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NCCN Guidelines for Patients® Version 1.2015
Ovarian Cancer
Presented with support from:
Available online at NCCN.org/patients

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NCCN Guidelines for Patients® Version 1.2015
Ovarian Cancer
NCCN Foundation® gratefully acknowledges support from the following individuals
NCCN and NCCN Foundation Boards of Directors
Anonymous Lisle M. Nabell, MD

Barbara Parker, MD Lori C. Pickens, MHA
Brian Garofalo Mara G. Bloom, JD, MS
David S. Ettinger, MD, FACP, FCCP Mark F. Kochevar and Barbara Redmond
Denise K. Reinke, MS, NP Michael and Gwyneth Neuss
Douglas W. and Victoria C. Blayney Michael Parisi, MBA, MA
Dr. and Mrs. David G. Pfister Myra Tanita, MHA
Dr. and Mrs. Thomas D’Amico Paul F. Engstrom, MD, FACP
Dr. and Mrs. Timothy J. Eberlein Peter F. Coccia, MD
Drs. Al B. Benson III and Alanah Fitch Ray Lynch, CPA, MBA
Frederick Groves Rebecca Caires, MBA
Gena Cook Robert C. Young, MD
Honorable Ellen Tauscher Terry S. Langbaum
John A. Gentile, Jr. Thomas J. Lynch, Jr., MD
John S. Greene Warren Smedley, MSHA
Joshua and Stephanie Bilenker
NCCN and NCCN Foundation Staff Contributing $100 or More
C. Lyn Fitzgerald, MJ Linda L. Leach

Christine MacCracken, MSHEd, BSN Lisa G. Kimbro, MBA, CPA
Diane E. Paul, MS, RN Marcie Reeder, MPH
Gary J. and Marianne Weyhmuller, MBA Michele A. Connelly, CFRE
Joan S. McClure Robert W. Carlson, MD
Kristina M. Gregory, RN, MSN, OCN
An additional fifty-three (53) donations were received from other staff members.
NCCN Guidelines for Patients®

Ovarian Cancer, Version 1.2015
Introduction
Ovarian Cancer
Learning that you have ovarian cancer can be overwhelming. The goal of this
book is to help you get the best care. It explains which tests and treatments
are recommended by experts in ovarian cancer.
The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit

alliance of 26 of the world’s leading cancer centers. Experts from NCCN®
have written treatment guidelines for doctors who treat ovarian cancer. These
treatment guidelines suggest what the best practice is for cancer care. The
information in this patient book is based on the guidelines written for doctors.
This book focuses on the treatment of ovarian cancer. Key points of this
book are summarized in the NCCN Quick Guide™ series for Ovarian
Cancer. NCCN also offers patient resources on breast cancer, kidney cancer,
melanoma, and many other cancer types. Visit NCCN.org/patients for the
full library of patient books, summaries, as well as other patient and caregiver
resources.

1
Credits
NCCN aims to improve the care given to patients with cancer. NCCN staff work with experts to create helpful programs and resources for many
stakeholders. Stakeholders include health providers, patients, businesses, and others. One resource is the series of books for patients called
the NCCN Guidelines for Patients®. Each book presents the best practice for a type of cancer. The patient books are based on clinical practice
guidelines written for cancer doctors. These guidelines are called the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Clinical
practice guidelines list the best health care options for groups of patients. Many doctors use them to help plan cancer treatment for their patients.
Panels of experts create the NCCN Guidelines®. Most of the experts are from NCCN Member Institutions. Panelists may include surgeons,
radiation oncologists, medical oncologists, and patient advocates. Recommendations in the NCCN Guidelines are based on clinical trials and the
experience of the panelists. The NCCN Guidelines are updated at least once a year. When funded, the patient books are updated to reflect the
most recent version of the NCCN Guidelines for doctors. For more information about the NCCN Guidelines, visit NCCN.org/clinical.asp.
NCCN staff involved in making the guidelines for patients and doctors include:
NCCN Guidelines for Patients NCCN Guidelines NCCN Marketing
Dorothy A. Shead, MS, Director Jennifer Burns Susan Kidney, Graphic Design Specialist
Patient and Clinical Information Operations Guidelines Coordinator
NCCN Drugs & Biologics Programs
Laura J. Hanisch, PsyD, Medical Writer/ Miranda Hughes, PhD
Rachael Clarke, Medical Copyeditor
Patient Information Specialist Oncology Scientist/Senior Medical Writer
Lacey Marlow
Associate Medical Writer
Sponsored in part by
NATIONAL OVarian Cancer COALITION
The National Ovarian Cancer Coalition is pleased to have provided part of the critical funding necessary
to ensure the production of the NCCN Patient Guidelines for Ovarian Cancer. These Guidelines are an
important resource that informs patients and promotes best practices for healthcare professionals, and aligns
with our mission “to save lives by fighting tirelessly to prevent and cure ovarian cancer and to improve the
quality of life for survivors.” For support or more information about our history and ground-breaking work to
empower the community, please visit www.ovarian.org or call us at 1-888-OVARIAN.
Endorsed by
Ovarian Cancer National Alliance FOUNDATION FOR Women’s CANCER
As an organization that advocates to ensure that every patient with The Foundation for Women’s Cancer, the only national organization
ovarian cancer has the same access to the standard of care, the encompassing all gynecologic cancers including ovarian cancer, is
Ovarian Cancer National Alliance is proud to support this resource for pleased to support this comprehensive resource for patients and their
patients and their families that helps them navigate treatment choices. families. It is especially important for women to be aware of their risks
ovariancancer.org/ and symptoms for this cancer, as well as treatment options, including
care by a gynecologic oncologist. foundationforwomenscancer.org
Supported by NCCN Foundation®
The NCCN Foundation supports the mission of the National Comprehensive Cancer Network® (NCCN®)
to improve the care of patients with cancer. One of its aims is to raise funds to create a library of books for
patients. Learn more about the NCCN Foundation at NCCN.org/foundation.
© 2015 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines for Patients® and illustrations
herein may not be reproduced in any form for any purpose without the express written permission of NCCN.
National Comprehensive Cancer Network (NCCN)

275 Commerce Drive • Suite 300
Fort Washington, PA 19034
215.690.0300

2
Contents
Ovarian Cancer
4 How to use this book 71 Part 6
Making treatment decisions
5 Part 1 Offers tips for getting a treatment plan that
Ovarian cancer basics meets all your needs.
Explains where ovarian cancer starts,
how it spreads, and the symptoms it may 81 Glossary:
cause. 82 Dictionary
88 Acronyms
13 Part 2
Testing for ovarian cancer 91 NCCN Panel Members
Describes the tests doctors use to find and
confirm (diagnose) ovarian cancer and 92 NCCN Member Institutions
plan treatment.
94 Index
23 Part 3
Cancer staging
Explains how doctors assess and rate the
extent of ovarian cancer in your body.
31 Part 4
Overview of cancer
treatments
Describes the treatments that are used for
ovarian cancer.
43 Part 5
Treatment guide
Presents the recommended course of
action from diagnosis to after cancer
treatment.

3
How to use this book
Who should read this book? Making sense of medical

terms
This book is about treatment for epithelial
ovarian cancer—the most common type of IIn this book, many medical words are included
ovarian cancer. It also discusses treatment for that describe cancer, tests, and treatments.
ovarian low malignant potential tumor, also These are words that you will likely hear from
called borderline epithelial ovarian cancer. your treatment team. Some of this information
Patients and those who support them— may be new to you, and it may be a lot to learn.
caregivers, family, and friends—may find this
book helpful. It may help you talk with your Don’t be discouraged as you read. Keep reading
treatment team, understand what doctors say, and review the information. Be sure to ask your
and prepare for treatment. treatment team to explain a word or phrase that
you don’t understand.
Does the whole book Words that you may not know are defined in the
apply to me? text or in the Dictionary. Words in the Dictionary
are underlined when first used on a page.
This book includes important information for Acronyms are defined in the text when first used
many situations. Thus, you will likely not get and are also defined in the Glossary. Acronyms
every test and treatment listed. Your treatment are words formed from the first letters of other
team can point out what applies to you and give words. One example is CBC for complete blood
you more information. As you read through this count.
book, you may find it helpful to make a list of
questions to ask your doctors.
The recommendations in this book are based

on science and the experience of NCCN
experts. However, each patient is unique and
these specific recommendations may not be
right for you. Your doctors may suggest other
tests or treatments based on your health and
other factors. This book does not replace the
knowledge and suggestions of your doctors.

4
1
Ovarian cancer basics

5
1 Ovarian cancer
basics
7 What are the ovaries?
8 How does ovarian cancer start?
10 How does ovarian cancer spread?
11 Symptoms of ovarian cancer
12 Review
Learning that you have cancer can

be overwhelming and confusing.
Part 1 explains some basics about
ovarian cancer that may help you
better understand this disease.
These basics may also help you start
planning for treatment.

6
1 Ovarian cancer basics What are the ovaries?
What are the ovaries? The ovaries make eggs for reproduction (making
babies). They also make female hormones that affect
The ovaries are a pair of organs that are part of breast growth, body shape, and the menstrual cycle.
the reproductive system in women (females). The Eggs pass out of the ovary and travel through the
reproductive system is the group of organs that work attached fallopian tube into the uterus. The uterus
together to make babies. In women, this system is where babies grow during pregnancy. It is also
includes the ovaries, fallopian tubes, uterus, cervix, called the womb. At least one ovary and a uterus are
and vagina. needed for a woman to have a menstrual cycle and
be able to become pregnant.
Each ovary is about the size and shape of a grape.
They are located in the pelvis—the area below the
belly (abdomen) between the hip bones. One ovary is
on the left side of the uterus and one is on the right.
Each ovary is connected to the uterus by a long, thin
tube called a fallopian tube. See Figure 1.1.
Figure 1.1
The female reproductive system
The reproductive system is a group of organs that work together to make babies. The female
reproductive system includes the ovaries, fallopian tubes, uterus, cervix, and vagina.
Fallopian tube
Uterus Fallopian tube
Ovary
Ovary
Cervix
Vagina
Illustration Copyright © 2015 Nucleus Medical Media, All rights reserved. www.nucleusinc.com

7
1 Ovarian cancer basics How does ovarian cancer start?
How does ovarian cancer start? Cancer cells make new cells that aren’t needed
and don’t die quickly when old or damaged. Over
Cancer is a disease of cells—the building blocks that time, cancer cells grow and divide enough to form a
form tissue in the body. Inside all cells are coded mass called a tumor. The first tumor formed by the
instructions for making new cells and controlling how overgrowth of cancer cells is called the primary tumor.
cells behave. These coded instructions are called
genes. Abnormal changes in genes can turn normal Types of ovarian cancer
ovarian cells into cancer cells. The ovaries are made up of three main types of cells:
epithelial cells, stromal cells, and germ cells. Cancer
Normal cells grow and divide to make new cells. New can start in each type of cell. Thus, there is more than
cells are made as the body needs them to replace one type of ovarian cancer.
injured or dying cells. When normal cells grow old
or get damaged, they die. Cancer cells don’t do this.
The changes in genes cause cancer cells to make too
many copies of themselves. See Figure 1.2.
Figure 1.2 Normal cell growth Cancer cell growth

Normal versus cancer cell
growth No cell death
Normal cells divide to make Cell death

new cells as the body needs
them. Normal cells die once
they get old or damaged.
Cancer cells make new cells
Healthy cell
that aren’t needed and don’t
die quickly when old or
damaged. Injured cell Uncontrolled
cell growth

8
1 Ovarian cancer basics How does ovarian cancer start?
Most ovarian cancers start in the epithelial cells. This cancer. LMP tumors don’t grow into the supporting
is called epithelial ovarian cancer. Epithelial cells form tissue of the ovary. The tumor cells may spread and
the outer layer of tissue around the ovary. This layer grow on the surface of nearby organs and tissues.
of tissue is called the epithelium. See Figure 1.3. But, they almost never grow into (invade) tissue the
About 90 out of 100 ovarian cancers are epithelial way fully cancerous cells do.
ovarian cancer. Because it is the most common type,
it is often simply referred to as ovarian cancer. Less common types of ovarian cancer include stromal
tumors and germ cell tumors. Stromal tumors start in
Ovarian LMP (low malignant potential) tumor also stromal cells of the ovary. Germ cell tumors start in
starts in the epithelial cells. It is a rare type of germ cells. These two tumors are very rare and are
epithelial ovarian cancer. This type of tumor is formed not discussed in this book.
by abnormal cells that aren’t clearly cancer cells.
Thus, it is also called borderline epithelial ovarian
Figure 1.3
Epithelial ovarian cancer
Most ovarian cancers

start in the epithelial
cells. Epithelial cells form
the outer layer of tissue Epithelium
around the ovary. This Ovary
layer of tissue is called the
epithelium. Cancer that
starts in these cells is called
epithelial ovarian cancer.
Epithelial tumor

9
1 Ovarian cancer basics How does ovarian cancer spread?
How does ovarian cancer

spread?
Figure 1.4 Lymph vessels and nodes
Cancer cells act differently than normal cells in three
key ways. First, cancer cells grow without control. Lymph vessels and nodes are found all over the
Unlike normal cells, cancer cells make new cells that body. Lymph nodes are small groups of special
aren’t needed and don’t die when they should. The disease-fighting cells. Lymph nodes are connected
to each other by a network of small tubes called
cancer cells build up to form a primary tumor. lymph vessels.
Second, cancer cells can grow into (invade) other

tissues. This is called invasion. Normal cells don’t
do this. Over time, the primary tumor can grow large
and invade tissues outside the ovary. Ovarian cancer
often invades the fallopian tubes and uterus.
Third, cancer cells don’t stay in one place as they

should. Unlike normal cells, cancer cells can spread
to other parts of the body. This process is called
metastasis. Ovarian cancer cells can break off
(shed) from the primary tumor to form new tumors
on the surface of nearby organs and tissues. These
are called “implants” or “seeds.” Implants that grow
into supporting tissues of nearby organs are called
invasive implants.
Cancer cells can also spread through blood or lymph

vessels. Lymph is a clear fluid that gives cells water
and food. It also has white blood cells that help fight
germs. It travels in small tubes (vessels) to lymph
nodes. Lymph nodes are small groups of disease-
fighting cells that remove germs from lymph. Lymph
vessels and nodes are found all over the body. See
Figure 1.4.
The uncontrolled growth, invasion, and spread of

cancer cells makes cancer dangerous. But, ovarian
LMP tumors are less dangerous than other forms of
epithelial ovarian cancer. This is because LMP tumors
grow on the surface of organs and rarely grow into
(invade) normal tissue.
Illustration Copyright © 2015 Nucleus Medical Media, All rights
reserved. www.nucleusinc.com

