Treatment for Ovarian Cancer

How do doctors decide on a treatment plan?

Doctors base treatment recommendations on several factors, including:

• Stage and grade
• Subtype
• Response of cancer to platinum chemotherapy (known as platinum sensitivity)
• Whether the cancer is newly-diagnosed or has recurred after one or more treatments
• Additional testing, including biomarkers and genetic testing for an inherited mutation

Make sure that you receive a copy of your cancer pathology report and test results. Ask your doctor to explain your diagnosis, stage, test results and treatment options in terms that you can understand. This will allow you to choose a treatment plan that is right for you. 

Treatment usually involves a combination of surgery and chemotherapy and may also include targeted or immunotherapy. You can read more about each below. Every treatment has potential risks and side effects. Before any new treatment or surgery, make sure your healthcare team tells you what to expect.

Surgery

A main goal of surgery for ovarian cancer is to remove all or as much of the cancer as is safely possible. Surgery may also be used to alleviate symptoms caused by the cancer. Surgery for ovarian cancer usually involves the removal of both ovaries and fallopian tubes, the uterus and the cervix. Depending on where the cancer has spread, the surgeon may also remove other abdominal tissue. This may include lymph nodes, the tissue around the large bowel called the omentum, sections of the bowel, bladder or other organs. 

• If all the visible cancer is removed during surgery, this is known as optimal debulking. Surgery also helps your doctor learn if the cancer has spread.  
• In some cases, chemotherapy is given before surgery to help make the tumor smaller to remove as much of the tumor as possible. This is known as neo-adjuvant chemotherapy. 

Timing of treatment

First-line therapy

The first medical treatment given is known as first-line treatment. Most people with high-grade and/or advanced ovarian cancer will receive chemotherapy as first-line treatment.

• Neoadjuvant chemotherapy is given before surgery to treat some advanced cancers. The goal is to shrink the tumors to help the surgeon remove as much of the cancer as possible. 
• Chemotherapy after surgery is used to prevent recurrence or to control the growth and spread of the cancer.
• Some people with advanced ovarian cancer will also receive immunotherapy or targeted therapy as part of their post-surgery treatment. 

Maintenance therapy

Maintenance therapy may be given to some people who experience a complete or partial response to chemotherapy to keep the cancer from coming back or growing. You can read more on maintenance therapy.

Second-line and later

People who have recurrence of their ovarian cancer after their initial treatment may receive additional chemotherapy, targeted therapy or immunotherapy depending on their initial response to treatment and the results of tumor biomarker testing. This is known as second-line treatment. For people whose cancer comes back or doesn't respond to second-line treatment, additional lines of treatment may be given.  

Chemotherapy

Ovarian cancer is usually treated with drugs known as platinum-based chemotherapy. Two common examples are carboplatin and cisplatin. A second type of chemotherapy, called a taxane, is usually combined with the platinum drug. Two common taxanes are paclitaxel and docetaxel.

Chemotherapy may be given in two different ways.

• Intravenous (IV) chemotherapy is injected into a vein. 
• Intraperitoneal (IP) chemotherapy is injected through a tube into the abdomen. Intraperitoneal therapy comes with additional side effects, and requires additional surgery to remove the port when chemotherapy is completed. 

Doctors use the response to chemotherapy for prognosis and treatment decisions if the cancer comes back.  

• Platinum-resistant cancers do not shrink during platinum chemotherapy, or they initially respond but come back within 6 months of treatment. 
• Platinum-sensitive cancers respond to platinum treatment and do not recur for at least six months or longer.   

What is targeted therapy?

Targeted therapy is a type of cancer treatment designed to attack or kill cancer cells, while sparing normal cells as much as possible. They are designed to target abnormal proteins, receptors or genes that are found in cancer cells or the surrounding tissue. Targeted therapies are used to treat advanced ovarian cancer. Types of targeted therapies most commonly used for ovarian cancer are:

• Avastin (bevacizumab)
• PARP inhibitors
• Antibody-drug conjugates (ADC)

Avastin 

Avastin is a medicine that helps treat ovarian cancer by blocking the blood supply that cancer needs to grow. It can be used together with chemotherapy, or sometimes after chemotherapy as a maintenance treatment. Sometimes, it’s also used with another medicine called Lynparza. You don’t need any special tests to receive Avastin to treat your  ovarian cancer.

PARP inhibitors 

PARP inhibitors work by blocking a protein used by cells to repair damage to their DNA. They were initially developed to treat cancers in people with an inherited BRCA1 or BRCA2 mutation. Over time, they have been found to be effective for treating ovarian cancer in people without mutations. Three PARP inhibitors are used to treat ovarian cancer:

• Lynparza (olaparib) 
• Rubraca (rucaparib)
• Zejula (niraparib) 

How PARP inhibitors are used in ovarian cancer

Lynparza, Rubraca and Zejula have all been approved for maintenance therapy after chemotherapy. Each has slightly different uses. Depending on the drug and situation, genetic testing or tumor testing may be needed before taking the drug. See the table below for more information about the indication for each. 

Research studies are looking at ways to further improve how these targeted therapies work for ovarian cancer patients. This includes: 

• developing new PARP inhibitors with fewer side effects. 
• combining PARP inhibitors with immunotherapy.
• developing ways to overcome resistance (when the drugs stop working) to treatment.

