Treatment Options for Ovarian Cancer Recurrence and Timing

Tubes with samples. Credit: dra_schwartz

What treatments are available for ovarian cancer recurrence? My ovarian cancer is back or it never went away after the first set of treatments. What should I do now? That is the question asked by most ovarian cancer patients at some point in time.  Unfortunately, for roughly 80% of people who undergo first-line chemotherapy, the cancer comes back.

The answer to this question depends on how the diagnosis of recurrence was made and how long after the end of initial treatment this happened.

Generally, there are three separate categories which carry three different prognoses and usually lead to three general different treatment plans. However, beyond that, please be aware that while there is a pretty standard approach to initial treatment options, treatment for recurrence is highly individualized.

While there are pretty good guidelines, there are no universally agreed upon standards of practice. In general, the more time passes before a recurrence the better the chances for a possible cure or long second remission. Also, more options are available in this scenario.
 

Recurrence After Six Months

If the recurrence is diagnosed at least 6 months after initial treatment (preferably closer to a year), the tumor is deemed to be “platinum sensitive” if the initial treatment contained a platinum drug (Carbo-platin or Cis-platin). The later the recurrence after this point, the more it might be reasonable to perform a “secondary cytoreduction” surgery to once again remove as much cancer as possible.

Most gynecologic oncologists would strongly consider this if the cancer recurs at least two years after initial treatment and a mass or masses is/are seen on scan or felt on examination. However, it may be a very good option prior to this time frame too, depending upon your specific situation.

Whether or not repeat secondary cytoreduction surgery is performed, many oncologists would suggest treating with the same drugs that were used the first time, especially if the recurrence is found more than a year after intial treatment.

If it is found between 6 months and a year after treatment, options might include re-treatment with Taxol and Cis-Platinum or Carbo-Platin, or using new drugs as discussed below. Most oncologists would favor new drugs within this time frame.
 

Recurrence Within Six Months

If the recurrence is diagnosed 6 months or less after the initial treatment, the tumor is deemed to be “platinum resistant”. The tumor likely grew back at some point towards the end or after the initial chemotherapy. In these situations, repeat surgery is rarely recommended as it is highly unlikely to improve length of life or quality of life. There are three main chemotherapy drugs available today which most oncologists use interchangeably. All work just about equally well and can be used in sequence, one at a time, as one drug or the other stops working. These are:Doxil, Topotecan and Gemzar. Combination therapies have also been tried, but generally without dramatically better success and with higher toxicity side effects.

However, each situation is different, so please ask your doctor about all possible options. While aggressive chemotherapy with these drugs can still be ongoing, you should keep in mind that the chances for cure are very small and keeping quality of life in mind is very important. Again, this is a risk/benefit discussion with your physician(s).  Learn more about platinum sensitive vs platinum resistant ovarian cancer recurrence.
 

Recurrence During Or Immediately After Treatment

If the recurrence is actually cancer growth during initial treatment, this is called “platinum refractory”, or an extreme case of resistance to chemotherapy. Additional chemotherapy can be given, mainly using the drugs discussed about, but the chances of response are quite low. Also, keep in mind that the drugs mentioned above are NOT the only ones available for treatment, they are just regarded as the best ones to try first. Ask your doctor(s) about others and what the chances are that they might help in your particular case. This may also be a good time to inquire about promising but unproven options through clinical trials
 

Clinical Trials

There are many clinical trials in progress for ovarian cancer that has recurred, and research looking at some of these options is encouraging. Talk to your oncologist about trials that may meet your specific situation, or consider a second opinion.  Some of these options include targeted therapy medications - that is, medications that are designed to specifically target cancer cells, and one medication of a new class of drugs called PARP inhibitors was just approved for use in 2015. 

Palliative vs. Curative Treatment Intent

A word about “palliative surgery” and “palliative radiation”. Even if surgery is no longer a curative option at some point in treatment, there may be surgical options which “palliate” or help resolve or calm symptoms. In rare cases this might be a intestinal bypass surgery, or removal of one blocked area of intestine (usually many segments are blocked) in order to allow someone to eat food for at least a number of months. In other cases, this might mean placing a tube directly into the stomach through the skin (gastrostomy) so that vomiting is relieved and a tube in the nose (NG tube) does not have to be in place for weeks or months.

Sometimes in advanced cancer, fluid accumulates in the chest. Various procedures to drain the fluid, including tubes and scarring procedures (pleurodesis) can help eliminate or reduce this fluid and help with breathing problems. These are just several examples, but on a case by case basis, some type of surgery or radiologically guided invasive procedure might be helpful to you. If you are suffering from a particular symptom, ask whether or not some type of surgical or invasive procedure might be helpful.

Finally, although rare, ovarian cancer may involve your bones, often producing severe pain. Also rarely it can spread to the brain and produce seizures. In both of these situations, radiation therapy to that area might be very helpful to reduce or eliminate symptoms.
 

Source:

National Cancer Institute. Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer Treatment–for health professionals (PDQ®). Recurrent or Persistent Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer Treatment. Updated 08/21/15. http://www.cancer.gov/types/ovarian/hp/ovarian-epithelial-treatment-pdq#section/_82

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