Early versus delayed treatment of relapsed ovarian cancer. Lancet 2011; 377:380.
- Rustin GJ. Follow-up with CA125 after primary therapy of advanced ovarian cancer has major implications for treatment outcome and trial performances and should not be routinely performed. Ann Oncol 2011; 22 Suppl 8:viii45.
- Fleming ND, Cass I, Walsh CS, et al. CA125 surveillance increases optimal resectability at secondary cytoreductive surgery for recurrent epithelial ovarian cancer. Gynecol Oncol 2011; 121:249.
- Domchek SM, Jhaveri K, Patil S, et al. Risk of metachronous breast cancer after BRCA mutation-associated ovarian cancer. Cancer 2013; 119:1344.
- OVARIAN CANCER SURVIVORSHIP
- OVERVIEW OF PRIMARY TREATMENT
- Initial surgical management
- Adjuvant chemotherapy
- Neoadjuvant therapy
- SPECIFIC LONG TERM EFFECTS IN OVARIAN CANCER SURVIVORS
- Physical toxicities
- - Neurotoxicity
- - Cognitive dysfunction
- - Fatigue
- - Gastrointestinal toxicity
- Surgical complications
- Medical complications
- Unrelated causes
- - Gynecologic effects
- Loss of fertility
- Sexual dysfunction
- Psychological effects
- - Depression
- - Anxiety
- - Guilt
- - Poor body image
- Spiritual well-being
- Social well-being
- PROMOTING A HEALTHY LIFESTYLE
- GUIDELINES FOR POSTTREATMENT FOLLOW-UP
- Role of CA 125 surveillance
- Risk of recurrence
- Breast cancer risk management in BRCA-positive mutation carriers with EOC
- Coordination of care