Treatments for ovarian cancer

Your healthcare team will create a treatment plan just for you. The plan is based on your health and specific information about the cancer. What you want is also important when planning treatment.

The treatments offered for ovarian cancer are also used for fallopian tube and primary peritoneal cancer. These cancers start in the same type of tissue as the most common type of ovarian cancer and are staged and treated the same way. But they are much rarer cancers.

When deciding which treatments to offer for ovarian, fallopian tube or primary peritoneal cancer, your healthcare team will consider:

• the type of cancer
• the stage of the cancer
• the grade of the cancer
• possible side effects
• your age
• your overall health
• any medical problems you have
• your lifestyle and what you prefer or want

Surgery and chemotherapy are the main treatments for these cancers. Sometimes other treatments are used, such as targeted therapy, radiation therapy and hormone therapy. Immunotherapy is rarely used.

Different types of targeted therapy are used for ovarian, fallopian tube and primary peritoneal cancer.

Angiogenesis is the growth of new blood vessels. A tumour has to make new blood vessels in order to grow, so anti-angiogenesis drugs try to cut off a tumour’s blood supply by stopping it from developing new blood vessels.

Bevacizumab (Avastin) is an angiogenesis inhibitor for advanced or recurrent cancer. If you have advanced ovarian, fallopian tube or primary peritoneal cancer, bevacizumab may be offered after the cancer has responded to chemotherapy with a platinum drug such as carboplatin or cisplatin. If you have recurrent cancer that did not respond to chemotherapy, bevacizumab may be combined with chemotherapy drugs to help them work better. Bevacizumab is given intravenously (by IV) every 2 to 3 weeks.

Poly ADP-ribose polymerase (PARP) is an enzyme that helps repair damage to DNA. PARP inhibitors block PARP so cancer cells can’t repair their DNA, which causes them to die.

PARP inhibitors may be used for advanced or recurrent ovarian, fallopian tube or primary peritoneal cancer. They may be offered after the cancer has responded to chemotherapy with a platinum drug, such as carboplatin or cisplatin. PARP inhibitors are used as maintenance therapy to prevent the cancer from coming back. The PARP inhibitors given may include the following:

• Olaparib (Lynparza) will only be offered if you have a BRCA1 or BRCA2 gene mutation or a positive homologous recombination deficiency (HRD) test, which means the cancer cells have difficulty repairing DNA damage and the tumour will be more sensitive to PARP inhibitors. Olaparib is usually taken by mouth twice a day.
• Niraparib (Zejula) may also be offered. You don't need to have a BRCA gene mutation or be HRD positive to take this drug. Niraparib is usually taken by mouth once a day.

Side effects of targeted therapy will depend mainly on the type of drug or combination of drugs, the dose, how it's given and your overall health. Tell your healthcare team if you have side effects that you think are from targeted therapy. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Talk to your doctor or pharmacist about what side effects to expect.

Find out more about targeted therapy. To make the decisions that are right for you, ask your healthcare team questions about targeted therapy.

Details on specific drugs change regularly. Find out more about sources of drug information and where to get details on specific drugs.

The type of immunotherapy drugs used for ovarian, fallopian tube and primary peritoneal cancer are called immune checkpoint inhibitors.

The immune system normally stops itself from attacking normal cells in the body by using specific proteins called checkpoints. Checkpoints slow down or stop an immune system response. Cells in the ovaries, fallopian tubes or peritoneum sometimes use these checkpoints to hide and avoid being attacked by the immune system. Immune checkpoint inhibitors work by blocking the checkpoint proteins so immune system cells (called T cells) attack and kill the cancer cells.

Immune checkpoint inhibitors may be offered if the cancer has certain genetic changes known as high microsatellite instability (MSI-H) or mismatch repair deficiency (dMMR).

If the cancer has either of these features, the following immune checkpoint inhibitors may be used:

• pembrolizumab (Keytruda)
• dostarlimab (Jemperli)

These immunotherapy drugs may not be covered by all provincial or territorial drug plans. Your doctor or healthcare team will discuss access to these drugs with you and about how you could benefit from this treatment.

Side effects of immunotherapy will depend mainly on the type of drug or drug combination, the dose, how it's given and your overall health. Tell your healthcare team if you have side effects that you think might be from immunotherapy. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Common side effects of immunotherapy for ovarian, fallopian tube or primary peritoneal cancer include:

• flu-like symptoms, such as fever and chills

• fatigue

• skin problems, including redness, rash, itching and dryness

• diarrhea

• nausea and vomiting

Find out more about immunotherapy. To make the decisions that are right for you, ask your healthcare team questions about immunotherapy.

Details on specific drugs change regularly. Find out more about sources of drug information and where to get details on specific drugs.

Don't wait until your next scheduled appointment to report any new symptoms, and symptoms that don't go away. Tell your healthcare team if you have:

• pain in the legs, lower back, pelvis or abdomen
• swelling of or pain in the abdomen
• change in bowel habits
• increasing bloating, nausea or vomiting
• weight loss

The chance that ovarian cancer will come back (recur) is greatest within 5 years, so you will need close follow-up during this time. You will also need close follow-up care for fallopian tube or primary peritoneal cancer, which are very similar to ovarian cancer. These cancers start in the same tissue as most ovarian cancers and are staged and treated the same way. But they are much rarer cancers.

Follow-up visits for ovarian, fallopian tube and primary peritoneal cancer are usually scheduled:

• every 3 to 4 months for the first 2 to 3 years after finishing initial treatment
• every 4 to 6 months for the next 3 years, and then once a year after that

During a follow-up visit, your healthcare team will usually ask questions about the side effects of treatment and how you’re coping.

Your doctor may do a physical exam, including:

• a pelvic exam
• feeling the neck, abdomen and legs for swelling
• feeling the lymph nodes in the groin

Tests are often part of follow-up care. You may have:

Tumour marker tests may be done to monitor how the treatment is working. Rising levels of a tumour marker may mean that the cancer has recurred. The doctor may order tests for different tumour markers for different types of cancer:

• cancer antigen 125 (CA125)
• alpha-fetoprotein (AFP)
• human chorionic gonadotropin (HCG or b-HCG)
• carcinoembryonic antigen (CEA)

Blood chemistry tests may be done to show how well certain organs are working. They can also be used to find abnormalities that may mean the cancer has spread to certain organs.

A complete blood count (CBC) may be done to check for anemia from long-term bleeding, especially if the cancer has spread to the small or large intestine (also called the bowel).

Imaging tests may be ordered to check how the treatment is working or to investigate new symptoms:

• chest x-ray
• CT scan

If the cancer has come back, you and your healthcare team will discuss a plan for your treatment and care.

The following are questions that you can ask the healthcare team about follow-up after treatment for cancer. Choose the questions that fit your situation and add questions of your own. You may find it helpful to take the list to the next appointment and to write down the answers.

• What is the schedule for follow-up visits?
• How often is follow-up scheduled with the cancer specialist?
• Who is responsible for follow-up visits?
• What will happen at a follow-up visit?
• What tests are done on a regular basis? How often are they done?
• Are there any symptoms that should be reported right away? Who do I call?
• Who can help me cope with long-term side effects of treatment?