Once a diagnosis of ovarian cancer is made, there are different types of treatment.

The treatment of ovarian cancer is based on the stage of the disease which is a reflection of the extent or spread of the cancer to other parts of the body. Staging is performed by the surgeon (gynecologic oncologist) when the ovarian cancer is removed. During the surgical procedure the surgeon will obtain small pieces of tissue (biopsies) from various sites in the abdominal cavity. During this procedure, depending on the stage (extent) of the disease, the surgeon will either remove just the ovary and fallopian tube or will remove both ovaries, fallopian tubes and uterus. In addition, the surgeon will attempt to remove as much of the cancer as possible.

Treatment of Ovarian Epithelial Cancer   

  • Stage I - Generally women with Stage I ovarian cancer have a total abdominal hysterectomy, removal of both ovaries and fallopian tubes, omentectomy, biopsy of lymph nodes and other tissues in the pelvis and abdomen. Young women whose disease is confined to one ovary are often treated by a unilateral salpingo-oophorectomy without a hysterectomy and removal of the opposite ovary being performed. Omentectomy and the other parts of the staging procedure are performed. Depending on the pathologist's interpretation of the tissue removed, there may be no further treatment if the cancer is low grade, or if the tumor is high grade the patient may receive combination chemotherapy.
  • Stage II - Treatment is almost always hysterectomy and bilateral salpingo-oophorectomy as well as debulking of as much of the tumor as possible and sampling of lymph nodes and other tissues in the pelvis and abdomen that are suspected of harboring cancer. After the surgical procedure, treatment may be one of the following:
    1) combination chemotherapy with or without radiation therapy or
    2) combination chemotherapy.
  • Stage III - Treatment is the same as for Stage II ovarian cancer. Following the surgical procedure, the patient may either receive combination chemotherapy possibly followed by additional surgery to find and remove any remaining cancer.
  • Stage IV - Treatment will probably be surgery to remove as much of the tumor as possible followed by combination chemotherapy.

Treatment of Recurrent Cancer   

Patients who develop recurrent cancer despite surgery and primary chemotherapy, and will be given salvage chemotherapy, may be placed into one of three groups (A-C):

Group A: are patients resistant to primary therapy and have shown tumor growth during treatment. This persisting tumor is considered to be refractory i.e. have absolute platinum-resistance. Secondary non-cross resistant chemotherapies or biological therapies should be considered.

Group B: are patients who respond well to initial chemotherapy, but develop recurrent cancer within months after the end of primary care. This group with relatively platinum resistant tumor has an intermediate prognosis.

Group C: are patients who showed a good response to primary chemotherapy, and did not develop recurrent cancer for more than 6 months after the end of primary treatment. This group with platinum-sensitive tumor shows the best responses to re-treatment with a platinum-containing regimen.

The probability of response to salvage chemotherapy is also markedly dependent upon on the number of preceding chemotherapy regimens, such that third and fourth line chemotherapies are of limited benefit. However, unique patients responding to multiple retreatments with even the same regimen of chemotherapy are sometimes observed. Tumor burden, as assessed by the size of the largest lesion and the number of disease sites and histology (serous having the best outcome) are also independent predictors of response to salvage chemotherapy.

Treatment of Sensitive Cancer   

Patients with recurrent chemotherapy-sensitive disease are usually treated again with primary chemotherapy usually carboplatin/paclitaxel, but toxicity must also be taken into consideration. If carboplatin or cisplatin was used alone for primary therapy, taxol should be considered for salvage chemotherapy. For low-volume disease, intraperitoneal chemo- or radiotherapy can be considered. These patients are also candidates for trials of high dose chemotherapy with autologous bone marrow support.

Treatment of Resistant Cancer   

The emergence of drug-resistant tumors during therapy for ovarian cancer remains an obstacle to improving long-term outcomes. Active areas of ovarian cancer research include clinical evaluation of non-cross-resistant antineoplastic agents that demonstrated single-agent activity in ovarian cancer during the 1990s: oxaliplatin, the new anthracyclines (epirubicin, liposomal doxorubicin), topotecan, oral etoposide, gemcitabine, and vinorelbine. Most of these new agents are currently being evaluated as a component of doublet and triplet combination regimens for advanced ovarian cancer, with use of sequential alternating doublet regimens gaining interest. The potential role of intraperitoneal therapy continues to be investigated. In addition, there are a variety of innovative treatment strategies on the horizon that are targeted at underlying disease processes, including anticancer vaccines, gene therapy, and antiangiogenic therapy. Based on this multitude of investigational questions and the low cure rates currently achieved, all women with advanced ovarian cancer should consider participation in clinical trials.

Taxol therapy can be considered for patients who had not received prior taxol therapy but have relatively platinum-resistant cancer. Such patients have a modest overall response rate, but may achieve relief of symptoms.

A large, randomized study comparing the efficacy and safety of topotecan versus paclitaxel in patients with relapsed epithelial ovarian cancer after firstline treatment with platinum only showed that these two compounds have similar activity. In this study, a number of patients crossed over to the alternative drug as third-line therapy, ie, from paclitaxel to topotecan and vice versa, permitting assessment of the degree of non-cross-resistance between these two compounds. Patients who had progressed after one platinum-based regimen were randomized to either topotecan (1.5 mg/m(2)/d) x 5 every 21 days (n = 112) or paclitaxel (175 mg/m(2) over 3 hours) every 21 days (n = 114). A total of 110 patients received cross-over therapy with the alternative drug (61 topotecan, 49 paclitaxel) as third-line therapy. Response rates to third-line cross-over therapy were 13.1% (8 of 61 topotecan) and 10.2% (5 of 49 paclitaxel; P =.638). Seven patients who responded to third-line topotecan and four patients who responded to paclitaxel had failed to respond to their second-line treatment. Median time to progression (from the start of third-line therapy) was 9 weeks in both groups, and median survival was 40 and 48 weeks for patients who were receiving topotecan or paclitaxel, respectively. The principal toxicity was myelosuppression; grade 4 neutropenia was more frequent with topotecan (81.4% of patients) than with paclitaxel (22.9% of patients). CONCLUSION: Topotecan and paclitaxel have similar activity as second-line therapies with regard to response rates and progression-free and overall survival.

Patients with recurrent platinum-resistance cancer can be given several secondary-chemotherapy regimens by itself or in combination with other chemotherapy drugs.