10
1 Ovarian cancer basics Symptoms of ovarian cancer
Symptoms of ovarian cancer Your doctor may suspect ovarian cancer based on
these signs and symptoms. But, many other health
One way to find ovarian cancer early is to know conditions could be the cause. Therefore, your doctor
the symptoms of the cancer. Symptoms are health will give more tests and exams to confirm or rule out
problems that you report to your doctor. Doctors ovarian cancer. This is described next in Part 2.
have outlined a set of symptoms that are often seen
in women with ovarian cancer. Ovarian cancer may
cause certain symptoms early or as it grows larger.
“ There was very little information available
The most common symptoms of ovarian cancer when I was diagnosed 11 years ago. Even
include: though I was a nurse, with the shock of
that diagnosis, I found it difficult to even
• Feeling bloated,
• Pain in the pelvis or belly (abdomen), know what questions to ask. This guide is
• Trouble eating or feeling full fast, and so valuable for a newly-diagnosed woman,
• Feeling the need to urinate often or urgently.
her family, and support team. An informed
These symptoms can also be caused by many other patient will be less fearful and better able
common health conditions. But, ovarian cancer is to work with her health care providers to
more likely to be the cause of these symptoms if they
promote a more successful outcome.”
are:
- Nancy, CRNP, Survivor
• New – began less than 1 year ago, and
• Frequent – occur more than 12 days each
month.
If this describes you, tell your doctor about your

symptoms. However, ovarian cancer does not always
cause symptoms. Or, ovarian cancer may not cause
symptoms until it has grown very large or has spread.
Your doctor may also think you have ovarian cancer

based on certain signs. Signs of ovarian cancer
include feeling a mass in your pelvis or fluid buildup in
your abdomen. Your doctor may feel a mass in your
pelvis because of a tumor or enlarged ovary. Ovarian
cancer can also cause excess fluid buildup (ascites)
in your pelvis and abdomen. This can cause swelling
and make your abdomen look or feel enlarged.

11
1 Ovarian cancer basics Review
Review
• The ovaries are a pair of organs that make • Cancer cells form a tumor since they don’t die
eggs for reproduction (making babies). They as they should.
also make hormones.
• Cancer cells can break away from the first
• Ovarian cancer often starts in the cells that (primary) tumor and spread to other tissues
form the outer layer of tissue around the and organs in the body.
ovaries. This is called epithelial ovarian
• Ovarian cancer may cause symptoms such
cancer.
as: feeling bloated, pain in the belly or pelvis,
• Ovarian LMP (low malignant potential) tumor trouble eating, and needing to urinate often or
is formed by abnormal cells that aren’t clearly urgently.
cancer cells.

12
2
Testing for ovarian cancer

13
2 Testing for ovarian
cancer
14 General health tests
16 Imaging tests
20 Blood tests
21 Tissue tests
22 Review
General health tests

Part 2 describes the tests that are
Medical and family history
recommended for ovarian cancer. Your medical history includes any health events in
These tests are used to find and your life and any medications you’ve taken. Your
doctors will want to know about all your illnesses,
confirm (diagnose) ovarian cancer
symptoms, and any prior tests or surgeries. It may
and plan treatment. They are also help to make a list of old and new medications while
used to monitor your health and at home to bring to your doctor’s office.
check treatment results. Ovarian cancer and other health conditions can run
in families. Therefore, your doctors will also ask
about the medical history of your blood relatives. It’s
Your doctor may suspect ovarian cancer if you have important to know who in your family has had what
certain symptoms. Or, ovarian cancer may have diseases. It’s also important to know at what ages the
been found by a prior surgery. To confirm (diagnose) diseases started. This information is called a family
ovarian cancer and plan treatment, a number of tests history.
are needed. Chart 2.1 lists the different types of tests
that are used for ovarian cancer. Read the next pages Genetic counseling and testing
to learn more about these tests, including when and Ovarian cancer often occurs for unknown reasons.
why each test is recommended. But, about 15 out of 100 ovarian cancers are due to
changes in genes that are passed down from a parent

14
2 Testing for ovarian cancer General health tests
to a child. This is called hereditary ovarian cancer. cancer. He or she may suggest genetic testing to look
Using your age, medical history, and family history, for changes in genes that increase the chances of
your doctor will assess how likely you are to have developing ovarian cancer.
hereditary ovarian cancer.
Hereditary ovarian cancer is most often caused by
NCCN experts also recommend genetic counseling changes (mutations) in the BRCA1 and BRCA2
for all women with ovarian cancer. Genetic counseling genes. When normal, these genes help prevent
is a discussion with a health expert about the risk for abnormal cell growth by fixing damaged cells. Genetic
a disease caused by changes in genes. This should testing can tell if you have a mutation in the BRCA
be led by someone with a lot of experience and genes or other genes.
expertise such as a genetic counselor.
Abdominal and pelvic exam
A genetic counselor has special training to help Doctors often give a physical exam along with taking
patients understand changes in genes that are related a medical history. A physical exam is a review of your
to disease. The genetic counselor can tell you more body for signs of disease. During this exam, your
about how likely you are to have hereditary ovarian doctor will listen to your lungs, heart, and intestines to
Chart 2.1 Tests for ovarian cancer
Type of test Recommended tests
• Family and medical history

General health tests • Genetic counseling and testing
• Abdominal and pelvic exam
• CBC (complete blood count)
Blood tests • Bloood chemistry profile with liver function tests
• CA-125 (cancer antigen 125) and other tumor markers
• Ultrasound
• CT (computed tomography) scan of the abdomen and pelvis
Imaging tests • MRI (magnetic resonance imaging) scan of the abdomen and pelvis
• Chest x-ray or other imaging tests of the chest
• GI (gastrointestinal) evaluation
• Biopsy
Tissue tests
• Review of tumor tissue

15
2 Testing for ovarian cancer Imaging tests
assess your general health. He or she will also look Imaging tests
at and touch parts of your body to check for abnormal
changes. Imaging tests take pictures (images) of the inside of
your body. Doctors use imaging tests to check if there
Your doctor will also give a physical exam of your is a tumor in your ovaries. The pictures can show
belly (abdomen) and pelvis—the area between your the tumor size, shape, and location. They can also
hip bones. This is called an abdominal and pelvic show if the cancer has spread beyond your ovaries.
exam. Different types of imaging tests are used to look for
ovarian cancer, plan treatment, and check treatment
For the abdominal exam, your doctor will feel different results.
parts of your belly. This is to see if organs are of
normal size, are soft or hard, or cause pain when Getting an imaging test is often easy. Before the test,
touched. Your doctor will also feel for signs of fluid you may be asked to stop eating or drinking for a few
buildup, called ascites. Ascites may be found in the hours. You may also need to remove metal objects
belly area or around the ovaries. from your body. The types of imaging tests used for
ovarian cancer are described next.
During the pelvic exam, your doctor will feel for
abnormal changes in the size, shape, or position Ultrasound
of your ovaries and uterus. A special widening An ultrasound is a test that uses sound waves to
instrument will be used to view your vagina and take pictures of the inside of the body. It is often the
cervix. A sample may be taken for a Pap test at this first imaging test given to look for ovarian cancer.
time. Ultrasound is good at showing the size, shape, and
location of the ovaries, fallopian tubes, uterus, and
nearby tissues. It can also show if there is a mass in
the ovary and whether the mass is solid or filled with
fluid.
This test uses a hand-held device called an

ultrasound probe. The probe sends out sound waves
that bounce off organs and tissues to make echoes.
The probe also picks up the echoes. A computer
uses the echoes to make a picture that is shown on a
screen. There are two types of ultrasounds that may
be used to look for ovarian cancer: transabdominal
ultrasound and transvaginal ultrasound. See Figure
2.1.
For a transabdominal ultrasound, a gel will be spread

on the area of skin near your ovaries. This includes
your belly (abdomen) and the area between your hip
bones (pelvis). The gel helps to make the pictures
clearer. Your doctor will place the probe on your

16
skin and guide it back and forth in the gel. For a CT scan
transvaginal ultrasound, your doctor will insert the
probe into your vagina. This may help the doctor see A CT (computed tomography) scan uses x-rays to
your ovaries more clearly. take pictures of the inside of the body. It takes many
x-rays of the same body part from different angles. All
Ultrasounds are generally painless. But, you may the x-ray pictures are combined to make one detailed
feel a little discomfort when the probe is inserted for picture of the body part.
a transvaginal ultrasound. An ultrasound can take
between 20 and 60 minutes to complete. More or less A CT scan of your chest, abdomen, and/or pelvis
time may be needed depending on the area of your may be given along with other initial tests to look for
body being looked at. ovarian cancer. This type of scan is good at showing
if the cancer has spread outside of the ovaries. But,
it is not good at showing small tumors. A CT scan
may also show if nearby lymph nodes are bigger than
normal, which can be a sign of cancer spread.
Figure 2.1 Ultrasound
An ultrasound uses sound waves to make pictures of the inside of the body. An ultrasound probe
sends out the sound waves. For a transabdominal ultrasound, the probe will be placed on the skin of
your belly. For a transvaginal ultrasound, it will be inserted into your vagina.
Transabdominal ultrasound Transvaginal ultrasound
Ultrasound picture Ultrasound picture
Ultrasound probe
Sound waves
Ultrasound probe
Sound waves

17
Before the CT scan, you may be given a contrast dye

to make the pictures clearer. The dye may be put in a
glass of water for you to drink, injected into your vein, Figure 2.2 CT scan machine
or both. It may cause you to feel flushed or get hives.
Rarely, serious allergic reactions occur. Tell your A CT machine is large and has a tunnel in the middle.
During the test, you will lie on a table that moves
doctors if you have had bad reactions in the past.
slowly through the tunnel.
A CT scan machine is large and has a tunnel in the

middle. See Figure 2.2. During the scan, you will
need to lie face up on a table that moves through the
tunnel. The scanner will rotate an x-ray beam around
you to take pictures from many angles. You may hear
buzzing, clicking, or whirring sounds during this time.
One x-ray scan is completed in about 30 seconds.

But, the full exam may take 15 to 60 minutes
to complete. More or less time may be needed
depending on the part of your body being scanned.
A computer will combine all the x-ray pictures into
one detailed picture. You may not learn of the results
for a few days since a radiologist needs to see the
pictures. A radiologist is a doctor who’s an expert in
reading the pictures from imaging tests.
MRI scan
An MRI (magnetic resonance imaging) scan uses
radio waves and powerful magnets to take pictures
of the inside of the body. It does not use x-rays. This
type of scan is good at showing the spine and soft
tissues like the brain.
An MRI scan of your abdomen and pelvis may be

used to look for ovarian cancer if the ultrasound was
unclear. An MRI scan of your chest may be used to
look for signs of cancer spread. This test may also
be used to check treatment results and to assess for
cancer spread to other parts of the body.
Getting an MRI scan is similar to getting a CT scan.

But, MRI scans take longer to complete. The full
exam can take an hour or more. For the scan, you
will need to lie on a table that moves through a

18
large tunnel in the scanning machine. The scan may This imaging test uses a scope to see inside your GI
cause your body to feel a bit warm. Like a CT scan, tract. A scope is a long, thin tube that can be guided
a contrast dye may be used to make the pictures into your body, often through the mouth, anus, or a
clearer. You may not learn of the results for a few surgical cut. One end of the scope has a small light
days since a radiologist needs to see and interpret and camera lens to see inside your body. At the other
the pictures. end of the scope is an eyepiece that your doctor looks
through to see the pictures shown by the camera.
PET scan
A PET (positron emission tomography) scan shows
how your cells are using a simple form of sugar. To
create pictures, a sugar radiotracer first needs to be
put into your body with an injection into a vein. The
radiotracer emits a small amount of energy that is
detected by the machine that takes pictures. Active
cancer cells use sugar faster than normal cells. Thus,
cancer cells look brighter in the pictures.
PET is very good at showing small groups of cancer

cells. This test may also be useful for showing if
ovarian cancer has spread. Sometimes, PET is
combined with CT—called a PET/CT scan.
Chest x-ray
An x-ray uses small amounts of radiation to make
pictures of organs and tissues inside the body. A
tumor changes the way radiation is absorbed and
will show up on the x-ray picture. A chest x-ray can
be used to show if cancer has spread to your lungs.
This test may be given with other initial tests when
ovarian cancer is first suspected or found. It may also
be given after treatment to check treatment results. A
chest x-ray is painless and takes about 20 minutes to
complete.
GI evaluation
The GI (gastrointestinal) tract is made of the organs
that food passes through when you eat. This includes
your stomach, small intestine, large intestine, and
rectum. A GI evaluation is an imaging test that is used
to view your GI tract. This test may be used in certain
cases to check for signs of cancer spread.

