Ovarian cancer medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Huda A. Karman, M.D.
Overview
Medical therapies, such as chemotherapy and radiation, are often employed post-surgerical therapy as a means to treat residual disease. The success of medical therapy often hinges on the histology of the tumor.
MedicalTherapy
- Epithelial ovarian cancer includes ovarian, fallopian tube, and peritoneal cancer and the combination of the three is referred to as (EOC) due to the similarity in their clinical behavior and characteristics
- EOC is usually diagnosed in its late stages due to its subclinical or nonspecific symptoms
- The mainstay of definitive diagnosis and initial management of ovarian cancer is surgical operation to determine if it is benign or malignant, determine its stage and grade, and then treat it accordingly
- The medical management of ovarian cancer is usually done as an adjuvant to the surgical therapy which means surgery first then adjuvant chemotherapy
- Based on the surgical staging and grading of the tumor the management can be one of the following:
- Adjuvant intravenous chemotherapy is not recommended in
- Early stage EOC (Stage IA or IB) with no high-risk features (clear cell histology or high tumor grade)
- Adjuvant intravenous chemotherapy:
- Carboplatin and paclitaxel (platinum-based combination)
- Every three weeks for six cycles
- Can be adjusted based on patient tolerance and the presence of risk factors
- Is recommended for the following:
- Early stage EOC (Stage IA or IB) with high-risk features (clear cell histology or high tumor grade)
- Early stage EOC (Stage IC or Stage II)
- Neoadjuvant chemotherapy is defined as initiating medical or systemic therapy before surgery.
- Carboplatin and paclitaxel (platinum-based combination)
- Followed by debulking surgery
- Then adjuvant therapy
- It is recommended for:
- Advanced EOC (Stage IIIC or IV)with a low chance of complete or optimal cytoreduction (unresectable tumor)
- EOC in patients with poor operation outcome due to comorbidities or poor performance status
- Temsirolimus, carboplatin, and paclitaxel are used for
- Clear cell ovarian cancer (stage III-IV)
- Sunitinib is used for
- Ovarian Clear Cell Adenocarcinoma
- Recurrent Ovarian Carcinoma
- Adjuvant intravenous chemotherapy is not recommended in
- Observation after adjuvant chemotherapy is recommended for patients with early-stage EOC
- Maintenance therapy with paclitaxel for 24 weeks after completion of the adjuvant therapy is recommended for patients with advanced EOC
- Management of patients with EOC recurrence:
- Platinum-sensitive: more than 6 months disease-free interval after completion of therapy
- Secondary chemotherapy with or without bavacizumab and secondary cytoreduction
- Platinum-resistant EOC: less than 6 months disease-free interval after completion of therapy and includes the following:
- * Platinum-refractory EOC: disease progression while on platinum therapy
- Both treated with
- Paclitaxel as a single agent
- Pegylated liposomal doxorubicin (PLD)
- If patient is not Paclitaxel candidate
- Bevacizumab plus single agent chemotherapy
- For patients with platinum-resistant recurrent disease
- Platinum-sensitive: more than 6 months disease-free interval after completion of therapy
- Chemotherapy is used after surgery to treat any residual disease, if appropriate. This depends on the histology of the tumor; some kinds of tumor (particularly teratoma) are not sensitive to chemotherapy. In some cases, there may be reason to perform chemotherapy first, followed by surgery.
- Many oncologists recommend intravenous (IV) chemotherapy including a platinum drug with a taxane as a preferred method of treating advanced ovarian cancer. However, three recent randomized studies clinical trials suggest that chemotherapy that is partly IV and partly via direct infusion into the abdominal cavity (intraperitoneal or IP) may improve median survival time.
- IP chemotherapy generally has higher toxicity and its advantages are still debated among specialists.
- Currently for Stage IIIC ovarian adenocarcinomas after optimal debulking, median time for survival is statistically significantly longer for patient receiving intraperitoneal chemotherapy.
- Patients in this clinical trial did report less compliance with IP chemotherapy, and fewer than half of the patients received all six cycles of IP chemotherapy.
- Despite this high "drop-out" rate, the group as a whole (including the patients that didn't complete IP chemotherapy treatment) survived longer on average than patients who received intravenous chemotherapy alone. These results can be interpreted in couple of ways. One could argue if the IP chemotherapy treatment group had completed the six cycles of chemotherapy their lives would have been prolonged even longer. Or the advantages of receiving IP chemotherapy are significant in the early phases of chemotherapy. Some specialists believe the IP chemotherapy toxicities will be unnecessary with improved IV chemotherapy drugs currently being developed.
- Radiation therapy is not effective for advanced stages because when vital organs are in the radiation field, a high dose cannot be safely delivered.