Ovarian cancer is often referred to as a silent disease because its symptoms can be vague or mimic common conditions. The disease is frequently diagnosed at an advanced stage, meaning cancer cells have moved from the initial site to other areas of the body. This spread, known as metastasis, classifies the cancer as advanced and necessitates a specialized, multi-faceted approach. Treatment for metastatic ovarian cancer focuses on controlling the disease, extending survival, and maintaining the patient’s quality of life through surgery, systemic therapies, and supportive care.
Understanding Metastatic Disease and Staging
Metastatic disease occurs when cancer cells separate from the primary tumor and travel through the lymphatic system or bloodstream to establish new tumors in distant organs. For ovarian cancer, this progression typically begins with spread within the abdominal cavity, often involving the peritoneum, the lining of the abdomen and pelvis. This is the most common route of dissemination.
The International Federation of Gynecology and Obstetrics (FIGO) staging system classifies metastatic ovarian cancer as Stage IV. Stage IV is divided into two subcategories based on the distant spread of the malignancy. Stage IVA is defined by a malignant pleural effusion, which is fluid containing cancer cells accumulated between the lung and the chest wall. Stage IVB, the most advanced classification, involves the spread of cancer to distant sites outside the abdominal cavity, such as the liver or spleen, or to lymph nodes located outside the abdomen.
The most common sites for distant spread, beyond the abdominal lining, are the liver, lungs, and distant lymph nodes. Understanding the specific location and extent of this spread is fundamental to planning the treatment strategy. Because of the disease’s nature at this stage, treatment regimens must be systemic to reach all areas where cancer cells may have settled.
Confirming the Diagnosis
Confirming metastatic ovarian cancer relies on advanced imaging, tumor marker analysis, and tissue confirmation. Computed Tomography (CT) scans visualize the extent of tumor deposits throughout the abdomen and pelvis, identifying masses, enlarged lymph nodes, and fluid accumulation. Positron Emission Tomography (PET) combined with CT (PET/CT) provides anatomical and metabolic information, helping to detect smaller, metabolically active metastatic sites. This combined imaging is useful in identifying extra-abdominal spread or monitoring for recurrence.
The serum tumor marker Cancer Antigen 125 (CA-125) is a glycoprotein frequently elevated in patients with epithelial ovarian cancer, particularly in advanced stages. While not a standalone diagnostic tool, a significant elevation in CA-125 levels with a pelvic mass suggests ovarian cancer. After treatment initiation, the primary use for CA-125 is monitoring the disease’s response to therapy and detecting recurrence. A drop in CA-125 level by 50% or more after the first chemotherapy cycle is a prognostic indicator of a positive treatment response.
Confirmation of cancer, including its specific cell type, requires a biopsy involving a tissue or fluid sample for pathological examination. A core biopsy of the primary tumor is often avoided due to the theoretical risk of spreading cancer cells within the abdominal cavity. Biopsies are typically performed during surgical removal of the tumor, or an image-guided needle biopsy may be taken from a metastatic site, such as a distant lymph node or liver deposit. This confirms the diagnosis and determines the molecular characteristics of the cancer. Molecular testing on this tissue is standard practice, helping identify specific genetic changes, like BRCA mutations or homologous recombination deficiency (HRD), which guide the use of targeted therapies.
Comprehensive Treatment Strategies
The management of metastatic ovarian cancer involves a sequenced, multi-modal approach combining surgery and systemic drug therapies. The primary goal is to maximize the removal of visible disease and then use systemic treatments to eliminate any remaining microscopic cancer cells.
Surgical Role in Metastatic Disease
Cytoreductive surgery, also known as debulking, is a primary initial treatment for many patients with advanced disease. The objective is to remove as much cancerous tissue as possible, aiming for no visible residual disease, known as “complete cytoreduction” or “optimal debulking.” Achieving this optimal status is strongly correlated with improved patient outcomes and prolonged survival.