19
2 Testing for ovarian cancer Blood tests
Blood tests Liver function tests

The liver is an organ that does many important jobs,
Doctors test blood to look for signs of disease and such as remove toxins from your blood. Liver function
assess your general health. These tests are not used tests measure chemicals that are made or processed
to confirm (diagnose) ovarian cancer. But, abnormal by the liver. Levels that are too high or low may be a
results may signal there’s a problem with certain sign of liver damage or cancer spread. Liver function
organs or body systems. Abnormal results may be tests are often done along with a blood chemistry
caused by ovarian cancer or other health conditions. profile.
Blood tests are given along with other initial tests
to assess for ovarian cancer. These tests may be CA-125 and other tumor markers
repeated to check how well cancer treatment is A tumor marker is a substance found in body tissue
working and to check for side effects. or fluid that may be a sign of cancer. CA-125 (cancer
antigen 125) is a tumor marker for ovarian cancer. It
For a blood test, your doctor will insert a needle into is a protein with sugar molecules attached to it that
your vein to remove a sample of blood. Blood is often is made by normal cells and ovarian cancer cells.
removed from a vein in the arm. The needle may High levels of CA-125 in the blood may be a sign of
bruise your skin and you may feel dizzy afterward. ovarian cancer or another health condition.
The blood sample will then be sent to a lab for testing.
The types of blood tests used for ovarian cancer are A CA-125 test measures the amount of CA-125 in
described next. the blood. This test is not used alone to diagnose
ovarian cancer. But, it may be done along with other
CBC initial tests if your doctor suspects ovarian cancer. It
A CBC (complete blood count) measures the number may also be done during and after treatment to check
of red blood cells, white blood cells, and platelets. treatment results.
Your doctor will want to know if you have enough red
blood cells to carry oxygen throughout your body,
white blood cells to fight infections, and platelets
to control bleeding. Your blood counts may be
abnormal—too low or too high—because of cancer or
another health problem.
Blood chemistry profile

A blood chemistry profile measures the levels of
different chemicals in your blood. Chemicals in your
blood come from your liver, bones, and other organs
and tissues. Doctors use this test to assess the health
of organs such as your liver and kidneys. Abnormal
levels—too high or too low—may be a sign that an
organ isn’t working well. Abnormal levels may be
caused by the spread of cancer or by other diseases.

20
2 Testing for ovarian cancer Tissue tests
Tissue tests
Biopsy
To confirm if you have ovarian cancer, a sample of
tissue must be removed from your body for testing.
This is called a biopsy. Doctors test tumor tissue to
check for cancer cells and to look at the features of
the cancer cells. Most often, the biopsy is done during
treatment with surgery to remove ovarian cancer. (For
surgery details, see Surgical staging in Part 3 and
Surgical treatment in Part 4.)
However, a biopsy may be done before treatment in

certain, rare cases. This may be done if the cancer
has spread too much to be removed by initial surgery.
In such cases, an FNA (fine-needle aspiration) biopsy
or paracentesis may be used. An FNA biopsy uses a
very thin needle to remove a small sample of tissue
from the tumor. For paracentesis, a long, thin needle
is inserted through the skin of the belly (abdomen) to
remove a sample of fluid.
The biopsy samples will be sent to a pathologist for

testing. A pathologist is a doctor who’s an expert in
testing cells to find disease. The pathologist will view
the samples with a microscope to look for cancer
cells. He or she will also assess the features of the
cancer cells.
Review of tumor tissue

Sometimes ovarian cancer is confirmed by a prior
surgery or biopsy performed by another doctor. In
this case, your cancer doctors will need to review
all of the prior results. This includes results of the
surgery, biopsy, and tests of tissue that was removed.
A pathologist will examine the tumor tissue with a
microscope to make sure it is ovarian cancer. Your
doctors will also want to know if the surgery left any
cancer in your body. All of this will help your current
doctors plan treatment.

21
2 Testing for ovarian cancer Review
Review
• Cancer tests are used to plan treatment. • Imaging tests can show if there is a tumor in
your ovaries and if the cancer has spread.
• Your medical and family history help inform
your doctor about your health. • Blood tests check for signs of disease.
• Genetic counseling may help you decide • A biopsy is the removal of samples of tissue to
whether to be tested for hereditary ovarian test for cancer cells.
cancer.
• A pelvic exam checks the health of your

ovaries and uterus.

22
3
Cancer staging

23
3 Cancer staging
24 Surgical staging
26 Staging systems
26 Ovarian cancer stages
29 Cancer grades and cell subtypes
30 Review
Surgical staging
Cancer staging is the process of
Cancer is often staged twice. The clinical stage
finding out how far the cancer has is based on tests done before surgery. It can give
grown and spread in your body. The your doctors an idea of how far the cancer may
have spread. But, to know the true extent of ovarian
cancer stage is a rating of the extent
cancer, surgery is needed. The pathologic stage is
of the cancer. Doctors use cancer based on the results of surgery and tests of tissue
staging to plan which treatments removed during surgery. It is the most important and
is used to plan treatment.
are best for you. Part 3 describes
the staging process and defines the During surgery to remove the cancer, your doctor
will perform a number of tests to find out exactly
stages of ovarian cancer.
how far it has spread. This is called surgical staging.
It is the most complete and accurate way to stage
ovarian cancer. NCCN experts recommend that this
surgery should be done by a gynecologic oncologist.
A gynecologic oncologist is a surgeon who’s an
expert in cancers that start in a woman’s reproductive
organs.
During surgical staging, your doctor will carefully

inspect tissues and organs near the tumor to see
where the cancer has spread. Some tissues will be
removed so they can be tested for cancer cells. This

24
3 Cancer staging Surgical staging
includes removing some or all of the omentum and • Pelvis – the area below the belly (abdomen)
nearby lymph nodes. Surgery to remove the omentum between the hip bones
is called an omentectomy. Surgery to remove nearby • Abdomen – the belly area between the chest
lymph nodes is called a lymph node dissection. Which and pelvis
surgical staging procedures you will have depends on • Diaphragm – the muscles below the ribs that
how far your doctors think the cancer has spread. help a person breathe
• Omentum – the layer of fatty tissue covering
Your doctor will also take biopsy samples from organs in the abdomen
nearby tissues where it looks like the cancer hasn’t • Peritoneum – the tissue that lines the inside
spread. This is done to check for cancer cells that of the abdomen and pelvis and covers most
have spread but can only be seen with a microscope. organs in this space
These are called microscopic metastases. Your • Ascites – abnormal fluid buildup in the
doctor will take samples from places where ovarian abdomen
cancer often spreads. See Figure 3.1. The number of
samples taken depends on how far your doctor thinks If you don’t have ascites, your doctor may “wash”
the cancer has spread. Biopsy sites may include the the space inside your belly (peritoneal cavity) with
following: a special liquid. This is called a peritoneal washing.
Samples of the liquid will then be tested for cancer
• Nearby lymph nodes – groups of special cells. These samples are called peritoneal washings,
disease-fighting cells but are often referred to as “washings.”
Figure 3.1
Possible biopsy sites in the abdomen and pelvis
Surgery is used for ovarian cancer staging. Biopsy samples will be taken from the tumor as well as
other organs and tissues near the ovaries. This may include the diaphragm, omentum, peritoneum,
ascites, and nearby lymph nodes.
Diaphragm
Omentum
Peritoneum
Ascites
Lymph nodes
Cancer in ovary

25
3 Cancer staging Staging systems | Ovarian cancer stages
Staging systems Ovarian cancer stages

A staging system is a standard way to describe the Ovarian cancers of the same stage tend to have
extent of cancer in the body. There are two staging a similar prognosis. A prognosis is the likely or
systems for ovarian cancer: the AJCC (American expected course and outcome of a disease. In
Joint Committee on Cancer) staging system and the general, earlier cancer stages have better outcomes.
FIGO (International Federation of Gynecology and But, doctors define cancer stages with information
Obstetrics) staging system. These staging systems from thousands of patients, so a cancer stage gives
are very similar. But, the FIGO system is used most an average outcome. It may not tell the outcome
often. for one person. Some people will do better than
expected. Others will do worse. Other factors not
In the FIGO system, the cancer stage is defined by used for cancer staging, such as your general
three main areas of cancer growth: health, are also very important.
• The extent of the first (primary) tumor, The stages of ovarian cancer are described next.
• The spread of cancer to nearby lymph The cancer stages are defined by the FIGO staging
nodes, and system.
• The spread of cancer to distant sites.
Stage I
The ovarian cancer stages are labeled by Roman The tumor (cancer) is only in the ovaries. Cancer
numerals I, II, III, and IV. The stages are also divided may be found in one or both ovaries. But, it has not
into smaller groups. This helps to describe the extent spread to any other organs or tissues in the body.
of cancer in more detail. The smaller groups are See Figure 3.2.
labeled by adding letters and numbers to the Roman
numerals. The next section describes each cancer
Figure 3.2 Stage I ovarian cancer
stage as defined by the FIGO staging system.
Stage I ovarian cancer is when cancer is only in the
ovaries and has not spread to other organs.
Derivative work of Diagram showing stage I ovarian cancer by Cancer

Research UK available at https://commons.wikimedia.org/wiki/
File%3ADiagram_showing_stage_1_ovarian_cancer_CRUK_193.svg
under a Creative Commons Attribution-Share Alike 4.0 International
license.

26
3 Cancer staging Ovarian cancer stages
Stage IA – Cancer is only in one ovary and the Stage II

tumor is contained inside the ovary. The outer sac Cancer is in one or both ovaries and it has spread to
(capsule) of the ovary is intact. There is no cancer other organs or tissues within the pelvis. Cancer has
on the outside surface of the ovary. No cancer cells not spread outside the pelvis or to any lymph nodes.
are found in ascites or washings. See Figure 3.3.
Stage IB – Cancer is in both ovaries. The capsules Stage IIA – Cancer has grown into and/or spread
are intact and there is no cancer on the outside implants on the uterus, fallopian tubes, or both.
surface of the ovaries. No cancer cells are found in
ascites or washings. Stage IIB – Cancer has grown into and/or spread
implants on other organs or tissues in the pelvis. This
Stage IC – Cancer is in one or both ovaries. And, may include the bladder, sigmoid colon, rectum, or
one or more of the following has happened: the peritoneum within the pelvis. The peritoneum is
the tissue that lines the inside of the abdomen and
• Stage IC1 – The capsule of the ovary broke pelvis and covers most organs in this space.
open (ruptured) during surgery. This is called
surgical spill.
• Stage IC2 – The capsule ruptured before
surgery, or cancer is on the outer surface of
the ovary.
• Stage IC3 – Cancer cells are found in ascites
or washings.
Figure 3.3 Stage II ovarian cancer
Stage II ovarian cancer is when the cancer has spread

to other organs or tissues in the pelvis.
Derivative work of Diagram showing stage 2A to 2C ovarian cancer

by Cancer Research UK available at https://commons.wikimedia.org/
wiki/File%3ADiagram_showing_stage_2A_to_2C_ovarian_cancer_
CRUK_214.svg under a Creative Commons Attribution-Share Alike 4.0
International license.

27
3 Cancer staging Ovarian cancer stages
Stage III Stage IV

Cancer in is one or both ovaries. It has spread Cancer has spread to distant sites in the body beyond
outside the pelvis to tissues in the belly (abdomen). the pelvis and abdomen. Cancer may have spread
And, one or both of the following has happened. to distant organs such as the lungs, brain, or skin. It
Cancer has spread to the tissue lining the inside of may have spread to the inside of the liver or spleen.
the abdomen (peritoneum). Cancer may have spread Cancer may have also spread to lymph nodes outside
to lymph nodes in the back part of the abdomen the abdomen—called distant lymph nodes. See
behind the peritoneum. See Figure 3.4. Figure 3.5.
Stage IIIA1 – Cancer has spread outside the pelvis, Stage IVA – Cancer cells are found in the fluid around
but only to lymph nodes in the back part of the the lungs—called pleural effusion. But, cancer has not
abdomen—called retroperitoneal lymph nodes. spread anywhere else outside the abdomen.
• Stage IIIA1 (i) – Cancer in the lymph nodes is Stage IVB – Cancer has spread to the inside of the
10 mm (millimeters) or smaller. liver or spleen, to distant lymph nodes, or to other
• Stage IIIA1 (ii) – Cancer in the lymph nodes organs outside the abdomen.
is larger than 10 mm.
Stage IIIA2 – Cancer has spread to the tissue lining

the abdomen, but it is so small it can only be seen Figure 3.4 Stage III ovarian cancer
with a microscope. Cancer may have also spread to
Stage III ovarian cancer is when the cancer has
lymph nodes in the back of the abdomen.
spread outside the pelvis to organs or tissues in the
abdomen.
Stage IIIB – Cancer has spread to the tissue
lining the abdomen and it can be seen without a
microscope. The areas of cancer spread are 2 cm
(centimeters) or smaller. Cancer may have also
spread to lymph nodes in the back of the abdomen.
Stage IIIC – Cancer has spread to the tissue

lining the abdomen and it can be seen without a
microscope. The areas of cancer spread are larger
than 2 cm. Cancer may have spread to lymph nodes
in the back of the abdomen. It may have also spread
to the outer surface of the liver or spleen.
Derivative work of Diagram showing stage 3A to 3C ovarian cancer

by Cancer Research UK available at https://commons.wikimedia.org/
wiki/File%3ADiagram_showing_stage_3A_to_3C_ovarian_cancer_
CRUK_225.svg under a Creative Commons Attribution-Share Alike 4.0
International license.

28
3 Cancer staging Cancer grades and cell subtypes
Cancer grades and cell Cancer grades

subtypes The cancer grade is a rating of how much the cancer
cells look like normal cells. The cancer grade is
Ovarian cancer is also classified based on what the a sign of how fast the cancer will likely grow and
cancer cells look like when viewed with a microscope. spread. Based on the features of the cancer cells, the
A pathologist will examine the cancer cells to find pathologist will score the cancer as Grade 1, 2, or 3.
out the cancer grade and cell subtype. A pathologist
is a doctor who’s an expert in testing cells with a • Grade 1 cancer cells look similar to normal
microscope to identify disease. Testing cancer cells cells. This is also called low grade. These
from tissue removed during surgery is the only way to cancer cells grow slowly and are less likely to
find out the cancer grade and cell subtype. spread.
• Grade 2 cancer cells look more abnormal
than Grade 1, but not as abnormal as Grade
3. These cancer cells grow at a medium
speed. They are more likely to spread than
Grade 1, but less likely than Grade 3.
• Grade 3 cancer cells look very different from
normal cells. This is also called high grade.
These cancer cells grow faster and are the
Figure 3.5 Stage IV ovarian cancer most likely to spread.
Stage IV ovarian cancer is when the cancer has

Some pathologists describe the grading in only two
spread outside the pelvis and abdomen to organs or
tissues far away in the body. classes: high grade or low grade. Low grade includes
the Grade 1 definition above. High grade includes the
Grade 2 and Grade 3 definitions.
Ovarian cancer cell subtypes

Ovarian cancer is divided (classified) into smaller
groups called cell subtypes. The cell subtype is based
on the features of the cancer cells. A pathologist will
view the cancer cells with a microscope to find out
the cell subtype. There are four main cell subtypes
of ovarian cancer. Serous is the most common. The
other main cell subtypes are mucinous, endometrioid,
and clear cell. However, all four subtypes are often
treated in the same way.
Derivative work of Diagram showing stage 4 ovarian cancer by

Cancer Research UK available at https://commons.wikimedia.org/wiki/
File%3ADiagram_showing_stage_4_ovarian_cancer_CRUK_233.svg
under a Creative Commons Attribution-Share Alike 4.0 International
license.

