OVARIAN CANCER

( By JASCAP )

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Treatment

Treatment for ovarian cancer

The main treatments used to treat ovarian cancer are surgery and chemotherapy. Radiotherapy is occasionally used if the cancer comes back or doesn't respond to other treatments.

Multidisciplinary team
Giving your consent
Second opinion

Multidisciplinary team

Your treatment will be planned by a team of specialists who work together to decide which treatment is best for you. This multidisciplinary team (MDT) will include:

A surgeon who specialises in gynaecological cancers called a gynaecological oncologist.
A clinical or medical oncologist (to advise on chemotherapy).
A radiologist (who analyses x-rays).
A pathologist (who advises on the type and grade of the cancer, and how far it has spread).

The MDT may also include a number of other healthcare professionals such as a:

gynaecological oncology nurse specialist
dietitian
physiotherapist
occupational therapist
psychologist or counsellor.

The government recommends that women with ovarian cancer are treated by a specialist gynaecological cancer team. These teams are based in larger cancer centres, so you may have to travel for your treatment.

The MDT will plan your treatment by taking into consideration a number of factors. This will include your age, general health, how well your kidneys are working, the type and size of the tumour, what it looks like under the microscope and whether it has spread beyond the ovary (the stage).

Giving your consent

Before you have any treatment, your doctor will explain the aims of the treatment to you. You will usually be asked to sign a form saying that you give your permission (consent) for the hospital staff to give it. No medical treatment can be given without your consent. Before you are asked to sign the form you should have been given full information about:

the type and extent of the treatment you are advised to have
the advantages and disadvantages of the treatment
any other treatments that may be available
any significant risks or side effects of the treatment.

If you don't understand what you have been told, let the staff know straight away so that they can explain it again. Some cancer treatments are complex, so it's not unusual for people to need repeated explanations.

It's often a good idea to have a friend or relative with you when the treatment is explained. This can help you remember the discussion more fully.

Patients often feel that hospital staff are too busy to answer their questions, but it's important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions. You can talk to the specialist gynaecological nurse at the hospital or to our specialist nurses.

You can always ask for more time to decide about the treatment if you feel that you can't make a decision when it's first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you don't have it. It's important to tell a doctor or your nurse if you decide not to have treatment, so that they can record your decision in your medical notes. You don't have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Second opinion

Usually a number of cancer specialists work together as a team and they use national treatment guidelines to decide on the most suitable treatment for a patient. Even so, you may want to have another medical opinion. Either your specialist, or your GP, should be willing to refer you to another specialist for a second opinion, if you feel it will be helpful. Getting a second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give you useful information.

If you do go for a second opinion, it may be a good idea to take a friend or relative with you, and have a list of questions ready, so that you can make sure your concerns are covered during the discussion.

Surgery for ovarian cancer

Surgery is often the first treatment for cancer of the ovary, and may sometimes also be needed to make the diagnosis. Your doctor will discuss with you the most appropriate type of surgery, depending on the type and size of your cancer and whether it has spread. Sometimes this information only becomes available during the operation itself, and so it's important to discuss all the possible options with your doctor before the operation.

Borderline and stage 1 ovarian cancer
Stage 2 and 3 ovarian cancer
Stage 4 ovarian cancer
After your operation
Drips and drains
Pain
Going home
Physical activity
Sex life
Early menopause
Fertility

Borderline and stage 1 ovarian cancer

If the cancer is in the early stages, surgery may be all the treatment thats needed. Its usually necessary to make a cut in the skin and muscle of the abdomen (a laparotomy). The ovaries, fallopian tubes and the womb are then removed. This is called a total abdominal hysterectomy and salpingo-oophorectomy.

In young women with borderline tumours, or low-grade, stage 1a cancer (see staging and grading) it may be possible to remove only the affected ovary and fallopian tube, and leave the womb and unaffected ovary. This will mean that you will be able to have children in the future. Women with stage 1b and 1c cancer, or those who have had their menopause, or don't want any more children, will usually be advised to have both ovaries and the womb removed.

The surgeon may remove a layer of fatty tissue called the omentum, which is close to the ovaries (an omentectomy). They will also take samples from other tissues, such as the lymph glands, to see if the cancer has spread. The surgeon will also put fluid into your abdomen and send some of it to be tested for cancer cells. This is known as an abdominal washing.

