Treatment for ovarian cancer

Friday 1 April, 2016

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On this page: Surgery | Chemotherapy | Radiotherapy | Targeted therapies | Palliative treatment | Key points | Susan's story


The treatment for ovarian cancer depends on the type of ovarian cancer you have, the stage of the cancer, your general health and fitness, your doctors’ recommendations, and whether you wish to have children.

Treatment options by types of ovarian cancer
Epithelial

Surgery is the main treatment for all stages of epithelial ovarian cancer. The aim is to remove as much of the cancer as possible. Sometimes, additional treatment is needed.

  • Early stage ovarian cancer – Stages IA and IB are usually treated with surgery only. Women with stage IC cancer are usually offered chemotherapy after surgery as there is a high risk of the cancer coming back.
  • Advanced ovarian cancer – Stages II, III and IV are usually treated with a combination of surgery and chemotherapy. New targeted therapies are being offered to women with a BRCA mutation. In some cases, radiotherapy is offered.
Germ cell

This is usually treated with surgery and/or chemotherapy.

Stromal cell

This is usually treated with surgery, sometimes followed by chemotherapy or targeted therapies.

Borderline tumour

This is usually treated with surgery only.

Surgery

Your gynaecological oncologist will talk to you about the most suitable type of surgery, which will depend on how far the cancer has spread (the stage). Often information about the stage becomes available during surgery.

Your treating doctor will explain the risks of surgery. This may include infertility. If having children is important to you, talk to your doctor before surgery and ask for a referral to a fertility specialist.

Laparoscopy or laparotomy

This is often recommended as a first step if ovarian cancer is suspected, and it will help provide more information about the stage. You are given a general anaesthetic and will have either a laparoscopy (with 3–4 small cuts in your abdomen) or a laparotomy (with a long, vertical cut from your bellybutton to your bikini line).

Tissue samples (biopsy) and fluid samples may then be taken from the abdomen. During the operation, the samples are sent to a specialist called a pathologist, who examines them for signs of cancer. This is called a frozen section analysis. If the pathologist confirms that cancer is present, the surgeon will continue the operation to remove all the cancer.

Debulking

If the cancer has spread, the gynaecological oncologist will remove as much of the cancer as possible. This is called surgical debulking. It’s often followed by chemotherapy, which will shrink any remaining cancer cells.

Types of surgery for ovarian cancer

Following the debulking surgery, you will have one or more of the procedures listed below.

Total abdominal hysterectomy

The uterus and the cervix are removed.

Total abdominal hysterectomy
Total hysterectomy with bilateral salpingo- oophorectomy

The uterus, both ovaries and fallopian tubes are removed. 

Total hysterectomy with bilateral salpingo- oophorectomy
Omentectomy

Removal of the omentum (sheet of fatty tissue that is attached to the stomach and bowel and hangs down in front of the intestines).

Lymphadenectomy

Some lymph nodes are removed. Lymph nodes are small, bean-shaped organs that filter toxins, including cancer cells, from the bloodstream.

Colectomy

If cancer spreads to the bowel, the part of the bowel with cancer is cut out and the healthy parts are sewn back together. Sometimes a new opening called a stoma is created (colostomy or ileostomy). This is usually temporary.

What to expect after surgery

When you wake up from surgery, you will be in a recovery room near the operating theatre, then you will be taken back to your bed on the hospital ward.

Tubes and drips

You will have several tubes in place, which will be removed as you recover:

  • A drip inserted into a vein in your arm (intravenous drip) will give you fluid, medicines and pain relief.
  • A small plastic tube (catheter) may be inserted into your bladder, and urine will be collected in a bag.
  • A tube down your nose into your stomach (nasogastric tube) may drain your stomach fluid to prevent you vomiting.
  • Tubes may be inserted in your abdomen to drain fluid from the site of the operation.
Compression devices and stockings

Some women have to use compression devices or wear elastic stockings to keep the blood in their legs circulating. Once you are mobile, compression devices will be removed so you can get out of bed, but you can still wear the stockings.

Pain

After an operation, it is common to feel some pain, but this can be controlled. Medicine may be given by an intravenous drip or through an injection close to the spine (epidural). This is similar to what may be given to women during childbirth. Some patients have a patient controlled analgesia (PCA) system. This machine allows you to self-administer pain relief by pressing a button.

Let your doctor or nurse know if you are in pain so they can adjust your medicine. Do not wait until the pain is severe. Everyone’s pain tolerance is different and medicine will be used to make you as comfortable as possible. Managing your pain will help you to recover and move around more quickly.

Injections

It is common to have daily anticoagulant injections in the abdomen to decrease the risk of developing a blood clot. These injections may continue for some time after the operation and while you’re having chemotherapy. A nurse will show you how to administer the injection before you leave hospital.