29
3 Cancer staging Review
Review
• Cancer staging is how doctors rate and • Ovarian cancer is staged during surgery to
describe the extent of cancer in the body. remove the cancer—called surgical staging.
• The cancer stage is a rating of how much the • The cancer grade is a rating of how much the
cancer has grown and spread. cancer cells look like normal cells.
• Ovarian cancer is grouped into stages to help • The cancer grade describes how fast or slow
plan treatment. the cancer will likely grow and spread.

30
4
Overview of cancer treatments

31
4 Overview of cancer
treatments
32 Surgical treatment
35 Chemotherapy
37 Targeted therapy
38 Hormone therapy
39 Clinical trials
42 Review
Surgical treatment
Part 4 describes the main types of
Surgery is used as the first and main (primary)
treatment for ovarian cancer. This treatment for most ovarian cancers. Primary
information may help you understand treatment is the main treatment given to rid the body
of cancer. NCCN experts recommend that ovarian
the treatment options listed in the
cancer surgery should be performed by a gynecologic
Treatment guide in Part 5. It may oncologist. A gynecologic oncologist is a surgeon
also help you know what to expect who is an expert in cancers that start in a woman’s
reproductive organs. Gynecologic oncologists and
during treatment. Not every person medical oncologists often work closely together to
with ovarian cancer will receive every plan the best treatment for ovarian cancer. A medical
oncologist is a doctor who is an expert in treating
treatment listed.
cancer with chemotherapy and other drugs.
There are two main goals of surgical treatment for

ovarian cancer. One goal is to find out how far the
cancer has spread. (See Surgical staging on page 24
for details.) The other goal of surgery is to remove all
or as much of the cancer from your body as possible.
To do so, the tumor is removed along with other
organs and tissues where cancer cells have or might
have spread.

32
4 Overview of cancer treatments Surgical treatment
A number of procedures may be done during surgical cervix are removed through a surgical cut in the belly
treatment for ovarian cancer. The type and extent of (abdomen). This is called a TAH (total abdominal
surgery you will have depends on many factors. This hysterectomy) and it is done along with a BSO. You
includes the tumor size, tumor location, and how far will not be able to have babies after a TAH and BSO.
the cancer has spread. Another key factor is whether
or not you want to be able to have babies after If cancer has spread outside the ovaries, then your
treatment. doctor will try to remove as much of the cancer
as possible. This is called debulking surgery or
Types of surgical treatment cytoreductive surgery. During this surgery, your
Surgical treatment often involves removing both doctor will attempt to remove all of the cancer that
ovaries, both fallopian tubes, and the uterus. A BSO can be seen. If the surgeon is able to remove all of
(bilateral salpingo-oophorectomy) is surgery to remove the tumors that are 1 cm or larger in size, the surgery
both ovaries and both fallopian tubes. When only one is called an optimal debulking. Optimal debulking is
ovary and the attached fallopian tube are removed, linked with better treatment outcomes.
it’s called a USO (unilateral salpingo-oophorectomy).
A USO is also called “fertility-sparing surgery.” This is Debulking surgery may remove all or part of nearby
because you will still be able to have babies after the organs where cancer has spread. See Figure 4.1.
surgery if you haven’t yet gone through menopause. A This may include removing organs such as your
USO is only an option if the cancer is only in one ovary. spleen, gallbladder, and appendix. It may also
remove part of your stomach, liver, pancreas, bladder,
A hysterectomy is surgery to remove the uterus. diaphragm, and intestines. Lymph nodes that look
When the uterus and the cervix are removed, it is different or are larger than normal should also be
called a total hysterectomy. Most often, the uterus and removed if possible.
Figure 4.1 Diaphragm

Debulking surgery sites Spleen
Liver Stomach
Debulking surgery removes as
much cancer as possible. The Gallbladder Pancreas
extent of the surgery depends on
how far the cancer has spread. It Peritoneum Omentum
may remove all or part of nearby
organs such as your liver, spleen, Large intestine Small intestine
stomach, gallbladder, pancreas,
intestines, appendix, and bladder. Appendix
Bladder

33
4 Overview of cancer treatments Surgical treatment
Surgery methods and tenderness in your belly and pelvis. This may
Most often, surgery is done using a laparotomy. A last for a few days or weeks. You may not be able to
laparotomy is a long surgical cut in the abdomen. It is return to normal activities for a few weeks. The time it
often an up-and-down (vertical) cut from the top of the takes to fully recover varies from person to person. It
belly button down to the pelvic bone. This lets your also varies depending on the extent of the surgery.
doctor see the tumor and other organs and tissues
in your abdomen and pelvis. Thus, a laparotomy is Risks and side effects of surgery
the most common and preferred method for ovarian With any type of surgery, there are some health risks
cancer surgery. NCCN experts recommend that it and side effects. A side effect is an unhealthy or
should be used when surgical staging or debulking unpleasant condition caused by treatment. Common
surgery is planned. side effects of any surgery include pain, swelling,
and scars. But, the side effects of surgery can differ
Laparoscopy is another surgery method that may be between people. They also differ based on the type
used in some cases. Laparoscopy uses a few small and extent of surgery.
cuts in the abdomen instead of one big one. Small
tools are inserted through the cuts to perform the Some common side effects of surgery for ovarian
surgery. One of the tools is called a laparoscope. cancer include leg swelling, trouble urinating, and
It is a long tube with a light and camera at the end. constipation. If you haven’t gone through menopause,
The camera lets your doctor see your ovaries and then surgery that removes both ovaries will cause
other tissues inside your abdomen. The other tools menopause. Menopause is the point in time when you
are used to remove tissue. Laparoscopy may be won’t have another menstrual period again. When
used in select cases, such as when cancer is only caused by surgery, the symptoms of menopause
in the ovaries. Rarely, it may be used when cancer may be sudden and more severe. Symptoms of
has spread outside the ovaries. This surgery should menopause include hot flashes, changes in mood,
only be done by a gynecologic oncologist with a lot of trouble sleeping, vaginal dryness, weight gain, and
experience. night sweats.
Preparing for surgery All of the side effects of ovarian cancer surgery are
Your treatment team will give you instructions on how not listed here. Ask your treatment team for a full
to prepare for your surgery. You may be asked to list of common and rare side effects. If a side effect
stop taking some medicines for a short time. You also bothers you, tell your treatment team. There may be
should not eat or drink after midnight the night before ways to help you feel better.
the surgery. On the day of your surgery, you will be
given medicine to put you into a deep sleep so you
won’t feel pain. This is called general anesthesia.
Surgery may take three or more hours to complete.
More or less time may be needed depending on how
much tissue is removed.
After the surgery, you will need to stay in the hospital

for a few days to recover. You may feel some pain

34
4 Overview of cancer treatments Chemotherapy
Chemotherapy The most common regimens used for initial

chemotherapy treatment are:
Chemotherapy is the use of drugs to kill cancer cells.
Many people refer to this treatment as “chemo.” • Paclitaxel and carboplatin,
Chemotherapy drugs kill fast-growing cells throughout • Paclitaxel and carboplatin (weekly),
the body, including cancer cells and normal cells. • Dose-dense paclitaxel and carboplatin,
• Paclitaxel and cisplatin, and
Most women with ovarian cancer receive • Docetaxel and carboplatin.
chemotherapy after primary treatment with surgery.
This is called adjuvant treatment. Your doctor may
also refer to this as primary chemotherapy. In certain
cases, chemotherapy may be given to shrink the Chart 4.1 Chemotherapy drugs for
cancer before surgery. ovarian cancer
Different types of chemotherapy drugs attack cancer

Brand name
cells in different ways. Some kill cancer cells by Generic name
(sold as)
damaging their DNA (deoxyribonucleic acid)—
Altretamine Hexalen
molecules that contain coded instructions for making
and controlling cells. Others interfere with parts of Capecitabine Xeloda
cells that are needed for making new cells. Carboplatin Paraplatin
Cisplatin Platinol, Platinol-AQ
Many types of chemotherapy drugs are used for
ovarian cancer. Two of the main types used are Cyclophosphamide Cytoxan
platinum agents and taxanes. Platinum agents Docetaxel Taxotere
damage DNA in cells, which stops them from making
Doxorubicin Adriamycin
new cells and causes them to die. Some platinum
agents used for ovarian cancer are carboplatin, Etoposide, oral VP-16
cisplatin, and oxaliplatin. Taxanes block certain cell Gemcitabine Gemzar
parts to stop a cell from dividing into two cells. Some
Ifosfamide Ifex
taxanes used for ovarian cancer are paclitaxel,
paclitaxel albumin-bound, and docetaxel. Chart 4.1 Irinotecan Camptosar
lists the chemotherapy drugs that are used for ovarian Liposomal doxorubicin Doxil
cancer.
Melphalan Alkeran
Because chemotherapy drugs differ in how they work, Oxaliplatin Eloxatin

more than one drug is often used. A combination Paclitaxel Taxol
regimen is the use of two or more drugs. When only
Paclitaxel, albumin-bound Abraxane
one drug is used, it is called a single agent. A regimen
is a treatment plan that specifies the drug(s), dose, Pemetrexed Alimta
schedule, and length of treatment. Topotecan Hycamtin
Vinorelbine Navelbine

35
4 Overview of cancer treatments Chemotherapy
Chemotherapy is given in cycles. A cycle includes vomiting, mouth sores, hair loss, fatigue, low blood
days of treatment followed by days of rest. Giving cell counts, increased risk of infection, bleeding or
chemotherapy in cycles lets the body have a chance bruising easily, and nerve damage (neuropathy).
to recover before the next treatment. The cycles vary
in length depending on which drugs are used. Often, Some side effects are more likely or more severe
the cycles are 7, 14, 21, or 28 days long. The number when certain combination regimens are used. The
treatment days per cycle and the number of cycles docetaxel and carboplatin regimen is more likely
given also varies depending on the regimen used. to increase the risk of infection. The paclitaxel
and carboplatin regimen is more likely to cause
How chemotherapy is given neuropathy. Neuropathy is a nerve problem that
Most of the chemotherapy drugs for ovarian cancer causes pain, tingling, and numbness in the hands
are liquids that are slowly injected into a vein. This and feet. Side effects also differ depending on
is called an IV (intravenous) infusion. Some drugs, how chemotherapy is given. IP chemotherapy
such as etoposide and altretamine, are pills that are tends to cause more severe side effects than IV
swallowed. chemotherapy. This includes infections, kidney
damage, pain in the belly, and nerve damage.
Chemotherapy can also be given as a liquid that is
slowly injected into the abdomen (peritoneal cavity). Not all side effects of chemotherapy are listed
This is called IP (intraperitoneal) chemotherapy. here. Be sure to ask your treatment team for a full
When given this way, higher doses of the drugs are list of common and rare side effects of the drugs
delivered directly to the cancer cells in the belly area. you receive. If a side effect bothers you, tell your
IP chemotherapy is given through a thin tube called treatment team. There may be ways to help you feel
a catheter. The catheter is often placed inside the better.
abdomen during surgery. Studies have shown that
patients live longer when they are able to receive
some of their chemotherapy in this manner.
Side effects of chemotherapy

A side effect is an unhealthy or unpleasant physical
or emotional condition caused by treatment. Each
treatment for ovarian cancer can cause side effects.
How your body will respond can’t be fully known.
Some people have many side effects. Others have
few. Some side effects can be very serious while
others can be unpleasant but not serious.
The side effects of chemotherapy depend on many

factors. This includes the drug, the dose, and the
person. In general, side effects are caused by the
death of fast-growing cells, which are found in the
intestines, mouth, and blood. As a result, common
side effects include not feeling hungry, nausea,

36
4 Overview of cancer treatments Targeted therapy
Targeted therapy cancer cells with BRCA mutations to repair damaged

DNA. If a cell is not able to repair damaged DNA,
Targeted therapy is treatment with drugs that target then it will die.
a specific or unique feature of cancer cells. These
drugs stop the action of molecules that help cancer Some common side effects of olaparib are nausea,
cells grow. Targeted therapy is less likely to harm vomiting, diarrhea, stomach pain, muscle or joint pain,
normal cells than chemotherapy. Two targeted feeling tired or weak, and not feeling hungry.
therapy drugs are approved to treat ovarian cancer:
bevacizumab (Avastin) and olaparib (Lynparza). Pazopanib
Pazopanib (Votrient) is another targeted therapy drug Pazopanib is a type of targeted therapy called a
that is sometimes used for ovarian cancer. These TKI (tyrosine kinase inhibitor). Tyrosine kinases
drugs attack cancer cells in different ways. are proteins in cells that are important for many
cell functions. This includes sending signals in cells
Bevacizumab for cell growth, survival, and death. Some tyrosine
Bevacizumab is a type of targeted therapy called an kinases send signals that tell cancer cells to grow and
angiogenesis inhibitor. Angiogenesis is the growth divide to make new cells. Some send signals for new
of new blood vessels. Like normal cells, cancer cells blood vessels to grow into the tumor so it can survive.
need the food and oxygen delivered in blood to live Pazopanib targets several tyrosine kinases and
and grow. Cancer cells send out signals that cause blocks the signals that help cancer grow and spread.
new blood vessels to grow into the tumor to “feed” it. Blocking these signals may slow cancer growth.
Bevacizumab blocks these signals so that new blood
vessels will not form. As a result, the cancer cells Common side effects of pazopanib include diarrhea,
won’t receive the blood they need to live. high blood pressure, change in hair color, nausea,
vomiting, fatigue, and not feeling hungry.
Some common side effects of bevacizumab are high
blood pressure, headache, nosebleeds, runny nose,
taste changes, skin rash, dry skin, and back pain.
Rare but serious side effects include stroke, heart
attack, kidney damage, holes in the intestine, and
bleeding within the body.
Olaparib
Olaparib is a type of targeted therapy called a PARP
(poly ADP-ribose polymerase) inhibitor. PARP is a
protein that helps repair damaged DNA in cells. The
BRCA1 and BRCA2 genes also help repair DNA in
cells. But, mutations in these genes block them from
making repairs. When cancer cells have mutations in
the BRCA genes, they rely on PARP to repair DNA.
Olaparib blocks the action of PARP so that it can’t
repair DNA in any cells. This makes it very hard for

37
4 Overview of cancer treatments Hormone therapy
Hormone therapy vaginal dryness, trouble sleeping, and night sweats.

