Ovarian cancer - treatment, outcome and prevention

The mainstays of treatments for ovarian cancer are surgery and chemotherapy.

Most women with ovarian cancer will need surgery, both as a diagnostic tool as well as for treatment (to remove the cancer).

As the majority of women with ovarian cancer are diagnosed with advanced disease, a combination of both surgery and chemotherapy is usually required.

The scheduling of the chemotherapy is dependent on the stage of the cancer. Chemotherapy following surgery, or both before and after surgery, is a possibility.

It is best if the treatment is done by a team of specialists. A multi-disciplinary team (MDT) usually includes a gynaecologist and an oncologist, and sometimes a GP and/or counsellor.

In terms of the most appropriate form of treatment, various factors are taken in consideration by the medical team:

• The type of ovarian cancer
• The stage of the cancer – how far it has spread
• The aggressiveness of the cancer
• Other factors like age and general health

The type or stage of the cancer may only be known after surgery, when a careful inspection and biopsies will be done to assess spread.

Surgery is dependent on the stage (spread) and grade (aggressiveness) of the cancer.

For borderline ovarian cancer or early-stage, low-grade cancers, only the affected area may be removed – especially if the patient wishes to still have children. If that is not an option, a total hysterectomy is done: the ovaries and fallopian tubes are removed and biopsies are done to check for spread. If there is no sign of spread, no further treatment may be necessary.

The aim of surgery for early-stage ovarian cancer (Stage 1) is to remove the cancer and fully stage the disease. Knowing the stage helps to determine if you need further treatment (chemotherapy) after surgery.

If the cancer is more advanced or aggressive, chemotherapy probably will be advised in order to reduce risk of recurrence. This is called adjuvant therapy.

For more advanced stages (Stage 2 - 4), which indicate spread outside the ovaries, some patients can be cured by using a combination of surgery and chemotherapy. However, in cases where cure is deemed not possible, the aim of the treatment is to control the cancer for as long as possible.

After surgery, if all the cancer could not be surgically removed, chemotherapy is given to shrink the cancer left behind. Some women may have further surgery.

It may be decided in advance that it wouldn’t be possible to remove all the cancer at surgery and so chemotherapy is used before surgery to shrink the cancer and make it easier to remove. This is called neo-adjuvant or primary chemotherapy.

After the first half of chemotherapy is completed, tests will be done to see if the cancer has shrunk enough to attempt surgery or interval debulking surgery (IDS). After surgery, the rest of the course of chemotherapy is administered.

With very advanced cancer, it may not be possible to remove the cancer surgically, or the patient may not be fit enough for surgery. The cancer is then not curable and chemotherapy may be used to shrink the cancer as much as possible and to slow its progress down. Radiotherapy may also be used to aid this treatment or to relieve symptoms.

Outcome
This depends largely on the stage at which the disease is first diagnosed. Younger patients with early-stage disease, less aggressive tumours, and maximal tumour removal at surgery do best. The five-year survival rates vary from 89.3 percent for stage I patients with tumour limited to the ovaries, to 13.4 percent for stage IV, which has distant spread.

Prevention
There is no known prevention, and there are no effective screening tests. Patients with positive family histories or known to carry the BRCA gene should have regular pelvic examinations, with further tests at the discretion of their doctors.

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