Ovar­i­an Can­cer — What Now? Ther­a­py options today

Clin­ic for Gyne­col­o­gy with a Cen­ter for Onco­log­i­cal Surgery

Those affect­ed and their rel­a­tives often expe­ri­ence the diag­no­sis of ovar­i­an can­cer as a deep turn­ing point in life: it is not uncom­mon for fear, stress and oth­er psy­cho­log­i­cal stress to be the result. There are var­i­ous options for sup­port and help — both in the direct envi­ron­ment and from var­i­ous experts. With our con­tri­bu­tion to the treat­ment of ovar­i­an can­cer, we would like to show can­cer patients, their fam­i­lies and friends ways to bet­ter under­stand and deal with the dis­ease In the fol­low­ing you can read how a ther­a­py typ­i­cal­ly pro­ceeds from diagnosis.

1. Con­sul­ta­tion hour

Do some research before and after your vis­its to get answers to all your questions.

First of all, your doc­tor will ask you what will lead you to him or her. He or she will want to know which exam­i­na­tions have already been done and whether you have writ­ten doc­u­ments for them, because these can be very help­ful. Please bring all the doc­u­ments you have about your state of health with you. You may also be asked about your com­plaints. Know­ing about the symp­toms does not nec­es­sar­i­ly help to clar­i­fy whether it is ovar­i­an cancer.

Then a gyne­co­log­i­cal specu­lum and pal­pa­tion exam­i­na­tion of the vagi­na (vagi­nal), the abdomen (abdom­i­nal) and part­ly also the rec­tum (rec­tal) take place, as you already know from the gyne­co­log­i­cal prac­tice. This exam­i­na­tion is sup­ple­ment­ed by a vagi­nal (and pos­si­bly abdom­i­nal) ultra­sound and a deter­mi­na­tion of the tumor mark­ers (includ­ing CA 125, CA 19–9, HE4). The tumor mark­ers only serve as indica­tive find­ings and are used to mon­i­tor the progress, e.g. after an oper­a­tion. They are not always suit­able as a spe­cif­ic indi­ca­tor of ovar­i­an can­cer, since inflam­ma­to­ry dis­eases, for exam­ple, can also be asso­ci­at­ed with an increase in the tumor marker.

Your doc­tor may also order a com­put­ed tomog­ra­phy (CT) scan. This pro­ce­dure is used to assess the spread of the tumor and enables good prepa­ra­tion for the oper­a­tion, which is almost always necessary.

The actu­al con­fir­ma­tion of the diag­no­sis is only pos­si­ble by tak­ing a tis­sue sam­ple. If ovar­i­an car­ci­no­ma is sus­pect­ed, this is obtained dur­ing an oper­a­tion; if ovar­i­an car­ci­no­ma is con­firmed, anoth­er major oper­a­tion usu­al­ly has to be per­formed. If ovar­i­an can­cer is very like­ly, this tis­sue sam­ple can also be tak­en right at the begin­ning of the major oper­a­tion, which will only be pro­ceed­ed after the final diag­no­sis by the pathol­o­gist. After know­ing all of the exam­i­na­tion results, your doc­tor will dis­cuss and plan this oper­a­tion with you.

2. Diag­nos­tics

The most impor­tant exam­i­na­tion if it is sus­pect­ed that ovar­i­an can­cer could be the case is the gyne­co­log­i­cal exam­i­na­tion as you know it from prac­tice, which is then car­ried out by an expe­ri­enced ovar­i­an can­cer expert. In addi­tion, the anus is then usu­al­ly exam­ined from the rec­tum. This is fol­lowed by an ultra­sound exam­i­na­tion of the vagi­na and abdomen.

The next step is usu­al­ly a blood test to deter­mine the tumor mark­er for ovar­i­an can­cer in the blood. The result can help to make the diag­no­sis but is not always meaningful.

Imag­ing with com­put­ed tomog­ra­phy (CT) may be nec­es­sary, but by no means always. In the case of very small, unclear herds, posi­tion emis­sion tomog­ra­phy (PET-CT) may also be used, but this is very rarely only necessary.

For this pur­pose, you will receive an appoint­ment at the Charité’s radi­ol­o­gy depart­ment via our patient man­age­ment; the results of the exam­i­na­tion can usu­al­ly be viewed by the doc­tors in our depart­ment after 5 days.

Final cer­tain­ty can only be obtained through a fine tis­sue exam­i­na­tion. For this, a tis­sue sam­ple must be obtained from the abdomen in an oper­a­tion and sent to the pathol­o­gist. You look at the tis­sue under the micro­scope and can tell whether it is a benign or malig­nant growth.

