At Memorial Sloan-Kettering, the primary treatments for epithelial ovarian cancer are surgery, chemotherapy, and radiation therapy, delivered alone or in combination with another therapy.
The standard treatment for ovarian cancer is surgery — for diagnosis, staging (determining the extent of cancer), and tumor debulking, or cytoreduction — followed by chemotherapy. To explore the abdomen for ovarian cancer, a surgery called laparotomy is necessary. In laparotomy, an incision is made in the abdomen, the area is examined, cancerous tissue is removed, and if necessary, fluid is drained from the abdominal region.
It is during laparotomy that tumor debulking is performed.
Debulking is a surgical procedure to treat ovarian cancer that usually involves removing not only the ovaries but also the uterus, cervix, fallopian tubes, and as much visible disease as possible — with the goal of leaving no tumor nodule behind that measures more than one centimeter. Eighty percent of patients at Memorial Sloan-Kettering are optimally, or successfully, debulked, meaning that residual tumor remaining after surgery is very small (one centimeter or less). Studies have shown that this excellent cytoreduction rate has led to improved survival for our patients.(1),(2)
Chemotherapy cannot penetrate a large, bulky ovarian tumor. By removing as much of the tumor as possible through debulking, the chemotherapeutic treatment is able to penetrate the tumor more effectively. This means that the tumor will be much more responsive to chemotherapy, which improves treatment success and potentially adds years to a patient's survival. (See below for information about chemotherapy.)
For women who want to have children, if the cancer is at a very early stage it is sometimes possible to remove only the affected ovary (unilateral oophorectomy) and its adjoining fallopian tube (unilateral salpingectomy). If the cancer has spread beyond one ovary, however, debulking usually requires removal of both ovaries and their adjoining fallopian tubes (salpingo-oophorectomy), the uterus (hysterectomy), and pelvic lymph nodes (lymphadenectomy). These tissues are then examined to determine whether the cancer has spread and whether additional therapy is needed.
If a malignant tumor is found beyond the female reproductive system organs, the surgeon attempts to remove as much of the cancer as possible. This may mean that portions of the diaphragm (the thin muscle below the lungs and heart that separates the chest from the abdomen), bowel, spleen, and/or liver need to be removed if the cancer has invaded and spread into these areas. For women with advanced ovarian cancer, our surgeons have shown(3),(4)that using a more aggressive debulking approach significantly improves the chances of survival and chance of long-term cure.
A second debulking operation may be beneficial for some women with recurrent ovarian cancer, depending on how long they were disease free and in how many sites the cancer recurred.
Minimally Invasive Surgery & Robotics
For cancers that appear to be confined to the ovary, our surgeons may be able to use less invasive techniques to remove the tumor(s). These laparoscopic procedures, performed through small incisions made into the abdomen, can be used to biopsy and stage, and also to determine the extent of a cancer.
Dr. Richard Barakat explains the advantages of robotic surgery for the treatment of cervical, endometrial, and ovarian cancers.
Depending on the size and location of the tumor, laparoscopy also can be used to remove cancerous tissue, meaning that a more extensive open surgery can be avoided. Such surgical approaches result in shorter hospital stays, a quicker recovery, and lower costs, and are as effective as conventional surgery. For selected younger patients, fertility preservation (retaining a normal ovary and the uterus) can be considered.
Memorial Sloan-Kettering surgeons have found that staging early-stage ovarian cancer with minimally invasive surgery is equally effective and accurate as staging during open surgery.(5) In addition, our surgeons may use the robotic da Vinci® Surgical System for staging purposes. To learn more, visit Diagnosis.
Our surgeons sometimes consult with thoracic surgeons to use a minimally invasive method called video-assisted thoracoscopic surgery (VATS) to diagnose and treat ovarian cancer. A tiny video camera is inserted into the woman's abdominal region through an endoscope, and the surgical team guides the camera within her body to explore the region, identify potential tumors, and remove tissue for biopsy. This procedure can be used to evaluate the extent of disease, to drain any fluid build-up in the abdominal area, and to select candidates for minimally invasive debulking or for neoadjuvant chemotherapy.(6)
To destroy any tumor cells that remain after surgery, Memorial Sloan-Kettering physicians recommend chemotherapy for the majority of women with ovarian cancer. This usually includes a combination of systemic and regional chemotherapy.
The most common chemotherapy drugs used as initial treatment for ovarian cancer include cisplatin or carboplatin, and paclitaxel or docetaxel, which are most often given in combination. For ovarian cancers that have recurred or returned, doctors may use topotecan, liposomal doxorubicin, etoposide, gemcitabine, vinorelbine, cyclophosphamide, and/or other drugs.
Systemic therapy is administered orally or injected into a vein and delivers chemotherapy drugs throughout the body. Regional therapy is the administration of chemotherapy drugs directly into the region of the body where the tumor(s) is/are located. To treat ovarian cancer, our oncologists use a kind of regional chemotherapy called intraperitoneal (IP) chemotherapy. Chemotherapy drugs are placed directly into the internal lining of the abdominal area (called the peritoneal cavity) through a surgically implanted catheter that has many small holes, out of which the chemotherapeutic agents flow. This treatment allows a high concentration of agents to reach the cancerous tissue for a prolonged period of time, and has been shown to increase effectiveness in several randomized clinical trials.
