Treatment

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The first step in treating ovarian cancer is removing as much of the cancerous growth as possible and any tissue to which the cancer has spread.

Often, this involves the removal of one or both ovaries, as well as the fallopian tube (the tube that connects the ovary to the uterus). The removal of one ovary is called a unilateral (one side) salpingo-oophorectomy and the removal of both ovaries is called a bilateral (two sides) salpingo-oophorectomy. The removal of one fallopian tube is called a unilateral salpingectomy, and the removal of both is called a bilateral salpingectomy.

The surgeon may also remove the uterus (hysterectomy) and/or part of the fatty lining of the abdominal cavity, where the cancer tends to spread (omentectomy).

The surgeon will also check your lymph nodes (small organs that fight infection and disease) for signs of disease, and may take tissue samples from various places in the abdominal cavity to check for cancer cells.

It is important to take out as much of the tumor as possible, a procedure called "tumor debulking," because it is associated with increased rate of survival.

If you are diagnosed with ovarian cancer, you should seek treatment from a gynecologic oncologist, a gynecologic surgeon with specialized training in cancers of the reproductive tract. You can find one through the Gynecologic Cancer Foundation at 1-800-444-4441 or www.wcn.org/gcf or the Society of Gynecologic Oncologists at 312-235-4060 or www.sgo.org.

Staging Ovarian Cancer

Ovarian cancer is staged based on the surgical findings.

• Stage I: Cancer is found in one or both of the ovaries but has not spread.

• Stage II: Cancer is found in one or both ovaries and/or has spread to the uterus, and/or the fallopian tubes (the pathway used by the egg to get from the ovary to the uterus), and/or other body parts within the pelvis, such as the bladder or rectum.

• Stage III: Cancer is found in one or both ovaries and has spread to the lymph nodes or the lining of the abdomen. (Lymph nodes, which produce and store infection-fighting cells, are found throughout the body.)

• Stage IV: This is the most advanced stage. Cancer is found in one or both ovaries and has spread outside the abdominal cavity to distant organs such as the liver or the lungs, or there are cancer cells in the fluid around the lungs.

• Recurrent or refractory: Recurrent disease means that the cancer has returned after treatment. Refractory disease means the cancer no longer responds to standard treatment.

If the disease has spread beyond the ovaries, chemotherapy is used following surgery. Radiation therapy is rarely used in the initial treatment of ovarian cancer.

After surgery, your doctor will typically recommend six cycles of chemotherapy administered every three to four weeks, followed by a rest period between cycles.

Anticancer drugs—chemotherapy—travel through the bloodstream to almost every area of the body. Drugs used to treat cancer may be given in different ways: Some are given by mouth; others are injected into a muscle, a vein or an artery. Some chemotherapies are given directly into the abdominal cavity (called intraperitoneal chemotherapy). You will be counseled regarding the best way for you to receive chemotherapy. The combination of both intravenous and intraperitoneal chemotherapy has been shown to increase survival in three large, well-designed studies of women newly diagnosed with ovarian cancer who are undergoing initial chemotherapy. Women with very little disease remaining in the abdomen after surgery are the best candidates for intraperitoneal chemotherapy.

The drugs most commonly used for the initial treatment of ovarian cancer are carboplatin and paclitaxel:

• Paclitaxel (Taxol): Taxol was approved in 1998 as a first-line treatment for advanced ovarian cancer. Taken from the bark of the Pacific yew tree, Taxol may be given in combination with other anticancer drugs through intravenous infusion. You may also receive Taxol intraperitoneally.

  Like most cancer drugs, Taxol may have serious side effects. Its most serious side effect is damage to the bone marrow; the soft, spongy tissue in the center of large bones that produces blood cells that fight infection. Thus, your body may not make enough white blood cells to protect you from infection, a condition called neutropenia. This makes you more vulnerable to infections.

  So while you're receiving Taxol, your doctor will recommend that you stay away from crowds and people with colds, flu or other infections, and discuss with your doctor the need for any vaccines (such as flu shots).

