Ovarian Cancer – Treatment Options
This section explains the types of treatments that are the standard of care for ovarian, fallopian tube, and peritoneal cancer. “Standard of care” means the best treatments known. Ovarian/fallopian tube epithelial cancers are treated the same way.
When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. These drugs may be given through a vein or taken orally. Clinical trials are an option to consider for treatment and care for all stages of cancer. Talk with your doctor if you are interested in a clinical trial about your eligibility, potential benefits, and the potential challenges of joining a clinical trial, including cost and the geographic location of the trial. Your doctor can help you consider all your treatment options.
In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.
Descriptions of the common types of treatments used for ovarian/fallopian tube cancers are described below. Your care plan also includes treatment for symptoms and side effects, an important part of cancer care.
Treatment options and recommendations depend on several factors, including the type, stage, and grade of the cancer, possible side effects, and the patient’s preferences and overall health or personal goals, such as a woman’s age and any plans to have children in the future.
Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for ovarian, fallopian tube, and peritoneal cancer because there are different treatment options.
Concerns about sexual health and having children
Women with ovarian, fallopian tube, or peritoneal cancer may have concerns about if or how their treatment may affect their sexual health and fertility. These topics should be discussed with the health care team before treatment begins. Premenopausal women who are still potentially able to get pregnant and want to preserve their fertility may want to talk with a reproductive endocrinologist (REI) before cancer treatment begins. It may be helpful to discuss what options for fertility preservation are covered by health insurance.
Surgery is an important treatment for these types of cancer. A gynecologic oncologist is a doctor who specializes in the treatment of gynecologic cancers, including surgery and medications such as chemotherapy.
As mentioned in Diagnosis, surgery is often needed to find out the complete extent of the disease. The goal is to provide an accurate stage. Minimally invasive surgery is often used to confirm a diagnosis and to determine if a debulking procedure (see below) should be done at the time of diagnosis or after chemotherapy has been given first. This is important because imaging tests aren’t always able to see the full extent of a disease.
For those patients with cancer that is confined to the ovary who proceed to have a debulking procedure, the surgery will also include a staging procedure that may involve the removal of various tissues, including lymph nodes, to see if there is evidence that the cancer has spread. For those patients with advanced cancer, removing as much of the cancer as possible is the goal. This procedure has been shown to provide the best benefit when combined with chemotherapy (see below) after surgery.
There are several surgical options for ovarian/fallopian tube cancer. The stage of the tumor determines the types of surgery. Sometimes doctors perform 2 or more procedures during the same surgery:
Salpingo-oophorectomy. This surgery involves removal of the ovaries and fallopian tubes. If both ovaries and both fallopian tubes are removed, it is called a bilateral salpingo-oophorectomy. If the woman wants to become pregnant in the future and has early-stage cancer, it may be possible to remove only 1 ovary and 1 fallopian tube if the cancer is located in only 1 ovary. That surgery is called a unilateral salpingo-oophorectomy. For women with a germ cell type of ovarian tumor, often only the ovary with the tumor needs to be removed, which preserves the woman’s ability to become pregnant.
Hysterectomy. This surgery focuses on the removal of a woman’s uterus and, if necessary, surrounding tissue. If only the uterus is removed, it is called a partial hysterectomy. A total hysterectomy is when a woman’s uterus and cervix are removed.
Lymphadenectomy/lymph node dissection. During this procedure, the surgeon may remove lymph nodes in the pelvis and paraortic areas.
Omentectomy. This is surgery to remove the thin tissue that covers the stomach and intestines.
Cytoreductive/debulking surgery. This surgery is used for women with metastatic cancer, which is cancer that has spread to another part of the body. The goal of cytoreductive surgery is to remove as much tumor as is safely possible. This may include removing tissue from nearby organs, such as the spleen, liver, and part of the small bowel or colon. This may also involve removing part of each of these organs. This procedure can help reduce a person’s symptoms, as it removes masses that may be pressing on other organs. It may help increase the effectiveness of other treatment(s) given after surgery, such as chemotherapy, to control the disease that remains. If the disease has spread beyond the ovaries, fallopian tubes, or peritoneum, doctors may use chemotherapy to shrink the tumor before cytoreductive or debulking surgery. This is called neoadjuvant chemotherapy. Your doctor may also administer chemotherapy during the time of surgery. A newly described method of this is called hyperthermic intraperitoneal chemotherapy (HIPEC).
