Which Comes First?
- Doctors usually treat ovarian cancer with surgery and chemotherapy
- Research shows that the sequence of treatment alone does not affect outcomes
- Surgery can be recommended first for advanced stage cancer, but chemotherapy can reduce the burden of disease before the operation
- Frailty can be a factor in deciding on chemotherapy first (called neoadjuvant chemotherapy) in favor of a big open surgery
“When ovarian cancer is diagnosed, often it’s advanced,” says Dr. Dwight Chen, gynecologic oncologist at Sutter Bay Medical Foundation in the Bay Area. “At that point, we know there needs to be a combination of treatments, which include surgery and chemotherapy.” But the decision about which comes first surgery or chemotherapy isn’t always simple.
Read MoreThe problem is, ovarian cancer surgeries are complex. Most women who undergo surgery for ovarian cancer treatment will have a large procedure, including:
- Hysterectomy: removal of the uterus and cervix
- Bilateral salpingo-oopherectomy: removal of your ovaries and both fallopian tubes
Removal of other organs depends on what doctors see at the time of surgery. If the cancer has spread to other organs, your doctor may have to remove portions of the bowel, omentum (a fatty apron that hangs off the colon), bladder, stomach, appendix, liver, spleen, or pancreas. While the physician’s goal is always to remove as much of the disease as possible, they also have to consider the patient’s health and quality of life.
Doctors use radiographic imaging and clinical examination to determine whether or not they will be able to remove all of the disease with confidence.
Chemotherapy-First Approach
For patients with widely distributed disease that cannot be safely removed without life-altering complications, the first line of defense is usually chemotherapy. Called neoadjuvant chemotherapy, the goal of this approach is to reduce the volume of disease, so doctors don’t have to remove as much tissue during surgery.
“There are some data that suggest that neoadjuvant chemotherapy is equivalent to surgery first followed by chemotherapy, including one large-multi-institutional trial out of Europe,” Dr. Chen says. “There are other studies that suggest, though, that a surgery first option may actually have an improved survival, particularly in patients who have aggressive up-front surgery.”
While studies are at odds about whether neoadjuvant chemotherapy improves survival for patients with ovarian cancer, the “chemo-first-protocol” does reduce the risk of surgical complications by 25 to 30 percent.
Toward Improved Outcomes
Ovarian cancer treatment is complex and often requires insight and expertise from a team of professionals ranging from radiologists and surgeons to oncologists and supportive care professionals. While the doctor’s goal is to remove as much of the disease as possible to improve the odds of survival, they also have to consider the patient’s health and quality of life.
The decision about whether or not to proceed with immediate surgery depends on a variety of factors, including:
- The stage of disease
- The extent of disease
- The patient’s health
- The risk of complications
“Certainly in patients who are older, patients who are not as healthy, patients who are malnourished, those patients would seem to benefit more from the neoadjuvant chemotherapy approach,” Dr. Chen says.
For patients who are otherwise healthy, the decision about whether to proceed with surgery or chemotherapy first should be made after an extensive conversation with their physician about the pros and cons of each approach in their particular case. Conversations with your health care team and careful planning can help you navigate the experience with the greatest ease.
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