3. Oper­a­tion

The stan­dard treat­ment for ovar­i­an can­cer is almost always surgery first. This should be done with­in 2–3 weeks of the diag­no­sis. The aim of the oper­a­tion is to con­firm the diag­no­sis, deter­mine the extent of the tumor and com­plete­ly remove (vis­i­ble) tumor tis­sue. If this is not com­plete­ly pos­si­ble, an attempt is made to remove as much tumor tis­sue as pos­si­ble, because the small­er the remain­ing tumor, the bet­ter the prog­no­sis (long-term survival).

The oper­a­tion has three objectives:

1. Con­fir­ma­tion and scope of the diag­no­sis (through his­to­log­i­cal analy­sis of tumor tissue)
2. Deter­mi­na­tion of tumor spread
3. Max­i­mum tumor reduc­tion or removal

The oper­a­tion is car­ried out via a lon­gi­tu­di­nal abdom­i­nal inci­sion (lon­gi­tu­di­nal laparo­to­my) from the pubic bone to the navel and, depend­ing on the extent of the oper­a­tion, even to the low­er edge of the ster­num. Surgery for ovar­i­an can­cer usu­al­ly takes 3–6 hours. Among oth­er things, due to the con­fir­ma­tion of the diag­no­sis using a tis­sue sam­ple. The pathol­o­gist exam­ines this direct­ly (quick sec­tion) and com­mu­ni­cates the result to the sur­geon over the phone, who then decides on the fur­ther extent of the oper­a­tion. The surgery usu­al­ly includes:

• Com­plete pal­pa­tion of the abdom­i­nal cav­i­ty with removal of parts of the peri­toneum if necessary
• Removal of the uterus (hys­terec­to­my), fal­lop­i­an tubes, and ovaries (adnex­ec­to­my)
• Removal of the large net­work, a lymph organ hang­ing from the intes­tine (omen­tec­to­my) and the enlarged lymph nodes (lym­phadenec­to­my) in the small pelvis and along the large ves­sels (main artery, large infe­ri­or vena cava)
• If nec­es­sary, appen­dec­to­my (appen­dec­to­my), if it is a mucus-pro­duc­ing tumor

In addi­tion, if nec­es­sary, all oth­er areas affect­ed by the tumor are removed. Organs or parts of organs may also have to be removed. For exam­ple, the spleen, part of the liv­er, part of the diaphragm or, more often, part of the intes­tine. If part of the intes­tine has to be removed, the affect­ed part is usu­al­ly cut out and the healthy ends sewn back togeth­er direct­ly. But some­times it can also be nec­es­sary to cre­ate an arti­fi­cial anus, usu­al­ly when the healthy bow­el is too short to cre­ate a direct con­nec­tion or oth­er sutures first need rest from the bow­el move­ment. In this case, the arti­fi­cial anus can be relo­cat­ed back after a heal­ing phase.

After the oper­a­tion you will first spend a few hours in the recov­ery room, where you will be asked whether you are in pain and will be giv­en addi­tion­al pain med­ica­tion imme­di­ate­ly if nec­es­sary. As a rule, the anes­thetists also put a perid­ual catheter (PDA) before the oper­a­tion, as is also the case with child­birth, which makes it pos­si­ble for you to expe­ri­ence as lit­tle pain as pos­si­ble. You will like­ly be trans­ferred from the recov­ery room to an inten­sive care unit for a day or two. After most­ly 2 days, you will then con­tin­ue to be cared for in a nor­mal hos­pi­tal ward until you can usu­al­ly be dis­charged home after 10 days.

While you are recov­er­ing from the oper­a­tion and with the help of the phys­io­ther­a­pists and nurs­es on the ward, get back on your feet as quick­ly as pos­si­ble and, for exam­ple, get your own tea, the results of the oper­a­tion and the tis­sue exam­i­na­tion are dis­cussed in a tumor con­fer­ence . In the tumor con­fer­ence, experts from oncol­o­gy, gyne­col­o­gy, radi­ol­o­gy and radi­a­tion ther­a­py meet and decide togeth­er which fur­ther treat­ment steps are nec­es­sary and rec­om­mend­ed to you.

After the oper­a­tion — check­list ques­tions to ask my doctor:

• Do I have a high-grade or a low-grade carcinoma?
• What stage is my ill­ness at?
• What oth­er treat­ments do you recommend?
• What treat­ment options are avail­able for me and why?
• What are their advan­tages or disadvantages?
• How much time do I have to make a deci­sion? Would you rec­om­mend that I get a sec­ond opinion?
• When is my next appointment?

