Surgery

To remove a suspicious mass, a doctor makes a long incision in the wall of the abdomen in a surgical operation called a laparatomy. If ovarian cancer is found, the doctor will remove, depending on the extent of the spread:

• Both ovaries and fallopian tubes (salpingo-oophorectomy)
• The uterus (hysterectomy)
• The omentum, a thin fatty pad of tissue that covers the intestines
• Nearby lymph nodes
• Samples of tissue from the pelvis and abdomen
• Fluid in the abdomen for analysis
• As much cancer that has spread, as possible, in a process called debulking
• If the stage appears early, laparoscopy or minimally invasive surgery may be appropriate

For a younger woman with earlier ovarian cancer, she may elect, with the guidance of her physician, to have only one ovary and fallopian tube removed along with the omentum, so she can remain fertile, if she wants children.

Some women who are elderly, too weak or have other medical conditions are treated with chemotherapy before surgery to shrink the tumors as much as possible. If the woman improves with the chemotherapy, surgery is then done to remove as much cancer as possible. Chemotherapy then follows.

Pain medications are available after surgery to address discomfort. The time it takes to heal after surgery can vary among women, but usually you will spend several days in the hospital. It can take several weeks before you can return to normal activities and until chemotherapy will begin.

Removing the ovaries will cause early menopause in younger women who have not yet gone through menopause and occurs because the ovaries are no longer present to make female hormones. Menopausal symptoms include hot flashes, vaginal dryness and night sweats. Drugs and lifestyle changes can help symptoms, which mostly will go away or lessen in time.

Chemotherapy

Chemotherapy uses drugs that target and kill cancer cells. After surgery, most women with ovarian cancer get as a first-line chemotherapy a combined treatment with a platinum-based drug and a taxane.

• Platinum-based drugs, such as cisplatin, (trade name Platinol) and carboplatin (trade name Paraplatin) have the chemical element platinum as part of their molecular structure. These drugs form highly reactive platinum complexes that bind and crosslink DNA, a double-stranded molecule inside the nucleus of the cell that controls cellular activity. The chemical crosslinking within the DNA prevents cancer cells from growing and causes them to die.
• Taxanes, include paclitaxel, (trade name Taxol) or docetaxel, (trade name Taxotere), are a type of drug originally extracted from the Pacific yew tree, but now are chemically synthesized. Taxanes target microtubules, structures akin to internal highways inside cells. Taxanes prevent the microtubules from reorganizing themselves so cancer cells are no longer able to divide and grow.

Chemotherapy is delivered in cycles, with each treatment period followed by a rest period. How the chemotherapy is delivered depends on the stage of the disease and how much of the tumor was removed:

• Intraperitoneal chemotherapy is done through a surgically implanted catheter in the peritoneum, or abdominal cavity, to destroy cancer located in the abdomen or pelvis. The catheter inside the abdominal cavity is connected to a port, which the surgeon situates between a rib and abdominal muscle. The port has a chamber outside of the skin for delivery of drugs, which then enter the catheter to wash over internal organs. Some of the drug also diffuses into the bloodstream.
• Systemic chemotherapy is done by mouth or intravenously, through the vein to destroy or control cancer throughout the body.

In January 2006, the National Cancer Institute announced that it was now recommending both systemic intravenous and intraperitoneal chemotherapy for certain women with advanced ovarian cancer, particularly women with stage III cancer whose tumor was debulked to less than one centimeter in size or had no visible sign of the disease. Approximately 60 percent of women diagnosed with ovarian cancer have stage III disease. The combined approach, with intraperitoneal treatment after intravenous drug therapy, is more toxic, with more side effects, but extends overall survival for women with advanced ovarian cancer by about a year compared to intravenous delivery alone.

Although many women have trouble completing all the chemotherapy rounds with the combined intravenous and intraperitoneal treatments, whatever they can withstand is still thought to be effective. Doctors believe that intraperitoneal therapy works by bringing the toxic drugs in a more concentrated form closer to the site of the disease and are therefore more effective at killing the cancer cells. Intravenous therapy, being more systemic, aims to kill cancer cells wherever they might be located in the body.

Women with earlier stage disease and women with cancers that cannot be reduced to less than one centimeter in size usually get intravenous chemotherapy with a platinum-based drug and a taxane.

Chemotherapy Side Effects

Chemotherapy works by targeting cancer cells, which are cells that rapidly divide as they grow in the body. But some normal cells that also grow quickly can be hurt by chemotherapy drugs. OCRA researchers are working to develop better “targeted therapies,” which attack cancer cells but leave healthy cells unharmed. Until we develop better targeted treatments, side effects often accompany treatment. Your doctor has many tools and drugs to effectively manage many side effects of chemotherapy. Don’t be afraid to talk to your doctor about side effects you are having.