Having pioneered the first clinical trials that evaluated IP chemotherapy in the late 1980s, Memorial Sloan-Kettering remains one of the most experienced centers to offer IP chemotherapy, with the largest number of patients to have undergone the procedure.
(See the NCI's clinical announcement on January 5, 2006, about IP chemotherapy treatment for advanced ovarian cancer. http://www.cancer.gov/clinicaltrials/developments/IPchemo-digest)
Intraperitoneal chemotherapy, which delivers chemotherapy through a surgically implanted catheter, may offer advantages for women with ovarian cancer.
For most women with advanced ovarian cancer who can have optimal debulking surgery, IP chemotherapy following initial surgery is extremely beneficial. One study conducted by the Gynecologic Oncology Group showed that women with stage 3 ovarian cancer who are given a combination of intravenous (IV) and intra-abdominal chemotherapy, following the successful surgical removal of tumors, experienced a median survival time 16 months longer than women who received IV chemotherapy alone.7
Incorporating new drugs available only through clinical trials at Memorial Sloan-Kettering, the Gynecologic Disease Management Team will tailor your chemotherapy program, monitor your response, and if necessary, adjust therapy at midpoint to achieve the best results. This innovation allows for treatment with greater flexibility in the event that the team observes warning signs that you may not have a complete remission at the end of therapy.
Radiation therapy may be given over a period of several weeks. It is rarely used as a primary treatment for ovarian cancer, but is sometimes considered after the removal of a recurrent tumor or in the treatment of a recurrence.
At the end of initial treatment for ovarian cancer, many patients will appear to be disease-free, but the risk of recurrence is often high. When a patient is in remission (meaning that there is a decrease in or disappearance of signs and symptoms of cancer), we offer a series of investigational therapies, called consolidation or maintenance therapies. These therapies can include IP chemotherapy treatment (if it was not already given as a part of the original therapy), non-cytotoxic chemotherapy, and immunologic approaches.
For those women who experience a relapse of ovarian cancer, our investigators are testing a variety of novel approaches, including new drugs and drug combinations. Our goal is to strike a balance between effective treatment and optimal quality of life in order to minimize the symptoms related to either treatment or disease.
Progress toward a better understanding of how ovarian cancer develops and how it responds to therapy will only be achieved through continued research. Memorial Sloan-Kettering has been a national center of excellence for ovarian cancer research for many years. Our Ovarian Cancer Program Project Grant has supported investigations for more than ten years and continues to be supplemented by other research grants held by members of the Gynecologic Disease Management Team. We also collaborate with the Gynecologic Oncology Group, a multi-institutional clinical research group supported by the National Cancer Institute, on studies that will improve both survival and quality of life for women with ovarian cancer.
Memorial Sloan-Kettering clinical investigators are assessing several new drugs for patients with ovarian cancers that have recurred or are resistant to standard treatment. These investigational approaches are sometimes offered to eligible patients as part of clinical trials.
One key area of research is immune therapy, which boosts the immune system's ability to destroy ovarian cancer cells. Researchers already know that cytokines (substances that activate the immune system) and vaccines can help program the body to recognize and destroy tumor cells before they become invasive cancers, and are searching for more effective ways to use them.
Unlike vaccines for infectious disease, which prevent the illness from developing, cancer vaccines are currently being tested after diagnosis and treatment in an attempt to prevent cancer from returning. Several of the vaccines being evaluated work by helping the immune system to recognize specific proteins on cancer cell surfaces — called antigens — and to mount a lethal attack against these cells.
The Gynecologic Disease Management Team is conducting several clinical trials of vaccines for ovarian cancer. These include vaccines that are “specific” (directed at specific cancer-cell targets) as well as “nonspecific” (directed at boosting overall immunity).
For example, one study underway is evaluating the safety and effectiveness of a specific vaccine that contains an antigen called abagovomab. By targeting CA-125, the protein made by ovarian cancer cells, researchers hope to reduce the risk of recurrence for women with ovarian cancer who are in clinical remission.
A second investigational approach involves PARP (poly-ADP-ribose polymerase) inhibitors, a new class of drugs currently being studied in ovarian cancer. Typically, PARP enzymes inside a cell repair damage to the cell's DNA. By stopping PARP activity in cancer cells, researchers may be able to prevent this repair so that cancer cells die off. In early studies, PARP inhibitors have been shown to work well in women with BRCA1 or BRCA2 mutations and ovarian cancer. PARP inhibitors also help chemotherapy drugs like carboplatin and topotecan work more effectively.
At Memorial Sloan-Kettering, we are currently running a number of trials to study the best way to use PARP inhibitors. Trials are currently evaluating the effects of adding these agents to initial therapy for ovarian cancer, or to chemotherapy at the time of recurrence, and comparing them to standard therapy (doxorubicin, or Doxil®) in women with platinum-resistant relapsed disease.