4. Genet­ic testing

Breast can­cer is the most com­mon form of can­cer in women. Around every 10th woman will devel­op it in the course of her life. The major­i­ty of these dis­eases occur spo­rad­i­cal­ly, only about 5 to a max­i­mum of 10% of the dis­eases can be traced back to indi­vid­ual genet­ic changes and thus occur more fre­quent­ly in fam­i­lies. These genet­ic changes can also be asso­ci­at­ed with an increased risk of devel­op­ing ovar­i­an cancer. 

Test­ing for this genet­ic change (BRCA 1 or 2 muta­tion) can also be deci­sive for treat­ment plan­ning in ovar­i­an can­cer, as there are drugs that can only be used if there is a genet­ic change.

The sus­pi­cion of a hered­i­tary cause of breast can­cer can­not be raised on the basis of an indi­vid­ual dis­ease, but is made tak­ing fam­i­ly his­to­ry into account. If you have one of the fol­low­ing cri­te­ria, there could be a genet­ic pre­dis­po­si­tion. In this case, please speak to your doc­tor. Genet­ic coun­sel­ing should be offered to all women with ovar­i­an, fal­lop­i­an tube, or peri­toneal cancer.

Fam­i­lies with:

• at least three women are or have had breast can­cer, regard­less of age.
• at least two women have or were diag­nosed with breast can­cer, one of them before the age of 51.
• at least one woman is or has had breast can­cer and one woman has ovar­i­an cancer.
• at least two women have or were diag­nosed with ovar­i­an cancer.
• at least a woman has or has had breast or ovar­i­an cancer.
• at least a woman has or was diag­nosed with breast can­cer when she was 35 years or younger.
• at least a woman has or has had bilat­er­al breast can­cer, the first time when she was 50 years old or younger.
• A man has had breast can­cer and a woman has breast or ovar­i­an can­cer, regard­less of age.
• A woman has or has had triple neg­a­tive breast cancer.
• A woman has or was diag­nosed with ovar­i­an cancer.

Source: Cen­ter for Famil­ial Breast and Ovar­i­an Can­cer Con­sul­ta­tion Hours

Genet­ic test­ing can be car­ried out with a blood sam­ple and also with a tumor sam­ple. You can read about the BRCA muta­tion / genet­ic breast and / or ovar­i­an can­cer on this page in a few weeks.

5. Chemother­a­py

Almost with­out excep­tion, chemother­a­py fol­lows the oper­a­tion to com­bat malig­nant cells that have remained in the body (adju­vant ther­a­py). In addi­tion, chemother­a­py can be used before a planned major oper­a­tion to reduce the size of the tumor (neoad­ju­vant) or, in the case of incur­able tumor dis­eases, to relieve symp­toms (pal­lia­tive).

The first chemother­a­py should be giv­en with­in 4 to 6 weeks from the day of surgery.

Chemother­a­peu­tic drugs (cyto­sta­t­ics) are able to kill tumor cells or at least inhib­it their growth. They are usu­al­ly giv­en intra­venous­ly (into a vein) and are dis­trib­uted through­out the body and also act through­out the body. Chemother­a­peu­tic agents (cyto­sta­t­ic agents) attack cells that are grow­ing or divid­ing par­tic­u­lar­ly quick­ly. A prop­er­ty that is par­tic­u­lar­ly true of can­cer cells. How­ev­er, healthy body cells are also affect­ed, which explains the side effects of chemother­a­py. For­tu­nate­ly, unlike can­cer cells, our healthy body cells have repair mech­a­nisms to repair the dam­age caused by cyto­sta­t­ic drugs.

How­ev­er, as a side effect of this high­ly effec­tive ther­a­py, all of your body hair will fall out. But after the end of the ther­a­py they grow back imme­di­ate­ly. Even if most patients get through the ther­a­py with almost no oth­er side effects thanks to sup­port­ive med­ica­tion, nau­sea and vom­it­ing and a weak­ened immune defense and blood clot­ting can occur. The fin­ger­tips and palms of the hands may also tin­gle due to the effect on the fine nerve cells there; this side effect, as well as unsight­ly dis­col­oration of the fin­ger­nails, usu­al­ly regress after the ther­a­py. Stay in touch with your doc­tor and nurs­es about your side effects. They can cer­tain­ly offer you fur­ther sup­port­ive mea­sures before it becomes nec­es­sary to reduce or dis­con­tin­ue the therapy.

