Ovarian Cancer Treatment
||How Is Ovarian Cancer Treated?
If you have received an ovarian cancer diagnosis, your healthcare team will recommend a treatment plan. Treatment for the disease is developing so rapidly that protocols are changing on an almost yearly basis. There are for example some exciting vaccines still being tested in cancer clinical trials which may in the very near future even prevent ovarian cancer. For this reason, any newly diagnosed patients should be encouraged to find out about the most up-to-date therapies on offer. A good source of information is the American National Cancer Institute (NCI), contact details below.
Generally however, treatment plans still follow a standard practice. Surgery is considered the first line of treatment although it may be supplemented with chemotherapy to ensure any remaining cancer cells are destroyed. First a laparotomy is performed before surgery to determine the size and extent of the tumor. If there are any signs of fluid collection, a sample will be sent to the lab for testing. If cancer is limited to the ovaries and there is no fluid collection, surgery will usually involve a complete hysterectomy, along with removal of both ovaries and fallopian tubes. If the woman is not postmenopausal, she will immediately enter premature menopause. Possibly the pelvic and aortic lymph nodes will also be removed. Cell samples may also be 'washed' from the stomach to test for signs of cancer spread. Sometimes surgery will be followed by chemotherapy. If ovarian cancer is more extensive, it may require tissues from surrounding organs to be removed, such as parts of the urinary and gastrointestinal tract (this is known as debulking surgery). Removing as much of the cancerous tissue as possible improves the woman’s long-term ovarian cancer survival rate. If the woman is young and wants to retain her childbearing abilities this may be possible if cancer is limited to one ovary.
Systemic chemotherapy is recommended where it is suspected that cancer has metastasized (spread) to distant parts of the body either through the bloodstream or lymph nodes. The patient is injected with chemo drugs via the vein (IV) or they can be taken orally. Occasionally in some ovarian cancer cases, drugs can be injected with a catheter directly into the abdominal cavity. This is known as intraperitoneal chemotherapy (IP chemotherapy). IP chemo has the advantage of placing the drugs exactly in the spot where they are needed; ovarian cancer usually spreads to the abdominal cavity first. Furthermore, levels in the bloodstream are kept low and controlled. While IP chemo can work very well, the side effects such as nausea and vomiting can be much worse than regular chemo. This commonly causes women to stop their treatment early. For this reason it is generally only given for advanced stages of the disease. What has still to be conclusively answered by scientists is: Can IP chemo offer women a better hope for cure than regular chemotherapy?
Chemotherapy is normally given by combining 2 or more drugs and is given in a cycle every 3 to 4 weeks. A typical course for ovarian cancer involves 3 to 6 cycles. For epithelial ovarian cancer typically a platinum compound, such as carboplatin or cisplatin is combined with a taxane such as Taxol or Taxotere. For IV chemo, most doctors recommend carboplatin instead of cisplatin because it has fewer side effects. If cancer comes back different drugs may be tried. These include Adriamycin, Doxil Cytoxan, Gemzar, Navelbine, Ifos and VP-16.
Radiation treatment is rarely used in the United States anymore to cure ovarian cancer, although it may be used in certain circumstances to support another treatment. Radioactive phosphorus is one form of radiation. A solution of the substance is infused in a half quart of fluid and is instilled into the abdomen cavity. The woman is asked to change her position every 10 to 15 minutes to allow the fluid to wash the abdomen wall and hopefully kill any cancer cells it comes into contact with. It has few side effects but can cause scarring of the intestine which may lead to bowel disorders. It used to be a standard treatment for ovarian cancer but is used less often these days. Brachytherapy, that is, implanting radioactive material directly inside the woman, is rarely used for ovarian cancer. External radiation applied to the abdominal area is occasionally given, but more commonly in advanced stages to reduce unpleasant symptoms caused by the cancer.
Second Look Surgery
In the past surgeons used to perform another surgery (laparoscopy/laparotomy) to check for cancer cells after chemotherapy was completed. The NCI no longer recommends this because studies have not shown that it increases life expectancy. If it is to be performed, they say, it should only be done so by a surgeon trained in gynecologic oncology and as part of a cancer clinical trial where new treatments are being considered. Those who argue its benefits state that it allows therapy to end if no sign of cancer is spotted, or it can point to the necessity of further treatment if cancer is found. It will also provide additional information which will help a doctor predict an overall prognosis.
As there are different types of ovarian cancer, treatment options may vary slightly. Here we will discuss treatment for invasive epithelial ovarian cancer, the most common type of malignant ovarian cancer. To understand the different stages and what they mean, see: Ovarian cancer stages.
