Treatment Overview

The choice of treatment and the long-term outcome (prognosis) for women who have ovarian cancer depends on the type and stage of cancer. Your age, overall health, quality of life, and desire to have children (preserve fertility) must also be considered.

• Surgery is done to confirm and treat cancer. Removal of all cancerous tissue and taking biopsies to check for the spread of cancer (surgical staging) is important for diagnosis and treatment, because the amount of cancer remaining (residual cancer) after the initial surgery may affect your outcome.
• Chemotherapy, which uses medicines to kill cancer cells, is recommended after surgery for most stages of ovarian cancer. Recent studies show that the addition of chemotherapy after surgery improves the outcome for some early-stage ovarian cancer.¹⁵ Chemotherapy is also recommended for all other stages of ovarian cancer. Chemotherapy that is given after a surgery is called adjuvant therapy.

Initial treatment

The goal of the initial surgery is to remove all visible cancer. The type of surgery you will need depends on the stage of your cancer and if you want to be able to have children after having the surgery.

If you have early-stage (stage I and low-grade [grade 1]) cancer and you wish to have children, your surgery may include:

• Removal of your cancerous ovary and fallopian tube.
• A biopsy of your other ovary.
• Removal of fatty tissue (omentum) that is attached to some of the abdominal organs.
• Removal of lymph nodes in the pelvis and near the large blood vessel (aorta) in the belly.
• Biopsies of other tissues and peritoneal fluids (peritoneal washings) from the belly to look for cancer cells.

Your uterus and the healthy ovary will remain, so it may be possible for you to become pregnant.

If you have a more advanced stage (stage II, III, or IV) of cancer or you have stage I and do not want to have children, your surgery may include:

• A hysterectomy, which removes your uterus, and a salpingo-oophorectomy, which removes your ovaries and fallopian tubes.
• Collection of peritoneal fluid.
• Removal of pelvic and aortic lymph nodes (lymph node dissection).
• Removal of fatty tissue (omentum).
• Removal of as much cancerous tissue as possible.
• Biopsies of any tissue that may be cancerous.

Because this surgery removes all the reproductive organs, you will not be able to become pregnant after having it.

Chemotherapy is recommended after surgery for most women. The current standard of treatment is 6 cycles of paclitaxel (Taxol) and carboplatin or cisplatin. Each chemotherapy cycle is scheduled every 3 to 4 weeks, so chemotherapy may last 4 to 6 months. Studies are looking at delivering chemotherapy directly into the belly (intraperitoneal chemotherapy). One study compared women with stage III ovarian cancer who had already had surgery. In that study, one group had treatment with paclitaxel delivered into a vein (intravenous) followed by intravenous cisplatin; the other group had treatment with intravenous paclitaxel followed by intraperitoneal cisplatin and paclitaxel. Although the intraperitoneal group had more severe side effects, overall survival was better than for the intravenous group.¹⁶

Treatment Overview

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Home treatment measures may help relieve some of the common side effects of cancer treatment, such as nausea, vomiting, fatigue, hair loss, stress, or sleep problems.

If both of your ovaries are removed, you are likely to experience menopausal symptoms after surgery. Home treatment measures may relieve some of these symptoms. If home treatment does not help your menopausal symptoms, talk to your doctor about other ways to manage your symptoms.

If you have recently been diagnosed with ovarian cancer, you may experience a wide variety of emotions in reaction to having cancer. Most women feel some denial, anger, and grief. There is no "normal" or "right" way to react to having cancer. You can take steps to manage your emotional reactions to learning that you have ovarian cancer. Some women find that talking with family and friends is comforting, while others may need to spend time alone to understand their feelings about their cancer.

If your emotions are interfering with your ability to make decisions about your health and to move forward with your life, it is important to talk with your doctor. Your cancer treatment center may offer counseling services. You may also contact your local chapter of the American Cancer Society to help you find a support group. Talking with other women who have had similar feelings after being diagnosed with cancer such as yours can help you accept and deal with your cancer.