Length of hospital stay

You will probably need to stay in hospital for 5–7 days.

Further treatment

Within a week of surgery, your doctor should have all the test results and will discuss any further treatment options with you. Further treatment will depend on the type of cancer, the stage of the disease and the amount of any remaining cancer. If ovarian cancer is advanced, it’s more likely to come back, so surgery will usually be followed by chemotherapy, and occasionally by targeted therapies. Radiotherapy is not often recommended.

What to expect when you get home

Some women say they start to feel better within six weeks of surgery, but recovery may take longer. How long it takes to recover depends on the type of surgery you had, other treatment or medical conditions you have had, and your support at home.

Rest

Take things easy and do only what is comfortable. You may like to try some meditation or relaxation techniques to reduce tension. You can also check with a social worker if it’s possible to get help at home.

Sex

Penetrative sex should be avoided for about six weeks after the operation to give your wounds time to heal. For more information speak to your medical team, call Cancer Council 13 11 20 or see sexuality, intimacy and cancer.

Lifting and exercise

Avoid heavy lifting or vacuuming for at least six weeks. If you have a partner or children, ask them to help around the house. You may be able to access home help – see support services for more information.

Talk to your doctor about starting to exercise. You should begin with gentle exercise and build up to more vigorous exercise, depending on how active you were before your surgery.

Driving

Your medical team will tell you how long you should avoid driving, which is usually a few weeks.

Other side effects

You may have bowel problems, such as constipation or diarrhoea. Some women go through menopause if their ovaries have been removed and they were still having periods before surgery. See tips on managing side effects.

Chemotherapy

Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs. The aim is to destroy cancer cells while causing the least possible damage to normal, healthy cells.

Women with epithelial ovarian cancer classified as stage IC or above are likely to need chemotherapy. Those with stage IA or IB epithelial ovarian cancer or borderline tumours may not need chemotherapy. However, chemotherapy may be recommended for stage IA or IB cancer with a high grade.

Chemotherapy may be used at different times:

After surgery

Chemotherapy is most commonly given after surgery (adjuvant chemotherapy) as there may be some cancer cells still in the body. Recent research shows that giving the drugs weekly improves the way they work1; however, in some hospitals, chemotherapy is given every 3–4 weeks over 5–6 months.

Before surgery

Some women with stage III or stage IV ovarian cancer have chemotherapy before surgery (neo-adjuvant chemotherapy). This usually involves three cycles of chemotherapy (see below) followed by surgery and then another three cycles.

Each chemotherapy treatment is called a cycle and is followed by a rest period to give your body time to recover. Ask your doctor about the treatment plan recommended for you.

Having chemotherapy

Chemotherapy is usually given as a combination of two drugs, or sometimes as a single drug. It’s delivered through an intravenous drip. To reduce the need for repeated needles, some women have a small medical appliance called a port-a-cath or catheter placed beneath their skin through which they receive chemotherapy. Others may have a peripherally inserted central catheter (PICC).

You will usually have chemotherapy as an outpatient (also called a day patient), but some women need to stay in hospital overnight.

Let your oncologist know if you are taking nutritional or herbal supplements as these can interact with chemotherapy and may lessen the effect.

For more information see Understanding Chemotherapy or call Cancer Council 13 11 20.

Blood tests during chemotherapy

Before each chemotherapy session, blood tests will be taken to ensure your body’s healthy cells have had time to recover. If your blood count has not recovered, your doctor may delay treatment.

Some women also have blood tests during treatment to check their tumour markers, such as CA125. If the CA125 level was high before chemotherapy, it can be monitored to see if the treatment is working.

Intraperitoneal chemotherapy

This is a way of giving chemotherapy directly into the space between the abdominal organs and the abdominal – called the abdominal cavity.

The drugs are given through a tube (catheter) that is put in place during surgery and removed once the course of chemotherapy ends.

Intraperitoneal chemotherapy is used only in specialised units in Australia. It may be offered to women with stage III disease with less than 1 cm of tumour remaining after surgery.

Ask your doctor for more information about this treatment and the advantages and side effects.

Side effects of chemotherapy

Chemotherapy can affect healthy cells in the body, which may cause side effects. Not all women will have side effects, and effects will vary according to the drugs you are given. Often they are temporary. Talk to your medical team about what to expect.

Fatigue

Your red blood cell level (haemoglobin) may drop, which can cause you to feel tired and short of breath. Travelling to and from treatment can also be exhausting.

Nausea

Some chemotherapy drugs may make you feel sick or vomit. Whether or not you feel sick is not a sign of how well the treatment is working. Anti-sickness drugs can be given to prevent or reduce nausea and vomiting.

