Treatment of Invasive Epithelial Ovarian Cancers, by Stage

The first step in treating most ovarian cancers is surgery to remove and stage the cancer. Debulking is also done as needed. (See Surgery for Ovarian Cancer.) Because fallopian tube and primary peritoneal cancers have the same staging system as ovarian cancers they are included in this section.

Stage I cancers

The initial treatment for stage I ovarian cancer is surgery to remove the tumor. Most often the uterus, both fallopian tubes, and both ovaries are removed (a hysterectomy with bilateral salpingo-oophorectomy). The treatment after surgery depends on the sub-stage of the cancer.

Stages IA and IB (T1a or T1b, N0, M0): The treatment after surgery depends on the way the cancer cells look in the lab (called the tumor grade).

• For grade 1 (also called low grade) tumors, most women don't need any treatment after surgery. Women who want to be able to have children after treatment might be given the option of having an initial surgery that removes only the ovary containing the cancer along with the fallopian tube on the same side.
• For grade 2 (high grade) tumors, patients are either watched closely after surgery without further treatment, or they are treated with chemotherapy (chemo). The chemo used most often is carboplatin and paclitaxel (Taxol) for 3-6 cycles, but cisplatin can be used instead of carboplatin, and docetaxel (Taxotere) can be used instead of paclitaxel.
• For grade 3 (high grade) tumors, the treatment usually includes the same chemotherapy that is given for grade 2 Stage IA and IB cancers.

Stage IC (T1c, N0, M0): Standard surgery to remove the cancer is still the first treatment. After surgery, chemo is recommended, usually with 3 to 6 cycles of treatment with carboplatin and paclitaxel.

Stage I fallopian tube and primary peritoneal cancers are treated the same way as stage I ovarian cancer.

Stage II cancers

For stage II (including IIA and IIB) cancers, treatment starts with surgery for staging and debulking. This includes a hysterectomy and bilateral salpingo-oophorectomy. The surgeon will try to remove as much of the tumor as possible.

After surgery, chemo is recommended for at least 6 cycles. The combination of carboplatin and paclitaxel is used most often. Some women with stage II ovarian cancer are treated with intraperitoneal (IP) chemotherapy instead of intravenous (IV) chemotherapy.

Stage II fallopian tube and primary peritoneal cancers are also treated with surgery for staging and debulking, followed by chemo.

Stage III cancers

Stage III cancers (including IIIA1, IIIA2, IIIB, and IIIC) are generally treated similarly to stage II cancers.

First, the cancer is surgically staged and the tumor is debulked (like stage II). The uterus, both fallopian tubes, both ovaries, and omentum (fatty tissue from the upper abdomen near the stomach and intestines) are removed. The surgeon will also try to remove as much tumor as possible. The goal is to leave behind no visible tumor or no tumor larger than 1 cm. When this goal is reached, the cancer is said to have been optimally debulked. Sometimes tumor is growing on the intestines, and in order to remove the cancer, part of the intestine will have to be removed. Sometimes pieces of other organs (like the bladder or liver) may also have to be removed to take out the cancer. The smaller the remaining tumor, the better the outlook will be.

After recovery from surgery, combination chemo is given. The combination used most often is carboplatin (or cisplatin) and a taxane, such as paclitaxel (Taxol), given IV (into a vein) for 6 cycles. The targeted drug bevacizumab (Avastin) might be given along with chemo as well. (If it is, it’s typically continued alone after chemo for up to about a year.) 

Another option is to give intra-abdominal (intraperitoneal or IP) chemo along with intravenous (IV) chemo, after surgery. IP chemo is usually only considered if the cancer was optimally debulked − it may not work as well if a lot of tumor is left in the abdomen.

After surgery, and during and after chemo, blood tests checking for the CA-125 tumor marker will be done to see how well the treatment is working. A CT scan, PET-CT scan, or MRI might also be done.

For women who are not healthy enough to have full staging and debulking surgery, chemo might be given as the first treatment. If the chemo works and the woman becomes stronger, surgery to debulk the cancer may be done, often followed by more chemo. Most often, 3 cycles of chemo are given before surgery, with at least 3 more after surgery (for a total of at least 6 cycles). Giving chemo before surgery is also sometimes an option for some women with advanced cancers that aren’t likely to be optimally debulked if surgery is done first.

Maintenance therapy: If the cancer shrinks a lot or appears to be gone after chemotherapy that includes a platinum drug (cisplatin or carboplatin), doctors might recommend additional treatment for some women. This is called maintenance therapy. It is aimed at killing any cancer cells that were left behind after treatment but are too small to be seen on tests. The goal of maintenance therapy is to keep the cancer from coming back. Drugs that might be used include bevacizumab, niraparib, rucaparib, and olaparib.

