Ovarian cancer medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Medical therapies, such as [[chemotherapy]] and [[radiation]], are often employed | Medical therapies, such as [[chemotherapy]] and [[radiation]], are often employed post-surgical therapy as a means to treat residual disease. The success of medical therapy often hinges on the [[histology]] of the [[tumor]]. | ||
==MedicalTherapy== | ==MedicalTherapy== | ||
*[[Epithelial ovarian cancer]] includes [[ovarian]], [[fallopian tube]], and | *[[Epithelial ovarian cancer]] includes [[ovarian]], [[fallopian tube]], and peritoneal cancer and the combination of the three is referred to as (EOC) due to the similarity in their clinical behavior and characteristics | ||
*EOC is usually diagnosed in its late stages due to its subclinical or nonspecific [[symptoms]] | *EOC is usually diagnosed in its late stages due to its subclinical or nonspecific [[symptoms]] | ||
*The mainstay of definitive [[diagnosis]] and initial | *The mainstay of definitive [[diagnosis]] and initial management of [[ovarian]] cancer is surgical operation to determine if it is [[benign]] or [[malignant]], determine its stage and grade, and then treat it accordingly | ||
*The medical management of [[ovarian cancer]] is usually done as an [[adjuvant]] to the [[surgical]] therapy which means surgery first then [[adjuvant]] [[chemotherapy]] | *The medical management of [[ovarian cancer]] is usually done as an [[adjuvant]] to the [[surgical]] therapy which means surgery first then [[adjuvant]] [[chemotherapy]] | ||
*Based on the [[surgical]] staging and grading of the tumor the management can be one of the following: | *Based on the [[surgical]] staging and grading of the tumor the management can be one of the following: | ||
| Line 18: | Line 18: | ||
***The prognosis is excellent with survival rate of 90% after surgery alone | ***The prognosis is excellent with survival rate of 90% after surgery alone | ||
**[[Adjuvant]] [[intravenous]] [[chemotherapy]]:<ref name="pmid19944452">{{cite journal| author=Chan JK, Tian C, Teoh D, Monk BJ, Herzog T, Kapp DS et al.| title=Survival after recurrence in early-stage high-risk epithelial ovarian cancer: a Gynecologic Oncology Group study. | journal=Gynecol Oncol | year= 2010 | volume= 116 | issue= 3 | pages= 307-11 | pmid=19944452 | doi=10.1016/j.ygyno.2009.10.074 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19944452 }} </ref><ref name="pmid18348296">{{cite journal| author=Chan JK, Tian C, Monk BJ, Herzog T, Kapp DS, Bell J et al.| title=Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study. | journal=Cancer | year= 2008 | volume= 112 | issue= 10 | pages= 2202-10 | pmid=18348296 | doi=10.1002/cncr.23390 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18348296 }} </ref> | **[[Adjuvant]] [[intravenous]] [[chemotherapy]]:<ref name="pmid19944452">{{cite journal| author=Chan JK, Tian C, Teoh D, Monk BJ, Herzog T, Kapp DS et al.| title=Survival after recurrence in early-stage high-risk epithelial ovarian cancer: a Gynecologic Oncology Group study. | journal=Gynecol Oncol | year= 2010 | volume= 116 | issue= 3 | pages= 307-11 | pmid=19944452 | doi=10.1016/j.ygyno.2009.10.074 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19944452 }} </ref><ref name="pmid18348296">{{cite journal| author=Chan JK, Tian C, Monk BJ, Herzog T, Kapp DS, Bell J et al.| title=Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study. | journal=Cancer | year= 2008 | volume= 112 | issue= 10 | pages= 2202-10 | pmid=18348296 | doi=10.1002/cncr.23390 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18348296 }} </ref> | ||
***[[Carboplatin]] and [[paclitaxel]] ( | ***[[Carboplatin]] and [[paclitaxel]] (platinum-based combination) | ||
***Every three weeks for six cycles | ***Every three weeks for six cycles | ||
***Can be adjusted based on the patient [[tolerance]] and the presence of [[risk factors]] | ***Can be adjusted based on the patient [[tolerance]] and the presence of [[risk factors]] | ||
*Five-year disease-free survival rates range from 40 to 80 percent | *Five-year disease-free survival rates range from 40 to 80 percent | ||
***Is recommended for the following: | ***Is recommended for the following: | ||
**** | ****Early stage EOC with high-risk features: | ||
****Stage IC (Ovary plus positive [[peritoneal]] washing) or Stage II (involve pelvis) EOC | ****Stage IC (Ovary plus positive [[peritoneal]] washing) or Stage II (involve pelvis) EOC | ||
****([[clear cell]] [[histology]] | ****([[clear cell]] [[histology]] | ||
| Line 34: | Line 34: | ||
***Then [[adjuvant]] therapy | ***Then [[adjuvant]] therapy | ||
***It is recommended for: | ***It is recommended for: | ||
****Advanced | ****Advanced EOC (Stage IIIC or IV)with a low chance of complete or optimal cytoreduction (unresectable [[tumor]]) | ||
****[[EOC]] in patients with poor operation outcome due to [[comorbidities]] or poor performance status | ****[[EOC]] in patients with poor operation outcome due to [[comorbidities]] or poor performance status | ||
**[[Temsirolimus]], [[carboplatin]], and [[paclitaxel]] are used for | **[[Temsirolimus]], [[carboplatin]], and [[paclitaxel]] are used for | ||
***[[Clear cell]] [[ovarian cancer]] ( | ***[[Clear cell]] [[ovarian cancer]] (stage III-IV) | ||
**[[Sunitinib]] is used for | **[[Sunitinib]] is used for | ||
***[[Ovarian]] Clear Cell [[Adenocarcinoma]] | ***[[Ovarian]] Clear Cell [[Adenocarcinoma]] | ||
***Recurrent Ovarian Carcinoma | ***Recurrent Ovarian Carcinoma | ||
*Observation after [[adjuvant]] [[chemotherapy]] is recommended for patients with early-stage | *Observation after [[adjuvant]] [[chemotherapy]] is recommended for patients with early-stage EOC | ||