What to think about during initial treatment

In about 70% of women with ovarian cancer, the cancer has already spread (metastasized) outside the pelvis by the time it is diagnosed.¹⁷ Advanced-stage cancer spreads most commonly to the lining of the abdominal cavity, the pelvic lymph nodes, and the fatty tissue around some of the abdominal organs.

Your long-term outcome depends on your age, the stage and grade of your cancer, and the amount of cancer remaining after your initial surgery.

Your quality of life becomes a critical issue when considering your treatment choices. Be sure to discuss your personal preferences with your oncologist when he or she recommends treatment.

You may be interested in participating in research studies called clinical trials. Clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information. Women who do not want standard treatments or are not cured using standard treatments may want to participate in clinical trials. These are ongoing in most parts of the United States and in some other countries for all stages of ovarian cancer.

For more information about specific ovarian cancer treatments, see the topics:

Ovarian Cancer – Health Professional Information [NCI PDQ].

Ovarian Cancer – Patient Information [NCI PDQ].

Ongoing treatment

After initial treatment for ovarian cancer, it is important to receive follow-up care. Your emotional reactions may continue throughout the course of your treatment, depending on your prognosis, the treatment methods used, and your quality-of-life decisions.

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Your gynecologic oncologist or oncologist will schedule regular checkups, usually every 3 months for the first 2 years after treatment. Your doctor may then recommend checkups every 6 to 12 months depending on your stage of cancer. These checkups will include:

• A physical exam of your neck, lungs, and abdomen, and a pelvic exam to check for recurring cancer or swollen lymph nodes.
• A CA-125 blood test to see if the cancer has returned.
• An abdominal and pelvic CT scan or MRI to check to see if cancer has spread, especially when new symptoms, such as belly pain, are present or if CA-125 levels are high.

Second-look surgery, after 6 cycles of chemotherapy, may be done in research studies or clinical trials if no sign of cancer is found during a physical exam; in blood tests; or with X-ray, CT, or MRI. Additional biopsies are done at the time of second-look surgery to determine the need for more treatment. Second-look surgery is not recommended as standard treatment because of the chance of complications and because it does not clearly increase survival rates.

Treatment if the condition gets worse

The long-term outcome (prognosis) for ovarian cancer that has returned after treatment (is recurrent) depends on whether the cancer has spread. Even with no sign of cancer after treatment, between 30% and 50% of women who are treated for ovarian cancer have cancer return within 5 years.⁴ Women who have cancer return within 6 months after their initial treatment are less likely to respond to more treatment with the same chemotherapy medicines than women whose cancer has returned more than 6 months after their initial treatment. Other chemotherapy medicines may be recommended for further treatment.³
Palliative care
If your cancer gets worse, you may want to think about palliative care. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different from care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life-not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.
Some treatments for recurrent ovarian cancer, such as chemotherapy and radiation, are considered palliative care. These treatments cannot cure your cancer, but they can extend your life, control your symptoms, reduce your pain, and make you feel more comfortable.
In addition to helping your body feel better, palliative care can help you feel better emotionally and spiritually. Talking with a palliative care provider may help you cope with your feelings about living with a long-term illness. It may also help your loved ones better understand your illness and how to support you. Or it could help you make future plans concerning your health and medical care.

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If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.
For more information, see the topic Palliative Care.
Complementary therapies
In addition to conventional medical treatment, you may wish to try complementary therapies to help manage your symptoms. But complementary therapies are not a substitute for conventional medical treatment that is recommended for ovarian cancer. Complementary therapies include:

• Acupuncture.
• Herbs.
• Biofeedback.
• Meditation.
• Yoga.
• Visualization.
• Vitamins and nutritional supplements.

Before you try any of these therapies, discuss their possible benefits and side effects with your doctor. Let him or her know if you are already using any such therapies. For more information, see the topic Complementary Medicine.

