Ovarian Cancer Treatment: The First Big Decision You’ll Have to Make

In the midst of dealing with your emotions–and lots of questions–after a diagnosis of ovarian cancer, you’ll have to start making decisions about your care. Ovarian cancer can be an aggressive disease, and doctors like to start women on treatment as soon as possible. While there will be many decisions to make over the years as you achieve remissions and choose maintenance therapies, the first decision you’ll need to make is usually the same for everyone:  surgery or chemotherapy first?

Which Comes First: Neoadjuvant Chemotherapy or Debulking Surgery?

The most common type of surgery for ovarian cancer is called debulking surgery, and the intention of this procedure is to remove as much of the tumor as possible. When chemotherapy is administered as an initial treatment before surgery, it’s called neoadjuvant chemotherapy. Most chemotherapy for ovarian cancer involves a combination of two drugs–usually taxol and carboplatin. Patients usually receive six treatments; all six may be given after surgery, or three might precede surgery, with three following it.

Whether you start your treatment with surgery or chemotherapy depends on many factors, including the extent of the cancer, your age, and your overall health. In the past, doctors preferred to do debulking surgery first. The idea was that removing as much of the cancer as possible paved the way for chemotherapy to be more successful. Recent studies suggest that the success rate and outcome for patients is the same regardless of which treatment comes first.

In this extensive debulking procedure, surgeons open the abdomen and spend hours examining organs and tissues for signs of disease, removing all visible tumor. Generally the ovaries, fallopian tubes and uterus are removed, as well as the omentum–an apron of fatty tissue that covers the abdominal organs and is a common site for cancer spread. Portions of other organs may need to be removed as well. And sometimes debulking surgery also involves a bowel resection, which means removing and reconnecting a part of the intestine. After a bowel resection many patients must use an ostomy bag, which collects the waste leaving the body through an opening in the abdomen. The ostomy bag is usually temporary, and can be reversed once the bowel heals.

Because this surgery is so extensive and can lead to complications such as serious infections, some patients opt to have chemotherapy first. Other people who may be advised to start treatment with chemotherapy first include patients with cancer that is so advanced or extensive that it would be impossible to remove most of it surgically. Once the tumors are first shrunk with chemotherapy,  the surgery has a better chance of success. There are also patients who are considered too weak or frail to withstand surgery. Treating the cancer with chemotherapy first can give them time to build their strength–with nutrition, exercise, medical treatment–so that they will come through surgery better.

“Chemotherapy versus primary debulking surgery is something that you would discuss with your doctor,” says Dr. Gilian Hsieh, gynecologic oncologist at the Sutter Bay Medical Foundation in the Bay Area in California. “It depends on your goals in terms of how much surgical morbidity [potential problems] you’re willing to tolerate.”

Studies showing that the success of treatment is the same regardless of whether surgery or chemotherapy is done first are especially good news considering that when the COVID-19 pandemic broke out some doctors were postponing surgery to protect patients from the risk of exposure to the virus in the hospital. Some patients who might have qualified for surgery first opted to begin treatment with chemotherapy instead.

There Is No One-Size-Fits-All Treatment

In addition to age and overall health, another factor that goes into the decision of which treatment to begin with has to do with lifestyle. Debulking surgery involves time in the hospital and recovery time afterwards, whereas while chemotherapy certainly has side effects, most of these can be managed well enough that women can continue with many normal activities.

Dr. Hsieh remembers one patient in her seventies who was very healthy and a good candidate for primary debulking surgery. But the woman opted for neoadjuvant chemotherapy instead. She was a caregiver for her grandchildren, and wanted to be able to continue taking care for them during her treatment. “She felt that neoadjuvant chemotherapy would be more in line with her goals for quality of life and maintaining good function during her treatment,” says Dr. Hsieh.

After three cycles of chemotherapy, the woman was able to undergo a less extensive surgical procedure. “For her, I felt comfortable doing a laparoscopic [minimally invasive] debulking surgery,” says Dr. Hsieh. After the initial chemotherapy and the surgery there were no remaining tumor cells that could be detected. She finished her initial therapy with three more rounds of chemotherapy. “She’s been off treatment for two years now and is doing really well,” says Dr. Hsieh.

Treatment for ovarian cancer doesn’t take the same path for everyone. Depending on the aggressiveness of the cancer and your health and lifestyle, different procedures might make sense at different times, allowing treatment to be individualized to you. Your doctor can work closely with you to ensure that you find the best approach to treating your cancer, while meeting your lifestyle goals.

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