Debulking surgery should be performed by an experienced gynecologic oncologist. Talk with your doctor before surgery about the risks and benefits of this procedure. Ask about the surgeon’s experience with debulking surgery and whether the surgery will be performed in a minimally invasive way or by an open incision. Sometimes, the surgery can be done robotically. Talk with your doctor about the different surgical options.
Side effects of surgery
Surgery can cause mild or more severe side effects. It typically causes short-term pain and tenderness. If there is pain, the doctor will prescribe an appropriate medication. For several days after the operation, you may have difficulty emptying your bladder (urinating) and/or having bowel movements. Surgery can also cause more severe effects, including infection, bleeding, or injury to other organs.
If the surgeon removes both ovaries, a woman can no longer become pregnant. The loss of both ovaries eliminates the body’s source of sex hormones, resulting in early menopause. Soon after surgery, a woman is likely to have menopausal symptoms, including hot flashes and vaginal dryness.
Studies have shown that women who have their surgery performed by a gynecologic oncologist are more likely to be successfully treated with surgery and have fewer side effects.
Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have.
Therapies using medication
Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a gynecologic oncologist or medical oncologist, a doctor who specializes in treating cancer with medication.
Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).
The types of systemic therapies used for ovarian, fallopian tube, and peritoneal cancer include:
- Targeted therapy
- Hormone therapy
Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescriptions or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.
Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells or by outright destroying the cancer cells.
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time. The type of the chemotherapy used depends on several factors. Patients may be given chemotherapy before or after surgery or as a primary treatment option.
If the chemotherapy stops or slows the cancer, then maintenance therapy with targeted treatments may be used for certain patients (see “Targeted therapy,” below).
Neoadjuvant chemotherapy is a medical term to describe chemotherapy that is given before surgery. It is done to reduce the size of a tumor before surgery. It is usually started after a biopsy, so the doctors can determine where the tumor began. Neoadjuvant chemotherapy is usually given for 3 to 4 cycles before considering surgery, called interval surgery. This treatment usually consists of carboplatin (available as a generic drug) given intravenously with paclitaxel (Taxol) or other drugs. The typical treatment cycle is to be given these drugs every 3 weeks. Talk with your doctor about which scheduling option is best for your treatment plan.
Adjuvant chemotherapy is a medical term to describe chemotherapy that is given after surgery to destroy any remaining cancer. For these types of cancer, the specific drugs typically are carboplatin given with paclitaxel or other drugs intravenously (IV). Most of these drugs are given once every 3 weeks.
Another approach is called “dose-dense” chemotherapy. This is when paclitaxel is given weekly instead of every 3 weeks. Research studies have shown conflicting results on the effectiveness of this approach. Some studies show better outcomes with dose-dense chemotherapy, and others show that the outcomes are the same. Recent clinical trials in the United States and Europe did not show a benefit of dose-dense chemotherapy, compared to chemotherapy given every 3 weeks in contrast to a clinical trial from Japan.
Adjuvant chemotherapy can also be infused directly into the abdomen through a second port. This is called intraperitoneal or “IP” chemotherapy. This approach may be considered for women with stage III cancer after a debulking surgery that removes all visible disease. However, the effectiveness of IP chemotherapy is not clear. While some research studies have shown that IP treatment may offer more benefit than IV treatment in some patients, more recent research has shown no difference between IV and IP chemotherapy, especially when bevacizumab (Avastin) is added to the treatment.