What To Think About

Some women with ovarian cancer may be interested in participating in research studies called clinical trials. Clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information. Women who do not want standard treatments or are not cured using standard treatments may want to participate in clinical trials. These are ongoing in most parts of the United States and in some other countries, for all stages of ovarian cancer.
Most treatments for ovarian cancer cause side effects. The side effects that you have depend on the type of treatment used, your age, and your overall health. Your doctor can talk to you about your treatment choices and the side effects associated with each treatment.

• Side effects of chemotherapy may include loss of appetite, nausea, vomiting, diarrhea, mouth sores, or hair loss.
• Side effects of surgery depend on how much surgery was done to treat the stage of your cancer.

Nausea and vomiting are side effects of chemotherapy for ovarian cancer. Your doctor can prescribe medicines to control nausea and vomiting.Talk to your doctor about what to expect and when you should call if you are having nausea or vomiting. Home treatment measures can also help you manage other side effects of treatment.

End-of-life issues

Some women with advanced-stage cancer may choose not to have treatment focused on prolonging life because they decide that for them the time, costs, and side effects of treatment are greater than the benefits. Making the decision about when to stop medical treatment aimed at prolonging life and shift the focus to end-of-life care can be difficult. For more information, see the following topics:

Care at the End of Life

Hospice Care

When To Call a Doctor

Ovarian cancer does not cause many symptoms in its early stages. And having symptoms does not always mean you have cancer. These symptoms may be caused by other problems. It is important to talk to your doctor if you have any new symptoms, such as:

• Ongoing cramps or pain in your belly.
• Ongoing pain in your pelvis or lower back.
• Abnormal bleeding from your vagina, especially after menopause if you are not using any hormonal medicines.
• Abnormal discharge from your vagina, containing mucus that may be tinged with blood.
• Pain or bleeding during sex.
• Nausea or loss of appetite or you cannot eat normally.
• Ongoing bloating or intestinal gas that is not relieved by home treatment measures.
• Bigger belly size or a lump that can be felt in your belly.
• Decreased energy level.
• A change in your bowel habits, such as constipation or diarrhea.
• A change in your bladder habits, such as urinary frequency or urgency.
• Weight loss.

Watchful Waiting

Watchful waiting is a period of time during which you and your doctor observe your condition or symptoms without using medical treatment. Watchful waiting is not appropriate if you have symptoms that do not go away. If you are concerned about your symptoms and you have a higher risk for ovarian cancer, call and make an appointment with your doctor.

Exams and Tests

There are no reliable screening tests for ovarian cancer. Ovarian cancer is confirmed and staged by biopsies that are taken during laparotomy surgery.

Some initial exams and tests are done before surgery if ovarian cancer is suspected. These tests include:

• Your medical history, to check what symptoms you have and what your chance of developing ovarian cancer is.
• A physical exam, including a pelvic exam and Pap test. An ovarian lump may be felt during a pelvic exam. A rectovaginal exam may also be done to feel the pelvic organs.
• A complete blood count (CBC), to check for anemia and other abnormal blood values.
• A chemistry screen to check for liver and kidney problems.
• A human chorionic gonadotropin (hCG) level may be done to rule out pregnancy or an ectopic pregnancy.
• A cancer antigen 125 (CA-125) level, to measure a protein found on the surface of many ovarian cancer cells.
• A pelvic and transvaginal ultrasound to look for an ovarian lump.

Additional tests may be done before surgery to determine if other areas of the body are involved. These tests include:

• A pelvic or abdominal CT scan or MRI to check for the spread of cancer.
• A chest X-ray to check for the spread of cancer.

