Ovarian Cancer: Considerations for Surgery

For most women with ovarian cancer, initial treatment will involve a combination of surgery and chemotherapy. Doctors typically recommend both interventions because ovarian cancer is often diagnosed late, and the surgery/chemo combination approach is considered to provide the best chance of completely eradicating the disease. But whether a patient undergoes chemotherapy or surgery first depends on many factors.

“When we as oncologists first meet a patient, we evaluate many aspects of that patient, from their physical examination to their CT scan evaluation,” Dr. Kris Zanotti, a gynecologic oncologist at University Hospitals in Cleveland, Ohio tells SurvivorNet. “We also try to get a good sense of that patient’s symptoms, their medical background, and their frailties.” All of these factors are considered before recommending the order of treatment.

Surgery First

Most surgeons prefer to start treatment with surgery. If surgery is possible as a first step, because a woman is deemed medically fit enough and the surgeon has a reasonable expectation of being able to remove the cancer, the surgeon will perform debulking (or cytoreductive) surgery. The goal of this surgery is to remove all visible traces of the cancer. Debulking surgery is an extensive procedure in which the ovaries, fallopian tubes and uterus are removed, as well as portions of other organs that are affected by the cancer. “This is often a lengthy surgery, there can be a risk for [needing a blood] transfusion, and the recovery can be lengthy as well,” Dr. Zanotti says.

Some of the risks associated with ovarian cancer surgery are:

• Infections such as blood infections, pneumonia, or urinary tract infection
• Slow return of bowel function
• Loss of strength that could delay chemotherapy

If no tumors larger than 1 cm remain after surgery, the cancer is considered “optimally debulked,” which gives the woman a better prognosis than if more tissue was left behind. However, since these procedures may not remove all of the cancer, some of which is microscopic, almost all women will need chemotherapy afterwards.

When Should Surgery Wait?

If a person is too frail–either as a result of the cancer, or because of their overall health–to undergo surgery as step one in the treatment process, doctors may recommend chemotherapy first, called neoadjuvant chemotherapy.

The goal with neoadjuvant chemotherapy is to shrink tumors enough so that they can be more easily removed in a later surgery. Successful chemotherapy will also help reduce symptoms so women feel better.

“Providing chemotherapy initially can lead to significant symptom improvement, and improvement in the patient’s performance status and their readiness for surgery,” Dr. Zanotti says.

Which First Approach is Best?

Weighing the risks versus benefits when it comes to the order of treatment is something you will have to do with your doctor. The best treatment strategy varies from woman to woman.

Doctors may recommend neoadjuvant chemotherapy if they believe a woman may experience serious side effects from surgery that would then delay additional treatments, Dr. Zanotti says.

In those cases, doctors often give three to four cycles of chemotherapy first, hoping the cancer will shrink enough for surgery to be successful. Women who get neoadjuvant chemotherapy and then surgery will often undergo several more rounds of chemotherapy after the procedure to assure all their cancer is gone.

While surgery first is often the preferred approach, particularly because many women present at an advanced stage, during the COVID-19 pandemic, many doctors are recommending neoadjuvant chemotherapy. By postponing the surgery until chemotherapy can shrink the tumors, patients are able to have less extensive surgery and shorter recovery time, keeping them out of the hospital as much as possible. Recent studies indicate that both approaches have similar success and survival rates.

Ultimately, the decision of when to have surgery involves a thoughtful discussion with your doctor, who will take into account your personal preferences, your health, and the stage of your disease when recommending surgery before — or after — chemotherapy.

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