Chemo or Surgery: Which Comes First for Ovarian Cancer Treatment & The COVID-19 Considerations

Doctors who are caring for ovarian cancer patients typically have two approaches to treatment. Both usually include a combination of chemotherapy and surgery, but the sequence of those treatments can vary, especially during the COVID-19 era when hospitals may be altering their protocols.

The decision whether to treat with surgery initially or with chemotherapy initially can be quite complex. There are two medical important factors that come into play. The first is to determine whether a patient is healthy enough to safely undergo a major surgical procedure. Do they have any underlying conditions or disease that would impair their recovery? Are they strong enough or are they too frail? And, 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 surgeries which can potentially be delayed.

If a patient isn’t initially a candidate for a big operation, doctors may decide to begin treatment with chemotherapy first and monitor their response. If they respond well to the chemo, and can get their health to a place where surgery should be safe, then doctors can proceed with surgery.

The second factor is the disease itself. Will a surgeon be able to remove all visible cancer? “If someone’s going to surgery, ideally the goal is to be able to get as much, if not all of the tumor out,” says Dr. Manojkumar Bupathi, medical oncologist at Rocky Mountain Cancer Centers in Littleton, Colorado. If doctors determine that they are unable to do that, then a patient will probably get what’s called neoadjuvant chemotherapy, which means they’d receive chemotherapy first, to try to shrink the tumor down to a level that’s more manageable to remove.

Neoadjuvant chemotherapy typically consists of three or four cycles of chemo prior to surgery, followed by additional chemo after surgery.

To help doctors decide the best course of treatment, they use several tools to assess the extent of the cancer, including imaging studies and what’s called a diagnostic laparoscopy — a minimally invasive surgical procedure that allows them to examine the organs inside the abdomen. Using a slender camera, they investigate the extent of the cancer, and determine whether they’re able to do what’s called a debulking procedure, to remove all visible disease.

If there is concern that the disease has spread beyond the ovaries and the pelvis–called stage 3 or stage 4 cancer–or the cancer has infiltrated organs or parts of organs that can’t be removed, then doctors have to consider neoadjuvant therapy.  Dr. Bupathi says that determining whether to administer chemotherapy “in the neoadjuvant setting”—as well as all aspects of your care—is dependent on imaging and then a frank, open discussion with your surgeon.

Multidisciplinary tumor boards, where a number of specialists review and discuss your treatment options, are often a part of the decision-making process. In cancer treatment, a tumor board review may include a medical oncologist, a surgical oncologist, a pathologist, and a radiation oncologist. These specialists can discuss 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 a patient’s tumor in advance so that the surgery has a good chance of success.

Many oncologists say they make it a point to clear up the misconceptions that many patients have about chemotherapy. While it may not be a walk in the park, “there is definitely a belief among patients that chemotherapy is worse than the disease itself,” one oncologist says. “What I hear most often is that the effects of chemotherapy are worse than the effect of cancer.” Patients especially fear the nausea and vomiting, and may wrongly believe they’ll be sick all of the time. And while that might have been the case 20 years ago, it is clearly not true nowadays. According to oncologists, patients should know that if they are throwing up, then they are not doing their job.

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