A Comprehensive, Holistic Approach to Treating Ovarian Cancer

Surgery, radiation, hormone therapy or chemotherapy may be used alone or in combination to treat gynecologic cancers. The treatment plan depends on a number of factors, including the type and stage of disease, the woman's age and her general health. Grants and shared research projects with the National Cancer Institute give Johns Hopkins patients unique added access to new treatments being evaluated for ovarian cancer.

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins was one of the institutions that pioneered the clinical study of two FDA-approved drugs now widely used to treat ovarian cancer: taxol, a drug made from the bark of the yew tree, and topotecan. Eligible patients who choose to participate in clinical trials frequently have access to promising new therapies for ovarian cancer.

Though many of these cancers are preventable, studies indicate that many women are not aware of the risks or preventive measures available.  The Johns Hopkins Breast and Ovarian Surveillance Service (BOSS) uses research discoveries about the inherited predispositions and genetic causes of these cancers to provide individualized risk assessment for women.  BOSS experts discuss cancer susceptibility and risk factors, genetic testing, and screening and prevention.

Gynecologic cancer patients have access to counseling and support services of the Kimmel Cancer Center, including therapists who specialize in cancer and its psychological impact on patients and families. 

Treatment Overview

Surgery
Treatment begins with surgery to remove as much of the ovarian cancer as possible and to determine where it has spread. Afterward, chemotherapy will most likely be recommended to destroy any malignant cells that have escaped the surgeon's knife. Radiation therapy is not routinely used for ovarian cancer. After chemotherapy, many patients have a "second-look" operation to see if the cancer has been eradicated. If not, more chemotherapy is administered at the time of diagnosis.

The extent of surgery depends on how advanced the disease is, but it almost always involves removing the ovaries, uterus and fallopian tubes. The only exceptions apply to some rare, less aggressive types of early ovarian cancer that develop in young women who haven't had children.

In addition to the reproductive organs, surgeons may also remove the appendix and a portion of an abdominal tissue called the "omentum," where cancer cells may cluster. The liver and intestines will also be checked for signs of cancer, and biopsies of normal-looking tissue may be taken to see if cancer cells are present. The abdominal cavity is also "washed" with a saline solution to check for cancer cells. These procedures contribute to determining the extent or "stage" of the cancer. After surgery, treatment is based on the stage of the cancer.

Staging
The following staging system was established by the International Federation of Gynecology and Obstetrics to describe the progression of ovarian cancer from its earliest to most advanced stages:
Stage I: Cancer is limited to the ovaries. Treatment: Surgery.
Stage IA: Cancer is inside one ovary but hasn't reached the surface; no fluid accumulation in the abdomen; no tumor on the ovary's external surface; the capsule surrounding the ovary is intact. Treatment: Surgery.
Stage IB: Cancer is in both ovaries; no fluid in the abdomen; no cancer on the outer surfaces of the ovaries; the ovarian capsules are intact.Treatment: Surgery.
Stage IC: The cancer is on the outer surface of one or both ovaries; the ovarian capsule is ruptured; or abdominal fluid is present or cancer cells were found in the fluid used to wash the abdomen during surgery. Treatment: Surgery, chemotherapy and perhaps radiation.
Stage II (A, B, C): Cancer has spread to the uterus, fallopian tubes or other parts of the pelvis; at stage IIC cancer has spread to the pelvis and the cancer is on the outer surface of one or both ovaries; the capsule has ruptured; or abdominal fluid is present or malignant cells appear in abdominal washings. Treatment: Surgery and chemotherapy.
Stage III (A, B, C): Cancer is in both ovaries with spread to abdominal lymph nodes or to the outer surface of the liver, intestine or other abdominal organs; at stage IIIA microscopic deposits of cancer cells are found on the outer surfaces of abdominal organs; at stage III B cancer is limited to the pelvis, the lymph nodes are negative but cancer no larger than two centimeters is found on abdominal organs; at stage IIIC cancer affecting the abdomen is larger than two centimeters and/or some lymph nodes are positive for cancer. Treatment: Surgery, including removal of the omentum, followed by chemotherapy.
Stage IV: One or both ovaries are affected; cancer has spread to the inside of the liver, to other abdominal organs or to organs outside the abdomen. Treatment: The same type of surgery as for stages IIIABC, followed by chemotherapy.

Chemotherapy
Chemotherapy for ovarian cancer is typically given intravenously every three to four weeks for six to 12 months. A combination of drugs, often platinum (Cisplatin) plus paclitaxel (Taxol), is recommended because they are more effective than a single agent. These drugs work by interfering with the ability of cancer cells to reproduce. While disrupting cancer cells, they also damage healthy cells and cause a number of unpleasant side effects. Possible side effects include:
• Nausea and vomiting, although these can now be controlled with Zofran (ondansetron), Kytril (granisteron) and Anzemet (dolasetron), given at the same time as the chemotherapy drugs
• Temporary hair loss
• Increase or decrease in appetite
• Fatigue
• Premature menopause
• Infertility
• Changes in the menstrual cycle
• Increased susceptibility to infection and sores in the mouth or vagina
The most serious side effect is the possibility of developing acute myeloid leukemia, a life-threatening disorder of white blood cells. This complication occurs in only a very small number of all cancer patients treated.

A variety of experimental chemotherapy regimens are being employed to increase survival in patients with advanced ovarian cancer.

Intraperitoneal chemotherapy may be recommended for women who responded well to the initial chemotherapy but who either are later found to have residual cancer cells in the abdomen later or have more advanced tumors. This form of chemotherapy involves delivering the drugs directly into the abdominal cavity.

Radiation
Radiation therapy is rarely used to treat ovarian cancer in the United States. When used, X-rays are aimed at the abdomen or an implant of radioactive material is inserted at the tumor site. When radiation is delivered externally, the skin over the treated area may redden as if it were sunburned, but this fades over time. Apart from this small risk, the side effects include fatigue, nausea and diarrhea.

Follow-up
After surgery and during chemotherapy, ovarian cancer patients may be monitored with CA125 tests. Rising levels of this protein indicate a recurrence and the need for more therapy. In addition, many doctors routinely perform "second-look" surgery after a six- or 12-month course of chemotherapy. This procedure involves opening the abdomen and taking tissue samples in a search for cancer cells. If additional cancer cells are found, chemotherapy is repeated.

"Second-look" surgery is somewhat controversial because additional cancer is often found or the cancer recurs. Opponents of a "second look" advocate continuing chemotherapy instead of subjecting patients to more surgery.

-Used with permission from HopkinsHealth, copyright Johns Hopkins.