  Your doctor should also prescribe medications such as filgrastim (Neupogen), pegfilgrastim (Neulasta) or sargramostim (Leukine) between chemotherapy cycles to quickly restore reduced white blood cell counts to normal levels to help prevent infection.

  Common side effects may include hair loss, bleeding gums, blood in stool or urine, burning or tingling in hands or feet, nausea and vomiting, pain in joints or muscles, skin rash or itching and fatigue. However, your doctor can give you certain medications before treatment to help minimize or even prevent many of these side effects. You may experience some discomfort during the intraperitoneal infusion of Taxol.

• Carboplatin (Paraplatin). This chemotherapy medication is also administered via intravenous infusion, usually in combination with Taxol. Carboplatin and cisplatin (another platinum agent) can also be infused intraperitoneally. Make sure your health care professional gives you medication to reduce nausea and vomiting before starting the infusion.

Other possible side effects include:

• pain

• diarrhea

• constipation

• change in taste

• hair loss or brittle hair

• lowered blood counts

• Numbness, burning or tingling in your fingers/toes

All side effects depend on the drugs given, the dose and the individual response of the patient. Most side effects end after treatment is stopped. Many side effects of chemotherapy have been reduced over the years, however, through refinement of the drugs, the delivery of the drugs and/or pretreating with other medications to prevent side effects like nausea. It's important to tell your health care professional about your reactions and side effects because he or she may be able to adjust treatments to help you feel better.

Loss of appetite can be a serious problem for women receiving chemotherapy. Yet eating well is important, since studies find women who eat well are better able to withstand the side effects of treatment. Eating well means getting enough calories to prevent weight loss and having enough protein in your diet to build and repair skin, hair, muscles and organs. Many women say that eating several small meals throughout the day is easier than eating three large meals.

In addition to the standard chemotherapy drugs, other drugs available include:

• Topotecan (Hycamtin): This drug is used to treat metastatic (cancer that has spread) ovarian cancer after initial or subsequent chemotherapy has failed. This is one of the first of a new kind of drugs that kills cancer cells by inhibiting an enzyme essential to the replication of human DNA. It is injected by a health care professional experienced in administering anticancer (chemotherapeutic) drugs.

• Liposomal doxorubicin (Doxil). This drug is also used to treat metastatic ovarian cancer that no longer responds to paclitaxel or carboplatin. Doxil stays in the blood longer than other chemotherapy drugs so it has more time to reach the tumor and shrink and delay its progression. Note: There is a risk of severe heart damage with prolonged use of Doxil, even years after you stop taking the drug. Discuss this risk with your health care professional and be sure to tell him or her about any other previous chemotherapy treatments and all drugs you are taking.

Serious side effects of chemotherapy that may require medical attention include:

• severe constipation or diarrhea

• difficulty breathing

• fever, chills, cough or urinary frequency

• mouth sores

• nausea, vomiting

• pain, swelling, redness or irritation at the injection site

• stomach pain

• unusual bleeding or bruising, pinpoint red spots on the skin

• unusual tiredness or weakness

After your treatment ends, your health care professional should discuss follow-up care. This typically involves regular blood tests—including CA-125 tests—x-rays, ultrasound studies or, more rarely, a second-look surgery to make sure the cancer has not returned.

Living with Recurrent Ovarian Cancer

Today, women with ovarian cancer are more likely than ever to live for years after diagnosis, thanks to more aggressive surgical techniques and the use of chemotherapies like Taxol and carboplatin. They're also more likely to seek help from health care professionals who specialize in ovarian cancer (gynecologic oncologists).

However, the probability of recurrence in ovarian cancer patients is significant. Most women experience a reoccurrence within three years of diagnosis.

Currently, there is no consensus regarding the most effective treatment for ovarian cancer that has returned. Many oncologists choose to retreat their patients with either single-agent platinum therapy (carboplatin) or a combination of platinum and another chemotherapy/biologic agent as long as it's been at least six months since the last treatment with the drug. This time span helps prevent the cancer from becoming resistant to the drug.

It is anticipated that emerging new therapies will help increase overall survival time and offer hope to those living with the disease.