You will be given a general anaesthetic and will have either a laparoscopy (with 3–4 small cuts in your abdomen) or a laparotomy (with a vertical cut from around your bellybutton to your pubic line).

A laparoscopy may be used to see if a suspicious mass is cancerous; if the cancer is advanced, you will usually have a laparotomy.

You may have a biopsy during surgery if you cannot have an image-guided biopsy, or to remove and check a suspicious tumour. The tissue samples will be sent to a pathologist, who will check them for signs of cancer.

The results will help decide if you need debulking surgery.

If cancer is found, the surgeon will remove as much visible cancer as possible. This is called debulking or cytoreductive surgery. You may also have chemotherapy before or after surgery.

Debulking usually means removing the ovaries, fallopian tubes, uterus and cervix. Depending on how far the cancer has spread, other organs or tissue may also be removed during the same operation.

• Omentectomy – The omentum is a sheet of fatty tissue that hangs down in front of the large bowel like an apron. If the cancer has spread to the omentum, it will need to be removed. The omentum may also be removed even if there is no visible sign cancer has spread, because it may contain cancer cells that cannot be seen during surgery.
• Lymphadenectomy – Cancer cells can spread from your ovaries to nearby lymph nodes. Your doctor may suggest removing some nodes in a lymphadenectomy (also called lymph node dissection).
• Colectomy – If cancer has spread to the bowel, some of the bowel may need to be removed. Rarely, a new opening called a stoma might be created (colostomy or ileostomy).
• Removal of other organs – Ovarian cancer can spread to many organs in the abdomen. In some cases, parts of the liver, diaphragm, bladder and spleen may be removed if it is safe to do so.

If ovarian cancer is found, all or some of the reproductive organs will be removed. The type of surgery you have will depend on how certain the gynaecological oncologist is that cancer is present and where the cancer has spread.

• Total hysterectomy and bilateral salpingo-oopherectomy – in most cases, surgery for ovarian cancer means removing the uterus and cervix, along with both fallopian tubes and ovaries. Removing the uterus will mean you cannot carry a child.
• Unilateral salpingo-oophorectomy – if cancer is found early and it is in one ovary, you may have only one ovary and fallopian tube removed. This is suggested for some young women who still wish to have children.

When you wake up after the operation, you will be in a recovery room near the operating theatre or in the intensive care unit. Once you are fully conscious, you will be taken back to your bed on the hospital ward.

The surgeon will visit you as soon as possible to explain the results of the operation. You are likely to have several tubes in place, which will be removed as you recover. These could include:

• a drip inserted into a vein in your arm (intravenous drip) which will give you fluid, medicines and pain relief
• a small plastic tube (catheter) inserted into your bladder to collect urine in a bag
• a tube inserted down your nose into your stomach (nasogastric tube) to drain stomach fluid and prevent vomiting
• tubes inserted into your abdomen to drain fluid from the site of the operation.

As with all major surgery, you will have some discomfort or pain, but this can be controlled. For the first 1–2 days, you may be given pain medicine through a:

• drip into a vein (intravenous drip)
• local anaesthetic injection into the abdominal wall (a transverse abdominis plane or TAP block) or into the spine (an epidural)
• patient-controlled analgesia (PCA) system – you press a button to give yourself a measured dose of pain relief.

Let your doctor or nurse know if you are in pain so they can adjust your medicines to make you as comfortable as possible. Pain that is treated early is better managed. After you go home, you can continue taking pain medicines as needed.

You will be encouraged to move around and be active as soon as you can. It is common to be given a daily injection of blood-thinning medicine to reduce the risk of blood clots.

Depending on your risk of clotting, you may be taught to give this injection to yourself so you can continue it for a few weeks at home. You may also be advised to wear compression stockings for 3–4 weeks to help the blood in your legs to circulate and to avoid clots.

You can expect some light vaginal bleeding after the surgery, which should stop within two weeks. Your treatment team will talk to you about how you can keep the wound clean to prevent infection once you go home.

If you had part of the bowel removed and have a stoma, a stomal therapy nurse will explain how to manage it.

Your stay in hospital will generally be 1–4 days. How long you stay will depend on the type of surgery you had and how quickly you recover. If you had laparoscopic surgery, you will be able to go home on the first or second day after the operation.

Pain in the shoulder

During a laparoscopy, carbon dioxide gas is used to inflate the abdomen. The gas can irritate nearby nerves. This can cause pain in the lower chest and up into the shoulder area, which is known as “referred pain”.

This type of pain can be quite uncomfortable and may last several days. Walking and mild pain medicines can help ease the pain in the shoulder. Applying heat to the area may also help.

Your recovery time will depend on the type of surgery you had, your general health, and your support at home. If you don’t have support from family, friends or neighbours, ask your nurse or the hospital social worker if it’s possible to get help at home.

In most cases, you will feel better within 1–2 weeks and should be able to fully return to your usual activities after 4–8 weeks. Ask your treatment team for more information about your particular circumstances.