Other common side effects of hormone therapy are
Hormone therapy is treatment that stops the body vaginal discharge, weight gain, swelling in the hands
from making certain hormones or stops the action of and feet, fatigue, and less interest in sex. Blood
the hormones. Hormone therapy is not used as initial clots are a rare but serious side effect of tamoxifen.
treatment for ovarian cancer. But, it may be used Aromatase inhibitors can weaken your bones and
for ovarian cancer that has come back after other may also cause joint and muscle pain.
treatments.
All of the side effects of hormone therapy are not
Estrogen and progesterone are hormones that help listed here. Ask your treatment team for a full list of
some ovarian cancers grow. Estrogen is mostly made common and rare side effects of the drug you receive.
by the ovaries and is made in small amounts by the If a side effect bothers you, tell your treatment team.
adrenal glands, liver, and body fat. Progesterone There may be ways to help you feel better.
is also mostly made by the ovaries. Blocking these
hormones from working or lowering hormone levels
may help slow ovarian cancer growth.
Different types of hormone therapy drugs work in

different ways. The hormone therapy drugs that may
be used for ovarian cancer include:
• Tamoxifen – This drug stops the effect of

estrogen on cancer cell growth. It is in a class
of drugs called antiestrogens.
• Anastrozole, exemestane, and letrozole –
These drugs lower estrogen levels in the
body. They are in a class of drugs called
aromatase inhibitors.
• Leuprolide acetate – This drug causes
the ovaries to make less estrogen and
progesterone. It is in a class of drugs called
LHRH (luteinizing hormone-releasing
hormone) agonists.
• Megestrol acetate – This drug stops the
effect of estrogen on cancer cell growth. It is
in a class of drugs called progestins.
Hormone therapy can cause a number of side effects.

A side effect is an unhealthy or unpleasant response
to treatment. The side effects may be mild or severe.
Symptoms of menopause are common. Such
symptoms include hot flashes, changes in mood,

38
4 Overview of cancer treatments Clinical Trials
Clinical trials will receive the best management of care. Third, the
results of your treatment—both good and bad—will be
New tests and treatments aren’t offered to the public carefully tracked. Fourth, you may help other patients
as soon as they’re made. They need to be studied with cancer.
first. New uses of tests and treatments also need to
be studied. Clinical trials have risks, too. Like any test or
treatment, there may be side effects. Also, new
A clinical trial is a type of research that studies a test tests or treatments may not work better than current
or treatment. Clinical trials study how safe and helpful treatments. Another downside may be that paperwork
tests and treatments are. When found to be safe and or more trips to the hospital may be needed.
helpful, they may become tomorrow’s standard of care.
Because of clinical trials, the tests and treatments in To join a clinical trial, you must meet the conditions
this book are now widely used to help patients. of the study. Patients in a clinical trial often have a
similar cancer type and general health. This helps
Tests and treatments go through a series of clinical ensure that any response is because of the treatment
trials to make sure they’re safe and work. Without and not because of differences between patients.
clinical trials, there’s no way to know if a test or You also must review and sign a paper called an
treatment is safe or helpful. Clinical trials are done in informed consent form to join a clinical trial. This form
a series of steps, called phases. The four phases of describes the study in detail, including the risks and
clinical trials are described next using the example of benefits.
a new drug treatment:
Ask your treatment team if there is an open clinical
Phase I trials aim to find the best dose and way to trial that you can join. There may be clinical trials
give a new drug with the fewest side effects. If a drug where you’re getting treatment or at other treatment
is found to be safe, it will be studied in a phase II trial. centers nearby.
Phase II trials assess if a drug works for a specific

type of cancer. They are done in larger groups of
patients with the same type of cancer.
Phase III trials compare a new drug to the standard

treatment. These are randomized, meaning patients
are put in a treatment group by chance.
Phase IV trials test new drugs approved by the

FDA (U.S. Food and Drug Administration) to learn
about short-term side effects, long-term side effects,
and safety. They involve many patients with different
types of cancer.
Joining a clinical trial has benefits. First, you’ll have

access to the most current cancer care. Second, you

39
4 Overview of cancer treatments Complementary and alternative medicine
Complementary and alternative medicine
CAM (complementary and alternative medicine) is a group of treatments

that aren’t often given by doctors. Doctors don’t use these treatments
often because they haven’t been shown to be effective by clinical trials.
There is much interest today in CAM for cancer. Many CAMs are being
studied to see if they are truly helpful.
Complementary medicines are treatments given along with usual

medical treatments. While CAMs aren’t known to kill cancer cells,
they may improve your comfort and well-being. Two examples are
acupuncture for pain management and yoga for relaxation.
Alternative medicine is used in place of usual medicine. Some

alternative medicines are sold as cures even though they haven’t been
proven to work. If there was good proof that CAMs or other treatments
cured cancer, they would be included in this book.
It is important to tell your treatment team if you are using any CAMs.
They can tell you which CAMs may be helpful and which CAMs may limit
how well medical treatments work.

40
4 Overview of cancer treatments My notes
My notes

41
4 Overview of cancer treatments Review
Review
• Primary treatment is the main treatment used • Targeted therapy drugs target a specific or
to rid the body of cancer. unique feature of cancer cells.
• Surgery is often used as primary treatment for • Hormone therapy stops the body from making
ovarian cancer. certain hormones or stops the action of the
hormones.
• Chemotherapy drugs kill fast-growing cells,
including cancer cells and normal cells. • A clinical trial studies a test or treatment to
see how safe it is and how well it works.

42
5
Treatment guide

43
5 Treatment guide
46 5.1 Ovarian LMP (low malignant
potential) tumor
Presents the treatment options for
tumors formed by abnormal cells that
aren’t clearly cancer cells because,
while they can spread and grow on the
surface of organs in the belly, they do
not invade these organs.
50 5.2 Stage I ovarian cancer
Presents the recommended treatments
for ovarian cancer that is only in the
ovaries.
56 5.3 Stage II, III, and IV ovarian cancer
Presents the treatment options for
ovarian cancer that has spread outside
the ovaries to tissues in the pelvis,
abdomen, or other parts of the body.
64 5.4 Follow-up after initial treatment
Presents the follow-up tests and next
treatments that are recommended after
initial treatment for ovarian cancer.

44
5 Treatment guide Ovarian cancer
Part 5 is a guide through the

treatment options for people with
epithelial ovarian cancer and ovarian
LMP tumors. It shows which tests and
treatments are recommended under
which conditions. This information is
taken from the treatment guidelines
written by NCCN experts for ovarian
cancer doctors.
The treatment options are organized by cancer stage.

Much effort has been made to make this guide easy
to read. Charts list the treatment options and map the
steps through the treatment process. The text along
with each chart explains the information presented
in the chart. Some words that you may not know are
defined on the page and in the Dictionary on page 82.
Words defined in the Dictionary are underlined when
first used on a page. More details about the tests,
stages, and treatments in this guide can be found in
Parts 2 through 4.

45
5 Treatment guide Ovarian LMP tumor
5.1 Ovarian LMP tumor
Chart 5.1.1 Primary treatment for ovarian LMP tumor
Prior surgery and staging Results Treatment options
• No invasive implants • Observation with follow-up tests

Surgical staging complete
• Observation with follow-up tests
• Invasive implants
• Chemotherapy

• No invasive implants • Fertility-sparing surgery + surgical staging
• Completion surgery
Surgical staging not complete
• Fertility-sparing surgery + surgical staging
• Invasive implants
• Surgery followed by chemotherapy
Chart 5.1.1 shows the primary treatment options attached fallopian tube, the omentum, and any tumor
for ovarian LMP tumor. This type of tumor is formed cells found outside the ovary. (See page 24 for more
by abnormal cells that aren’t clearly cancer cells. details about surgical staging.)
Ovarian LMP tumor may be found by chance during
surgery or tests for another health problem. Most The second factor is whether or not invasive implants
often, it is confirmed (diagnosed) after surgery to were found. Tumor cells that spread and grow on
remove the tumor from your body. Surgery is also the surface of nearby organs are called noninvasive
used as primary treatment for this type of tumor. implants. The tumor cells rarely grow into (invade)
tissue—called invasive implants.
Primary treatment is the main treatment used to
rid your body of a disease. There is more than one The third factor is whether or not you want to be
primary treatment option for ovarian LMP tumor. Your able to have babies after treatment. Fertility-sparing
doctor will look at three key factors to help decide surgery is always an option for ovarian LMP tumor.
which option is best for you. This surgery only removes the affected ovary and its
fallopian tube. The other ovary, fallopian tube, and
The first factor is whether or not the initial surgery the uterus are left so that you will still be able to have
and staging were complete. Surgical staging is babies.
considered complete if surgery removed the whole
tumor, the affected ovary and supporting tissues, the

46
Primary treatment options
Observation with follow-up tests is an option for

Next steps: 
all patients. Observation is a period of testing to
watch for tumor growth. If surgical staging was See Chart 5.1.2 on page 48 for follow-
complete and no invasive implants were found, up tests that are recommended during
then this is the only option recommended. If invasive
implants were found, a second option is to receive observation and after surgery.
chemotherapy—treatment for epithelial ovarian
cancer.
See Chart 5.2.3 on page 54 for
If surgical staging was not complete, then chemotherapy treatment for epithelial
another option is to have more surgery. If you want to
ovarian cancer.
be able to have babies, then you may have fertility-
sparing surgery and surgical staging procedures.
For surgical staging, biopsy samples will be taken
from the tumor and nearby tissues. The omentum
and nearby lymph nodes may also be removed. (See
page 24 for full details about surgical staging.)
If you don’t want to have babies, then you may have

completion surgery. Completion surgery removes the
remaining ovary (or ovaries), fallopian tubes, uterus,
omentum, and any tumor cells found on nearby
tissue. In some cases, nearby lymph nodes may also
be removed.
If invasive implants were found, then surgery may be

followed by chemotherapy—treatment for epithelial
ovarian cancer. If no invasive implants were found,
then no other treatment is recommended after either
surgery. Instead, you will begin observation with
follow-up tests.

47
Chart 5.1.2 Follow-up testing after treatment
Follow-up tests and schedule
Follow-up visits every 3 to 6 months for 5 years, then once a year with:
• Physical exam and pelvic exam
• CA-125 blood test or other tumor markers as needed
• CBC and blood chemistry profile as needed
• Ultrasound as needed if you had fertility-sparing surgery
• Completion surgery, if you had fertility-sparing surgery and are finished having babies
Chart 5.1.2 shows the follow-up tests that are chemistry profile may be done to check the health of
recommended during observation and after primary certain organs and body systems.
treatment for ovarian LMP tumor. Observation is a
period of testing to watch for tumor growth. Follow- Ultrasound uses sound waves to make pictures of the
up tests are given on a regular basis to watch for inside of the body. It may be used to look for signs
signs that tumor cells have come back or spread after of tumor growth if you had fertility-sparing surgery.
treatment. Many of the follow-up tests are the same This type of surgery only removes one ovary and its
as those used to find and confirm the tumor. See Part fallopian tube so that you will still be able to have
2 on page 14 for more details about each test. babies. Once you are finished having babies, you
should have surgery to remove the remaining ovary,
Follow-up visits are recommended every 3 to 6 fallopian tube, and uterus. This is called completion
months for 5 years. After that, they are recommended surgery.
once a year. A physical exam and pelvic exam should
be done at every follow-up visit. These exams help
your doctor check for physical signs that the tumor
has come back. Such signs may include swelling or
bloating in your belly, abnormal lumps, or sudden
Next steps: 
changes in weight.
If follow-up tests show that the tumor
Blood tests to measure CA-125 or other tumor
markers are recommended if levels were high when
has come back, see Chart 5.1.3
the tumor was first found. Rising CA-125 levels on page 49 for the next treatment
after treatment may be an early sign that the tumor
options.
has come back. A CBC measures the number of
each type of blood cell in a sample of blood. A blood

48
Chart 5.1.3 Treatment for ovarian LMP tumor relapse
Follow-up results Next steps Treatment options
If no invasive implants
Clinical relapse
Relapse based on symptoms, • Surgical evaluation, and
If invasive implants
imaging test results, or • Debulking if needed
• Surgery only
increase in CA-125 levels
• Surgery followed by chemotherapy
Chart 5.1.3 shows the treatment options for LMP

tumor that has come back after treatment. This is
called a recurrence or relapse. After a clinical relapse,
Next steps: 
you may have surgery so that your doctor can see
where the tumor has spread. This is called surgical For recommended follow-up tests
evaluation. You may also have surgery to remove
as much of the tumor as possible. This is called during observation, see Chart 5.1.2
debulking surgery. on page 48.
The treatment options for a relapse depend on
whether or not tumor cells have grown into (invaded) For surgery options, see Chart 5.1.1
nearby tissues. These are called invasive implants. If on page 46.
there aren’t any invasive implants, then observation
with follow-up tests is recommended. If there are
invasive implants, then you have two treatment For chemotherapy treatment for
options to choose from. One option is to have surgery
epithelial ovarian cancer, see Chart
only, as described for primary treatment in Chart
5.1.1. The second option is to have surgery followed 5.2.3 on page 54.
by chemotherapy—treatment for epithelial ovarian
cancer.

