If you have ovarian cancer, your recommended treatment plan will depend on several factors, such as your overall health, whether you want to have children in the future, and your personal preference. Surgery is typically the first plan of attack, both to help doctors stage the cancer — that is, to assess how advanced it is — and to remove as much of the tumor as possible.

Unless ovarian cancer is caught early, surgery is generally followed by chemotherapy. Other treatments include targeted therapy and immunotherapy, and sometimes radiation therapy and hormone therapy.

Always talk to your doctor before starting any treatment or combining treatments, to discuss which options may be best for you.

No matter how early doctors diagnose ovarian cancer, surgery is usually part of the treatment plan. The type of surgery performed will depend on how far the cancer has spread and your general health.

Surgery for most ovarian cancers has two main goals: staging the cancer and removing as much of the tumor as possible (a process called debulking). Staging the cancer is essential in order for the doctors to determine the best treatment and make a prognosis (a prediction of the course of the disease).

The types of surgery you may have include:

• Removal of one ovary: For early stage ovarian cancer that is limited to one ovary, your surgeon may remove just the affected ovary and the fallopian tube on that side. The ability to have children is preserved. 

• Removal of both ovaries: For cancer that’s in both ovaries but hasn’t spread beyond them, both ovaries and both fallopian tubes will be removed. Pregnancy is still possible with a frozen embryo or egg, or with an egg from a donor, since the uterus remains intact.

• Removal of both ovaries and the uterus: If the cancer is more extensive, or if you don’t plan to have children in the future, the surgeon may remove both ovaries, both fallopian tubes, the uterus, nearby lymph nodes, and a fold of fatty abdominal tissue called the omentum.

For advanced ovarian cancer, surgery will be performed to remove as much of the tumor as possible, with chemotherapy given before or after surgery (or both).

Surgery that leaves behind no visible cancer or reduces the tumor size to 1 centimeter or less is associated with a better prognosis.Chemotherapy uses powerful chemicals to kill fast-growing cells, including cancer cells, in the body. These drugs may be given as pills or an injection into a vein.Most people with ovarian cancer — those who have epithelial ovarian cancer, the most common kind — will receive two different chemotherapy drugs in combination: One is a type of drug called a platinum-based compound, usually cisplatin (Platinol) or carboplatin (Paraplatin), and the other is a category of drug called a taxane, such as paclitaxel (Taxol) or docetaxel (Taxotere).

These drugs are generally administered in three to six cycles of treatments, with a rest period between cycles.

Other chemotherapy drugs used to treat ovarian cancer include:

• paclitaxel protein-bound (Abraxane)

• altretamine (Hexalen)

• capecitabine (Xeloda)

• cyclophosphamide (Cytoxan)

• etoposide (Vepesid)

• gemcitabine (Gemzar)

• ifosfamide (Ifex)

• irinotecan (Camptosar)

• doxorubicin liposomal (Doxil)

• melphalan (Alkeran)

• pemetrexed (Alimta)

• topotecan (Hycamtin)

• vinorelbine (Navelbine)

Common side effects of chemotherapy include:

• Anemia

• Bleeding

• Constipation

• Diarrhea

• Fatigue

• Hair loss

• Infection

• Loss of appetite

• Nausea and vomiting

Intraperitoneal Chemotherapy

Some women with advanced ovarian cancer may be candidates for intraperitoneal (IP) chemotherapy, in which cisplatin and paclitaxel are injected into the abdominal cavity through a catheter (thin tube).Patients who might benefit from this treatment are those who have been diagnosed with stage 3 cancer (the cancer has not spread beyond the abdomen), with tumors that have been “optimally” debulked (meaning they are no larger than 1 centimeter after surgery).

IP chemotherapy directs a concentrated dose of drugs to the tumor site. Medication is also absorbed into the bloodstream and can attack cancer cells elsewhere in the body.

IP treatment seems to help some patients live longer. But it can also cause more extreme side effects than intravenous (IV) medication, such as abdominal pain, nausea, and vomiting.