A treatment plan that adds bevacizumab to adjuvant chemotherapy with carboplatin and paclitaxel, followed by a course of bevacizumab alone, was approved by the U.S. Food and Drug Administration (FDA) in 2018. Bevacizumab is a targeted therapy that stops blood vessel growth (see “Targeted therapy,” below). This adjuvant treatment is approved for women with stage III or stage IV ovarian/fallopian tube/peritoneal cancer. In general, bevacizumab used for ovarian/fallopian tube cancer has prolonged the time before the cancer returns in some patients.
Talk with your doctor about which plan is best for your situation. With each of these approaches, doctors consider a variety of factors, such as age, kidney function, and other existing health problems before recommending a treatment schedule.
Side effects of chemotherapy
For ovarian, fallopian tube, and peritoneal cancer, the side effects of chemotherapy depend on the individual and the dose used. Side effects can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, peripheral neuropathy, and diarrhea. These side effects usually go away after treatment is finished.
Possible side effects of chemotherapy include difficulty with concentration and memory. For example, the patient may have issues with attention span or memory, sometimes called “chemobrain.” Other possible side effects include losing the ability to become pregnant, called infertility, and early menopause. Rarely, certain drugs may cause some hearing loss or kidney damage. Patients may be given extra fluid intravenously to protect their kidneys. Before treatment begins, patients should talk with their health care team about possible short-term and long-term side effects of the specific drugs they will receive. It is important to note that many side effects can be reduced by adjusting the dose and/or schedule.
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.
Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them.
For ovarian/fallopian tube cancer, some targeted therapy drugs are directed at specific genes that might be found with abnormalities in certain types of epithelial ovarian/fallopian tube cancer. Standard chemotherapy has been effective in treating most ovarian/fallopian tube cancer. Typically, about 20% of high-grade tumors have mutations in the BRCA genes. Other tumor mutations are less common.
The BRCA mutation, even if found only in the tumor and not in the blood, may increase the effectiveness of certain classes of drugs, such as poly ADP-ribose polymerase (PARP) inhibitors (see below).
Other types of less common ovarian/fallopian tube cancer include low-grade serous, endometrioid, clear cell, and mucinous cancers. These tumors have a variety of mutations, including BRAF, PI3KCA, and PTEN, which mean targeted treatment may be available.
PARP inhibitors. PARP inhibitors block an enzyme involved in repairing damaged DNA. By blocking this enzyme, DNA inside cancer cells may be less likely to be repaired, leading to cell death and possibly slowing down or stopping tumor growth. The BRCA genes (BRCA1 and BRCA2) are normally involved in DNA repair, and a mutation in these genes interferes with this pathway function. PARP inhibitors make it difficult for cells that otherwise have a BRCA mutation to grow and divide.
PARP inhibitors are also effective in women who do not have BRCA mutations, particularly in those who have cancer that has a deficiency in repairing DNA damage. This is called homologous recombination deficiency (HRD). This includes people with platinum-sensitive recurrent disease (see more below). There are tests that can be done to see if a tumor has evidence of HRD and the patient could benefit from treatment with a PARP inhibitor.
PARP inhibitors may be used for maintenance therapy after first- or second-line platinum-based therapy and to treat recurrent cancer (see sections below). ASCO does not recommend that people with early-stage (stage I or II) epithelial ovarian cancer receive PARP inhibitors in combination with first platinum-based treatment. ASCO also does not recommend using PARP inhibitors more than once in the overall treatment plan.
This is an active area of research. Talk with your doctor about the potential benefits and risks of PARP inhibitors.
Anti-angiogenesis inhibitors. Drugs called anti-angiogenesis inhibitors block the action of a protein called vascular endothelial growth factor (VEGF). These drugs have been shown to increase the cancer’s response to treatment and delay the time it takes for the cancer to return. VEGF promotes angiogenesis, which is the formation of new blood vessels. Because a tumor needs nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor.
Bevacizumab, an antibody that binds VEGF and prevents it from being active, has been shown to be effective in treating ovarian/fallopian tube cancer. It may be combined with chemotherapy to treat stage III or stage IV disease (see “Chemotherapy,” above). It is also used as a maintenance drug (see below).