If it is unclear before surgery what stage the cancer is, the surgeon may remove just the affected ovary and fallopian tube and take a number of biopsies and abdominal washings. Depending on the results of the biopsies and washings, further surgery to remove the womb and remaining ovary and fallopian tube - sometimes called completion surgery - may be needed.

Chemotherapy is usually given after surgery if it wasn't possible to remove all the tumour, or if there is a risk that some cancer cells may have been left behind.

Stage 2 and 3 ovarian cancer

If ovarian cancer has already spread, an operation to remove both ovaries, the fallopian tubes and the womb (total abdominal hysterectomy and salpingo- oophorectomy), and as much of the tumour as possible will be done. This is known as de-bulking surgery. The surgeon will also take biopsies or remove some of the lymph nodes in the abdomen and pelvis. They may also have to remove the omentum, the appendix and part of the lining of the abdomen (the peritoneum). This operation can be complicated and should ideally be done by a specialist gynaecological oncologist.

If the cancer has spread to the bowel, a small piece of bowel may be removed and the two ends joined together. Rarely the two ends can't be rejoined and the upper end of the bowel will be brought out onto the skin of the abdomen. This is known as a colostomy and the opening of the bowel is known as a stoma. A bag is worn over the stoma to collect the stool (bowel motions). Your doctor or specialist nurse will discuss this with you.

Chemotherapy is usually given after the operation to try and kill any cancer cells that couldn't be removed.

Sometimes a second operation will be done after three or four cycles of chemotherapy, as it may now be possible to remove the remaining cancer. This is known as interval de-bulking surgery.

Stage 4 ovarian cancer

It may be possible to have an operation to remove some of the cancer. However, sometimes surgery isn't possible if the cancer is very advanced, or if a woman isn't well enough for a major operation. Chemotherapy, and occasionally radiotherapy are the main treatments used for women in this situation.

After your operation

After your operation you will be encouraged to start moving about as soon as possible and you will usually be helped to get out of bed the next day. While you are in bed, it's important to move your legs regularly and do deep breathing exercises to help prevent chest infections and blood clots. You will be shown how to do the exercises by a physiotherapist or specialist nurse. You will also be given some stockings to wear that help to prevent blood clots in your legs.

Drips and drains

A drip (intravenous infusion) will be used to give you fluids until you are able to eat and drink again, which is usually the next day. Many women are able to eat light meals after about 48 hours.

You may have a small tube called a catheter, which is put into the bladder and drains your urine into a collecting bag. This will be removed after a day or two.

You are also likely to have a drainage tube in your wound to drain excess fluid into a small bottle. This is usually removed after a few days.

Pain

It is quite normal to have some pain or discomfort for a few days but this can be controlled with effective painkillers. The anaesthetist will often discuss pain control with you before your operation. If the pain is not controlled, it is important to let your doctor or nurse know as soon as possible so that your painkillers can be changed.

Going home

Most women are able to go home 510 days after their operation, once the stitches or clips have been taken out. If you think you might have problems when you go home (for example, if you live alone or have several flights of stairs to climb), let the nurse or social worker know when you are admitted to the ward so that help can be arranged. Your nurse specialist can offer or arrange support or counselling for you and your family. Social workers are often available to give practical advice. Many are also trained counsellors.

Before you leave hospital you will be given an appointment to attend an outpatient clinic for your post-operative check up. This is a good time to discuss any problems you may have. If you have any problems or worries before this time, you can phone your ward nurses or hospital doctor.

Physical activity

You will need to avoid strenuous physical activity or heavy lifting for at least three months. You will also be advised not to drive for about six weeks after your operation and may find it uncomfortable to wear a seatbelt for some time. It's best not to start driving until you are comfortable wearing a seatbelt as a passenger first. Some insurance companies have guidelines about this.

Sex life

One of the common questions women ask after a hysterectomy is whether the operation will affect their sex life. To allow the wound to heal properly, most women are advised to wait at least six weeks after their operation before having sexual intercourse. Many women have no problem in having a sexual relationship after this time. However, others find that the surgery has shortened their vagina and slightly changed its angle. This can mean that they have different sensations and responses during sex. If this occurs it can be upsetting. Women who have this effect may take time to come to terms with their feelings and any physical effects such as pain. Your specialist nurse can help you if you are having problems after your surgery.

