Surgery or Chemo First? Here's What Oncologists Consider
- After an ovarian cancer diagnosis, your course of treatment will depend on a number of factors, such as the stage of your cancer, how far it's spread, and your overall health
- Surgery and chemotherapy are usually both indicated for ovarian cancer treatment. How doctors combine them and which they do first depends on the patient
- The goal of surgery, in addition to staging the cancer, is to remove all or most all visible disease. This is called debulking
- If the cancer is very widespread, doctors may choose to do chemo first to try to shrink the tumor before they operate
Doctors look at the CT scans and other imaging studies "to assess where we might find the tumors," to look at the size of the disease, and how accessible it is, says Dr. Michael McHale, division chief of gynecologic oncology at the University of California, San Diego. We look to see "whether there's a lot of fluid in the abdomen or where [your] lungs are." Another consideration is what other medical conditions the patient has.
Read MoreSurgery is a common first-treatment option in cases where doctors think they'll be able to remove most of the cancer. This is referred to as debulking surgery. "The goal of surgery is not just to make a diagnosis, but also to reduce what we call the burden of disease, or the extent of disease that we see throughout the abdomen and the pelvis," says Dr. McHale. "We know that if we are able to remove all of the tumors, wherever they may be located, it will have a significant impact in terms of how well a patient will do long-term."
During surgery, the uterus, tubes, and ovaries are typically removed, along with any additional cancer that is visible. This may include a portion of the large or small intestine. Chemotherapy administered after surgery targets cancer cells that were either not visible or not removable during the procedure.
If no visible diseaseor less than 1 cm (about half an inch) of the tumorremains after surgery, then the procedure is considered successful. From this size, chemotherapy can often further shrink the tumor to a point where there will be virtually no cancerous tissue detectable.
For women with early-stage cancer that has not spread beyond the ovaries, minimally invasive, robotic surgery may be an option. But "that's a small percentage of patients," says Dr. McHale.
When Chemo Comes First
In cases where, based on all the information available, doctors believe that the cancer has spread too widely for surgery to remove all of it up front, they'll most likely recommend chemotherapy first. This technique of having patients undergo surgery inbetween cycles of chemotherapy is called neoadjuvant chemotherapy. Doctors use this chemo-first approach in an effort to shrink down the cancer so that surgery can be as successful as possible later on. Then, following surgery, a patient will typically go through another few rounds of chemo to kill any remaining cancer cells.
Neoadjuvant chemotherapy may be paired with bevacizumab (brand name Avastin) a drug that is used for ovarian cancer. The drug is administered intravenously and can be given in combination with other chemotherapy drugs. Avastin works by affecting the growth of blood vessels, starving tumors of the blood they need as nourishment. Avastin may also be used as a maintenance therapy for a year or so after surgery and was just approved by the FDA to be used in conjunction with olaparib (brand name LYNPARZA) in HRD (Homologous Recombination Deficiency) positive women who show a response to platinum-based chemotherapy. The results of a recent trial showed an increase in progression-free survival from an average of 17 to 37 months in women with HRD and a BRCA mutation using this regimen. For women with HRD but no BRCA mutation the improvement was 16.6 to 28 months.
“The Art of Medicine”
Weighing all the factors and making these decisions is part of what doctors call "the art of medicine." That means making the best decisions possible with the information that's available to them. It's important to note that there is no one treatment that's best for everyone. Treatment decisions vary from patient to patient, and even from one cancer center to another. A patient, in consultation with a trusted oncologist, will make the decisions that both agree are best for her.
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