Early Detection

For most women, the United States Preventive Services Task Force (USPSTF) does not recommend having a CA-125 blood test or a transvaginal ultrasound to find ovarian cancer early.¹³ There is no evidence that having regular tests helps women live longer by finding ovarian cancer early. Still, experts recommend that women who have inherited a BRCA gene change and have not had their ovaries removed have a transvaginal ultrasound and a CA-125 blood test at least once a year, starting at age 35. Women who have inherited a BRCA1 gene change (not a BRCA2 gene change) may want to start having these regular tests as early as age 25.¹⁴

What Increases Your Risk

Risk factors for ovarian cancer include:

• A family history. Between 10% and 20% of women with ovarian cancer have a close female relative who had ovarian or breast cancer. Women with a family history may develop ovarian cancer at an earlier age, such as in their 40s, rather than at the more typical age of postmenopausal women in their 50s. Women who have BRCA1 or BRCA2 gene mutations have between a 16% and 60% chance of developing ovarian cancer during their lifetime.
• Increasing age. Ovarian cancer most often affects postmenopausal women.
• Never having a baby.
• Starting menstrual cycles before age 12 and going through menopause at an older age. The more menstrual cycles you have, the more risk you have for ovarian cancer.
• Being unable to become pregnant (infertility). Women who do not use birth control and are sexually active but who are unable to become pregnant may have a higher chance for ovarian cancer.
• Use of estrogen or hormone replacement therapy. Some studies have shown that some women who use these hormones have a slightly increased risk of developing ovarian cancer, and other studies have shown no increased risk.In general, experts advise women considering hormone replacement therapy for symptoms of menopause to take the smallest dose possible to control symptoms, and to take the medicine for the shortest time that they can.
• Women who are of Ashkenazi Jewish ancestry (Jews whose ancestors came from Eastern Europe) may have an increased risk because of changes to the BRCA1 or BRCA2 genes. Women with this ancestry have higher rates of these gene changes.
  

  Should I have a gene test for breast and ovarian cancer?



• Polycystic ovary syndrome (PCOS). Elevated levels of male hormones (androgens) commonly found in PCOS may increase your risk for ovarian cancer.


• A history of breast cancer. Women with a personal history of breast cancer or a family history of breast cancer have a higher risk for ovarian cancer.

More research is needed to confirm if certain other factors can increase a woman's chances of getting ovarian cancer, such as:

• Exposure to asbestos.
• A history of endometriosis or ovarian cysts.
• Smoking.
• Diets high in lactose (a milk sugar), which is found in foods such as milk and ice cream.

Cause

The cause of ovarian cancer is not known. Genetics are a risk factor for some women. A family history of ovarian or breast cancer is found in 10% to 20% of women with ovarian cancer.¹ In general, fewer than 2 in 100 women (less than 2%) will get ovarian cancer in their lifetime. That risk goes up to 4 or 5 in 100 if one family member has had ovarian cancer, and 7 in 100 if two relatives have had it. But if at least two first-degree relatives (meaning mother, sister, or daughter) have had ovarian cancer, the risk is 25 to 50 in 100 (25% to 50%).²

Women who inherit changes (genetic mutations) in the BRCA1 and BRCA2 genes have a higher chance of developing ovarian cancer and breast cancer. Women who inherit the gene change in BRCA1 have a lifetime chance of 20 to 60 out of 100 of getting ovarian cancer. For women who inherit the gene change in BRCA2, the lifetime chance is 10 to 35 out of 100.³

You have a higher chance of developing ovarian cancer if you:

• Are unable to become pregnant (infertility).
• Have never had a baby.
• Have not used hormonal birth control methods. Hormonal methods change the normal cycle of the female hormones, estrogen and progesterone, so ovulation does not occur each month.

If you have a strong family history of ovarian or breast cancer, you may want to talk with your doctor or a genetic counselor about having a blood test to look for BRCA1 and BRCA2 gene changes. Women who inherit these changes in one or both of these genes have a higher chance of developing ovarian cancer, breast cancer, or both.

Ovarian Cancer Guide

What is ovarian cancer?

