Ovarian cancer treatment: understanding key decisions

Surgery: a specialized and regulated procedure

Ovarian cancer surgery aims to remove all visible lesions. In its standard form, it includes the removal of both ovaries, the fallopian tubes, the uterus, and the omentum, a fatty membrane in the abdominal cavity that is frequently affected. Depending on the extent of peritoneal carcinomatosis, other structures may be involved (portions of the colon or bladder): this is what makes this a complex procedure, distinct from routine gynecological surgery.

The surgical approach depends primarily on the stage of the disease. Laparotomy (abdominal incision) remains the standard approach for advanced stages. Laparoscopy may be considered for certain early stages.

The complexity of this surgery warrants that it be entrusted to a specialized gynecologic oncologist within a center that has the required expertise. Decree No. 2022-689 of April 26, 2022, regulates the authorizations for facilities permitted to perform these procedures by imposing criteria for specialization and a minimum annual volume of activity.

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Starting with surgery or chemotherapy: a defining decision

This is one of the first major decisions after diagnosis, and it is not the same for every patient. Two strategies are possible:

• Primary surgery : considered when lesions are accessible and their complete removal is technically feasible from the outset. It is preferred when the patient's general health allows for it. ‍
• Neoadjuvant chemotherapy (before surgery): offered when lesions are too extensive for complete removal right away, or when the patient's general condition does not allow for immediate major surgery. Surgery is then performed after 3 to 4 cycles of chemotherapy: this is known as interval surgery.

The criteria guiding this choice include the extent of peritoneal carcinomatosis as assessed by imaging and laparoscopy, the patient's nutritional and general health, and the center's expertise.

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It is perfectly reasonable to want to understand why this sequence was chosen for your situation. A second opinion can help ensure that this decision is based on all the information in your medical file, without calling into question the approach recommended by your care team.

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Chemotherapy and targeted therapies: drug treatment

Standard chemotherapy combines two drugs: carboplatin and paclitaxel, administered via intravenous infusion over several cycles (usually 6). This protocol is used in the neoadjuvant setting (before surgery) and then in the adjuvant setting (after), depending on the chosen strategy.

Depending on the tumor's genetic profile and the response to initial treatment, maintenance therapies may be offered after chemotherapy. Their goal is to reduce the risk of recurrence:

• PARP inhibitors (olaparib, niraparib): reserved for patients whose tumor has a BRCA1/BRCA2 mutation or homologous recombination deficiency (HRD). These oral medications block a DNA repair mechanism that tumor cells rely on. ‍
• Bevacizumab (anti-angiogenic): blocks the tumor's blood supply. Used in combination with chemotherapy and then as maintenance therapy for certain profiles, based on criteria defined by a multidisciplinary team (MDT). ‍
• Hyperthermic Intraperitoneal Chemotherapy (HIPEC) : a specialized surgical technique that involves instilling heated chemotherapy directly into the abdominal cavity at the end of the procedure. It is performed for specific indications in expert centers and is validated by an MDT.

For rare low-grade forms (low-grade serous tumors, less aggressive endometrioid forms), hormone therapy may be considered. Immunotherapy is not used in standard practice for this cancer; it is currently the subject of ongoing clinical trials.

In the event of a recurrence, treatment options are re-evaluated by an MDT based on the time elapsed since the end of the initial treatment and the tumor's profile. This is often a time when an additional expert opinion can help explore all available options, including eligibility for a clinical trial.

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Fertility preservation: an urgent decision to address from the start

Standard surgery for ovarian cancer involves the removal of both ovaries, the fallopian tubes, and the uterus, making any future pregnancy impossible. For young women who wish to keep their options for motherhood open, this question should be raised during the very first consultation, before the surgical strategy is finalized.

In very specific cases (stage IA, low-grade, compatible histological type), conservative treatment may be discussed: this may allow for the preservation of the uterus and the unaffected contralateral ovary. This option is not applicable in the majority of situations.

At the same time, an oncofertility consultation can be offered before treatment begins to evaluate available preservation options: cryopreservation of oocytes, ovarian cortex, or embryos. This type of consultation is organized quickly and does not delay the start of treatment.

If this is a concern for you, a second opinion before surgery can help ensure that all options have been considered for your specific situation.

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