Stage IV cancers

In stage IV, the cancer has spread to distant sites, like the liver, the lungs, or bones. These cancers are very hard to cure with current treatments, but they can still be treated. The goals of treatment are to help patients feel better and live longer.

Stage IV can be treated like stage III, with surgery to remove the tumor and debulk the cancer, followed by chemo (and possibly the targeted drug bevacizumab [Avastin]). (If bevacizumab is given, it might be continued alone after chemo or with olaparib.)

Another option is to treat with chemo first. Then, if the tumors shrink from the chemo, surgery may be done, followed by more chemo. Most often, 3 cycles of chemo are given before surgery, with at least 3 more after surgery. 

Maintenance therapy: If the cancer shrinks a lot or appears to be gone after chemotherapy that includes a platinum drug (cisplatin or carboplatin), doctors might recommend additional treatment for some women. This maintenance therapy is aimed at killing any cancer cells that were left behind after treatment. The goal of maintenance therapy is to keep the cancer from coming back. Drugs that might be used include bevacizumab, niraparib, rucaparib, and olaparib.

Another option is to limit treatments to those aimed at improving comfort (but not at fighting the cancer). This type of treatment is called palliative.

Recurrent or persistent ovarian cancer

Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs like the lungs or bone). Persistent tumors are those that never went away completely after treatment. Advanced epithelial ovarian cancer often comes back months or years after the initial treatment.

Sometimes, more surgery is recommended. Most women with recurrent or persistent ovarian cancer are treated with some form of chemo. Which chemo drugs are used depends on what was used the first time and how well it worked (how long the cancer stayed away). The longer it takes for the cancer to come back after treatment, the better the chance that additional chemo will work. If it has been at least 6 months since any chemo, carboplatin and paclitaxel are often used (even if these drugs were given before). Giving carboplatin with another drug is also an option.

If the cancer comes back in less than 6 months (or if it never went away at all), different chemo drugs usually will be tried. There are many different chemo drugs that can be used to treat ovarian cancer, so some women may receive several different chemo regimens over several years.

Treatment with targeted drugs might also be helpful. For example, bevacizumab (Avastin) may be given with chemo. A PARP inhibitor drug such as olaparib (Lynparza), rucaparib (Rubraca), or niraparib (Zejula) may also be an option at some point. The antibody-drug conjugate mirvetuximab soravtansine (Elahere) might also be an option in some cases.

In addition, some women benefit from hormonal treatment with drugs like anastrozole, letrozole, or tamoxifen.

Someone who didn't initially receive chemo can be treated with the same drugs that are used for newly diagnosed cancer − usually carboplatin and paclitaxel.

A clinical trial for new treatments might provide important advantages for women with recurrent or persistent ovarian cancer. Ask your cancer care team for information about suitable clinical trials for your type of cancer.

Palliative treatments

Palliative treatments are used to relieve the symptoms of ovarian cancer.

Women with ovarian cancer can have a buildup of fluid in the abdomen. This is called ascites. It can be very uncomfortable but can be treated with a procedure called paracentesis. After the skin is numbed, a needle is used to withdraw the fluid, often several quarts, into a bottle. Often, ultrasound is used to guide the needle. Often the fluid builds up again, and this procedure needs to be repeated. Sometimes a catheter (a thin flexible tube) is placed into the abdomen and left there so that fluid can be removed as often as is needed without using a needle. Another option is to inject chemo directly into the abdomen to slow the buildup of fluid. Treatment with bevacizumab (Avastin) may also help slow fluid buildup. These treatments can relieve symptoms for some women and, rarely, might help some women live longer. Often, however, their effects are temporary, and the cancer returns or persists.

Ovarian cancer can also block the intestinal tract. This is called obstruction, and can cause abdominal pain, nausea, and vomiting. Dealing with an intestinal blockage can be difficult. There are several procedures that might be done, depending on the type of obstruction and your overall health:

• Doctors may place a tube through the skin and into the stomach to allow the stomach juices to drain, so that the digestive tract isn’t completely blocked.
• Sometimes a stent (a stiff tube) can be put into the large intestine to relieve a blockage. Since this option has a high risk of complications, you should discuss the risks and benefits with your doctor first.
• For some women, surgery can be done to relieve intestinal obstruction. This is usually only done if you are well enough to get additional treatments (like chemo) after surgery. Often, however, the cancer has grown so much in the abdomen that surgery to unblock the intestine doesn't work.