Fighting Ovarian Cancer
by Andrew Berchuck, MD
Every year 22,000 women in the United States will be newly diagnosed with ovarian cancer. More women are living as survivors because therapy can significantly prolong life and, in some cases, cure the disease. For women facing a diagnosis of ovarian cancer, the options for treatment have grown in recent years.
Surgery is usually performed first to determine the stage of the disease and to remove as much of the cancer as possible if it has spread. In ovarian cancers that appear to be contained locally, about one-third of women actually have more advanced disease, so it’s important for surgeons to perform biopsies of lymph nodes and other areas of the abdomen to determine disease spread. If the cancer is found at an early stage, it might be possible to preserve a woman’s fertility by retaining the uterus and one ovary.
Most women receive chemotherapy after the initial surgery. This typically includes carboplatin along with a taxane drug, which are typically given intravenously every three weeks for about six months. Chemotherapy for ovarian cancer is usually well tolerated, but loss of appetite and nausea for a few days after each treatment are common and can be managed effectively with medications. The strength of chemotherapy can be tailored to each woman based on her general health and other factors. Some women may develop allergies to the chemotherapy, but these can usually be overcome with additional medications.
Chemotherapy treatment can cause a decline in cells produced by the bone marrow, including white and red blood cells and platelets. Blood counts do not usually decline to dangerous levels but should be monitored closely. If the levels of blood cells remain low, this can delay subsequent treatments. Sometimes blood transfusions or growth factor injections are prescribed to combat these issues.
Surgery is usually performed first to determine the stage of the disease and to remove as much of the cancer as possible if it has spread.
Numbness, pain, and loss of feeling can occur in the hands and feet following chemotherapy. In most cases, this condition (called neuropathy) is mild and reversible after treatment is discontinued. It’s important to tell your oncologist at each visit if you have any of these symptoms and whether they are worsening. In some cases, neuropathy may become debilitating and require reductions in the dose of chemotherapy or even switching to another therapy.
It’s important to eat a healthy diet and get lots of sleep to stay strong during chemotherapy treatment. However, there is no evidence that vitamins or nutritional supplements improve survival, and in some cases, they may be harmful. It’s important to let your oncologist know if you are taking any of these products.
Although most women with ovarian cancer undergo surgery and then chemotherapy, some may not be able to withstand surgery and are treated with chemotherapy first. In other cases, chemotherapy may be given first because tests show it will not be possible to remove most of the cancer. After several cycles of chemotherapy, tumors often shrink dramatically and surgery may be more successful. Recent studies have shown that this approach, called neoadjuvant chemotherapy, is fairly equivalent to a surgery-first approach. The decision of whether to begin with chemotherapy or with surgery should be made in consultation with your oncologist.
Intraperitoneal (IP) Chemotherapy
Some studies have suggested an advantage to administering chemotherapy directly into the abdomen in what’s called an intraperitoneal infusion. A higher concentration of drug is achieved via IP chemotherapy, but it causes more severe side effects; therefore, women who receive it should be in good overall health.
Biological Targeted Therapies
As we learn more about ovarian cancer at the molecular level, new drugs are being developed to disrupt some of the basic functions of cancer cells. Bevacizumab is a targeted agent that inhibits the development of new blood vessels in tumors. Studies have shown that when this drug is infused along with chemotherapy and then continued every three weeks, the recurrence of ovarian cancer can be delayed by three to six months on average. A number of other drugs that starve tumors of blood vessels are also under development, as are different biologically targeted treatments.
Although most women with ovarian cancer undergo surgery and then chemotherapy, some may not be able to withstand surgery and are treated with chemotherapy first.
About 10 percent of ovarian cancers develop in women with inherited mutations in either the BRCA1 or BRCA2 genes. Women with these mutations have a high risk of ovarian cancer and are usually advised to have their fallopian tubes and ovaries removed before cancer develops. Ovarian cancers that do develop in women with these mutations have been shown to respond more favorably to conventional chemotherapy. In addition, a new class of drugs called PARP inhibitors are currently being studied in clinical trials and appear to be particularly effective in BRCA1 and BRCA2 mutation carriers.
Most women with ovarian cancer have a blood test done at each follow-up visit to measure a protein called CA125, which is elevated in most ovarian cancers. In women who develop recurrence of cancer after treatment, the CA125 level will often start to rise before the disease can be detected clinically. It seems logical that earlier detection of recurrent disease would improve outcomes, but a recent clinical trial found that CA125 monitoring did not increase survival time. In view of this, some women may elect not to have CA125 levels measured and to forego additional treatment until the cancer becomes symptomatic.
The treatment of recurrent ovarian cancer is individualized for each woman. In some cases, secondary surgery may be helpful, particularly if the disease appears to be confined to a few tumors that can be removed completely. Chemotherapy often involves retreatment with platinum or taxane regimens. When these drugs stop working, there are several other options for chemotherapy treatment.
A diagnosis of ovarian cancer can be emotionally traumatic. Most women with ovarian cancer are cared for by gynecologic oncologists, cancer specialists who are engaged in comprehensive treatment, including surgery, chemotherapy, and addressing issues related to quality of life and survivorship. Women should be surrounded by a care team that also includes nurse oncologists, social workers, and cancer support services. Even women with optimal family support can benefit from counseling and medications to ease anxiety and depression, so it’s important to express your emotional concerns to your doctor.
Women with ovarian cancer and their families should try to understand all the recommendations made by their healthcare team. A good bit of useful information is available online at websites such as foundationforwomenscancer.org. Moreover, you should not hesitate to seek a second opinion at any point. You may also want to consider participating in a clinical trial, as they offer cutting-edge therapies and provide a path forward to better treatment protocols.
Groups at both the national and local level are working to raise awareness of ovarian cancer and to generate funds for research. These efforts also provide ovarian cancer survivors the opportunity to engage with each other and achieve a sense of purpose, power, and community as we all work together to improve diagnosis, treatment, and prevention of ovarian cancer.
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Dr. Andrew Berchuck is director of the gynecologic oncology program at the Duke University Cancer Institute in Durham, NC. He is involved in translational ovarian cancer genomics research and treatment of people with cancer on a daily basis. He is past president of the Society of Gynecologic Oncology and is the recipient of the Barbara Thomason Ovarian Cancer Professorship from the American Cancer Society.
This article was published in Coping® with Cancer magazine, May/June 2012.