Once it is determined that ovarian, fallopian tube or primary peritoneal cancer is present, treatment is scheduled by a gynecologic oncologist (a physician trained to treat cancers of a woman's reproductive system). Gynecologic oncologists can perform surgery on and give chemotherapy to women with ovarian cancer. A treatment plan is developed. Treatment usually involves
surgery and chemotherapy, and sometimes
radiotherapy, regardless of the subtype of ovarian cancer. Surgical treatment may be sufficient for well-differentiated malignant tumors confined to the ovary. The addition of chemotherapy may be required for more aggressive tumors confined to the ovary. For patients with advanced disease, a combination of surgical reduction with a combination chemotherapy regimen is standard. Since 1980, platinum-based drugs have had an important role in treating ovarian cancer.
Borderline tumors, even following spread outside of the ovary, are managed well with surgery, and chemotherapy is not seen as useful.
Second-look surgery and
maintenance chemotherapy have not been shown to provide benefit. For low-grade, unilateral stage-IA cancers, only the involved ovary (which must be unruptured) and the Fallopian tube will be removed. This can be done, especially in young people who wish to preserve their fertility. However, a risk of microscopic metastases exists,, and staging must be completed. In advanced cancers, where complete removal is not an option, as much tumor as possible is removed in a procedure called
debulking surgery. This surgery is not always successful, and is less likely to be successful in women with extensive metastases in the peritoneum, stage- IV disease, cancer in the
transverse fissure of the liver,
mesentery, or diaphragm, and large areas of ascites. Debulking surgery is typically done once. Computed tomography (abdominal CT) is often used to assess if primary debulking surgery is possible, but low certainty evidence also suggests fluorodeoxyglucose‐18 (FDG) PET/CT and MRI may be useful as an addition for assessing macroscopic incomplete debulking. More complete debulking is associated with better outcomes: women with no macroscopic evidence of disease after debulking have a median survival of 39 months, as opposed to 17 months with less complete surgery. Several different surgical procedures can be employed to treat ovarian cancer. For stage I and II cancer, laparoscopic (keyhole) surgery can be used, but metastases may not be found. For advanced cancer, laparoscopy is not used, since debulking metastases requires access to the entire peritoneal cavity. Depending on the extent of the cancer, procedures may include a bilateral salpingo-oophorectomy, biopsies throughout the peritoneum and abdominal lymphatic system,
omentectomy,
splenectomy,
bowel resection,
diaphragm stripping or resection,
appendectomy, or even a posterior
pelvic exenteration. or
LGSOC. This is particularly important in germ cell tumors because they frequently metastasize to nearby lymph nodes. It also can be helpful in people who had their first surgery done by a generalist and in epithelial ovarian cancer. The major side effect of oophorectomy in younger women is early
menopause, which can cause
osteoporosis. After surgery, hormone replacement therapy can be considered, especially in younger women. This therapy can consist of a combination of estrogen and progesterone, or estrogen alone. Estrogen alone is safe after hysterectomy; when the uterus is still present, unopposed estrogen dramatically raises the risk of
endometrial cancer. Surgery outcomes are best at hospitals that do a large number of ovarian cancer surgeries. There is also no apparent difference between total abdominal hysterectomy and supracervical hysterectomy for advanced cancers. Approximately 2.8% of people having a first surgery for advanced ovarian cancer die within two weeks of the surgery (2.8%
perioperative mortality rate). Chemotherapy in ovarian cancer typically consists of
platins, a group of
platinum-based drugs, combined with non-platins. Platinum-based drugs have been used since 1980. Common therapies can include
paclitaxel,
cisplatin,
topotecan, doxorubicin,
epirubicin, and
gemcitabine.
Carboplatin is typically given in combination with either
paclitaxel or
docetaxel; the typical combination is carboplatin with paclitaxel. Platinum combinations can offer improved survival over single platinum. In people with relapsed ovarian cancer, evidence suggests topotecan has a similar effect on overall survival as paclitaxel and topotecan plus thalidomide, whilst it is superior to treosulfan and not as effective as pegylated liposomal doxorubicin in platinum-sensitive people. Chemotherapy can be given
intravenously or
in the peritoneal cavity. Typical cycles of treatment involve one treatment every 3 weeks, repeated for 6 weeks or more. Fewer than 6 weeks (cycles) of treatment is less effective than 6 weeks or more.) For recurrent germ cell tumors, an additional 4 cycles of BEP chemotherapy is the first-line treatment for those who have been treated with surgery or platins. Tumors that have a high expression of a protein called ALDH1A1 are found to be resistant to chemotherapy and this resistance can be overcome by blocking ALDH1A1. If the tumor is determined to be platinum-resistant,
vincristine,
dactinomycin, and
cyclophosphamide (VAC) or some combination of paclitaxel, gemcitabine, and
oxaliplatin may be used as a second-line therapy. Novocure sponsored a phase-2 trial proving the efficacy of
tumor treating fields in recurrent platinum-resistant ovarian carcinoma, in conjunction with weekly paclitaxel chemotherapy. Radiotherapy late effects (and occurrence rates) include
osteonecrosis (8-20%),
bladder ulceration (2.5%) and
irreversible lumbosacral plexopathy.
Hormonal therapy Despite the fact that 60% of ovarian tumors have
estrogen receptors, ovarian cancer is only rarely responsive to hormonal treatments. A Cochrane review found a lack of evidence about the effects of tamoxifen in people with relapsed ovarian cancer. Estrogen alone does not have an effect on the cancer, and
tamoxifen and
letrozole are rarely effective. For epithelial ovarian cancers, the most common test upon follow-up is the CA-125 level. However, treatment based only on elevated CA-125 levels and not any symptoms can increase side effects without prolonging life, so the implications of the outcome of a CA-125 test can be discussed before taking it. The recommendation as of 2014 is that recurrent cancer may be present if the CA-125 level is twice normal. Imaging without these indications is discouraged because it is unlikely to detect a recurrence, improve survival, and because it has its own costs and side effects.
Palliative care Palliative care focuses on relieving symptoms and increasing or maintaining quality of life. This type of treatment's purpose is not to cure the cancer but to make the woman more comfortable while living with cancer that can not be cured. It has been recommended as part of the treatment plan for any person with advanced ovarian cancer or patients with significant symptoms. In platinum-refractory and platinum-resistant cases, other palliative chemotherapy is the main treatment. Pleural effusions can be treated in a similar manner, with repeated
thoracentesis,
pleurodesis, or placement of a drain. Palliative radiotherapy typically lasts for only a few treatments, a much shorter course of therapy than non-palliative radiotherapy. The same psychosocial problems can develop in family members. Emotional effects can include a
fear of death,
sadness, memory problems, and difficulty concentrating. When optimism was adopted by those at the beginning of their treatment, they were less likely to develop distress. Those who have a fear of the cancer recurring may have difficulty in expressing
joy even when disease-free. The more treatments that a woman undergoes, the more likely the loss of
hope is expressed. Women often can cope and reduce negative psychosocial effects through several strategies. Activities such as traveling, spending additional time with family and friends, ignoring
statistics, journaling, and increasing involvement in
spiritually-based events are adaptive. == Prognosis ==