What is the standard treatment for ovarian cancer?

Standard Treatment for Ovarian Cancer

The standard treatment for ovarian cancer consists of surgical debulking (including total abdominal hysterectomy and bilateral salpingo-oophorectomy) followed by platinum-based chemotherapy, with the specific approach determined by disease stage. 1, 2, 3

Treatment by Stage

Early Stage Disease (FIGO I and IIA)

• Surgery should include total abdominal hysterectomy, bilateral salpingo-oophorectomy with omentectomy, staging biopsies, and pelvic/para-aortic lymph node sampling 1
• For FIGO stage Ia/b well-differentiated, non-clear cell histology: surgery alone is adequate 1
• For FIGO stage Ia/b poorly differentiated, clear cell histology, and all grades of stage Ic and IIA: adjuvant chemotherapy with carboplatin (AUC 5-7) should be considered after optimal surgery 1, 4
• In younger patients wanting to preserve fertility with localized, unilateral tumors (stage I) and favorable histology, unilateral salpingo-oophorectomy may be considered 1

Advanced Disease (FIGO IIB-IIIC)

• Upfront maximal surgical cytoreduction with the goal of no residual disease should be undertaken 1, 5
• Standard surgical approach includes:
  • Total abdominal hysterectomy with bilateral salpingo-oophorectomy 1, 6
  • Complete excision of the lumbar-ovarian vessels 1, 6
  • Complete infragastric omentectomy 1, 6
  • Appendectomy 1
  • Pelvic and para-aortic lymphadenectomy when indicated 1, 6
• Recommended chemotherapy: carboplatin AUC 5-7.5 plus paclitaxel 175 mg/m² every three weeks for 6 cycles 1, 4
• If initial maximal cytoreduction was not performed, interval debulking surgery should be considered in patients responding to chemotherapy or showing stable disease 1

Stage IV Disease

• Patients with stage IV disease can obtain survival advantage from maximal surgical cytoreduction at initial laparotomy 1
• Young patients with good performance status, pleural effusion as only site of disease outside abdominal cavity, and small volume metastases should be considered for surgery 1
• If surgery is not planned, diagnosis should be confirmed by biopsy and chemotherapy administered as recommended for stage IIB-IIIC disease 1

Surgical Considerations

• The volume of tumor left in place after initial surgery is of prognostic value - patients without residual disease (complete excision) or minimal residue (optimal excision) have better survival 1, 5
• Tumor resection must be as complete as possible, with the goal of removing all visible disease 1, 6
• Ultra-radical surgery should only be considered if a prolonged postoperative course would not delay the start of chemotherapy 1
• If a standard operation does not result in complete or optimal resection, chemotherapy can be started immediately and two or three courses given before a second attempt at interval debulking surgery 1

Chemotherapy Considerations

• Carboplatin is FDA-approved for the initial treatment of advanced ovarian carcinoma in established combination with other approved chemotherapeutic agents 4
• For single-agent therapy in recurrent disease, carboplatin is effective at 360 mg/m² IV on day 1 every 4 weeks 4
• Dose adjustments should be made based on blood counts, with reductions to 75% of the prior course dose if platelets <50,000 or neutrophils <500 4
• Patients with impaired kidney function (creatinine clearance below 60 mL/min) require dose adjustments to prevent severe bone marrow suppression 4

Follow-up and Recurrence

• Despite an initial remission rate of 80%, approximately 75% of patients with advanced-stage disease experience cancer relapse within 2 years 3
• "Second-look" surgery following completion of chemotherapy in patients whose disease appears to be in complete remission is not recommended routinely as it has not been shown to benefit patients 1
• Secondary cytoreduction surgery for recurrence is controversial and has no proven benefit, but may be considered in cases with favorable features such as a single mass or several masses likely to be completely excised and in cases of late relapse 1

Prognosis

• With treatment, early-stage ovarian cancer has a 5-year overall survival of 70% to 95% 3
• The 5-year overall survival rate for advanced-stage ovarian cancer is 10% to 40% 3
• Individuals with BRCA-related gene variants have a 5-year overall survival rate of approximately 70% with PARP inhibitor treatment 3
• Approximately 20% of women with advanced-stage ovarian cancer survive beyond 12 years after treatment and are effectively cured 5