Chemother­a­py for ovar­i­an can­cer con­sists of 2 drugs, name­ly car­bo­platin and pacli­tax­el. The drugs are giv­en 6 times with a min­i­mum inter­val of 3 weeks. A ther­a­py ses­sion lasts about 4–6 hours and this is what doc­tors call chemother­a­py, the peri­od of 3 weeks after chemother­a­py is called a cycle. In total, chemother­a­py takes place in 6 cycles.

Before the chemother­a­py, your doc­tor will inform you and you must also sign that you con­sent to the treat­ment. You can also ask your own ques­tions dur­ing this conversation.

Before each med­ica­tion, a blood test is nec­es­sary to deter­mine whether your kid­neys and immune sys­tem are fit enough for the ther­a­py. This blood sam­ple can also be tak­en in a prac­tice near you, in which case the results of the blood test must be faxed to the chemo out­pa­tient depart­ment 2 days before the chemother­a­py appoint­ment. Thanks a lot for this. We also need infor­ma­tion about your height and cur­rent weight, as the dose of ther­a­py is adapt­ed to your body.

Chemother­a­py is best giv­en through a port. A port is a small met­al cham­ber that is placed under the skin on the base of the breast and is con­nect­ed to the blood sys­tem. This requires a very small oper­a­tion, which is usu­al­ly car­ried out by the doc­tors in radi­ol­o­gy under local anesthesia.

6. Anti­body ther­a­py / con­ser­va­tion therapy

In addi­tion to chemother­a­py, the anti­body beva­cizum­ab (Avastin) is used for treat­ment in addi­tion to chemother­a­py in ovar­i­an can­cer, which also affects the upper part of the abdomen. This anti­body ther­a­py inhibits can­cer growth by sup­press­ing the for­ma­tion of new blood ves­sels. As a result, the can­cer, which needs a lot of blood to grow, is no longer ade­quate­ly sup­plied with oxy­gen and nutrients.

This ther­a­py is usu­al­ly giv­en from the 2nd cycle of chemother­a­py along with chemother­a­py. After chemother­a­py, anti­body ther­a­py should be con­tin­ued every 3 weeks for a total of 15 months. The hair will grow back again dur­ing this time and the oth­er pos­si­ble side effects of chemother­a­py will already subside.

Con­ser­va­tion­al therapy:

The PARP inhibitors are also slow­ly find­ing their way into ther­a­py, even with the first occur­rence of ovar­i­an can­cer and are not only used for relaps­es, as they have been for sev­er­al years PARP inhibitors inhib­it the DNA repair mech­a­nisms of tumors.

You prob­a­bly know that cell divi­sion cre­ates two iden­ti­cal copies of a cell, each with a com­plete set of genes (DNA). Dur­ing this dou­bling process, mis­takes can nat­u­ral­ly arise spon­ta­neous­ly in the dou­ble-strand­ed DNA, e.g. in which pieces of the genet­ic infor­ma­tion of a sin­gle strand break off. These errors in the copy­ing process are also one of the rea­sons why can­cer can devel­op in the first place. Nor­mal­ly, these errors are cor­rect­ed by genes (for exam­ple BRCA1 / 2) that are respon­si­ble for the for­ma­tion of repair enzymes (such as poly-ADP-ribose poly­merase (PARP)). How­ev­er, if these genes are mod­i­fied in such a way that the enzymes can­not pro­duce them, the repair process can­not take place. This would be fatal for healthy cells, but not so bad for can­cer cells, since the DNA dam­age can ulti­mate­ly bring tumor growth to a standstill.

So researchers have tak­en these process­es in the cel­lu­lar micro­cosm as a mod­el and devel­oped drugs that specif­i­cal­ly inhib­it the cancer’s own repair mech­a­nisms: the so-called PARP inhibitors. These enzyme inhibitors bind to the com­plex of DNA and repair enzyme of the tumor, so that, among oth­er things, the entire dou­ble strand breaks. What is pos­si­ble with nor­mal body cells is not pos­si­ble with can­cer cells: name­ly, repair­ing dou­ble-strand breaks. Instead, the can­cer tries to find alter­na­tive ways to repair DNA in order to sur­vive. This also leads to the desta­bi­liza­tion of the DNA until the cell is prac­ti­cal­ly dri­ven into “sui­cide” and tumor growth comes to a com­plete standstill.