One common fear is that cancer can be passed on to your partner during intercourse. This is not true and it is perfectly safe for you to continue to have a sexual relationship.

Early menopause

In younger women who are still having periods, removing the ovaries will bring on an early menopause.

The physical effects of this may include:

hot flushes
dry skin
dryness of the vagina,
which can make sexual intercourse uncomfortable reduced sexual desire.

Lubricants such as Aquaglide, Senselle®, Sylk® or Replens MD® can be bought from most chemists and can ease any discomfort during intercourse.

Some women may be prescribed hormone replacement therapy (HRT) following treatment for ovarian cancer. This can help to reduce some of the problems caused by the menopause. You can discuss with your doctor whether taking HRT would be helpful.

Fertility

Younger women in particular, often find it difficult to come to terms with the fact that they can no longer have children after a hysterectomy. They may also be worried that they have lost a part of their female identity. These are very natural, understandable emotions to have at this time. It can help to discuss any fears or worries with a sympathetic friend or with the specialist nurse. Counselling can be arranged either by the hospital or through your GP. There are also support organisations that can help.

We have information on cancer and fertility which you may find useful.

Chemotherapy for ovarian cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. The drugs work by disrupting the growth of cancer cells. Ovarian cancer is usually very sensitive to chemotherapy and in most women the tumours will become smaller or disappear.

Chemotherapy drugs are sometimes given as tablets (orally) or, more usually, by injection into a vein (intravenously).

Borderline and stage 1 ovarian cancer
Advanced-stage ovarian cancer
The drugs that are used
Side effects
Benefits and disadvantages

Borderline and stage 1 ovarian cancer

Women with borderline tumours, or those with low-grade or stage 1a ovarian cancer may not need chemotherapy after their surgery.

Chemotherapy is often recommended after surgery for women with moderate or high- grade ovarian cancer or those with stage 1b or 1c cancer. Giving chemotherapy after surgery is known as adjuvant chemotherapy. Generally six sessions of chemotherapy are given, over 56 months.

Advanced-stage ovarian cancer

Chemotherapy is sometimes given before surgery (neo-adjuvant chemotherapy), or if you are too unwell for a major operation. It is also often used after surgery to try to shrink any remaining tumours.

If the cancer has spread to the liver, or beyond the abdomen, it may not be possible to remove it and so chemotherapy is the main treatment used. Chemotherapy is also used if the cancer comes back after surgery.

The drugs that are used

After surgery, the most commonly used drug to treat ovarian cancer is carboplatin, which may be given with paclitaxel (Taxol®).

Other drugs that are less commonly used, or may be used if the cancer comes back, are topotecan (Hycamtin®), doxorubicin, liposomal doxorubicin (Caelyx®, Myocet®) and cisplatin.

Intravenous chemotherapy is given as a session of treatment, usually over several hours. This is followed by a rest period of a few weeks, which allows your body to recover from any side effects of the treatment. Together, the treatment and the rest period is known as a cycle of chemotherapy. Most women have six cycles of chemotherapy. Women who are given neo-adjuvant chemotherapy generally have three cycles of chemotherapy before the operation, followed by three further cycles.

Chemotherapy is usually given to you as an outpatient, but sometimes it will be given as an inpatient, which will mean spending a few days in hospital.

Chemotherapy can also be given directly into the abdomen through a small tube. This is known as intraperitoneal chemotherapy. Research has shown that intraperitoneal chemotherapy, given alongside intravenous chemotherapy, can help to improve survival for a small number of women. However, it can also cause unpleasant side effects, such as pain, infection and digestive problems. As a result this way of giving chemotherapy isn't commonly used in the UK.

Your doctor can discuss whether intraperitoneal chemotherapy is an appropriate treatment for you.

Our booklet on chemotherapy discusses the treatment and its side effects in more detail. Information about individual drugs and their particular side effects are also available.

Side effects

Chemotherapy can cause unpleasant side effects, but any that occur can often be well controlled with medicines.

Lowered resistance to infection

Chemotherapy can reduce the production of white blood cells by the bone marrow, making you more prone to infection. Contact your doctor or the hospital straightaway if:

your temperature goes above 38C (100.5F)
you suddenly feel ill (even with a normal temperature).

