PALLIATIVE SURGERY. CHEMOTHERAPY
PALLIATIVE SURGERY
Most patients who are not cured of ovarian cancer develop intestinal obstruction as the terminal event of their disease process. It appears that 50-75% of these patients can undergo some type of palliative resection or bypass surgery. These patients will survive 4-6 months with the ability to eat. The mortality of surgery is 12-30%, and the rate of developing serious complications is 15-49%.
The patient and her family should be informed of the serious nature of the surgery and the limited success rate. However, for some patients, the ability to live at home for 4-6 months with the ability to eat a limited diet is sufficient reason to undertake the procedure. The recent improvements in the use of percutaneous gastrostomy make this surgery an acceptable alternative for many patients because they can have limited oral intake supplemented by intravenous fluids administered at home.
CHEMOTHERAPY
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Although surgery is an important aspect in the management of ovarian cancer, surgery alone is rarely curative and by itself will provide only brief palliation of advanced disease. Most patients with ovarian cancer require adjunctive chemotherapy. Fortunately, 75-80% of patients will respond to chemotherapy. Unfortunately, many patients develop resistance to chemotherapy before complete eradication of the cancer. For these patients, secondary or salvage chemotherapy is an important part of their treatment.
Primary Chemotherapy. In the 1960s, single alkylating agents were the chemotherapy of choice for epithelial ovarian cancer. The most commonly used drugs were melphalan and chlorambucil. Overall response rates were 45-55%, and complete clinical response was seen in 1520% of cases. In the 1970s, multidrug regimens resulted in an improvement in overall response rates as well as in complete clinical responses. The introduction of cisplatin in the late 1970s resulted in combination chemotherapy regimens that achieved overall response rates of 70-80% with complete clinical response rates of approximately 50%. The addition of cisplatin to multidrug regimen improves response rates and survival. Because of the ease of administration, most patients are treated with the combination of carboplatin and cyclophosphamide.
The Gynecologic Oncology Group recently reported the results of a randomized trial of cisplatin and paclitaxel in advanced epithelial ovarian cancer. In the trial, patients with stage III disease (tumors >1 cm) or stage IV disease received either cisplatin and cyclophosphamide or cisplatin and paclitaxel. There was a significant improvement in complete response rate, overall response rate, and disease-free survival for patients who received paclitaxel. Based on this study, the standard primary chemotherapy regimen for advanced ovarian cancer is cisplatin and paclitaxel. Several clinical trials are under way to define the best dose and duration of administration for paclitaxel. Other studies are evaluating the complications of carboplatin and paclitaxel. The Gynecologic Oncology Group has recently begun a trial of high-dose chemotherapy using paclitaxel, carboplatin, and melphalan with peripheral progenitor stem cell support.
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Salvage Chemotherapy. About 15-20% of patients with advanced epithelial ovarian cancer will be “cured” by initial surgery and primary chemotherapy. Most patients, however (75-80%), either will have residual disease at the conclusion of initial therapy or will develop recurrent disease. For these patients, salvage therapy will be required. The most important issues to consider are the size and location of the persistent disease and whether the patient responded to primary chemotherapy. The definition of “platinum or paclitaxel responder” requires the patient to have had an initial response to chemotherapy drugs and to have not developed regrowth of disease within 6 months.