Antibody drug conjugates (ADCs)

Antibody-drug conjugates combine a targeted therapy with chemotherapy. The targeted portion of the drug attaches to cancer cells and delivers the chemotherapy directly into the cell. With regular chemotherapy, both healthy and cancer cells are exposed to the drug, which leads to many of the chemotherapy side effects. The goal of ACDs is to minimize exposure of normal cells to the toxic effects of the chemotherapy. The two ADCs most commonly used in ovarian cancer are:

• Enhertu (trastuzumab deruxtecan)
• Elahere (mirvetuximab soravtansine-gynx) 

Enhertu

Enhertu is a type of targeted therapy approved for treatment of advanced, platinum-resistant ovarian cancer if tumor testing shows a biomarker called HER2-positive. 

Elahere

Elahere may be used for recurrent ovarian cancer that tests positive for a biomarker known as FRα (folate receptor alpha).

Other targeted therapies

Below is a list of other targeted therapies that may be used to treat certain types of ovarian cancer, often after chemotherapy stops working. Some require testing for less-common  biomarkers which may be rare in ovarian cancer. 

• Vitrakvi (larotrectinib) is approved for treatment of cancers that are metastatic or cannot be removed with surgery and have worsened with other treatments. It targets a specific genetic change called an NTRK fusion. This type of genetic change is found in a range of cancers.
• Retevmo (Selpercatinib) if tumor testing is positive for a biomarker called RET gene fusion. 

Speak with your doctor if you have advanced ovarian cancer and you are not sure if you had biomarker testing, or if you don't understand your test results.

What is immunotherapy?

Immunotherapies are cancer treatments that help the body’s immune system detect and attack cancer cells. Immune checkpoint inhibitors are a type of immunotherapy used to treat several types of cancer, including some types of ovarian cancer. Some cancer cells can switch off the immune system. Immune checkpoint inhibitors are drugs that prevent this from happening. This allows the immune system to find, unmask and destroy cancer cells.

• Keytruda (pembrolizumab) is an immune check point inhibitor approved for treatment of metastatic cancer with a biomarker known as MSI-high (or dMMR). Although this biomarker is not common in ovarian cancer, it is often seen in people with a Lynch syndrome gene mutation who develop cancer. It is also approved for treating people with a biomarker known as TMB-high. 
• Jemperli (dostarlimab) is an immunotherapy approved for treatment of metastatic cancer with a biomarker known as MSI-high (or dMMR). Although this biomarker is not common in ovarian cancer, it is often seen in people with a Lynch syndrome gene mutation who develop cancer.

See our Immunotherapy section for more information. 

What is maintenance therapy?

Maintenance therapy may be given to some people after they complete chemotherapy treatment to decrease the chance that the cancer will come back, or to delay the cancer from coming back. Two types of targeted therapies are used for maintenance therapy, Avastin (bevacizumab) and PARP inhibitors.

The choice of maintenance therapy for ovarian cancer depends on a few factors:

• Whether you were initially treated with chemotherapy alone or chemotherapy plus Avastin:  Avastin may be used as maintenance therapy in women who received the drug as part of their initial treatment.  
• How well your cancer responded to chemotherapy: maintenance therapy is used for women whose cancer disappeared (complete response) or shrank (partial response) during their most recent chemotherapy treatment.
• How many previous lines of chemotherapy treatment you have received: first-line or front-line is the first treatment given; second-line is used if the cancer returns; if the cancer comes back again, the next treatment regimen is called third-line, etc.
• Results of genetic testing for an inherited mutation: some maintenance therapy regimens are approved for women with an inherited mutation in BRCA1 or BRCA2.
• Results of tumor testing: some maintenance therapies are approved for women with a tumor mutation in BRCA1 or BRCA2 or a tumor biomarker called HRD-positive.

Avastin for maintenance therapy

Avastin may be used as maintenance therapy for people who received Avastin with chemotherapy as part of their initial treatment and had a complete or partial response. There are two ways that Avastin may be used for maintenance therapy:

• As first-line or later-line maintenance therapy used alone. Women do not need to have an inherited or tumor mutation or any type of biomarker test in order to receive maintenance treatment with Avastin alone. 
• As first-line maintenance therapy combined with the PARP inhibitor Lynparza in people with a BRCA1 or BRCA2 inherited or tumor mutation or in women whose tumor is HRD-positive. 

PARP inhibitors for maintenance therapy

PARP inhibitors are a type of targeted therapy that can be used as treatment or as maintenance after treatment. PARP inhibitors are only used for maintenance therapy to treat people who had a complete or partial response to their most recent treatment with chemotherapy. Three PARP inhibitors have received FDA approval for ovarian cancer maintenance therapy:

• Lynparza (olaparib)
• Rubraca (rucaparib)
• Zejula (niraparib)

First-line maintenance therapy

• Lynparza may be used alone or in combination with Avastin as maintenance therapy for women with an inherited BRCA mutation or a BRCA mutation in their tumor.
• Lynparza may also be used in combination with Avastin (see above) for women whose tumor is HRD-positive. 
• Zejula is approved to be used as maintenance therapy for any woman regardless of her BRCA or HRD status. 

Second-line or higher 

• Lynparza may be used as maintenance therapy for women with ovarian cancer who have received two or more lines of chemotherapy who had either a complete or partial response to the most recent line of recurrence therapy. Lynparza may be given to people with an inherited BRCA mutation (found through genetic testing) or a tumor BRCA mutation (found through biomarker testing). 

Treatment side effects

Your healthcare team should explain what you should expect from all treatments, including:

• all of the possible risks and side effects of each treatment.
• which side effects may be serious and how to tell. 
• when and who you should call if you experience a side effect.
• what can be done to treat or alleviate each side effect. 

Make sure you let your healthcare team know if you experience any side effects of your treatment. For more information about possible treatment side effects, see our section on Cancer Treatment by Treatment Type.