Changed bowel habits

Many women become constipated while on chemotherapy. This may be caused by anti-nausea drugs or because food intake changes. Your doctor will talk to you about taking laxatives. Diarrhoea (loose, watery bowel movements) is another possible side effect.

Risk of infections

Chemotherapy drugs lower the number of white blood cells that fight infection, so you may become more susceptible to colds and the flu. Let your doctor know if you have any signs of infection, which can be treated with antibiotics.

Joint and muscle pain

This may occur after your treatment session. It may feel like you have the flu, but the symptoms should disappear within a few days. Taking paracetamol may help.

Hair loss

It is likely that you will lose your head and body hair, depending on the chemotherapy drug you receive. The hair will grow back after treatment is completed, but the colour and texture may change. For more details, call Cancer Council 13 11 20 for a free copy of the Hair Loss fact sheet, or download it from your local Cancer Council website.

Numbness or tingling in your hands and feet

This is called neuropathy and can be a side effect of certain chemotherapy drugs. Let your doctor know if this happens, as your dose of chemotherapy may need to be adjusted.

For ways to prevent or reduce the side effects of chemotherapy, see managing side effects.

Radiotherapy

Radiotherapy uses x-rays to kill or damage cancer cells. It is used less often than chemotherapy for ovarian cancer. Doctors sometimes recommend radiotherapy to ease symptoms that are not responding to chemotherapy or when chemotherapy can no longer be given (palliative treatment). If the cancer has spread, you will usually receive radiotherapy to the pelvis, or other affected parts of your body.

Before treatment starts, the radiation oncology team will plan your treatment, and will explain the treatment schedule and the possible side effects.

During radiotherapy, you will lie on an examination table, and a radiotherapy machine will be moved around you depending on the body part being treated. The radiation therapist will position you and the machine and then leave the room.

You will not feel anything during the treatment, which will only take a few minutes each time. You may be in the room for a total of 10–20 minutes for each appointment. The number of radiotherapy sessions you have will depend on the type and size of the cancer. You may have treatment for a week or daily treatment for several weeks.

For more information about radiotherapy treatment and its side effects, talk to your doctor and nurses, call Cancer Council 13 11 20 or see Understanding Radiotherapy.

Side effects

The side effects of radiotherapy vary. Most are temporary and disappear within a few weeks or months after treatment. Common side effects include feeling tired, diarrhoea, needing to pass urine more often and burning when you pass urine (cystitis), and a slight burn to the skin around the treatment site.

More rarely, you may have some nausea or vomiting. If this occurs, you will be prescribed medicine to control it.

Targeted therapies

New types of drugs known as targeted therapies are being used to treat certain types of ovarian cancer, such as recurrent epithelial tumours or stromal tumours, or in certain situations (for example, when chemotherapy has not been successful).

One of these new treatments is called bevacizumab (Avastin). It works by stopping the cancer developing new blood vessels and growing. Bevacizumab is given with chemotherapy every three weeks as an infusion into a vein.

The most common side effects experienced by women taking bevacizumab include wound healing problems, bleeding, high blood pressure and kidney problems. In very rare cases, small tears (perforations) may develop in the bowel wall.

For more information about targeted therapies, talk with your medical team.

Palliative treatment

If the cancer is more advanced when it is first diagnosed or returns after treatment, your doctor will discuss palliative treatment for symptoms caused by the cancer, such as pain.

Palliative treatment aims to manage symptoms without trying to cure the disease. It can be used at any stage of advanced ovarian cancer to improve quality of life. It is not just for people who are about to die and does not mean giving up hope. Rather, it is about living for as long as possible in the most satisfying way you can.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. The treatment may include chemotherapy and radiotherapy. If you are experiencing swelling and are uncomfortable, you may have a procedure called paracentesis or ascitic tap to drain the extra fluid.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, practical and spiritual needs. For more information, visit your local Cancer Council website or call 13 11 20 for free copies of Understanding Palliative Care and Living with Advanced Cancer.

Key points

  • Your treatment will depend on many factors, including the type of ovarian cancer, its stage, whether you wish to have children and your overall health and fitness.
  • Ovarian cancer is usually treated with surgery. In most women with ovarian cancer, surgery involves a total abdominal hysterectomy, including the removal of both fallopian tubes and ovaries, and the omentum (fatty tissue).
  • During the operation, the doctor may take tissue samples to check for signs of cancer. This is called a frozen section analysis or biopsy.
  • It will take some time to recover from an operation. Most women start to feel better within six weeks, but it may take longer.
  • After surgery, you may have further treatment. Most women have chemotherapy, but they may also have radiotherapy or targeted therapies.
  • Chemotherapy is the treatment of cancer with anti-cancer drugs. It is usually given soon after an operation for 5–6 months. Side effects may include tiredness, nausea and vomiting, and hair loss.
  • Radiotherapy uses x-rays to kill cancer cells or damage them. You may have treatment to your pelvis, but it can also be given to other parts of the body if the cancer has spread. Side effects may include fatigue, diarrhoea and nausea.
  • Palliative treatment aims to improve your quality of life by relieving the symptoms of cancer.