49
5 Treatment guide Stage I ovarian cancer
5.2 Stage I ovarian cancer
Chart 5.2.1 Primary treatment for newly diagnosed ovarian cancer
Cancer stage Treatment options
• Surgery to remove one ovary and its fallopian tube +

Stage IA surgical staging
Cancer is only in one ovary • Surgery to remove both ovaries, both fallopian tubes,
and the uterus + surgical staging
Stage IB • Surgery to remove both ovaries, both fallopian tubes,

Cancer is in both ovaries only and the uterus + surgical staging
Stage IC • Surgery to remove one ovary and its fallopian tube +

Cancer is in one or both ovaries and cancer is on surgical staging
the ovary surface, the ovary capsule has ruptured, • Surgery to remove both ovaries, both fallopian tubes,
and/or cancer cells are in ascites or washings and the uterus + surgical staging
Chart 5.2.1 shows shows the primary treatment Primary treatment options
options for newly diagnosed stage I ovarian cancer.
For ovarian cancer confirmed by a prior surgery, see The most common treatment for stage I ovarian
Chart 5.2.2 on page 52. Stage I ovarian cancer is cancer is surgery to remove both ovaries, both
when cancer is only in the ovaries and has not spread fallopian tubes, and the uterus. This is the only
to other tissues or organs. (See Part 3 on page 26 for recommended option when cancer is in both
more details about each cancer stage.) ovaries—stage IB. If cancer is only in one ovary—
stage IA or IC—a second option is surgery to remove
Primary treatment is the main treatment used to rid the the ovary with cancer and its fallopian tube. This is
body of cancer. Surgery is used as primary treatment called fertility-sparing surgery. It may be used if you
for stage I ovarian cancer. Surgery is also used to find want to be able to have babies after treatment.
out how far the cancer has spread—called surgical
staging. The type and extent of surgery you will have Along with either of these options, you will also have
depends on the cancer stage and other factors. For surgical staging. Surgical staging involves taking
full details on each surgery, see Part 4 on page 32. biopsy samples of the tumor and nearby tissues to
test for cancer cells. It is done to check for cancer
cells that have spread outside the ovaries or pelvis
and can only be seen with a microscope. These

50
are called microscopic metastases. During surgical

staging, biopsy samples will be taken from organs
and tissues where ovarian cancer often spreads. The
Next steps: 
omentum and nearby lymphs will also be removed.
See page 24 for more details about surgical staging. After completing primary treatment,
see Chart 5.2.3 on page 54 for
treatments that are recommended
next.

51
Chart 5.2.2 Primary treatment for ovarian cancer confirmed by prior surgery or biopsy
Results of prior surgery or biopsy Treatment options
Surgery and staging complete • No more surgery needed
Likely stage IA or IB, grade 1

Cancer is in one or both ovaries only and it is low grade • Surgical staging
(slow-growing)
If doctors think no cancer remains

• Surgical staging
Likely stage IA or IB, grade 2 • Completion surgery and surgical staging
Cancer is in one or both ovaries only and it is medium • No more surgery, start chemotherapy
grade
If doctors think some cancer remains
• Completion surgery and surgical staging
Likely stage IA or IB, grade 3 or clear cell, or stage IC If doctors think no cancer remains
Cancer is in one or both ovaries only, and it’s high grade • Completion surgery and surgical staging
(fast-growing), or cancer is also on the ovary surface, the • No more surgery, start chemotherapy
ovary capsule has ruptured, and/or cancer cells are in If doctors think some cancer remains
ascites or washings • Completion surgery and surgical staging
Chart 5.2.2 shows the primary treatment options for The main factor is whether or not the prior surgery
stage I ovarian cancer that was confirmed by a prior and staging were complete. Surgical staging is
surgery or biopsy. Stage I ovarian cancer is when considered complete if the prior surgery removed all
cancer is only in the ovaries and has not spread to of the cancer, both ovaries, both fallopian tubes, the
other tissues or organs. Primary treatment is the main uterus, nearby supporting tissues, the omentum, and
treatment used to rid the body of cancer. nearby lymph nodes. (See page 24 for full details
about surgical staging.)
Surgery is often used as primary treatment for stage
I ovarian cancer. But, there is more than one option The cancer stage and cancer grade are also
and more than one type of surgery to choose from. important. The cancer stage describes how far the
Which option is best for you depends on a few key cancer has grown and spread. The cancer grade
factors. describes how fast the cancer will likely grow based
on how much the cancer cells look like normal cells.

52
Grade 1 cancer tends to grow more slowly, grade For ovarian cancer that is likely stage IA
3 tends to grow more quickly, and grade 2 is in or IB, grade 2, the treatment options depend on
between. (See page 29 for more details about cancer whether or not the prior surgery removed all of the
grades.) cancer. If your doctor thinks no cancer remains, then
you have three options to choose from. The first
option is to have surgical staging alone as described
Primary treatment options above. The second option is to have completion
surgery and surgical staging. Completion surgery
To plan primary treatment, your doctor will first assess removes the remaining ovary (or ovaries), fallopian
the results of the prior surgery. If the prior surgery tubes, uterus, nearby supporting tissue, the omentum,
and staging were complete, then no more surgery is and any cancer that can be seen. The third option
needed at this time. See Next steps at the end of this is to start treatment with chemotherapy instead of
section. having more surgery. See Next steps below. If your
doctor thinks some cancer remains, then completion
If surgery and staging were not complete, surgery and surgical staging are recommended.
then more surgery is recommended. This is to
confirm the cancer stage and, if needed, remove any For ovarian cancer that is likely stage IA
remaining cancer. The type and extent of surgery or IB, grade 3 or clear cell, or stage IC, the
depends on the likely cancer stage, cancer grade, treatment options depend on whether or not the prior
and how much (if any) cancer remains. For full details surgery removed all of the cancer. If your doctor
on each surgery, see Part 4 on page 32. thinks no cancer remains, then one option is to have
completion surgery and surgical staging. Another
For ovarian cancer that is likely stage IA option is to start treatment with chemotherapy instead
or IB, grade I, surgical staging is recommended. of having more surgery. If your doctor thinks some
Surgical staging involves taking biopsy samples of cancer remains, then completion surgery and surgical
the tumor and nearby tissues to test for cancer cells. staging are recommended.
It is done to check for cancer cells that have spread
outside the ovaries or pelvis and can only be seen
with a microscope. These are called microscopic
metastases. During surgical staging, biopsy samples
will be taken from organs and tissues where ovarian
cancer often spreads. The omentum and nearby
Next steps: 
lymph nodes will also be removed. See page 24 for
more details about surgical staging. After completing primary treatment,
see Chart 5.2.3 on page 54 for
treatments that are recommended
next.

53
Chart 5.2.3 Treatment after surgery for stage I ovarian cancer
Stage IA or IB, grade 1

Cancer is in one or both ovaries only and it is low • Observation with follow-up tests
grade (slow-growing)
Stage IA or IB, grade 2

Cancer is in one or both ovaries only and it is
• Chemotherapy given in a vein (IV) for 3 to 6 cycles
medium grade
Stage IA or IB, grade 3 or clear cell

Cancer is in one or both ovaries only, and it is high • Chemotherapy given in a vein (IV) for 3 to 6 cycles
grade (fast-growing)
Stage IC
Cancer is in one or both ovaries and cancer is on
• Chemotherapy given in a vein (IV) for 3 to 6 cycles
the ovary surface, the ovary capsule has ruptured,
and/or cancer cells are in ascites or washings
Chart 5.2.4 Chemotherapy regimens for stage I ovarian cancer
Chemotherapy regimens Length of a cycle
Paclitaxel and carboplatin 21 days (3 weeks)

Paclitaxel and carboplatin 7 days (1 week)
Docetaxel and carboplatin 21 days (3 weeks)
Chart 5.2.3 shows the options that are Which option is recommended after surgery depends
recommended after surgery for stage I ovarian on the cancer stage and the cancer grade. The
cancer. Most women with ovarian cancer will receive cancer stage is a rating of how much the cancer has
chemotherapy after primary treatment with surgery. grown and spread. The cancer grade describes how
This is called adjuvant treatment. Your doctor may fast the cancer will likely grow based on how much
also refer to this as primary chemotherapy. the cancer cells look like normal cells. Grade 1 cancer

54
tends to grow more slowly, grade 3 tends to grow a week may be a good option. Giving these drugs
more quickly, and grade 2 is in between. (See page once a week tends to cause fewer side effects than
26 for details about cancer stages and page 29 for when they are given once every three weeks. (For
details about cancer grades.) more details about chemotherapy drugs, see Part 4
on page 35.)
Treatment options
Testing during chemotherapy treatment
For stage IA or IB ovarian cancer, the options depend
on the cancer grade. For grade 1, observation with During treatment, your doctor will give tests to check
follow-up tests is recommended. Observation is a how well the chemotherapy is working and to assess
period of testing to watch for cancer growth after for side effects. A physical and pelvic exam should
treatment. For grade 2, observation with follow-up be done at least every 2 to 3 cycles. You may also
tests is still an option. A second option is to receive have other tests as needed. This may include imaging
chemotherapy given in a vein. This is called IV tests, CBC, blood chemistry profile, and tests of CA-
chemotherapy. For all other stage I ovarian cancers, 125 or other tumor markers. (See Part 2 on page 14
IV chemotherapy is the only recommended option. for details about each test.)
The number of chemotherapy cycles recommended

depends on whether or not surgical staging was
completed. It may have been completed during the
initial surgery or a second surgery. If so, 3 to 6 cycles of
chemotherapy should be given. If surgical staging was
Next steps: 
not completed, then at least 6 cycles should be given.
See Chart 5.4.1 on page 64 for follow-
Chart 5.2.4 shows the chemotherapy regimens that up tests that are recommended during
are recommended for stage I ovarian cancer. Which
drug or regimen is best for you depends on a number observation and after completing
of factors. This includes your age, overall health, and chemotherapy treatment.
performance status—a rating of how well you are able
to do daily activities. Another key factor is your risk
for neuropathy—a nerve problem that causes pain,
tingling, and numbness in the hands and feet.
Neuropathy is a common side effect of paclitaxel.

If you have a high risk for nerve problems, then
docetaxel and carboplatin may be a better option for
you. Some patients may not be able to tolerate the
severe side effects of chemotherapy. This includes
patients who are older than 65, have other health
problems, or have trouble doing daily activities. For
these patients, paclitaxel and carboplatin given once

55
5 Treatment guide Stage II, III, and IV ovarian cancer
5.3 Stage II, III, and IV ovarian cancer
Chart 5.3.1 Primary treatment for newly diagnosed ovarian cancer
Stage II
• Surgery to remove both ovaries, both fallopian tubes, the
Cancer has spread to nearby organs and
uterus, and all cancer that can be seen + surgical staging
tissues in the pelvis
If all cancer can be removed

Stage III or IV • Surgery to remove both ovaries, both fallopian tubes, the
Cancer has spread outside the pelvis to the uterus, and all cancer that can be seen
tissue lining the abdomen and/or to nearby
lymph nodes, or cancer has spread to If all cancer can’t be removed
organs outside the abdomen • Start chemotherapy to the shrink cancer, then surgery as
described above
Chart 5.3.1 shows the primary treatment options for Primary treatment
newly diagnosed stage II, III, and IV ovarian cancer.
For ovarian cancer confirmed by a prior surgery, see Surgery is often used as primary treatment for ovarian
Chart 5.3.2 on page 58. Primary treatment is the main cancer. The type and extent of surgery depends on
treatment given to rid the body of cancer. The primary the cancer stage. For more details about each type of
treatment options depend on the cancer stage. The surgery, read Part 4 on page 32.
cancer stage is a rating of how far the cancer has
grown and spread. For stage II ovarian cancer, you will have
surgery to remove both ovaries, both fallopian tubes,
Stage II ovarian cancer is when cancer has spread to the uterus, and all cancer that can be seen. Surgical
nearby organs in the pelvis such as the other ovary, staging procedures should also be done. This is
the fallopian tubes, and the uterus. Stage III ovarian to check for cancer cells that have spread outside
cancer has spread outside the pelvis to tissues in the pelvis and can only be seen with a microscope.
the abdomen. Stage IV ovarian cancer has spread During surgical staging, biopsy samples will be taken
outside the abdomen to distant sites. (See Part 3 on from nearby organs and tissues where ovarian cancer
page 26 for more details about each ovarian cancer often spreads. The omentum and nearby lymph
stage.) nodes will also be removed. (See page 24 for more
details about surgical staging.)

56
For stage III or IV ovarian cancer, the treatment oncologist is involved in this assessment and
options depend on how much tissue the cancer has treatment decision. You will likely have a biopsy to
grown into. If the cancer hasn’t grown into a lot of confirm ovarian cancer before starting chemotherapy
tissue and can be safely removed, then surgery is treatment. After a few cycles of chemotherapy, your
recommended. In this case, surgery will remove both doctor will check the status of the cancer. If your
ovaries, both fallopian tubes, the uterus, and all or as doctor thinks all the cancer can be safely removed,
much cancer as possible. Surgery may also remove then you will have surgery as described above.
all or part of organs or tissues the cancer has spread
to. This is called debulking surgery or cytoreductive
surgery. It aims to reduce the amount of cancer in
your body as much as possible. The goal is to not
leave behind any tumors that are 1 cm or larger.
Surgical staging isn’t needed because the cancer has
Next steps: 
clearly spread outside the pelvis.
After primary treatment, see Chart
If the cancer has grown into a lot of tissue, it might not
5.3.3 on page 60 for treatments that
be possible to safely remove it all with initial surgery.
Your doctors may decide to give chemotherapy are recommended next.
first to try to shrink the cancer before surgery.
(See Chart 5.3.3 on page 60 for chemotherapy
recommendations.) It is important that a gynecologic

57
Chart 5.3.2 Primary treatment for ovarian cancer confirmed by prior surgery or biopsy
Cancer stage Results of prior surgery Treatment options
Surgery and staging were complete • Start chemotherapy
Likely stage II, III, or IV

Cancer has spread to tissues in Some cancer remains and can
the pelvis, outside the pelvis, or likely be removed by surgery
outside the abdomen
Some cancer remains that likely • Start chemotherapy to shrink the
can’t be removed by surgery cancer, then completion surgery
Chart 5.3.2 shows the primary treatment options for of the cancer, both ovaries, both fallopian tubes, the
stage II, III, and IV ovarian cancers confirmed by a uterus, nearby supporting tissues, the omentum, and
prior surgery or biopsy. The cancer stage is a rating of nearby lymph nodes. (See page 24 for more details
how far the cancer has grown and spread. about surgical staging.)
Stage II ovarian cancer is when cancer has spread to

nearby organs in the pelvis such as the other ovary, Primary treatment
the fallopian tubes, and the uterus. Stage III ovarian
cancer has spread outside the pelvis to tissues in To plan primary treatment, your doctor will first assess
the abdomen. Stage IV ovarian cancer has spread the results of the prior surgery. If the prior surgery
outside the abdomen to distant sites. (See page 26 and staging were complete, then no more surgery is
for more details about each cancer stage.) needed at this time. See Next steps at the end of this
section. If the prior surgery was not complete, the
Primary treatment is the main treatment given to rid treatment options depend on how much cancer is left.
the body of cancer. Surgery is often used as primary
treatment for ovarian cancer. But, there is more than If the remaining cancer can likely be removed,
one option and more than one type of surgery to then completion surgery is recommended. Completion
choose from. Which option is best for you depends on surgery removes the remaining ovary (or ovaries),
a few key factors. fallopian tubes, uterus, nearby supporting tissue, the
omentum, and any cancer that can be seen.
The main factor is whether or not the prior surgery
and staging were complete. Surgical staging is If all the remaining cancer likely can’t be
considered complete if the prior surgery removed all removed, then chemotherapy may be given in

58
a vein to try to shrink the cancer before surgery.