Maintenance therapy using targeted therapy
Maintenance therapy is a medical term to describe treatment used to reduce the risk of cancer coming back, called a recurrence, or to delay the time to recurrence. The drugs are used to “maintain” a clinical remission, which is when there is no evidence of disease after the course of chemotherapy treatment has been completed.
Targeted therapy is used to maintain remission in women whose ovarian/fallopian tube/peritoneal cancer has completely responded to their initial chemotherapy and the disease is in a clinical remission.
Niraparib (Zejula), olaparib (Lynparza), and rucaparib (Rubraca) are PARP inhibitors approved by the FDA for use in maintenance therapy for ovarian/fallopian tube/peritoneal cancer. If the cancer has been slowed or put into remission by first-line platinum-based chemotherapy, ASCO recommends maintenance therapy with olaparib or niraparib for patients newly diagnosed with stage III or IV ovarian cancer. People who have a BRCA mutation should be offered olaparib or niraparib as maintenance therapy. Those with HGSC or high grade endometrioid ovarian cancer should be offered niraparib. If treatment with bevacizumab and chemotherapy has stopped or slowed the cancer, olaparib plus bevacizumab may be used as maintenance therapy for stage III or IV HGSC or endometrioid ovarian cancer in those with a BRCA mutation, have cancer with HRD, or both.
If second-line platinum chemotherapy stopped or slowed the cancer, maintenance therapy with olaparib, rucaparib, or niraparib is recommended in those who have not already received a PARP inhibitor. Although women with a BRCA mutation will have the highest benefit, all women can potentially receive and benefit from a PARP inhibitor. Recent data show an overall survival benefit with olaparib, and data for the others is still pending at this time.
PARP inhibitors are taken by mouth daily. Common side effects are nausea, fatigue, vomiting, low blood counts, and altered taste.
Nausea can be treated with an antiemetic medication. If nausea continues or worsens, ASCO recommends lowering the dose of the PARP inhibitor.
A low red blood cell count, called anemia, should be monitored and may be treated with a blood transfusion. If the anemia still persists or gets worse, the doctor may lower the dose of the PARP inhibitor or give growth factor therapy, which helps produce more blood cells.
Similarly, a low white blood cell count will be monitored. If a low white blood cell count, called neutropenia, is severe enough and causes a fever or lasts at least 5 to 7 days, PARP inhibitor treatment should stop until the neutropenia gets better and the dose lowered. If lowered red or white blood cell counts continue even after PARP treatment is stopped, the patient should be checked for myelodysplatic syndromes (MDS) or acute myeloid leukemia (AML). These conditions may be related to PARP inhibitor treatment or other cancer treatments.
A low platelet count, called thrombocytopenia, may occur in those treated with niraparib. Lowering the dose of the PARP inhibitor or stopping treatment may be needed when this is ongoing or severe. If you have a low body weight or platelet count before starting niraparib, your doctor may recommend starting at a lower dose of niraparib to allow for better tolerance.
Bevacizumab, an anti-angiogenesis inhibitor that is given by vein, is approved by the FDA for maintenance therapy of ovarian/fallopian tube/peritoneal cancer. In 2020, the FDA also approved the combination of bevacizumab with olaparib for maintenance therapy.
Hormone therapy may be used to treat some low-grade serous tumors if they come back, or recur. These include tamoxifen (Soltamox) and aromatase inhibitors, such as letrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin). Hormone therapy is also used to treat stromal tumors, such as recurrent granulosa cell tumors.
Radiation therapy is not used as a first treatment for ovarian/fallopian tube cancer. It may be used to treat some people with clear cell ovarian cancer after chemotherapy. Occasionally, it can be an option for treating small, localized recurrent cancer. It may also be an option for ovarian/fallopian tube cancer that has spread to other parts of the body. See “Remission and the chance of recurrence” below for more information about treatment options for recurrent ovarian/fallopian tube cancer.