Researchers are investigating the effectiveness of giving IP chemotherapy during surgery using heated drugs, known as heated intraperitoneal chemotherapy (HIPEC), or “hot” chemotherapy.In this procedure, surgeons remove all visible tumors, then pump chemotherapy medication, which has been heated to 103 degrees Fahrenheit, through the abdominal cavity. Surgeons physically rock the patient on the operating table to make sure the drug reaches all areas of the abdomen.Some research has shown that HIPEC can extend some patients’ lives. However, the use of this treatment remains controversial, and researchers are still investigating its effectiveness in treating ovarian cancer.Targeted therapy attacks cancer by focusing on traits that the cancer cells need to survive. Instead of killing cancer cells outright, as standard chemotherapy does, targeted drugs interfere with the way these cells function, which can ultimately cause them to die.

Targeted drugs used to treat ovarian cancer include bevacizumab, PARP inhibitors, antibody-drug conjugates, and drugs that target NTRK gene changes.

Bevacizumab

Bevacizumab (Avastin) works by attaching to a protein called VEGF, which is involved in the formation of new blood vessels, ultimately slowing or stopping the growth of cancer cells. It’s given as an IV infusion every two to three weeks.

Side effects of bevacizumab include fatigue, bleeding, high blood pressure, low white blood cell counts, headaches, mouth sores, loss of appetite, and diarrhea. Serious side effects include blood clots, severe bleeding, slow wound healing, and perforations in the colon.

PARP Inhibitors

PARP inhibitors work by preventing cancer cells from repairing their damaged DNA, leading to cancer cell death. PARP inhibitors used to treat ovarian cancer include:

• niraparib (Zejula)

• olaparib (Lynparza)

• rucaparib (Rubraca)

These drugs are given as pills. Side effects include nausea, vomiting, diarrhea, fatigue, loss of appetite, changes in taste, anemia, abdominal pain, and muscle and joint pain.

Antibody-Drug Conjugates

An antibody-drug conjugate is a laboratory-made antibody linked to a chemotherapy drug. The antibody targets a specific protein on cancer cells, delivering the chemotherapy drug directly to the cancer.

Mirvetuximab soravtansine (Elahere) is used to treat ovarian cancer that has high levels of the folate receptor-alpha (FR-alpha) protein and no longer responds to platinum-based chemotherapy drugs.

Elahere is given as an IV infusion, typically once every three weeks. Common side effects include fatigue, nausea, vomiting, diarrhea or constipation, abdominal pain, low blood cell counts, and changes in mineral levels in the blood. Serious side effects include eye problems, lung disease, and nerve damage.

Drugs Targeting NTRK Gene Changes

A small number of ovarian cancers have NTRK gene mutations. Two drugs used to stop the proteins made by these abnormal genes are:

• entrectinib (Rozlytrek)

• larotrectinib (Vitrakvi)

These drugs are given as pills to take by mouth, once or twice a day. Side effects include fatigue, dizziness, nausea, vomiting, diarrhea or constipation, and weight gain. Serious side effects include abnormal liver tests, heart problems, and confusion.

Immunotherapy stimulates a person’s own immune system to better identify and attack cancer cells.

Normal healthy cells use “checkpoint” proteins to turn on and off signals to start an immune response. These checkpoint proteins normally help stop your immune system from overreacting or damaging healthy cells. But cancer cells sometimes use checkpoint proteins to hide from the immune system. Checkpoint inhibitors are drugs that target the checkpoint proteins, allowing the immune system to mount an attack against the cancer cells.Pembrolizumab (Keytruda) is a checkpoint inhibitor that targets the PD-1 protein, and it’s used for certain types of advanced ovarian cancer.

Pembrolizumab is given as an IV infusion every three weeks. Side effects include fatigue, nausea, cough, itching, skin rash, loss of appetite, diarrhea or constipation, and joint pain. Serious side effects include infusion reactions, including fever, chills, dizziness, wheezing, and trouble breathing, and autoimmune reactions that may lead to organ damage.

• Ovarian cancer treatment usually starts with surgery, to stage the cancer and remove as much of the tumor as possible, followed by chemotherapy.

• Various treatment options, such as chemotherapy, targeted therapy, and immunotherapy, are used for ovarian cancer, but any treatment plan should be discussed thoroughly with your healthcare provider and tailored to your specific circumstances.

• The effectiveness of newer treatments, such as heated intraperitoneal chemotherapy, still requires more research and is being investigated.

Additional reporting by Pamela Kaufman and Julie Marks.