(See Chart 5.3.3 on page 60 for chemotherapy
recommendations.) After a few cycles of
Next steps: 
chemotherapy, your doctors will check the status of
the cancer. If your doctors think all the cancer can After primary treatment, see Chart
be safely removed, then you will have completion
5.3.3 on page 60 for treatments that
surgery as described above. Completion surgery after
3 cycles of chemotherapy is preferred. But, surgery are recommended next.
may be performed after 4 to 6 cycles based on your
doctor’s judgment.

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Chart 5.3.3 Treatment after surgery for stage II, III, or IV ovarian cancer
Cancer stage Adjuvant treatment options
If <1 cm of cancer is left after surgery

Stage II or III • Chemotherapy given in the abdomen (IP), or
Cancer has spread to nearby organs and • Chemotherapy given in a vein (IV) for a total of 6 to 8 cycles
tissues in the pelvis, or it has spread to
tissues in the abdomen If >1 cm of cancer is left after surgery
• Chemotherapy given in a vein for a total of 6 to 8 cycles
Stage IV
Cancer has spread outside the abdomen to • Chemotherapy given in a vein for a total of 6 to 8 cycles
organs and tissues in other parts of the body
Chart 5.3.4 Chemotherapy regimens for stage II, III, and IV ovarian cancer
Chemotherapy regimens Route given Length of a cycle
Paclitaxel and cisplatin Injection in a vein (IV) and abdomen (IP) 21 days (3 weeks)
Paclitaxel and carboplatin Injection in a vein (IV) 21 days (3 weeks)
Dose-dense paclitaxel and carboplatin Injection in a vein (IV) 21 days (3 weeks)
Paclitaxel and carboplatin Injection in a vein (IV) 7 days (1 week)
Docetaxel and carboplatin Injection in a vein (IV) 21 days (3 weeks)
Bevacizumab with paclitaxel and carboplatin Injection in a vein (IV) 21 days (3 weeks)
Chart 5.3.3 shows the options that are surgery. The cancer stage is a rating of how much the
recommended after surgery for stage II, III, or IV cancer has grown and spread. The goal of surgery is to
ovarian cancer. Most women with ovarian cancer will not leave behind any tumors that are 1 cm or larger.
receive chemotherapy after primary treatment with
surgery. This is called adjuvant treatment. Your doctor
may also refer to this as primary chemotherapy. Treatment options
There are a few adjuvant treatment options to choose For stage II or III ovarian cancer, the treatment
from. Which option is best for you depends on the options depend on how much cancer is left after
cancer stage and how much cancer is left after surgery. If no tumors 1 cm or larger remain, then you

60
have two options to choose from. One option is to a week may be a good option. Giving these drugs
receive chemotherapy given in the abdomen. The once a week tends to cause fewer side effects than
second option is to receive chemotherapy given in a when they are given once every three weeks.
vein. If any remaining tumors are 1 cm or larger, then
you will receive chemotherapy given in a vein. It is important that your kidneys are working well if you
may receive a combination of IV and IP chemotherapy.
For stage IV ovarian cancer, you will receive Your doctor may give a blood test to check for
chemotherapy given in a vein. chemicals that your kidneys filter out of your blood.
High levels of certain chemicals may be a sign that your
Chemotherapy given in the abdomen is called kidneys aren’t working well. If you have trouble doing
IP chemotherapy. Chemotherapy given in a vein is daily activities, have a high risk for neuropathy, or your
called IV chemotherapy. It is important to discuss the kidneys aren’t working well, then IP chemotherapy may
differences between IP and IV chemotherapy with not be a good treatment option for you.
your doctor. (See Part 4 on page 35 for more details
about chemotherapy treatment.)
Testing during chemotherapy treatment
Even if you had some chemotherapy before surgery,
you will likely have more chemotherapy after During treatment, your doctor will give tests to see
surgery. A total of 6 to 8 chemotherapy cycles is how well the chemotherapy is working and to check
recommended for stage II, III, and IV ovarian cancer. for side effects. A physical and pelvic exam should
If you had 3 cycles before surgery, then you will have be done at least every 2 to 3 cycles. You may also
no more than 5 cycles after surgery. have other tests as needed. This may include imaging
tests, CBC, blood chemistry profile, and tests of CA-
Chart 5.3.4 lists the chemotherapy regimens that are 125 or other tumor markers. (See Part 2 on page 14
recommended for stage II, III, and IV ovarian cancer. for details about each test.)
Which drug or regimen is best for you depends
on a number of factors. This includes your age, Your doctor will also give some tests after chemotherapy
overall health, and how well your kidneys and other treatment is finished to check how well it worked. An
organs are working. Your doctor will also check your outcome or improvement related to treatment is called a
performance status—a rating of how well you are able treatment response.
to do daily activities. Another key factor is your risk
for neuropathy—a nerve problem that causes pain,
tingling, and numbness in the hands and feet.
Neuropathy is a common side effect of paclitaxel.

Next steps: 
If you have a high risk for nerve problems, then
docetaxel and carboplatin may be a better option for After completing primary
you. Some patients may not be able to tolerate the
severe side effects of chemotherapy. This includes
chemotherapy, see Chart 5.3.5
patients who are older than 65, have other health on page 62 for the next treatment
problems, or have trouble doing daily activities. For
options.
these patients, paclitaxel and carboplatin given once

61
Chart 5.3.5 Treatment after primary chemotherapy
Chemotherapy results Treatment options
• Clinical trial
Complete response
Tests show that the cancer is completely gone;
• Maintenance treatment with paclitaxel
all signs and symptoms have disappeared
• Maintenance treatment with pazopanib
Partial response • Clinical trial

The cancer has improved but it’s not completely • Start recurrence treatment
gone; some signs and symptoms remain • Best supportive care
Persistent or progressive disease • Clinical trial

The cancer stayed the same or it continued to • Best supportive care only
grow during treatment • Start recurrence treatment
Chart 5.3.5 shows the options that are Treatment options

recommended after primary chemotherapy for stage
II, III, or IV ovarian cancer. The next options depend If tests showed a complete response, then
on how well primary chemotherapy worked. An you have four main options to choose from. The
outcome or improvement related to treatment is called first option is to receive treatment within a clinical
a treatment response. trial. A clinical trial is a type of research that studies
how safe and helpful a treatment is. The second
A complete response is when there are no signs of option is to begin observation with follow-up tests.
cancer on the imaging tests, physical exam, or CA- Observation is a period of testing to watch for cancer
125 blood tests after treatment. A partial response is growth after treatment. Another option is to begin
when tests show a decrease in the amount of cancer, maintenance treatment with paclitaxel or pazopanib.
tumor size, or CA-125 levels. It means that the cancer Maintenance treatment is given to continue (maintain)
improved, but it is not completely gone. Persistent good treatment results. For maintenance treatment,
disease is cancer that stayed the same—didn’t get paclitaxel is given in a vein on Day 1 of a 28-day
better or worse—during treatment. Progressive cycle for a total of 12 cycles. But, not all doctors
disease is cancer that continued to grow (progress) recommend paclitaxel as maintenance treatment. It is
during or after treatment. important to discuss the benefits and risks with your
doctor.

62
If tests showed a partial response or

persistent or progressive disease, then you
have three main options to choose from. The first
Next steps: 
option is to receive treatment within a clinical trial.
(See page 39 for more details about clinical trials.) A For follow-up tests that are
second option is to start recurrence treatment—drugs
recommended during observation,
given after prior treatments failed to kill all the cancer
or keep it away. Another option is to receive best see Chart 5.4.1 on page 64. The
supportive care. Supportive care is treatment given follow-up tests listed in Chart
to relieve the symptoms of cancer or side effects of
cancer treatment. It aims to improve quality of life
5.4.1 are also recommended after
and relieve any discomfort you have. Supportive care maintenance or other treatments.
may be given alone. It may also be given along with
recurrence treatment or treatment within a clinical
trial. (See Part 4 on page 32 for more details about For recurrence treatment, see Chart
each treatment.) 5.4.3 on page 68.

63
5 Treatment guide Follow-up after initial treatment
5.4 Follow-up after initial treatment
Chart 5.4.1 Follow-up testing after treatment
Follow-up tests and schedule
Follow-up visits every 2 to 4 months for 2 years, then every 3 to 6 months for 3 years,
then once a year after 5 years with:
• Physical exam and pelvic exam
• CA-125 blood test or other tumor markers if initial results were high
• CBC and blood chemistry profile as needed
• CT, MRI, PET/CT, or PET of the chest, abdomen, and pelvis as needed
• Chest x-ray as needed
• Genetic counseling if not already done
Chart 5.4.1 shows the follow-up tests that are The physical exam and pelvic exam help your doctor
recommended during observation and after check for physical signs that the cancer has come back.
completing cancer treatment. Observation is a period Such signs may include swelling or bloating in your
of testing to watch for cancer growth. Follow-up tests belly, abnormal lumps, or sudden changes in weight.
are used to check for signs of cancer return (relapse)
or spread (metastasis). Doctors also use follow-up Blood tests to measure CA-125 or other tumor
tests to monitor your health and check for side effects markers are recommended if levels were high when
of treatment. the cancer was first found. Rising CA-125 levels
after treatment may be an early sign that the cancer
has come back. A CBC measures the number of
Follow-up tests each type of blood cell in a sample of blood. A blood
chemistry profile may be done to check the health of
Follow-up tests are recommended every 2 to 4 certain organs and body systems.
months for 2 years, then every 3 to 6 months for 3
years, then once a year. Many of the tests used for Imaging tests of your chest, abdomen, and pelvis may
follow-up will be the same as those used to find and be used to check if the cancer has spread. A CT, MRI,
confirm (diagnose) ovarian cancer. Read Part 2 on PET, or PET/CT scan may be used. A chest x-ray may
page 14 for more details about each test. be used to show if cancer has spread to your lungs.
(See page 16 for more details about each type of

64
imaging test.) If you had fertility-sparing surgery, then

ultrasound may be used to check for cancer in the
other ovary. Once you are finished having babies, you
Next steps: 
should have surgery to remove the remaining ovary,
fallopian tube, and uterus. This is called completion If tests show signs of cancer return,
surgery.
see Chart 5.4.2 on page 66 for the
Genetic counseling is also recommended if it was next treatments.
not done before treatment. Genetic counseling is
a discussion with a health expert about the risk
for a disease caused by changes in genes. This
is recommended because some health problems,
including ovarian cancer, can run in families. (See
page 14 for more details.)

65
Chart 5.4.2 Treatment for ovarian cancer that has come back
Follow-up results Prior treatment Treatment options
Symptoms, imaging tests, or rising

• Surgical treatment with or without
CA-125 levels signal that cancer No prior chemotherapy
chemotherapy
has come back
• Clinical trial
Biochemical relapse
• Delay recurrence treatment until
(increase in CA-125 levels is the only Prior chemotherapy
symptoms appear (clinical relapse)
sign that cancer has come back)
• Start recurrence treatment right away
• Clinical trial
Finished chemotherapy
• Start recurrence treatment
<6 months ago
Clinical or radiographic relapse • Best supportive care
(symptoms or imaging test results
show signs that cancer has come • Maybe more surgery, then
back after a complete response) Finished chemotherapy • Clinical trial
>6 months ago • Platinum-based chemotherapy (preferred)
• Other recurrence treatment
Chart 5.4.2 shows the options for ovarian cancer unexplained weight loss, upset stomach, constipation,
that has come back after prior treatment. The return trouble eating or feeling full fast, fatigue, and needing
of cancer after treatment is called a recurrence to urinate often or urgently.
or relapse. The treatment options are based on
the type of relapse and whether or not you’ve had Once follow-up tests or symptoms signal a relapse,
chemotherapy before. you may have imaging tests if they weren’t done
recently. This may include a CT, MRI, PET, or PET/CT
A biochemical relapse is when CA-125 levels are scan of your chest, abdomen, and pelvis. (See Part 2
increased, but you don’t have any symptoms and on page 14 for more test details.)
imaging tests show no signs that cancer has come
back. A radiographic relapse is when imaging tests
show signs that the cancer has come back. A clinical
relapse is when you have symptoms that signal
the cancer has come back. Symptoms of a relapse
include pain or bloating in your pelvis or belly,