Ovarian cancer happens when cells that are not normal grow in one or both of your ovaries. This topic is about epithelial ovarian cancer, the most common type.

This cancer is often cured when it is caught early. But most of the time, the cancer has already spread by the time it is found.

It is frightening to hear that you or someone you love may have ovarian cancer. It may help to talk with your doctor or join a support group to deal with your feelings.

What causes ovarian cancer?

We do not know what causes it. Some women who have it also have a family history of cancer. But most do not.

Some women are more likely than others to get this rare cancer. Women who are past menopause or who have never been pregnant are more likely to get ovarian cancer.

What are the symptoms?

Ovarian cancer does not usually cause symptoms at first. But most women do have some symptoms in the 6 to 12 months before ovarian cancer is found. The most common symptoms are gas and pain or swelling in the belly. Other symptoms are diarrhea or constipation, or an upset stomach.

But these symptoms are so general that they are more likely to be blamed on a number of other causes. Most of the time, the cancer has already spread by the time it is found.

How is ovarian cancer diagnosed?

Sometimes the doctor may feel a lump in or on an ovary during a routine pelvic exam. Often a lump may be seen during an ultrasound. Most lumps are not cancer.

The only way to know for sure that a woman has ovarian cancer is with biopsies taken during surgery. The doctor makes an incision in the belly so that he or she can look inside. The doctor will remove bits of any tumors that are found and send them to a lab to confirm that they contain cancer.

There is a blood test called CA-125 (cancer antigen 125) that is sometimes done to look for cancer in women at high risk. So far, there is not enough proof to show that this test works to find ovarian cancer early in most women. Too much CA-125 in the blood can be caused by many things, like the menstrual cycle, endometriosis, and uterine fibroids, as well as many types of cancer.

How is it treated?

Surgery is the main treatment. The doctor will remove any tumors that he or she can see. This usually means taking out one or both ovaries. It may also mean taking out the fallopian tubes and uterus. After surgery, most women have several months of chemotherapy, which means taking drugs that kill cancer cells.

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This cancer often comes back after treatment. So you will need regular checkups for the rest of your life. If your cancer does come back, treatment may help you feel better and live longer.
Ovarian cancer is very serious, but many women do survive it. It depends on your age and overall health, how far the cancer has spread, and how much cancer is left behind during surgery.
It may help to talk to other women who are going through the same thing. People who take part in support groups usually feel better, sleep better, and feel more like eating. Your doctor or your local branch of the American Cancer Society can help you find a support group. You can also look on the Internet to find support sites where women with this cancer can talk to each other.

What are your chances of getting ovarian cancer?

This cancer most often affects women who are past menopause. Women are more likely to get ovarian cancer if others in their family have had it. They are more likely to get it if they have had breast cancer.
You may also be more likely to get this cancer if:

• You never had a baby.
• You started your menstrual cycles before age 12 and went through menopause after age 50.
• You are unable to become pregnant.
• You have used hormone replacement therapy for menopause symptoms.

Symptoms

Ovarian cancer does not cause many symptoms in its early stages. This is why most cases are not found until the cancer has spread.⁴ Most women do have symptoms in the 6 to 12 months before ovarian cancer is found. Symptoms that occur in later stages are most likely caused by the pressure of the growing cancer. Symptoms include:

• Ongoing cramps or pain in your belly.
• Ongoing pain in your pelvis or lower back.
• Abnormal bleeding from your vagina, especially after menopause if you are not using any hormonal medicines.
• Abnormal discharge from your vagina, containing mucus that may be tinged with blood.
• Pain or bleeding during sex.
• Nausea or loss of appetite, or you cannot eat normally.
• Ongoing bloating or intestinal gas that is not relieved by home treatment measures.
• Bigger belly size or a lump that can be felt in your belly.
• Decreased energy level.
• A change in your bowel habits, such as constipation or diarrhea.
• A change in your bladder habits, such as urinary frequency or urgency.
• Weight loss.