* | *Maintenance therapy with [[paclitaxel]] for 24 weeks after completion of the [[adjuvant]] therapy is recommended for patients with advanced EOC | ||
*Management of patients with | *Management of patients with EOC recurrence: | ||
** [[Platinum]]-sensitive: more than 6 months disease-free interval after completion of therapy | **[[Platinum]]-sensitive: more than 6 months disease-free interval after completion of therapy | ||
*** Secondary [[chemotherapy]] with or without | *** Secondary [[chemotherapy]] with or without bavacizumab and secondary cytoreduction | ||
** [[Platinum]]-resistant EOC: less than 6 months disease-free interval after completion of therapy and includes the following: | ** [[Platinum]]-resistant EOC: less than 6 months disease-free interval after completion of therapy and includes the following: | ||
** * [[Platinum]]-refractory EOC: disease progression while on [[platinum]] therapy | ** * [[Platinum]]-refractory EOC: disease progression while on [[platinum]] therapy | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Huda A. Karman, M.D.
Overview
Medical therapies, such as chemotherapy and radiation, are often employed post-surgical therapy as a means to treat residual disease. The success of medical therapy often hinges on the histology of the tumor.
MedicalTherapy
- Epithelial ovarian cancer includes ovarian, fallopian tube, and peritoneal cancer and the combination of the three is referred to as (EOC) due to the similarity in their clinical behavior and characteristics
- EOC is usually diagnosed in its late stages due to its subclinical or nonspecific symptoms
- The mainstay of definitive diagnosis and initial management of ovarian cancer is surgical operation to determine if it is benign or malignant, determine its stage and grade, and then treat it accordingly
- The medical management of ovarian cancer is usually done as an adjuvant to the surgical therapy which means surgery first then adjuvant chemotherapy
- Based on the surgical staging and grading of the tumor the management can be one of the following:
- Adjuvant intravenous chemotherapy is not recommended in
- Early stage EOC (Stage IA or IB) and/or grade I (well-differentiated) tumor [1][2]. with no high-risk features (clear cell histology or high tumor grade)
- The prognosis is excellent with survival rate of 90% after surgery alone
- Adjuvant intravenous chemotherapy:[3][4]
- Carboplatin and paclitaxel (platinum-based combination)
- Every three weeks for six cycles
- Can be adjusted based on the patient tolerance and the presence of risk factors
- Adjuvant intravenous chemotherapy is not recommended in
- Five-year disease-free survival rates range from 40 to 80 percent
- Is recommended for the following:
- Early stage EOC with high-risk features:
- Stage IC (Ovary plus positive peritoneal washing) or Stage II (involve pelvis) EOC
- (clear cell histology
- high tumor grade (grade 3)
- Is recommended for the following:
- First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer[5][6][7][8][9]
- Neoadjuvant chemotherapy is defined as initiating medical or systemic therapy before surgery.
- Carboplatin and paclitaxel (platinum-based combination)
- Followed by debulking surgery
- Then adjuvant therapy
- It is recommended for:
- Advanced EOC (Stage IIIC or IV)with a low chance of complete or optimal cytoreduction (unresectable tumor)
- EOC in patients with poor operation outcome due to comorbidities or poor performance status
- Temsirolimus, carboplatin, and paclitaxel are used for
- Clear cell ovarian cancer (stage III-IV)
- Sunitinib is used for
- Ovarian Clear Cell Adenocarcinoma
- Recurrent Ovarian Carcinoma
- Neoadjuvant chemotherapy is defined as initiating medical or systemic therapy before surgery.
- Observation after adjuvant chemotherapy is recommended for patients with early-stage EOC
- Maintenance therapy with paclitaxel for 24 weeks after completion of the adjuvant therapy is recommended for patients with advanced EOC
- Management of patients with EOC recurrence:
- Platinum-sensitive: more than 6 months disease-free interval after completion of therapy
- Secondary chemotherapy with or without bavacizumab and secondary cytoreduction
- Platinum-resistant EOC: less than 6 months disease-free interval after completion of therapy and includes the following:
- * Platinum-refractory EOC: disease progression while on platinum therapy
- Both treated with
- Paclitaxel as a single agent
- Pegylated liposomal doxorubicin (PLD)
- If patient is not Paclitaxel candidate
- Bevacizumab plus single agent chemotherapy
- For patients with platinum-resistant recurrent disease
- Platinum-sensitive: more than 6 months disease-free interval after completion of therapy
- Chemotherapy is used after surgery to treat any residual disease, if appropriate. This depends on the histology of the tumor; some kinds of tumor (particularly teratoma) are not sensitive to chemotherapy. In some cases, there may be a reason to perform chemotherapy first, followed by surgery.
