Ovarian Cancer

Ovarian cancer can affect women of any age, although it is most common in those between 55 and 65 years of age Even though ovarian cancer is a rare disease, it is the number one cause of death among all gynecological malignancies. Due to the fact that still more than 2/3 of the women who first present with this disease will be diagnosed in a late, advanced stage, ovarian cancer remains a therapeutic dilemma with still many open questions.

Ovarian cancer arises in the surface of the ovaries, even though new theories strongly support a potential origin from the fallopian tubes. It is a disease that very often tends to involve the peritoneal layers of the abdomen; a thin membrane which covers all organs of the abdominal cavity. True organ metastases in liver, lung or bones like for example more common in advanced breast cancer are here very rare.

Due to this behavioral pattern surgery consists not only removal of the ovaries but also “stripping” of the affected peritoneum, which then however grows back with a few days till weeks. This is why surgery may be extensive and should always aim at removal of all visible disease, since we know that only in these cases patients will have the overall best survival. Due to the special techniques that have to be applied, surgery should be performed only by experienced gynecological oncologists especially trained in these surgeries. In the hands of experienced surgeons surgical morbidity can be kept low.

No matter how optimal surgery is, chemotherapy is needed in more than 90% of the cases. Although we usually begin treatment by offering surgery before chemotherapy (primary debulking surgery), sometimes we may reverse the sequence and give chemotherapy first (neoadjuvant chemotherapy) followed by surgery and then chemotherapy again (delayed primary surgery) in cases where the patients are not fit enough for an extensive surgery.

Chemotherapy currently typically consists of two drugs, paclitaxel and carboplatin given every three weeks, however recent advances are causing us to look more carefully at changing the schedule of paclitaxel such that it is given every week, or alternatively considering a new targeted treatment directed against the blood vessels that feed the cancer (Bevacizumab or Avastin), and careful selection of patients that would benefit from these approaches whilst avoiding unacceptable side effects is required. Following concurrent Bevacizumab and chemotherapy, the Bevacizumab usually continues to be given for up to a year.

If ovarian cancer comes back after the first treatment, there are many opportunities and approaches possible to controlling the disease, which usually involve more chemotherapy but may also involve surgery depending on the tumour pattern of the recurrence and the clinical symptoms of the patient. The true value of surgery in relapsed disease is currently a focus of current clinical trials, however form retrospective evidence we know that if surgery can achieve complete tumor resections patients appear to have a better overall prognosis.

However, since  relapsed disease can never be completely cured 2nd line treatment is usually necessary. In these cases an “aggressive” surgical approach should be carefully discussed with the patient.

Active ovarian cancer research has resulted in new drug treatments approaches and there increasing information on the different kinds of ovarian cancer, based on the understanding of what drives the formation and growth of ovarian cancer (the so-called molecular understanding of the disease). The hope is that understanding the molecular profile of the ovarian cancer cells from patients genes (DNA, RNA) and cell proteins will allow us to personalise treatments to individual patients by giving us insights into assessing risk of cancer returning, prognosis for the patient and the choice of the best treatment.

Further information on ovarian cancer and its research to improve chances of cure can be obtained from the national ovarian cancer charity Ovarian Cancer Action:

www.ovarian.org.uk