‘Force of life’, Susan Renouf’s story

Extract from Good Weekend, 16 November 2013 Author: Jane Cadzow

Lady Susan Renouf was home alone, dozing on the sofa, when her GP rang with the results of her scans. The way she remembers it, “He said, ‘It’s the doctor here. You’ve got cancer. Masses. Everywhere in your body.’” The news was difficult to absorb. “I put the phone down and I think I went back to sleep for a while,” she says. “I woke up and I thought, ‘This is a terrible dream. I dreamt the doctor rang and told me I had cancer!’”

When Renouf thinks about it, she realises that for much of last year she lacked some of her usual oomph. “It was my 70th birthday, so I thought, ‘I’ve got to make a special effort’, because a lot of friends were planning a few little festivities. But I just wasn’t feeling great. Very listless. If I didn’t have to get out of bed in the morning, I didn’t.”

When she returned to Australia after three months in the UK and Europe, “a couple of girlfriends said to me, ‘Gosh, you’ve got a funny colour.’ I said, ‘Well, I’ve been in the English summer.’”

By last November, she had become accustomed to an odd sensation in her abdomen: “Funny little jabbing pains.” She went to her doctor, but for one reason or another it was January before the scans were done. The cancer had spread. “The prognosis was less than five months to live,” she says with a tight, bright smile.

She had three months of chemotherapy, followed by surgery to remove as much of the cancer as possible. “When I went under, I thought, ‘Well, I don’t know if I’m coming out of it,’” she says. In the event, she was on the table longer than expected: “It had invaded the lower part of my bowel and wrapped itself around my appendix. So that was another 21⁄2 hours under anaesthetic. It was an 11-hour operation.” Then she had a second course of chemotherapy. “Luckily, I didn’t find the chemo as traumatic as I thought it would be,” she says. “I didn’t have the nausea or the vomiting. I lost my hair, of course.”

Wigs felt hot and itchy, and scarves kept slipping out of place, so she preferred to go bareheaded most of the time. When two of her grandsons arrived to visit her, her skull was as smooth as a billiard ball. “Totally bald,” she says cheerfully, remembering their gasps when she opened the front door. “I said, ‘It’s a long story, boys. Come in.’”

Susan’s mother, Joan Rossiter, died in 1979 at 64. She had a brain tumour, which Renouf has only recently learnt was metastatic.

“It turns out that my mother had ovarian cancer,” she says. Tests have shown that Renouf has inherited faults in one of the two genes – BRCA1 and BRAC2 – that act as gynaecological tumour suppressors. Her daughters and a niece have subsequently undergone genetic testing, and to her great relief all the results so far have been normal.

She hasn’t forgotten that she briefly considered refusing treatment for her cancer. She sees now that quietly putting an end to it all would have been wildly out of character. “If I’m going,” she says, “I’m going with a bang.”

But she hopes to be around for a long time yet. She says she was touched by a get well message from her youngest grandson, Woody, then aged 10. “He said, ‘I know you will get better, Granny, because for me you are irreplaceable.’ I’m reading this. ‘Irreplaceable? Woody! I’ve got to live for you!’”

Tell your cancer story.

1. Cancer Australia, First-line chemotherapy for the treatment of women with epithelial ovarian cancer, Cancer Australia, Sydney, 2014.


Reviewed by: Prof Martin K Oehler, Director Gynaecological Oncology, Royal Adelaide Hospital, SA; Dr Serene Foo, Medical Oncologist, Mercy Hospital for Women, Austin Health and Epworth Eastern Hospitals, VIC; Maira Kentwell, Senior Genetic Counsellor and Manager, Department of Genetic Medicine and Familial Cancer Centre, The Royal Melbourne Hospital, VIC; Jane Lucas, Consumer; Cindy Morgan, Consumer; Shannon Philp, Nurse Practitioner – Gynaecological Oncology, Chris O’Brien Lifehouse, NSW; Lea Rawlings, Perth Support Coordinator, Ovarian Cancer Australia; Deb Roffe, 13 11 20 Consultant, Cancer Council SA, SA; and Merran Williams, Clinical Nurse, Bloomhill Cancer Care, QLD.