The successful treatment of ovarian cancer requires the involvement and coordination of several different treatment approaches, including surgery, chemotherapy and, in rare cases, radiation therapy. Nearly all women with ovarian cancer will undergo surgery and chemotherapy. The role of surgery in the initial management of ovarian cancer is to obtain a specimen for determining an accurate diagnosis, provide local treatment of the cancer in the pelvis and abdomen, and obtain other prognostic information to determine the stage of cancer and what additional treatment may be necessary.

Despite surgical removal of the cancer, many patients with ovarian cancer will already have microscopic cancer cells, called micrometastases, that have spread away from the ovary to other locations in the abdomen and distant parts of the body. These micrometastases often cannot be detected by currently available tests. Surgery is a local therapy and cannot treat micrometastatic cancer. Therefore, additional systemic treatment using chemotherapy is required to treat micrometastatic cancer. Information obtained during surgery and from other tests determines whether additional treatment with chemotherapy is necessary. Because most patients with ovarian cancer have advanced disease at diagnosis, the majority of patients will receive chemotherapy as part of the overall treatment plan.

Historically, patients with ovarian cancer were initially treated with “initial debulking”, maximal surgical removal of their cancer followed by chemotherapy. Over the past several years there has been increasing interest in administering chemotherapy prior to surgery. This is referred to as neoadjuvant therapy and surgery to remove cancer with chemotherapy administered before and after surgery is referred to as “interval debulking.” By administering chemotherapy first, micrometastatic cancer cells may be more easily destroyed and chemotherapy may reduce the amount of cancer, thereby allowing for more complete removal of the cancer. Currently, the majority of patients are still offered initial debulking surgery followed by chemotherapy. However, neoadjuvant chemotherapy and interval debulking are increasingly being used and patients may want to inquire as to the potential risks and benefits of interval debulking.

Laparotomy (Initial Debulking)

For patients diagnosed with ovarian cancer during surgery, the first phase of treatment is surgical laparotomy or exploration of the abdomen. During a laparotomy, the surgeon makes an incision down the middle of the abdomen and attempts to remove as much of the cancer within the abdomen and pelvis as possible. The goal of laparotomy is to accurately diagnose and stage the cancer and gain prognostic information that can determine whether additional therapy is necessary.

Patients with stage I disease may have the entire cancer removed and may not need to receive additional treatment. Patients with stage II-IV disease undergo surgical "debulking" or removal of the cancer. Typical debulking during the laparotomy includes a total hysterectomy (removal of the uterus), bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes), omentectomy (removal of a flap of fatty tissue covering the bowel in the abdomen), and "debulking" to remove any visible cancer within the abdomen. If the cancer appears to be limited to the ovaries or the pelvis, the surgeon will also cut small pieces of tissue (biopsy) from the upper abdomen, collect abdominal fluid samples and remove lymph nodes so that they can be examined under a microscope to determine whether they contain cancer. These extensive and time-consuming surgeries are best performed by a gynecologic oncologist, who is a surgeon specialized in the treatment of female pelvic cancers.

For patients with metastatic ovarian cancer (cancer detected outside the abdomen), surgery may be beneficial for relief of symptoms and to improve duration of survival. Surgery to remove cancer in the abdomen may help relieve pain, prevent obstruction or blockage of the bowel, and improve a patient's nutritional status.

The typical surgery for ovarian cancer prevents women from future childbearing because the reproductive organs (ovaries and uterus) are removed. Occasionally, ovarian cancer will occur in a younger woman who wishes to maintain fertility. If the cancer involves only one ovary and the surgery shows no cancer beyond a single ovary, a unilateral salpingo-oophorectomy (removal of one ovary and fallopian tube) can be performed. This allows the patient to bear children and still provides adequate treatment for the cancer. After childbearing is complete, the remaining ovary and the uterus are often removed in an effort to prevent a recurrence.

Despite surgical removal of the cancer, the majority of patients with stage II-IV ovarian cancer will experience a recurrence. This is because patients have micrometastases, which are undetectable microscopic cancer cells that have spread from the original site of cancer to distant locations in the body. In other cases, patients have visible spread of cancer cells outside the ovary into the abdomen, pelvis, or lymph nodes that cannot be completely removed by surgery. When the cancer is removed with surgery so that no remaining cancer is larger than 1 cm (about three-quarters of an inch), the cancer referred to as "optimally debulked." When cancer larger than 1 cm remains after the surgery, the cancer is referred to as "suboptimally debulked." Patients with optimally debulked cancer are more likely to live longer and less likely to experience cancer recurrence following chemotherapy than patients who are suboptimally debulked.