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy. This type of radiation is given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. Proton therapy, which uses protons rather than x-rays to treat cancer, may also be used as an alternative to traditional radiation therapy. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.
Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished.
Physical, emotional, and social effects of cancer
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.
During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.
How epithelial ovarian/fallopian tube cancer is treated
As discussed in the Introduction, most cases of ovarian/fallopian tube cancer are epithelial carcinoma. Of those, a great majority are high-grade serous cancer (HGSC). Treatment for early stage, HGSC ovarian/fallopian tube cancer often involves surgery and adjuvant chemotherapy. Treatment for more advanced HGSC includes surgery with adjuvant chemotherapy and/or targeted therapy, neoadjuvant chemotherapy followed by surgery, or chemotherapy alone if surgery is not possible.
How ovarian germ cell tumors are treated
The first treatment for ovarian germ cell tumors is usually surgery. In almost all cases, doctors can perform the surgery in a way that preserves fertility. Doctors may recommend adjuvant chemotherapy after surgery, depending on the stage and subtype of germ cell cancer. Chemotherapy usually consists of a combination of bleomycin (available as a generic drug), cisplatin (available as a generic drug), and etoposide (available as a generic drug) given by IV. The overall approach and medications given are similar to those used in male germ cell cancer, which is a type of testicular cancer.
How stromal tumors are treated
Stromal tumors are a rare form of ovarian cancer. They are found in the connective tissue that holds the ovaries together. For a stage I stromal tumor, treatment usually consists of surgery only. For high-risk, early-stage tumors or stage III or IV disease, doctors often consider combination chemotherapy. You should discuss the potential risks and potential benefits with your doctor.
Chemotherapy for a stromal tumor usually involves the combination of bleomycin, cisplatin, and etoposide. Chemotherapy can be used after surgery or for tumors that have come back after treatment, called recurrent disease. Researchers are looking at chemotherapy with carboplatin (available as a generic drug) and paclitaxel as alternatives. For recurrent disease, doctors may use hormonal therapy. Studies are being done to test tumors to find other targeted drugs to treat ovarian stromal tumors.
How metastatic cancer is treated
If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option.
New treatments for these types of cancer include experimental combinations of chemotherapy, targeted therapy, and another type of systemic therapy called immunotherapy, also called biologic therapy. These combinations are designed to boost the body’s natural defenses to fight the cancer. Because the benefits of these options are still being studied, their risks must be weighed against possible improvements in symptoms and lifespan. Palliative care will be important to help relieve symptoms and side effects.
For most people, a diagnosis of metastatic cancer is very stressful and difficult. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may be helpful to talk with other patients, including through a support group.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. It is important to talk with your doctor about the possibility of the cancer returning. This is particularly important after treatment for ovarian/fallopian tube cancer, as many women experience at least 1 recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return.
If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).
When this occurs, a new cycle of testing will begin to discover as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options.
How recurrent cancer is treated
Chemotherapy is typically used to treat a recurrence of ovarian, fallopian tube, and peritoneal cancer. A primary goal of the treatment of recurrent disease is to reduce or prevent symptoms of the disease while keeping the side effects of treatment to a minimum. Treatment for women with recurrent disease is generally based on the time since her last treatment using a platinum chemotherapy drug. Platinum chemotherapy drugs include carboplatin and cisplatin. There is also evidence that surgery may be an effective option for certain patients with recurrent disease, and this should be discussed with your gynecologic oncologist.
If the cancer comes back more than 6 months after platinum chemotherapy, doctors call it “platinum-sensitive disease.” If the cancer returns in less than 6 months after platinum chemotherapy, doctors call it “platinum-resistant disease.” However, doctors are now starting to consider other factors than just the cancer’s previous response to platinum chemotherapy when deciding which treatment to use for recurrent ovarian, fallopian tube, and peritoneal cancers.