- Many oncologists recommend intravenous (IV) chemotherapy including a platinum drug with a taxane as a preferred method of treating advanced ovarian cancer. However, three recent randomized studies clinical trials suggest that chemotherapy that is partly IV and partly via direct infusion into the abdominal cavity (intraperitoneal or IP) may improve median survival time.
- IP chemotherapy generally has higher toxicity and its advantages are still debated among specialists.
- Currently for Stage IIIC ovarian adenocarcinomas after optimal debulking, the median time for survival is statistically significantly longer for patient receiving intraperitoneal chemotherapy.
- Patients in this clinical trial did report less compliance with IP chemotherapy, and fewer than half of the patients received all six cycles of IP chemotherapy.
- Despite this high "drop-out" rate, the group as a whole (including the patients that didn't complete IP chemotherapy treatment) survived longer on average than patients who received intravenous chemotherapy alone. These results can be interpreted in a couple of ways. One could argue if the IP chemotherapy treatment group had completed the six cycles of chemotherapy their lives would have been prolonged even longer. Or the advantages of receiving IP chemotherapy are significant in the early phases of chemotherapy. Some specialists believe the IP chemotherapy toxicities will be unnecessary with improved IV chemotherapy drugs currently being developed.
- Radiation therapy is not effective for advanced stages because when vital organs are in the radiation field, a high dose cannot be safely delivered.
References
- ↑ Young RC, Walton LA, Ellenberg SS, Homesley HD, Wilbanks GD, Decker DG; et al. (1990). "Adjuvant therapy in stage I and stage II epithelial ovarian cancer. Results of two prospective randomized trials". N Engl J Med. 322 (15): 1021–7. doi:10.1056/NEJM199004123221501. PMID 2181310.
- ↑ Ahmed FY, Wiltshaw E, A'Hern RP, Nicol B, Shepherd J, Blake P; et al. (1996). "Natural history and prognosis of untreated stage I epithelial ovarian carcinoma". J Clin Oncol. 14 (11): 2968–75. doi:10.1200/JCO.1996.14.11.2968. PMID 8918494.
- ↑ Chan JK, Tian C, Teoh D, Monk BJ, Herzog T, Kapp DS; et al. (2010). "Survival after recurrence in early-stage high-risk epithelial ovarian cancer: a Gynecologic Oncology Group study". Gynecol Oncol. 116 (3): 307–11. doi:10.1016/j.ygyno.2009.10.074. PMID 19944452.
- ↑ Chan JK, Tian C, Monk BJ, Herzog T, Kapp DS, Bell J; et al. (2008). "Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study". Cancer. 112 (10): 2202–10. doi:10.1002/cncr.23390. PMID 18348296.
- ↑ Kyrgiou M, Salanti G, Pavlidis N, Paraskevaidis E, Ioannidis JP (2006). "Survival benefits with diverse chemotherapy regimens for ovarian cancer: meta-analysis of multiple treatments". J Natl Cancer Inst. 98 (22): 1655–63. doi:10.1093/jnci/djj443. PMID 17105988.
- ↑ Tewari D, Java JJ, Salani R, Armstrong DK, Markman M, Herzog T; et al. (2015). "Long-term survival advantage and prognostic factors associated with intraperitoneal chemotherapy treatment in advanced ovarian cancer: a gynecologic oncology group study". J Clin Oncol. 33 (13): 1460–6. doi:10.1200/JCO.2014.55.9898. PMC 4404424. PMID 25800756.
- ↑ Hess LM, Benham-Hutchins M, Herzog TJ, Hsu CH, Malone DC, Skrepnek GH; et al. (2007). "A meta-analysis of the efficacy of intraperitoneal cisplatin for the front-line treatment of ovarian cancer". Int J Gynecol Cancer. 17 (3): 561–70. doi:10.1111/j.1525-1438.2006.00846.x. PMID 17504373.
- ↑ Jaaback K, Johnson N, Lawrie TA (2016). "Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer". Cochrane Database Syst Rev (1): CD005340. doi:10.1002/14651858.CD005340.pub4. PMID 26755441.
- ↑ Walker JL, Brady MF, Wenzel L, Fleming GF, Huang HQ, DiSilvestro PA; et al. (2019). "Randomized Trial of Intravenous Versus Intraperitoneal Chemotherapy Plus Bevacizumab in Advanced Ovarian Carcinoma: An NRG Oncology/Gynecologic Oncology Group Study". J Clin Oncol. 37 (16): 1380–1390. doi:10.1200/JCO.18.01568. PMC 6544459 Check
|pmc=value (help). PMID 31002578.