Neo-adjuvant Chemotherapy
In some cases surgery may be too much for a patient to handle or stage IV(4) cancer is present which means it is far more advanced than usual. For example, rarely, a large amount of disease may be present deep in the liver or in the lungs or brain. In such cases, surgery cannot remove these tumors effectively, leaving behind a lot of cancer.Ovarian cancer that has spread beyond the abdomen and into organs like the liver and lungs can also be more aggressive and therefore resistant to chemotherapy. In such cases, or in situation where the patient is very sick extensive surgery may not be tolerated. In such situations, it is arguably better to see if the chemotherapy will work first, before exposing the patient to all the risk of a radical aggressive cyto-reductive (de-bulking) surgery.
Administering chemotherapy before surgery offers a chance to test the chemotherapy for effectiveness. If it makes the cancer partly shrink away, surgery is still possible and is often performed half way through the planned six cycles (every 3 weeks x6) of chemotherapy.
After the surgery removes more cancer in the abdomen, including removal of the ovaries, more chemotherapy is administered to complete six cycles. Another benefit of this approach is that the surgery is often less extensive, often avoiding the need to remove bowel segments. This is because the chemo can cause the cancer to pull back and be less adherent to intestine.
Adjuvant Intra-venous Chemotherapy
Patients with early stage and low grade ovarian cancers (stage Ia or Ib, grade 1) are not generally offered chemotherapy because the cure rates are not improved from the already great 95% range. Once the grade jumps to grade 2 or 3, and the stage is Ic or greater, chemotherapy is usually indicated because it improves the chances for cure.The current standard of practice for chemotherapy that is being given for the first time after a diagnosis of ovarian cancer is to give three to six cycles of chemotherapy; three to four for Stage Ib and Ic, while Stage II and up usually require six.
After suboptimal surgery (more than 1cm marble size tumors left), six cycles of intra-venous chemotherapy is the current standard.
Adjuvant Intra-peritoneal Chemotherapy
Recent studies have shown that patients who have optimal cyto-reductive surgery (less than 1cm marble size tumors remain) may benefit more from giving the chemotherapy directly into the abdominal cavity through a special catheter placed at the time of surgery.While the initial results were very impressive, there have been concerns about the benefit being exaggerated and the side effects being downplayed too much. It is certainly an option for certain patients and worth discussing with your gynecologic oncologist.
Palliative Chemotherapy
In situations where the ovarian cancer is very advanced, the patient is very debilitated with many medical problems other than cancer, or after recurrence the primary goal of treatment shifts from possible cure to symptom control. Control of symptoms, like massive ascites (fluid in the belly), is called palliation.Palliative chemotherapy is given for a variable number of cycles and treatment in these cases has to be individualized. If the patient is tolerating the treatment well, and it is working, often the chemotherapy is continued until it looks like the cancer is starting to grow back (progression).
Chemotherapy for Recurrence
Chemotherapy for recurrent or persistent cancer is usually a type of palliative treatment. There is an increasing group of drugs that are available to treat recurrences. They are work in a different biochemical way, so if one stops working another one can be started.Unfortunately, in most cases, each time a new drug is started the chances that it will work and the length of time it works gets smaller and smaller. One exception to this is if recurrence is found very late (many years). In this case, additional chemotherapy may be curative in a very small percentage of patients. In fact, often surgery is also performed as well. Even if cure is not possible in most cases, the chances that the cancer will stay away for years a second time is increased.
