“Research published during the last few years has investigated the effectiveness of a new approach involving giving some chemotherapy, then performing surgery, followed by completing chemotherapy.”Professor Sean Kehoe, Lawson Tait Professor of Gynaecological Cancer
Ovarian cancer affects around 7,000 women each year in the UK, a figure expected to rise to 10,000 by 2035. It is the most common type of cancer in women over the age of 50 years, but some rarer types of ovarian cancer can develop in younger women.
At first presentation to the doctor, 75% of women will have an advanced stage of the disease, which means that it has already spread outside of the ovaries. Whilst advanced disease can be treated, many of these women will develop recurrent disease.
For women who present with the disease at a stage that it is confined to the ovaries, known as early stage disease, the cure rates are 90% or higher.
However, attempts to detect the disease earlier through screening have so far failed. This is, in part, due to research in the last few years which has revealed that many of the more advanced ovarian cancers actually come from the fallopian tubes. Of course, in such a situation when the ovaries are detected as abnormal this means the disease has spread already – explaining why the screening is not effective. It’s akin to examining the lymph glands in the armpits to detect a breast cancer.
In most cases, the standard approach to care for many years has been to have an operation followed by chemotherapy – drugs given through the blood stream. Research published during the last few years has investigated the effectiveness of a new approach involving giving some chemotherapy, then performing surgery, followed by completing chemotherapy. Clinical trials comparing this to the standard approach in women with advanced disease showed that giving chemotherapy first resulted in many benefits, including reducing the side effects of treatments and spending less time in hospital after the operation. Furthermore, this new approach did not impact on the overall survival patterns and both approaches resulted in the same long-term outcomes.
But when two large studies of the chemotherapy first approach were combined, it was shown that ‘chemotherapy first’ actually gave a better survival than having an operation first in women with the most advanced stage of the disease, called stage four. Of course, there will always be exceptions where it may be judged in certain individuals that an operation first may be better – for example to alleviate any symptoms that the disease is causing in the stomach.
The ‘chemotherapy first’ approach has some benefits to research, too. Women will have a biopsy of their tumour before any chemotherapy and a second biopsy at the operation, therefore any disease changes due to some chemotherapy can be examined. Such research should help in understanding how chemotherapy can be effective and insights as to why some tumours may not respond as well as others to the chemotherapy been given. Indeed, it may be in the future that some diseases need a change in chemotherapy during the first treatments if these are not working as well as anticipated. It should be possible in the near future to develop systems to identify diseases that need an alternative type of chemotherapy.
The other change in care is the surgical approach. For decades, the ‘surgery first’ approach was to remove as much disease as possible, sometimes leaving some behind. Nowadays, the aim of surgery is for the removal of all the disease at operation. This can mean more extensive surgery compared to before in women with advanced disease.
Disease in the liver, below the lungs, and in the spleen will, where possible, be removed. Again, though, this is not for all as the patient needs to be well enough to tolerate such surgery. Selecting the right women, and being as sure as possible that all disease can be removed, is challenging. Again, ongoing research is trying to select the right women for the right approach. This is part of the evolution of cancer treatment whereby ‘individualised’ treatments will become more common.
One important challenge now is whether early disease in the fallopian tubes can be detected before is has spread. So far, this remains elusive. However, in about 10-15% of women developing ovarian cancer, there is an inherited genetic cause, and in these women, removing the tubes and ovaries reduces the risk of cancer.
In other women who do not have a family history, we presently do not know the effect of removing the fallopian tubes on reducing the risk of ovarian cancer – though again this is undergoing investigation.
Overall the life expectancy for women with ovarian cancer has improved. Identifying different approaches and challenging the accepted treatment strategies with new ideas can lead to improving the outcome for those with this disease, and equally drive forward research areas which should hopefully lead to a better understanding of this condition.