Surgery or Chemotherapy First for Ovarian Cancer Treatment?

The first is to determine whether you are healthy enough to safely undergo a major surgical procedure. Do you have any underlying conditions or disease that would impair your recovery? Are you strong enough or too frail? Again, remember that your clinician may recommend altering your treatment order depending on the COVID conditions in your area and your hospital's policies on elective surgeries.

If, at the time of a diagnosis, you're not ready for a big operation, doctors may decide to begin treatment with chemotherapy first and monitor your response. If you do well with the chemo, and can get your health to a place where surgery should be safe, then your doctor can take you to the OR.

Can Your Surgeon Remove All Visible Cancer?

The second factor is the disease itself. Will a surgeon be able to remove all visible cancer?
Doctors look at imaging studies such as CT scans to see where the disease is, and how accessible it is. Our goal for surgery is "to get rid of the majority, or all, of the disease," says Dr. Parker. If, for instance, the cancer is confined to the ovaries and the omentum (the fatty apron that hangs from the intestines), and your surgeon believes she or he can remove it from the beginning, and if you are healthy and strong, then surgery will likely come first, followed with chemotherapy.

Chemo First Can Shrink the Tumor

If your doctor determines that she or he can’t get out all visible disease then you'll likely get what's called neoadjuvant chemotherapy, which means you'll receive chemotherapy prior to surgery to try to shrink the tumor down to a level that's more manageable to remove.

Surgery to remove all or most all of the tumor is called debulking. Patients whose tumor is optimally debulked (down to a centimeter or less of tumor) have a better prognosis than patients who are left with larger tumors following their surgery.

"There are benefits of doing chemotherapy first for women who have fluid around the lung [or in the abdomen] that the cancer makes, or if have a lot of cancer that’s coating the bowel and affecting their ability to eat and digest,” Dr. Parker says. “In those situations, if we do surgery first we’re much more likely to need to resect bowel, or take out pieces of bowel, or for someone to end up with a colostomy, which is where the bowel comes to the skin and drains into a bag.

"If we do chemotherapy first we can really dry up that fluid from the cancer, we can shrink a lot of that disease that’s in the lining of the abdomen, get you nutritionally stronger and better able to tolerate surgery. And then be less likely to need [extensive] work on the bowel."

The medical term for surgery done between cycles of chemo is called an interval debulking. “It's where we give three treatments of chemotherapy, so one treatment every three weeks for three treatments, then do the surgery, then follow that with three more treatments of chemotherapy."

In Some Cancer Centers, a Group of Specialists Confer

Some cancer treatment centers have what are called multidisciplinary tumor boards, where a group of specialists review and discuss your treatment options. A tumor board review may include a medical oncologist, a surgical oncologist, a pathologist, and a radiation oncologist. These different types of specialists confer about what the surgeon thinks he or she can do upfront versus what the rest of the medical team thinks they can do to help shrink your tumor in advance so that your surgery has the best chance of success.

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