About 25 percent of women diagnosed with invasive ovarian cancer are in Stage 1 of the disease, which offers the best cure rate. Most will be recommended a total hysterectomy which involves surgical removal of the uterus, and a bilateral salpingo-oophorectomy (BSO) which involves removing both ovaries and fallopian tubes. About 25 percent of stage 1 patients will also have lymph nodes in the pelvic region removed. If the woman wishes to become pregnant in the future it may be possible just to remove one ovary and one fallopian tube, if cancer is restricted to one ovary. This decision will also depend on which subgroup of stage 1 cancer the woman has and the grade of the tumor cells. Once the tumor has been removed it will be examined under a microscope and graded. A grade 1 tumor will have cancer cells that appear like normal ovarian cells. Most women with grade 1 tumors will not require further treatment. If a woman has been staged with Stage 1a, grade 1 tumor before surgery and wishes to retain her fertility, she may be offered the option of only removing one ovary and fallopian tube. Women with grade 2 tumors (which mean the tumor cells have some similarity to normal ovarian cells) will be monitored closely after surgery, or they may be offered chemo. Grade 3 tumors are nearly always treated with chemo after surgery.
It should be noted that surgery alone does not always cure Stage 1 patients - cancer will return in about 20 percent of cases. Yet there is no agreement among experts about which patients at this stage should be treated with adjuvant therapy. Recommendations are based on the subgroup (1a, 1b or 1c), the grade of tumor and type of cancer cells present.
As so few women are diagnosed at Stage 2 ovarian cancer, little is known about treatment at this stage. The same surgery as Stage 1 will probably be applied. Some surgeons may even wash the abdomen during surgery with radioactive phosphorus. Chemotherapy will be recommended for at least 6 cycles. Some women may be treated with intraperitoneal (IP) chemotherapy instead of intravenous (IV) chemotherapy. Many women are recommended IP chemo AFTER surgery and AFTER a course of regular systemic chemo.
There is still some debate as to the best course of treatment for advanced stages of ovarian cancer. At this time the NCI recommends a total hysterectomy involving removal of the uterus, both ovaries, both fallopian tubes and the omentum (a fatty tissue near the stomach). The goal is leave no tumor behind larger than 1cm in size. When the surgeon manages this, it is said that the cancer has been 'optimally debulked'. This may mean having to remove parts of the urinary or gastrointestinal tracts. Surgery is usually followed by chemo, either IP or IV chemotherapy. Some surgeons give women with more advanced stages of the disease doses of chemo before surgery in the hope that it may shrink the tumor and make it less likely that cancer cells will escape during the operation. Sometimes radiation therapy is given directly to the abdomen during surgery.
Once the treatment plan has been completed, some doctors may recommend consolidation therapy. This is additional chemo given after it appears the initial treatment plan has been successful. It is more of a maintenance therapy to consolidate the benefits of the first treatment. The aim is to kill any possible lurking cancer cells which neither the surgeon nor laboratories managed to pick up, and so prevent a recurrence. Although one study showed that giving the drug paclitaxel every 4 weeks for a year lengthened the time before cancer came back, it did not help a woman live longer.
Currently there are no treatments available which can cure Stage 4 ovarian cancer. However treatment can allow patients to live longer and improve their quality of life. There is no single type of treatment recognized by surgeons as the best way to treat advanced stages of the disease. Some believe women should not be treated by surgery at all, but rather just with chemo. Others believe Stage 3 surgery combined with chemo is the best course. While others think chemo before surgery, followed by surgery and more chemo offers the best results. Another option is to limit treatment only to what reduces pain and discomfort for the woman. This is known as palliative care.
About 15 percent of epithelial ovarian cancers are described as low malignant potential (LMP) tumors; of which 75 percent are discovered in the early stages. LMP tumors are seen as borderline cancer although they can look the same as invasive epithelial tumors. A biopsy of the tumor will determine if it malignant or not. Most women in Stage 1 or 2 will be recommended a total hysterectomy in addition to removal of the ovaries and fallopian tubes. If the woman still wishes to become pregnant it may be possible to remove just one ovary and fallopian tube, if the tumor is limited to one ovary. Further treatment such as chemotherapy or radiation is not usually necessary. If the tumor spreads it can cause implants to grow on surrounding organs. If these implants remain on the surface of those organs they are usually just observed (because they grow very slowly and even if they do spread they are rarely fatal). If the implants start to grow into the organs they become known as invasive and debulking surgery is necessary. That means, as much of the tissue is removed. Chemotherapy or radiation is only usually recommended for implants which return.
Germ cell tumors account for about 5 percent of all ovarian cancers. They are treated in much the same way as other types of the disease, with surgery followed by chemotherapy and occasionally radiation. In the early stages of the disease, fertility may be preserved by just removing one ovary and fallopian tube. If after careful staging and surgery the woman is found to be free of cancer, no further treatment is necessary.
What Follow Up Is Needed?
|Related Articles on Ovary Cancer
For more details, see the following:
• Symptoms of ovarian cancer and causes of ovarian cancer.
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