Here are the cells affected by chemotherapy, the resulting side effects and suggestions to help manage the side effects:

• Blood-producing cells : Blood-producing cells in the bone make a range of blood cells that fight infection, help blood clot and carry oxygen to all parts of the body. When chemotherapy damages the white blood producing cells, you become susceptible to infections because of a shortage of white blood cells, or with the platelet producing cells you can bruise or bleed easily because of a shortage of platelets and you can feel weak and tired because of a shortage of red blood cells. Throughout chemotherapy your nurses and doctors check for low levels of blood cells. If levels are too low, medicines are available to boost them up.
• Managing infection : Try to avoid cuts and scrapes, wash your hands often, avoid crowds and people with colds, coughs or other infectious diseases. Drink plenty of fluids and bathe daily, using moisturizer to soften dry and potentially cracked skin.
• Managing fatigue : Understand your energy level and make accommodations. Do things you enjoy when you have the energy but rest or take naps when you feel the need to. Although exercise when you are tired seems counterintuitive, many women find activities, such as walking or gentle yoga, invigorating. Talk to your doctor before doing any exercise routine. Eating well is very important, too.
• Cells in hair roots : Most women being treated for ovarian cancer lose their hair. The hair will eventually grow back, but can be slightly different in color and texture.
• Managing hair loss : Some women choose to wear a wig so that the loss of hair doesn’t become an outward manifestation of their disease as they try to go about their life. Because women know their hair will fall out from chemotherapy, some will have parties to cut it or will donate their hair to make wigs for other women with cancer.
• Cells that line the digestive tract : Nausea, poor appetite, vomiting, constipation and diarrhea, mouth and lip sores are typical side effects of chemotherapy. Drugs are available to help some of these problems.
• Managing poor appetite : Some chemotherapy drugs create taste changes in patients. Food may taste salty or bitter but usually tastes normal again once treatment is over. Non-alcoholic mouthwash and other products can decrease dryness of the mouth. It is important to eat nutritious food, high in protein, when undergoing chemotherapy. Your doctor may recommend that you see a nutritionist to help you eat right during this time. Eating smaller meals, a few times a day, is often recommended, as is trying to relish food and making it pleasant to experience, like dining with friends and family. Smoking, using tobacco and consuming harsh foods or alcohol increase the severity of these side effects.
• Managing nausea and vomiting : Often women feel nauseated before a cycle of chemotherapy because of prior experience. Anti-anxiety drugs and complementary medical techniques, such as meditation, relaxation training or ginger, can help. Nausea and vomiting that occurs after chemotherapy can be treated with anti-emetics (anti-nausea) medications. Eating and drinking slowly and after vomiting, and staying hydrated, are very important. These side effects must be managed during chemotherapy treatments because uncontrolled vomiting and nausea can interfere with the patient’s ability to receive treatments.
• Managing diarrhea : Diarrhea is a common side effect of chemotherapy that usually occurs in the days immediately following a chemotherapy treatment. Patients with diarrhea need to remember that they can become dehydrated quickly and should be sure to hydrate themselves.
• Managing constipation : Drink plenty of fluids, eat high fiber foods, move around, try to be consistent with your bowel activity and take a fiber laxative. Talk to your doctor before taking any anti-constipation remedy.Managing mouth and lip sores: Use a soft toothbrush to avoid injuring your mouth and keep your mouth moist, by drinking plenty of fluids. Avoid spicy and harsh foods that can be irritating to your mouth.

Other Side Effects

• Nerve Problems : Certain chemotherapy drugs can cause peripheral neuropathy, an increase in numbness caused by damage to the nerves that transmit signals between extremities and the central nervous system. This damage to the nerves often causes a tingling sensation or loss of control in the hands or feet. Acupuncture or massage and physical therapy may lessen these side effects, which are usually temporary and improve or resolve when chemotherapy treatment stops.
• Sexuality and Intimacy Issues : Interest in sexual intimacy often decreases for chemotherapy patients for many reasons, including additional stress and the side effects of treatment. Patients need to maintain a positive self-image during this time and sustain open communication with their partners. When a patient is ready to engage in sexual activity, she should consider taking the following actions:
• Make time for rest before and after sexual activity to preserve energy
• Use water-soluble lubricants as her vagina may be drier than usual due to hormonal changes.
• Experiment to find comfortable positions and avoid those that will tire her quickly.
• “Chemobrain” : Many women experience forgetfulness and have trouble with concentration after receiving chemotherapy. This absentmindedness is often temporary; however, about 15 percent of chemo patients experience permanent problems. Since the cause is unknown, no treatment exists for this side effect. Women who have experienced this side effect offer several suggestions for dealing with it:
• Minimize distractions while performing important tasks.
• Keep a daily organizer/journal to keep track of appointments.
• Use the calendar on your computer and voicemail messages to remind yourself of meetings.