What is the primary treatment for ovarian cancer stage 4?

Primary Treatment for Stage IV Ovarian Cancer

The primary treatment for stage IV ovarian cancer consists of maximal surgical cytoreduction followed by combination chemotherapy with carboplatin and paclitaxel for six cycles. 1

Surgical Management

• Patients with stage IV disease may obtain a survival advantage from maximal surgical cytoreduction at initial laparotomy, although this has not been addressed in randomized trials [III, B] 1
• Surgery should include total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with the goal of achieving no residual disease 1
• Young patients with good performance status, pleural effusion as the only site of disease outside the abdominal cavity, small volume metastases, and no major organ dysfunction are the best candidates for upfront surgery 1
• If surgery is not feasible due to patient factors or extent of disease, diagnosis should be confirmed by biopsy and neoadjuvant chemotherapy administered 1

Chemotherapy Regimen

• The standard chemotherapy regimen is carboplatin AUC 5-7.5 plus paclitaxel 175 mg/m² over 3 hours every 3 weeks for 6 cycles 1
• Carboplatin is FDA-approved for initial treatment of advanced ovarian carcinoma in established combination with other approved chemotherapeutic agents 2
• This combination has demonstrated improved survival outcomes compared to previous regimens 3, 4
• If initial maximal cytoreduction was not performed, interval debulking surgery should be considered after 3 cycles of chemotherapy in patients responding to treatment or showing stable disease [II, B], followed by 3 additional cycles 1

Alternative Approaches

• Neoadjuvant chemotherapy followed by interval debulking surgery is a viable alternative for patients with extensive disease not initially resectable, though data suggest survival outcomes may be inferior to successful primary surgery followed by chemotherapy 1
• Intraperitoneal chemotherapy should be considered an option for selected patients who are optimally cytoreduced (residual disease <1 cm) in centers where the expertise exists 1

Response Evaluation and Follow-up

• CA125 levels should be monitored before each cycle of chemotherapy as they correlate with tumor response and survival [III, A] 1
• CT scans should be performed after cycle 6 unless there is evidence of non-responding disease, in which case earlier imaging is indicated 1
• An interim CT scan after 3 cycles of chemotherapy should be considered for patients who are CA125-negative or for whom interval debulking surgery is being considered 1

Maintenance Therapy

• Current data do not strongly support maintenance/consolidation treatment beyond 6 cycles 1
• However, data for 12 months of paclitaxel maintenance should be discussed with patients regarding potential improvement in progression-free survival [II, C] 1
• Patients with partial response or elevated CA125 after 6 cycles but continuing evidence of response can be considered for 3 additional cycles of the same chemotherapy [V, B] 1
• For advanced-stage disease, maintenance therapy with bevacizumab and/or PARP inhibitors may be considered, particularly for patients with BRCA mutations who may have significantly improved survival with PARP inhibitors 4

Common Pitfalls and Caveats

• "Second-look" surgery following completion of chemotherapy in patients whose disease appears to be in complete remission shows no evidence of survival benefit and should only be undertaken as part of a clinical trial 1
• Dose-limiting toxicities of carboplatin include thrombocytopenia, while paclitaxel contributes to sensory neuropathy and hair loss 5
• Despite high initial remission rates (approximately 80%), about 75% of patients with advanced-stage disease will experience relapse within 2 years 4
• The 5-year overall survival rate for advanced-stage ovarian cancer is generally 10-40%, though patients with BRCA-related gene variants may have better outcomes (approximately 70%) with appropriate targeted therapy 4