You will have a blood test before having more chemotherapy, to make sure that your cells have recovered. Occasionally it may be necessary to delay your treatment if your blood count is still low.

Bruising or bleeding

Chemotherapy can reduce the production of platelets, which help the blood to clot. Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.

Low number of red blood cells (anaemia)

You may become anaemic. This may make you feel tired and breathless.

Nausea and vomiting

Some of the chemotherapy drugs used to treat cancer of the ovary may cause nausea and vomiting. There are very effective anti-sickness drugs (anti-emetics) to prevent or reduce nausea and vomiting. Your doctor will prescribe these for you.

Sore mouth and loss of appetite

Some chemotherapy drugs can make your mouth sore and cause small mouth ulcers. Regular mouthwashes are important and your nurse will show you how to do these properly. If you don't feel like eating during treatment, you could try replacing some meals with nutritious drinks or a soft diet.

Hair loss

Unfortunately, some chemotherapy drugs used to treat ovarian cancer can make your hair fall out. You can ask your doctor if the drugs you are having are likely to cause hair loss. Most patients are entitled to a free wig from the NHS. Your doctor or nurse will be able to arrange for you to see a wig specialist. You may prefer to wear a bandana, hat or scarf.

If your hair does fall out, it will grow back over a period of 36 months once the chemotherapy has finished.

Numbness or tingling in hands or feet

This is due to the effect of some chemotherapy drugs on nerves and is known as peripheral neuropathy. Tell your doctor if you notice these symptoms. The problem usually improves slowly a few months after treatment is over, but for some people it can be permanent.

Tiredness

Chemotherapy affects people in different ways. Some people find they are able to lead a fairly normal life during their treatment, but many find they become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it.

Although they may be difficult to cope with, most of these side effects will disappear once your treatment is over.

Benefits and disadvantages

Many women are nervous of having chemotherapy, because of the possible side effects, and ask what would happen if they did not have it.

Early-stage ovarian cancer

In women with early-stage ovarian cancer, if chemotherapy is given after surgery, it is given to reduce the chance of the cancer coming back. It does this by killing any tiny groups of cancer cells that may be left behind after an operation.

Chemotherapy can't guarantee that the cancer will not come back, but it can reduce the chance that it will. The risk of the cancer coming back varies according to each woman's situation. Your doctor can usually give you an idea of whether your cancer is likely to come back or not. They can also give you information about the likely side effects of chemotherapy for you.

If the chance of your cancer coming back is small, chemotherapy may only slightly reduce the risk of the cancer coming back. The additional benefit of the chemotherapy would be small and the chance of doing well without it would still be good. However, if the risk of the cancer coming back is higher, chemotherapy may greatly reduce the chance of recurrence, and increase the chance of cure.

It is important to talk to your specialist about:

the chance of the cancer coming back
the chances of a cure without the chemotherapy
how much the chemotherapy is likely to improve things.

This information can help you decide whether the benefit of the chemotherapy is worth the side effects of the treatment.

Advanced ovarian cancer

When the cancer has spread to other parts of the body, such as the abdomen or pelvis, the aim of chemotherapy is to try and shrink the cancer. This can reduce symptoms, maintain a good quality of life and help you live longer. For many women the chemotherapy will shrink the cancer. However, for some women the

chemotherapy will have little or no effect on the cancer and they will have the side effects of the treatment with little benefit. The fitter you are the more likely you are to benefit and the less likely to have side effects.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss in detail with your doctor whether you want to have chemotherapy. If you choose not to have chemotherapy, you can still be given medicines to control any symptoms that you have. This is known as supportive care (or palliative care).

Radiotherapy for ovarian cancer

Radiotherapy treats cancer by using high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells.

Radiotherapy is rarely used to treat cancer of the ovary. It may occasionally be used to treat an area of cancer that has come back after surgery and chemotherapy, when other treatment options are no longer appropriate. It may also be used to reduce bleeding or feelings of pain and discomfort. This is known as palliative radiotherapy.

Radiotherapy is given in the hospital radiotherapy department. A course of palliative treatment may be between one to ten sessions. Each session lasts a few minutes. The length of your treatment will depend on the type and size of the cancer. Your doctor will discuss your treatment with you in detail beforehand.

Our radiotherapy booklet gives more details about this treatment and its side effects.

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