These rel­a­tive­ly new PARP inhibitors work hand in hand with chemother­a­peu­tic agents that specif­i­cal­ly cause DNA dam­age in the tumor. If the treat­ing physi­cians have deter­mined that the tumor has changes (muta­tions) in spe­cif­ic tumor-sup­press­ing genes, the inhibitor can be used in com­bi­na­tion with chemother­a­py or as main­te­nance ther­a­py after the chemother­a­py cycles. This is par­tic­u­lar­ly impor­tant when there is a high prob­a­bil­i­ty that the tumor will return despite stan­dard ther­a­py, e.g. if it is dis­cov­ered late. The ther­a­py cur­rent­ly seems to be actu­al­ly effec­tive in var­i­ous can­cers, such as breast, fal­lop­i­an tube, peri­toneum and espe­cial­ly ovar­i­an can­cer. Stud­ies show that PARP inhibitors in such can­cers increase the time it takes for the tumor to recur from an aver­age of one to around four years.

Side effects

Unfor­tu­nate­ly, side effects can­not always be avoid­ed with this ther­a­py either. Tired­ness, nau­sea, vom­it­ing, diar­rhea and abdom­i­nal pain, wors­en­ing liv­er and kid­ney val­ues, ane­mia and a lack of blood platelets can affect your well-being to a greater or less­er extent. Under cer­tain cir­cum­stances, the side effects can be so severe that the ther­a­py has to be inter­rupt­ed or reduced. If such a ther­a­py is car­ried out on you, your attend­ing doc­tor will cer­tain­ly always remain in dia­logue with you and choose the most promis­ing option for you. If you have any ques­tions about this, don’t hes­i­tate to ask.

The health insur­ance com­pa­ny will assume the costs

Not all health insur­ances have yet to cov­er the costs of treat­ment with PARP inhibitors when ovar­i­an can­cer first occurs. How­ev­er, you can ask your doc­tor to apply for reim­burse­ment if the treat­ment is suit­able for you. Alter­na­tive­ly, your doc­tor may be able to find a clin­i­cal study in which you can ben­e­fit from free treat­ment with the inhibitor and inten­sive med­ical super­vi­sion at the same time.

7. Fol­low-up care

After can­cer treat­ment, we rec­om­mend that you take part in reg­u­lar med­ical fol­low-up care. Here, not only are exam­i­na­tions car­ried out to detect a recur­rence of the can­cer at an ear­ly stage, but also

You should also be sup­port­ed and accom­pa­nied in your recov­ery. Fol­low-up care rough­ly cov­ers the peri­od in which the patient is still deal­ing with the con­se­quences of the dis­ease and its treatment.

Exam­i­na­tion intervals:

Since the risk of a relapse (recur­rence of the dis­ease) in ovar­i­an can­cer is high­est with­in the first 3 years after the oper­a­tion, close fol­low-up exam­i­na­tions are car­ried out dur­ing this time:

• Up to 3 years after surgery: Fol­low-up exam­i­na­tions every 10–12 weeks
• From the 3rd year after the oper­a­tion: Fol­low-up exam­i­na­tions every 6 months
• From the 5th year after the oper­a­tion: Fol­low-up exam­i­na­tions every 6–12 months

These are gen­er­al rec­om­men­da­tions that serve as a guide. Your doc­tors will work with you to cre­ate an indi­vid­ual after­care plan based on your indi­vid­ual situation.

Exam­i­na­tion:

The fol­low-up exam­i­na­tion for ovar­i­an can­cer con­sists of a con­ver­sa­tion in which you are asked about typ­i­cal symp­toms that could be a sign of a recur­rence of the dis­ease, as well as a gyne­co­log­i­cal exam­i­na­tion with rec­tal pal­pa­tion and a gyne­co­log­i­cal ultra­sound of the vagi­na and an ultra­sound of the abdomen.
In addi­tion, the tumor mark­er Ca125 is deter­mined, the course of which, not the indi­vid­ual val­ue, can also be meaningful. 

A CT exam­i­na­tion is only nec­es­sary if the exam­i­na­tion revealed unclear abnor­mal­i­ties. After the exam­i­na­tion, there is also the oppor­tu­ni­ty to speak to your doc­tor about top­ics that con­cern you or about which you have ques­tions. The best thing to do is to pre­pare and make a few notes before­hand about what you want to talk about.

Pos­si­ble top­ics for your fol­low-up consultation:

• Nutri­tion
• Sex­u­al­i­ty
• Pre­ven­tion
• Reha­bil­i­ta­tion
• Deal­ing with my family
• Addi­tion­al psy­cho-onco­log­i­cal support
• Cre­ative therapies
• Healthy liv­ing
• Social prob­lems
• Genet­ic predisposition