Patients who undergo laparotomy for ovarian cancer may experience lower abdominal pain after the operation. Complications related to surgery may include bleeding, infection, slow recovery of bowel function, temporary difficulty with emptying the bladder or other less common conditions. Your surgeon should explain the risk of side effects associated with treatment.

Second-Look Laparotomy

After completion of chemotherapy, patients undergo a physical examination, a CA-125 blood test and radiologic studies to evaluate the effectiveness of treatment. When all of these tests are negative for cancer, a patient is said to be in a complete clinical remission. Many patients in complete remission still have microscopic cancer that was not detected with the available tests. Some doctors recommend additional surgical evaluation after completion of chemotherapy in order to further evaluate the response to treatment. This operation is called a "second-look laparotomy." A second-look laparotomy is the most accurate method of detecting persistent cancer cells when CA-125 levels are normal.

Second-look laparotomy will detect evidence of cancer in at least half of patients thought to be in clinical remission. Even when the second-look laparotomy does not detect any cancer cells, cancer still recurs in approximately 30-50% of patients.

Routine second-look laparotomy is no longer recommended as standard treatment. Many doctors recommend that it only be used as part of a clinical trial. This is because a second-look laparotomy only has value to a patient if the information gained during the laparotomy can change a patient's outcome or subsequent treatment options. This is important for patients to understand because undergoing a second or unnecessary surgery is associated with additional risks and emotional discomfort. These risks include bowel obstruction, adhesions and pain.

Secondary Debulking

When second-look laparotomy detects residual cancer, the additional surgical removal of the cancer is referred to as secondary debulking. While some clinical studies suggest that patients who undergo "additional debulking" at second-look laparotomy may live longer, other doctors do not agree.

Strategies to Improve Treatment

The following are all surgical treatment strategies currently being evaluated in clinical studies. Given the poor outcomes of treatment for ovarian cancer, the greatest benefit to patients wishing to pursue aggressive or potentially curative treatments may be participation in clinical studies.

Neoadjuvant Chemotherapy and Interval Debulking: The combination of surgical debulking and chemotherapy treatment is the standard of care for treatment of stage II-IV ovarian cancer. There is some controversy, however, regarding the timing of surgical debulking.

Neoadjuvant refers to the administration of anti-cancer chemotherapy prior to surgery. When surgery is performed after chemotherapy treatment, it is referred to as interval debulking. Some doctors believe that neoadjuvant chemotherapy and interval debulking can reduce the size of the cancer, thereby allowing easier surgical removal and more effective results from the subsequent chemotherapy.

In 1995, doctors from Europe reported in the New England Journal of Medicine the results of the first significant comparative trial directly evaluating interval surgical debulking as part of an overall treatment plan for women with advanced ovarian cancer. In this clinical study, women with stage IIB to IV ovarian cancer were suboptimally surgically debulked at diagnosis. Patients were initially treated with 3 cycles of cyclophosphamide and Platinol® chemotherapy and then reevaluated. Patients who had no evidence of progressive cancer either received additional debulking surgery or no additional surgery. All patients were then treated with 3 more cycles of cyclophosphamide and Platinol® chemotherapy.

Women who underwent interval debulking surgery survived longer and experienced a longer time to cancer recurrence than women not treated with interval debulking surgery. On average, women treated with interval debulking survived 26 months, compared to 20 months and were alive without evidence of cancer recurrence for 18 months, compared to 13 months for women not treated with interval debulking. Two years from treatment, 56% of women treated with interval debulking survived, compared to only 46% not treated with debulking surgery. Approximately 15% of patients experienced complications from the interval debulking surgery, although these complications were minor in nature.

Researchers from Germany recently conducted a clinical trial evaluating neoadjuvant chemotherapy in 63 patients with stage III ovarian cancer and ascites. Patients were divided into two groups: one group (control group) received standard therapy consisting of debulking surgery followed by chemotherapy, while the other group (treatment group) received three cycles of neoadjuvant chemotherapy followed by the standard treatment regimen.

The rate of complete cancer removal was 32% in the group of patients who received neoadjuvant chemotherapy, compared to only 13% in the group of patients who only received standard therapy. Importantly, this transferred into improved survival, with patients who received neoadjuvant therapy surviving on average 42 months after treatment, compared to only 23 months for patients who received standard treatment. There was no difference between the two groups in time spent in surgery, blood transfusion requirements, side effects or mortality during surgery. The results of this clinical trial suggest that neoadjuvant chemotherapy may significantly improve survival in patients with stage III ovarian cancer. More research is currently underway to confirm these results in larger clinical trials.

These clinical trials demonstrate that women treated with chemotherapy prior to surgery are more likely to live longer and experience a longer time until cancer recurrence. Additional confirmatory studies are ongoing to evaluate the role of neoadjuvant therapy and interval debulking surgery.