The National Comprehensive Cancer Network (NCCN) recommends that ovarian cancer patients should be initially treated with surgery and chemotherapy. Around 75 percent of women with advanced stage disease who receive this regimen go into remission.
Treatments are based on the cancer histology type, stage and each patient’s individual needs. Some women diagnosed with stage I cancer localized to a single ovary may opt to only have that ovary and fallopian tube removed. This is sometimes called fertility-sparing surgery.
In some women with advanced stage III or IV disease, a surgeon will recommend chemotherapy before surgery (called neoadjuvant therapy) to reduce the size of the tumors so they can be removed more easily during the debulking surgery.
The standard of care for most women is treatment that includes a platinum drug, like carboplatin, a taxane, like paclitaxel (Taxol) and sometimes bevacizumab (Avastin). More recently, a class of drugs called PARP (Poly ADP-ribose polymerase) inhibitors have been approved as maintenance treatment following this chemotherapy. Such drugs can help keep the cancer from coming back.
For women diagnosed with low grade serous or endometrioid types, hormonal therapy — aromatase inhibitors like letrozole (Femara) or anti-estrogens like tamoxifen (Nolvadex) — may be an option. Find more information about low grade serous ovarian cancer treatment options at https://letstalkaboutlgsoc.com/.
Treatments for Newly Diagnosed
This table lists the most commonly used treatments for women diagnosed with advanced ovarian cancer. Groups of drugs are used in combination and are taken either before (neo-adjuvant) or after surgery. These drugs are listed in the National Comprehensive Cancer Network (NCCN) guidelines as preferred treatment options. Please take this information to your doctor as an aid for your discussions.
|Carboplatin or Cisplatin
|Drugs can be given by vein (iv) or directly into the peritoneal cavity (ip) on different schedules (weekly, every three weeks). The outcome of the debulking surgery (optimal vs. sub-optimal*) will influence the choice of regimen.
|Adding Avastin to first line chemo and continuing to take it after the chemo is finished can help keep the cancer from coming back – particularly in patients with high risk disease.**
|*Optimal: less than 1 cm of cancer remains after surgery; sub-optimal: more than 1 cm of cancer remains
**Stage IV disease, debulking surgery was sub-optimal (>1 cm remaining disease), or ascites was present at diagnosis
|5-FU (Fluorouracil)/Leucovorin or Capecitabine (Xeloda)
| Treatment with 5-FU or Capecitabine and Oxaliplatin after surgery may be as effective as Carboplatin and Paclitaxel
To see how effective these drugs are, click here.
To see side effects associated with this drug, click here.
|*For criteria used to highlight these trials, click here.
|For women with stage III ovarian cancer eligible for primary debulking surgery, adding HIPEC after cytoreduction may improve the outcome compared to surgery alone
|*For criteria used to highlight these trials, click here.
|Hormonal therapy with Letrozole (Femara) after surgery may be as effective as chemotherapy followed by Letrozole (Femara) maintenance
There are other treatments, including PARP inhibitors and immunotherapies, being evaluated in clinical trials for initial treatment of ovarian cancer. Visit the clinical trials page and scroll down to find them.
Maintenance Treatments After First-line Chemotherapy
These tables list the drugs most commonly used for maintenance after first-line treatment. These drugs are listed in the National Comprehensive Cancer Network (NCCN) guidelines as preferred treatment options. Please take this information to your doctor as an aid for your discussions.
PARP (Poly ADP-ribose polymerase) inhibitors, olaparib (Lynparza) and niraparib (Zejula) were recently approved as maintenance therapy following first line treatment based on their effectiveness in preventing recurrence. Women with BRCA1 or 2 gene mutations detected in their blood (germline; hereditary) or tumor (somatic) received the most benefit from such treatment. Therefore, genetic testing for inherited cancer risk can be important – even if there is no family history. If negative, tumor testing can be performed to determine if a BRCA mutation is found only in the tumor (called “somatic”).
One additional biomarker is called HRD (homologous recombination deficiency). HRD testing provides an estimate of the “BRCAness” characteristic of the tumor by measuring the genomic instability that results from problems with DNA damage repair. This increased damage occurs in tumors that do not have a functional BRCA protein (e.g., due to a mutated BRCA gene). It also sometimes occurs when the BRCA gene is not mutated but other genes in the DNA damage repair pathway are altered. In those cases the HRD test is positive. Studies show that women whose tumors are HRD positive may have more benefit from PARP inhibitor treatment than those whose tumors are HRD negative (also called HRP for homologous recombination proficient).
|Adding Avastin to frontline chemo, and continuing after chemo, helps keep the cancer from coming back, particularly in patients with high-risk disease*
|After a response to first-line treatment, taking Zejula increases the time before the cancer returns
|Increases the time before cancer returns in women with BRCA-mutated** cancer
|For women with BRCA-mutated** or HRD***-positive tumors who have a response to first-line treatment, the combination of Lynparza with Avastin increases the time before cancer returns
|*Stage IV disease, debulking surgery was sub-optimal (>1 cm remaining disease), or ascites was present at diagnosis
**BRCA-mutated patients have a mutation in the BRCA1 or BRCA2 gene detected in their blood (germline mutation) or tumor (somatic mutation)
***HRD stands for homologous recombination deficiency. This is similar to LOH, which stands for loss of heterozygosity. HRD and LOH are changes in tumor DNA that indicate the tumor looks like one that is BRCA-positive, also called “BRCAness”.
There are other treatments, including other PARP inhibitors and vaccines, being evaluated in clinical trials for maintenance treatment after first-line therapy. Visit the clinical trials page and scroll down to find them.