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CancerSmart Web Cast May 3, 2007 -- Drs. Carol Brown, Nadeem Abu-Rustum, and Paul Sabbatini present, "What You Should Know About the Screening and Treatment of Gynecologic Cancers."
Run time: 71 minutes. |
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The primary treatments for epithelial ovarian cancer are surgery, chemotherapy, and radiation therapy, delivered alone or in combination with another therapy.
Surgery
The standard treatment for ovarian cancer is surgery -- for diagnosis, staging, 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.
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Debulking
Debulking is a surgical procedure to treat ovarian cancer that usually involves the removal of not only the ovaries but 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. The majority of patients at Memorial Sloan-Kettering are "optimally" debulked.
Chemotherapy cannot penetrate a large, bulky ovarian tumor because the flow of the treatment is blocked. 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 chemotherapeutic treatment, 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 will be examined to determine whether the cancer has spread and whether additional therapy will be needed.
If a malignant tumor is found beyond the female reproductive system organs, the surgeon will attempt 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 that using a more aggressive debulking approach improves survival by 15 months.1
A second debulking operation may be beneficial for some women with recurrent ovarian cancer, depending on how long she was disease free and in how many sites the cancer recurred.2
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Minimally Invasive Surgery
For cancers that appear to be confined to the ovary, our surgeons may be able to use less-invasive techniques to remove the tumor or tumors. 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.
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.
Our surgeons also use a minimally invasive method called video-assisted thoracoscopic surgery (VATS) as a way 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.3
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Pelvic Exenteration
Some women whose advanced ovarian cancer has spread to other abdominal organs may choose an extensive surgery known as pelvic exenteration. The operation requires Memorial Sloan-Kettering's gynecologic surgeons to remove cancerous tissue and reconstruct the remaining organs so the patient retains optimal function. This is an extremely radical procedure reserved for women with limited treatment options.
Because this procedure is physically and emotionally demanding, investigators at Memorial Sloan-Kettering have initiated a trial to learn more about the physical, emotional, educational, and sexual needs of women treated with pelvic exenteration.
Chemotherapy
To destroy any tumor cells that remain after surgery, chemotherapy is recommended for the majority of women with ovarian cancer. A combination of systemic and regional chemotherapy is usually administered to women with ovarian cancer.
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, 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, a kind of regional chemotherapy called intraperitoneal (IP) chemotherapy is used. 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 flows. This allows a high concentration for a prolonged period of time to reach the cancerous tissue, a treatment which has been shown to increase effectiveness in several randomized clinical trials.
For most women with advanced ovarian cancer who can have optimal debulking surgery, IP chemotherapy following initial surgery is found to be extremely beneficial. One study conducted by the Gynecologic Oncology Group showed that women with stage III 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.4
(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)
The Gynecologic Disease Management Team will tailor your chemotherapy program using some of the newest drugs only available through clinical trials at Memorial Sloan-Kettering, 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
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.
Second-Look Operations
In certain situations, a second-look procedure may be recommended to measure the effectiveness of therapy and to help decide whether more chemotherapy or radiation therapy is needed. Most of these second-look operations are performed laparoscopically -- through a small incision in the abdomen, guided by a laparoscope -- to reduce potential complications and shorten recovery time. The majority of patients do not require such procedures.
Investigational Approaches
Find a Clinical Trial Find out about new research studies for ovarian cancer 
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Memorial Sloan-Kettering clinical investigators are assessing several new drugs for patients with ovarian cancers that have recurred or with cancers that prove to be resistant to standard treatment. These investigational approaches are sometimes offered to eligible patients through the clinical trial process.
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Immune Therapy
One key area of research at Memorial Sloan-Kettering is finding ways to boost the immune system's ability to destroy ovarian cancer cells. Cytokines (substances that activate the immune system) and vaccines may help program the body to recognize and destroy tumor cells before they become invasive cancers.
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 the 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.
1 D. S. Chi, C. C. Franklin, D. A. Levine, F. Akselrod, P. Sabbatini, W. R. Jarnagin, R. DeMatteo, E. A. Poynor, N. R. Abu-Rustum, and R. R. Barakat, Improved optimal cytoreduction rates for stages IIIC and IV epithelial ovarian, fallopian tube, and primary peritoneal cancer: a change in surgical approach, Gynecologic Oncology 94(3), 2004: 650-4. [PubMed Abstract]
D. S. Chi, E. L. Eisenhauer, Y. Sonoda, N. R. Abu-Rustum, M. L. Gemignani, D. A. Levine, M. L. Hensley, P. Sabbatini, C. L. Brown, and R. R. Barakat, Improved overall survival for patients with advanced ovarian, tubal, and primary peritoneal carcinoma as a result of a change in surgical approach: A follow-up study, Journal of Clinical Oncology, 2007 ASCO Annual Meeting Proceedings Part I. 25(18S), 2007: 5530. [2007 ASCO Abstract]
2 D. S. Chi, K. McCaughty, J. P. Diaz, J. Huh, S. Schwabenbauer, A. J. Hummer, E. S. Venkatraman, C. Aghajanian, Y. Sonoda , N. R. Abu-Rustum, and R. R. Barakat, Guidelines and selection criteria for secondary cytoreductive surgery in patients with recurrent, platinum-sensitive epithelial ovarian carcinoma, Cancer 106(9), 2006: 1933-9. [PubMed Abstract]
3 D. S. Chi, N. R. Abu-Rustum, Y. Sonoda, S. W. Chen, R. M. Flores, R. Downey, C. Aghajanian, and R. R. Barakat, The benefit of video-assisted thoracoscopic surgery before planned abdominal exploration in patients with suspected advanced ovarian cancer and moderate to large pleural effusions, Gynecologic Oncology 94(2), 2004: 307-11. [PubMed Abstract]
4 D. K. Armstrong, B. Bundy, L. Wenzel, H. Q. Huang, R. Baergen, S. Lele, L. J. Copeland, J. L. Walker, and R. A. Burger, for Gynecologic Oncology Group, "Intraperitoneal cisplatin and paclitaxel in ovarian cancer," New England Journal of Medicine 354(1), 2006: 34-43. [PubMed Abstract]
Last Updated: Jan. 2, 2008
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