How is recurrent ovarian cancer treated?

Updated: Aug 10, 2020
  • Author: Andrew E Green, MD; Chief Editor: Yukio Sonoda, MD  more...
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Answer

In most patients who present with advanced epithelial ovarian cancer, the disease recurs, and the prognosis for these patients is poor. Treatment of recurrent disease may involve surgery, chemotherapy, and radiation. If a localized mass is present, surgery may play a role prior to the initiation of further chemotherapy. Participation in clinical trials should be considered. 

Recurrent ovarian cancer is classified into two categories, depending on the length of time the patient remained disease-free after completing chemotherapy: (1) relapse that occurs more than 6 months after initial chemotherapy is considered platinum-sensitive; (2) earlier relapse is considered platinum-resistant.

Patients with platinum-sensitive disease may exhibit a good response if rechallenged with a platinum-based regimen. [95, 96]  The probability of response increases with the duration of the disease-free interval. For platinum-sensitive recurrent disease, National Comprehensive Cancer Network (NCCN) guidelines recommend any of the following as preferred regimens [45] :

  • Carboplatin or cisplatin plus gemcitabine
  • Carboplatin plus liposomal doxorubicin, with or without bevacizumab
  • Carboplatin plus paclitaxel, with or without bevacizumab

The addition of gemcitabine to carboplatin plus paclitaxel did not improve overall survival or progression-free survival; therefore, it is not a good candidate for a third non–cross-resistant drug in the treatment of advanced ovarian cancer. [99]  In a phase III randomized study, topotecan and cisplatin followed by carboplatin and paclitaxel were more toxic and without improved efficacy. [83]

A study by Joly et al found that pegylated liposomal doxorubicin with carboplatin instead of paclitaxel was associated with a low rate of hypersensitivity reaction among patients with relapsed ovarian cancer. [100]  

Single-agent therapy is usually given for recurrent disease, although bevacizumab may be added in some cases. [45]  Agents that may elicit a response in patients whose disease is resistant to platinum-based therapies include the following:

  • Liposomal doxorubicin
  • Topotecan
  • Oral etoposide
  • Gemcitabine
  • Docetaxel
  • Vinorelbine
  • Ifosfamide
  • 5-fluorouracil (with leucovorin)
  • Altretamine (Hexalen)
  • Tamoxifen (an oral antiestrogen that exhibits modest activity but has a favorable toxicity profile)

A randomized multicenter phase II trial of the North-Eastern German Society of Gynecological Oncology Ovarian Cancer Study Group indicated similar effectiveness and less toxicity in platinum-resistant recurrent ovarian cancer for weekly topotecan compared with conventional 5-day schedules. [101]  

A study by Haldar et al found that epithelial growth factor inhibitors, including pertuzumab, may add activity to standard chemotherapy in women with platinum-resistant ovarian cancer. [102]

Samples of recurrent tumor or ascitic fluid can be sent to one of several laboratories for chemotherapeutic assay. This assay involves culturing tumor cells in media containing a range of chemotherapy agents. This allows selection of chemotherapy agents with the greatest potential for activity and avoidance of those associated with extreme resistance.

Single agents available for targeted therapy include PARP inhibitors.


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