• Rest up – When you get home from hospital, take things easy and do only what is comfortable. You may like to try meditation or some relaxation techniques to reduce anxiety or tension.
• Lifting  – Avoid heavy lifting (more than 3–4 kg) or heavy work (e.g. gardening) for at least 6–8 weeks. This will depend on the method and kind of surgery you’ve had.
• Work  – Depending on the type of work you do, you will probably need time off work. Ask your treatment team how long this might be.
• Driving  – You will need to avoid driving after the surgery until pain in no way limits your ability to move freely. Discuss this issue with your doctor. Check with your car insurer for any exclusions regarding major surgery and driving.
• Exercise  – Your treatment team will probably encourage you to walk on the day of the surgery. Research suggests that exercise helps manage some treatment side effects and speed up a return to usual activities. Speak to your doctor about suitable exercise and ask for a referral to a physiotherapist or exercise physiologist. To avoid infection, it’s best to avoid swimming for 5–6 weeks after surgery.
• Eat well  – To help your body recover from surgery, eat a well-balanced diet that includes a variety of foods. Include proteins such as lean meat, fish, eggs, milk, yoghurt, nuts and legumes/beans.
• Bowel problems  – You may experience constipation after having a hysterectomy and taking strong pain medicines. You will probably be offered stool softeners while you’re taking pain medicines and until your bowel movements return to normal.
• Sex – Sexual intercourse should be avoided for up to eight weeks after a hysterectomy. Ask your doctor or nurse when you can have sex again, and explore ways you and your partner can be intimate.

For stage 3 or 4 ovarian cancer, chemotherapy is sometimes given before surgery (neoadjuvant chemotherapy). The aim is to shrink the tumours to make them easier to remove.

After three or four cycles of chemotherapy, you will have a CT scan to check how the tumour has responded. Your doctor will then decide about having an operation.

If you have surgery, you will have another two to three cycles of chemotherapy afterward. If you do not have surgery, you will continue with a further three cycles of chemotherapy.

Chemotherapy is usually given 2–4 weeks after the surgery (adjuvant chemotherapy) as there may be some cancer cells still in the body. For ovarian cancer, the drugs are usually given in repeating cycles spread over 4–5 months, but this can vary.

Your treatment team will talk to you about your specific schedule. Some people may have chemotherapy with a targeted therapy drug.

Chemotherapy may be recommended as the main treatment if you are not well enough for a major operation or when the cancer cannot be surgically removed.

Chemotherapy is usually given as a combination of two or more drugs, or sometimes as a single drug. In most cases, the drugs are injected into a vein (intravenously).

To reduce the need for repeated needles, you may receive chemotherapy through a small medical appliance or tube inserted beneath your skin. This may be called a port-a-cath or a peripherally inserted central catheter (PICC), or it may have another name.

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

Chemotherapy is commonly given as a period of treatment followed by a break. This is called a cycle. The break between the cycles lets your normal cells recover and your body regain its strength.

Occasionally, chemotherapy is given directly into the abdominal cavity (the space between organs in the abdomen and the walls of the abdomen). This is known as intraperitoneal chemotherapy.

In this method, the drugs are delivered through a tube (catheter) that is put in place during surgery and removed once the course of chemotherapy is over. Intraperitoneal chemotherapy is used only in specialised units in Australia.

It may be offered for stage 3 cancer with less than 1 cm of tumour remaining after surgery. Some studies have shown it may be more effective than giving chemotherapy through an intravenous drip.

There are other studies looking at giving heated intraperitoneal chemotherapy (HIPEC) at the time of surgery. Ask your medical oncologist for more information about this type of chemotherapy, its benefits and risks, and if it is suitable for you.

You will have blood tests before each chemotherapy cycle, to check your body’s healthy cells have had time to recover. If your blood count has not recovered, which can be common, there may be a delay before your next treatment.

If you had raised CA125 levels when you were diagnosed, you may also have blood tests during treatment to check what is happening to these levels. The blood tests will check if:

• CA125 levels fall during treatment – this can mean the chemotherapy is destroying the cancer cells
• CA125 levels stay the same or rise during treatment – this may mean the cancer is not responding to chemotherapy.

Olaparib and niraparib

These targeted therapy drugs are used to treat people with high-grade epithelial cancer who have changes in the BRCA genes or other genes related to ovarian cancer. You may be offered olaparib or niraparib after initial chemotherapy.

This is known as maintenance treatment. Or you may have olaparib or niraparib if the cancer has come back (recurred).

Olaparib is taken as a tablet twice a day and niraparib is taken as a tablet once a day for as long as they appear to be helping control the cancer.

Bevacizumab

This targeted therapy drug is sometimes used to treat advanced epithelial tumours. It is given with chemotherapy every three weeks as a drip into a vein (intravenous infusion).

Treatment will continue for about 12 months if used as part of the initial treatment, or for as long as it’s working if it is used for cancer that has come back.

Other targeted therapy drugs may be available in clinical trials. Talk with your doctor about what new drugs are available and whether you are a suitable candidate.