For patients with extensive disease, treatment may involve neoadjuvant chemotherapy first to shrink tumors, followed by interval debulking surgery. This approach makes the surgery less extensive and increases the likelihood of achieving a complete cytoreduction. The procedure may involve removing the uterus, both ovaries and fallopian tubes, the omentum (a fatty apron in the abdomen), and any visible tumor deposits on the bowel, liver, or diaphragm.
Chemotherapy Regimens
Chemotherapy remains the backbone of systemic treatment, utilizing drugs that target rapidly dividing cells throughout the body. The standard first-line regimen typically consists of a combination of a platinum-based agent, such as carboplatin, and a taxane, most commonly paclitaxel. These drugs are usually administered intravenously in cycles, often every three weeks, for six courses.
Chemotherapy is used in multiple settings: neoadjuvant (before surgery), adjuvant (after surgery), and maintenance (to prevent recurrence). Intraperitoneal (IP) chemotherapy, where drugs are delivered directly into the abdominal cavity, may be considered for select patients to concentrate the drug at the site of spread. If the cancer returns, the choice of subsequent chemotherapy depends heavily on the platinum-free interval. This interval—the time elapsed since the last dose of platinum-based therapy—indicates the cancer’s sensitivity to the drug class.
Targeted Therapy and Immunotherapy
Targeted therapies focus on specific molecular pathways that fuel cancer growth. Poly(ADP-ribose) polymerase (PARP) inhibitors, such as olaparib, niraparib, and rucaparib, are a major class used for maintenance therapy. These oral agents prevent cancer cells with defects in DNA repair, particularly those with BRCA mutations or HRD, from fixing their DNA damage, leading to cell death.
Anti-angiogenic agents like bevacizumab, a monoclonal antibody, target the vascular endothelial growth factor (VEGF) protein. By blocking VEGF, bevacizumab inhibits the formation of new blood vessels that tumors need to grow, effectively starving the cancer. This drug is often combined with chemotherapy and continued as maintenance therapy, particularly for patients with Stage IV disease or those who could not achieve optimal debulking.
Immunotherapy, which harnesses the body’s immune system to fight cancer, holds a limited but emerging role in ovarian cancer treatment. Immune checkpoint inhibitors, such as pembrolizumab and dostarlimab, are approved for use in a small subset of advanced ovarian cancers. These cancers exhibit specific genomic features, like microsatellite instability-high (MSI-H) or high tumor mutational burden (TMB-H). Ongoing research explores combinations of immunotherapy with PARP inhibitors and chemotherapy to improve response rates.
Supportive Care and Quality of Life
Supportive care, often referred to as palliative care, is an integral component of managing metastatic ovarian cancer and should be initiated alongside active anti-cancer treatment. This specialized care focuses on providing relief from the symptoms and side effects of the disease and its treatment, aiming to improve the patient’s quality of life.
One common symptom is ascites, the buildup of fluid in the abdominal cavity, causing swelling, pain, and shortness of breath. The primary intervention for symptomatic relief is paracentesis, a procedure where a needle or catheter is inserted into the abdomen to drain the excess fluid. For patients requiring frequent drainage, a long-term indwelling catheter or a peritoneovenous shunt may be placed for ongoing fluid management at home.
Malignant bowel obstruction is a severe complication occurring when a tumor mass blocks the passage of food and waste through the intestines, causing nausea, vomiting, and abdominal pain. Management may involve medical treatment with medications like steroids (dexamethasone) and antiemetics to reduce swelling and control symptoms. For some patients, surgical intervention to bypass the obstruction or the placement of an endoscopic stent can provide significant palliative benefit.
Managing symptoms like fatigue, pain, and nausea is important for daily well-being and is accomplished through a dedicated team of professionals. Nutritional support from a dietitian is necessary to combat cancer-related weight loss and maintain strength. Psychological support is provided by a multidisciplinary team, including psycho-oncologists, licensed clinical social workers, and counselors. These professionals offer individual and group counseling to help patients and their families navigate the emotional challenges of a serious illness, including anxiety, depression, and grief.