Treatment for platinum-sensitive recurrent disease
If the cancer is localized, additional surgery may be beneficial. Talk about this with your doctor. Surgery is usually considered only if the time following chemotherapy has been 1 year or longer. If the cancer comes back to more than 1 place in the body, chemotherapy is the appropriate next step. For women with platinum-sensitive disease (greater than 6 months from the last dose of platinum), clinical trials suggest using IV carboplatin and combining it with liposomal doxorubicin (Doxil), paclitaxel, or gemcitabine (Gemzar) may be beneficial.
Clinical trials showed the addition of bevacizumab to carboplatin combinations extended the time before the disease came back but did not change how long patients lived. You should discuss the risks and possible benefits of this approach with your doctor.
The following PARP inhibitors are approved for the treatment of recurrent ovarian, fallopian tube, and peritoneal cancer:
- Niraparib (Zejula). Niraparib is approved for maintenance therapy in adults with recurrent ovarian/fallopian tube/peritoneal cancer and can also be used after treatment for recurrent disease with HRD (see “Maintenance therapy using targeted therapy,” above).
- Olaparib (Lynparza). Olaparib is approved for the treatment of persistent or recurrent ovarian/fallopian tube/peritoneal cancer in women who have the BRCA mutation and who have received 3 or more lines of chemotherapy. The SOLO2 clinical trial investigated the use of olaparib for maintenance therapy, which was approved by the FDA. The FDA also approved the use of olaparib in combination with bevacizumab for maintenance therapy.
- Rucaparib (Rubraca). Rucaparib is approved for the treatment of BRCA-positive advanced ovarian/fallopian tube/peritoneal cancer in women who have received 2 or more lines of chemotherapy. The Ariel3 clinical trial is investigating the use of rucaparib for maintenance therapy.
ASCO recommends treatment with a PARP inhibitor for women with recurrent ovarian cancer who:
- Have not received a PARP inhibitor and have a BRCA1 or BRCA2 mutation.
- Have not received a PARP inhibitor, the cancer has HRD, and the cancer has not recurred within 6 months of last dose of platinum chemotherapy.
ASCO does not recommend the use of PARP inhibitors in combination with chemotherapy, targeted therapy, or immunotherapy for the treatment of recurrent cancer, except in clinical trials.
Treatment for platinum-resistant recurrent disease
In general, if the cancer returns in less than 6 months after platinum chemotherapy, the next chemotherapy is chosen from a list of medications that have all shown similar ability to shrink cancer. Doctors choose them based on possible side effects and preference based on schedule of dosing. These medications may include, but are not limited to:
- Liposomal doxorubicin
- Docetaxel (Taxotere)
- Nab-paclitaxel (Abraxane)
- Pemetrexed (Alimta)
- Cyclophosphamide (available as a generic drug)
- Topotecan (Hycamtin)
- Vinorelbine (Navelbine)
- Irinotecan (Camptosar)
For platinum-resistant cancer, most doctors recommend single and sequential use (1 drug after another) of these medications, but they are sometimes used in combination. ASCO does not recommend PARP inhibitors for the treatment of recurrent ovarian/fallopian tube cancer that is resistant to platinum chemotherapy.
Symptoms of recurrent ovarian, fallopian tube, and peritoneal cancer
The symptoms of recurrent ovarian/fallopian tube cancer are similar to those experienced when the disease was first diagnosed. The 4 most common symptoms are bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms (urgency or frequency). However, other symptoms may include persistent indigestion, gas, nausea, diarrhea, or constipation; unexplained weight loss or gain, especially in the abdominal area; abnormal bleeding from the vagina; pain during sexual intercourse; fatigue; and lower back pain.
In addition to monitoring symptoms, doctors may be able to diagnose a recurrence by measuring the level of CA-125 in the blood in women whose levels were elevated prior to treatment (see Diagnosis). CA-125 is a substance called a tumor marker that is found in higher levels in women with ovarian/fallopian tube cancer. In 95% of patients who have a recurrence, there is a rise in the CA-125 level. However, sometimes a recurrence can happen without an elevation of this marker, depending on the tumor type.
Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope.
If treatment does not work
Recovery from ovarian/fallopian tube cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families.
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