66
Treatment options best supportive care. Supportive care is treatment

given to relieve the symptoms of cancer or side
If cancer comes back and you haven’t had effects of cancer treatment. It aims to improve
chemotherapy yet, then the options are the same quality of life and relieve any discomfort you have.
as those used for newly diagnosed ovarian cancer. Supportive care may be given alone. It may also be
This means that you will have surgery to remove the given along with recurrence treatment or treatment
cancer and chemotherapy may be given next. The within a clinical trial. (See Part 4 on page 32 for more
type and extent of surgery depends on how far the details about each treatment.)
cancer has spread. If it looks like the cancer is only
in your pelvis, then surgical staging may be done. If it If you finished chemotherapy at least 6 months ago,
looks like the cancer has spread outside your pelvis, then you may have surgery to remove as much of the
then you will have surgery to remove as much cancer cancer as possible. After surgery, or without surgery,
as possible. See Chart 5.3.1 on page 56 for full you still have three other options to choose from.
details and treatment recommendations. One option is to receive treatment within a clinical
trial. The second option is to receive platinum-based
For a biochemical relapse after prior chemotherapy as recurrence treatment. This is the
chemotherapy, there are three options to choose preferred option especially for the first recurrence.
from. The preferred option is to join a clinical trial. The third option is to receive a different type of drug
A clinical trial is a type of research that studies how for recurrence treatment. See Next steps for details.
safe and helpful a test or treatment is. The second
option is to wait and not start treatment until you have
symptoms of a relapse. The third option is to start
recurrence treatment right away.
For a clinical or radiographic relapse after

Next steps: 
chemotherapy, the options depend on long it’s
been since you finished treatment. If you finished For recurrence treatments, see Chart
chemotherapy less than 6 months ago, there are
5.4.3 on page 68.
three options to choose from. The first option is to
receive treatment within a clinical trial. The second
option is to start recurrence treatment, which is
described on page 68. The third option is to receive

67
Chart 5.4.3 Recurrence treatment
Preferred options
If cancer is platinum-sensitive: If cancer is platinum-resistant:

• Bevacizumab • Bevacizumab
• Carboplatin • Docetaxel
• Carboplatin/docetaxel • Etoposide (oral)
• Carboplatin/gemcitabine • Gemcitabine
• Carboplatin/gemcitabine/bevacizumab • Liposomal doxorubicin
• Carboplatin/liposomal doxorubicin • Liposomal doxorubicin/bevacizumab
• Carboplatin/paclitaxel • Olaparib
• Carboplatin/paclitaxel (weekly) • Paclitaxel (weekly)
• Cisplatin • Paclitaxel (weekly)/bevacizumab
• Cisplatin/gemcitabine • Topotecan
• Olaparib • Topotecan/bevacizumab
Other options
• Altretamine • Megestrol acetate

• Aromatase inhibitors • Melphalan
• Capecitabine • Oxaliplatin
• Cyclophosphamide • Paclitaxel
• Doxorubicin • Paclitaxel, albumin-bound
• Ifosfamide • Pemetrexed
• Irinotecan • Tamoxifen
• Leuprolide acetate • Vinorelbine
Chart 5.4.3 shows the options that are away. Recurrence treatments include chemotherapy,
recommended for recurrence treatment. Recurrence hormone therapy, and targeted therapy drugs. (See
treatment is given after prior chemotherapy Part 4 on page 32 for more details about each type
treatment failed to kill all of the cancer or keep it of drug.) Which option is best for you depends on a

68
number of factors, including the type and length of the Cancer is called “platinum-sensitive” if the
treatment response to prior chemotherapy. relapse happens at least 6 or more months after
the last chemotherapy treatment. This means that
Recurrence treatment is used to treat ovarian cancer platinum-based chemotherapy drugs worked well
that has come back after a partial or complete against the cancer. Therefore, you may receive
response to prior chemotherapy. It is also used to platinum-based chemotherapy again as recurrence
treat ovarian cancer that did not respond or continued treatment. This is the preferred option, especially if it
to grow during prior chemotherapy treatment. When is the first recurrence. But, other types of drugs may
cancer comes back after a complete response, also be considered.
the options depend on how long it has been since
chemotherapy ended.
Cancer is called “platinum-resistant” if the

relapse happens less than 6 months after the last
chemotherapy treatment. This means that platinum-
based chemotherapy drugs such as cisplatin and
carboplatin did not work very well against the cancer.
Therefore a different type of drug is recommended for
recurrence treatment.

69
5 Treatment guide My notes
My notes

70
6
Making treatment decisions

71
6 Making treatment
decisions
72 Have a treatment plan
75 Your role in planning
75 Getting a 2nd opinion
76 Questions to ask your doctors
80 Websites | Review
Have a treatment plan

Having cancer can feel very stressful.
Learning you have cancer starts an unplanned
While absorbing the fact that you journey to an unknown place. A treatment plan is
have cancer, you must also learn like having a roadmap for your journey. It is a written
course of action through treatment and beyond. It can
about tests and treatments. And,
help you, your loved ones, and your treatment team.
the time you have to decide on a
treatment plan may feel short. Parts A treatment plan addresses all cancer care needs
while respecting your beliefs, wishes, and values.
1 through 5 aimed to teach you about It is likely to change and expand as you go through
ovarian cancer, its treatment, and treatment. The plan will include the role of your
doctors and how you can help yourself. A treatment
other challenges. Part 6 aims to help
plan often has the following parts:
you talk with your doctors and make
treatment decisions that are right for Cancer information
Cancer can greatly differ even when people have
you. cancer in the same organ. Test results that describe
the cancer are reported in the treatment plan. Such
test results include the cancer site, cell type, cancer
stage, and other features of the cancer. If done, test
results of known gene changes are also included.
See Part 2 on page 14 to read more about the tests
used for ovarian cancer.

72
6 Making treatment decisions Have a treatment plan
Your treatment team may receive care from nurses, social workers, and
Treating ovarian cancer takes a team approach. other health experts. Ask to have the names and
Gynecologic oncologists and medical oncologists contact information of your health care providers
often work closely together to plan the best treatment included in the treatment plan.
for ovarian cancer. A gynecologic oncologist is a
doctor who’s an expert in surgery to treat cancers that Cancer treatment
start in a woman’s reproductive organs. A medical There is no single treatment practice that is best for
oncologist is a doctor who is an expert in treating all patients. There is often more than one treatment
cancer with chemotherapy and other drugs. NCCN option, including clinical trials. Clinical trials study how
experts recommend that a gynecologic oncologist well a treatment works and its safety.
should perform the initial surgery for ovarian cancer
when possible. A guide to ovarian cancer treatment options can be
found in Part 5. The treatment that you and your
Your primary care doctor can also be part of your doctors agree on should be reported in the treatment
team. He or she can help you express your feelings plan. It is also important to note the goal of treatment
about treatments to the team. Treatment of other and the chance of a good treatment outcome. All
medical problems may be improved if he or she is known side effects should be listed and the time
informed of your cancer care. Besides doctors, you required to treat them should be noted. See Part 4 for
“Knowledge and expectations can impact every aspect of treatment and

survivorship. As a gynecologic oncologist, ensuring that my patients
understand their diagnosis and treatment options builds the foundation for a
strong patient-doctor relationship and successful ovarian cancer treatment.
As the daughter of an ovarian cancer survivor, I have personally faced the
fear and anxiety that comes with the uncertainty
of this diagnosis. Patients and their families need
accurate, reliable, and patient-centered information
to ease this uncertainty and guide them to the best
possible care.”
Kara Long Roche, M.D., M.Sc.

Gynecologic Oncologist

73
6 Making treatment decisions Have a treatment plan
a list of some common side effects of ovarian cancer of great anxiety. This is a very normal response. You
treatments. may need support to address issues that arise from
not having regular visits with your cancer care team.
Your treatment plan may change because of new In addition, your treatment plan should include a
information. You may change your mind about schedule of follow-up cancer tests, treatment of long-
treatment. Tests may find new results. How well term side effects, and care of your general health.
the treatment is working may change. Any of these
changes may require a new treatment plan. Advance care planning
Talking with your doctor about your prognosis can
Stress and symptom control help with treatment planning. If the cancer can’t be
Cancer and its treatments can cause bothersome controlled or cured, a care plan for the end of life can
symptoms. The stress of having cancer can also be made. However, such talks often happen too late
cause symptoms. There are ways to treat many or not at all. Your doctor may delay these talks for
symptoms, so tell your treatment team about any that fear that you may lose hope, become depressed, or
you have. have a shorter survival. Studies suggest that these
fears are wrong. Instead, there are many benefits to
You may lose sleep before, during, and after advance care planning. It is useful for:
treatment. Getting less sleep can affect your
mood, conversations, and ability to do daily tasks. • Knowing what to expect,
If possible, allow yourself to rest, let people do • Making the most of your time,
things for you, and talk with your doctor about sleep • Lowering the stress of caregivers,
medication. Behavioral sleep medicine—a type of talk • Having your wishes followed,
therapy—may also help. • Having a better quality of life, and
• Getting good care.
Feelings of anxiety and depression are common
among people with cancer. At your cancer center, Advance care planning starts with an honest talk
cancer navigators, social workers, and other experts between you and your doctors. You don’t have to
can help. Help can include support groups, talk know the exact details of your prognosis. Just having
therapy, or medication. Some people also feel better a general idea will help with planning. With this
by exercising, talking with loved ones, or relaxing. information, you can decide at what point you’d want
to stop chemotherapy or other treatments, if at all.
You may be unemployed or miss work during You can also decide what treatments you’d want for
treatment. Or, you may have too little or no health symptom relief, such as surgery or medicine.
insurance. Talk to your treatment team about work,
insurance, or money problems. They will include Another part of the planning involves hospice care.
information in the treatment plan to help you manage Hospice care doesn’t include treatment to fight the
your finances and medical costs. cancer but rather to reduce symptoms caused by
cancer. Hospice care may be started because you
Survivorship care aren’t interested in more cancer treatment, no other
Cancer survivorship begins on the day you learn of cancer treatment is available, or because you may be
having ovarian cancer. For many survivors, the end of too sick for cancer treatment. Hospice care allows you
active treatment signals a time of celebration but also to have the best quality of life possible. Care is given

74
6 Making treatment decisions Your role in planning | Getting a 2nd opinion
all day, every day of the week. You can choose to have options, and agree on a treatment plan. Your doctors
hospice care at home or at a hospice center. One know the science of treating ovarian cancer. But, you
study found that patients and caregivers had a better know your personal concerns and goals. By working
quality of life when hospice care was started early. together, you may feel more comfortable and satisfied
with your care and treatment plan. You’ll likely get the
An advance directive describes the treatment you’d treatment you want, at the place you want, and by the
want if you weren’t able to make your wishes known. doctors you want.
It also can name a person you’d want to make
decisions for you. It is a legal paper that your doctors
have to follow. It can reveal your wishes about life-
sustaining machines, such as feeding tubes. It can Getting a 2nd opinion
also include your treatment wishes if your heart or
lungs were to stop working. If you already have an The time around a cancer diagnosis can be very
advance directive, it may need to be updated to be stressful. People with cancer often want to start
legally valid. treatment as soon as possible. They want to make the
cancer go away before it spreads any farther. While
cancer can’t be ignored, there is time to think about
and choose which treatment plan is best for you.
Your role in planning
You may wish to have another doctor review your
The role patients want in treatment planning differs. test results and the treatment plan your doctor has
Your doctors and treatment team will give you the recommended. This is called getting a 2nd opinion.
information you need to make informed choices. But, You may completely trust your doctor, but a 2nd
you may prefer to let others take the lead in deciding opinion on which treatment is right for you can help.
your treatment. This may be due to a high level of
stress. It may be hard to hear or know what others Copies of all of the test results need to be sent to
are saying. Stress, pain, and drugs can limit your the doctor giving the 2nd opinion. Some people feel
ability to make good decisions. You may have never uneasy asking for copies from their doctors. However,
heard the words used to describe ovarian cancer, a 2nd opinion is a normal part of cancer care.
tests, or treatments. Likewise, you may think that your
judgment isn’t any better than your doctors’. When doctors have cancer, most will talk with more
than one doctor before choosing their treatment.
You may rely on your doctors alone to make the right What’s more, some health plans require a 2nd opinion.
decisions. You can also have loved ones help. They If your health plan doesn’t cover the cost of a 2nd
can gather information, speak on your behalf, and opinion, you have the choice of paying for it yourself.
share in decision-making with your doctors. Even if Choosing your cancer treatment is a very important
others decide which treatment you will receive, you decision. It can affect length and quality of life.
still have to agree by signing a consent form.
On the other hand, you may prefer to take the lead or

share in decision-making. In shared decision-making,
you and your doctors share information, weigh the

75
6 Making treatment decisions Questions to ask your doctors
Questions about testing

1. What tests will I have?
2. Where will the tests take place? Will I have to go to the hospital?
3. How long will it take? Will I be awake?
4. Will any test hurt?
5. What are the risks?
6. How do I prepare for testing?
7. Should I bring a list of my medications?
8. Should I bring someone with me?
9. How soon will I know the test results?
10. Who will explain the test results to me?
11. Can I have a copy of the test results and pathology report?
12. Who will talk with me about the next steps? When?

76
Questions about treatments

1. What treatments do you recommend?
2. Will I have more than one treatment?
3. What are the risks and benefits of each treatment? What about side effects?
4. Will my age, general health, and other factors affect my treatment choices?
5. Would you help me get a 2nd opinion?
6. How soon should I start treatment? How long does treatment take?
7. Where will I be treated? Will I have to stay in the hospital or can I go home after each treatment?
8. What can I do to prepare for treatment?
9. What symptoms should I look out for during treatment?
10. How much will the treatment cost? How can I find out how much my insurance company
will cover?
11. How likely is it that I’ll be cancer-free after treatment?
12. What is the chance that the cancer will come back?
13. What should I do after I finish treatment?
14. Are there supportive services that I can get involved in? Support groups?

77
Questions about clinical trials

1. Is there a clinical trial that I could take part in?
2. What is the purpose of the study?
3. What kinds of tests and treatments does the study involve?
4. What does the treatment do?
5. Has the treatment been used before? Has it been used for other types of cancers?
6. Will I know which treatment I receive?
7. What is likely to happen to me with, or without, this new treatment?
8. How might the study change my daily life?
9. What side effects can I expect from the study? Can the side effects be controlled?
10. Will I have to stay in the hospital? If so, how often and for how long?
11. Will the study cost me anything? Will any of the treatment be free?
12. What type of long-term follow-up care is part of the study?

78
6 Making treatment decisions My notes
My notes

79
6 Making treatment decisions Websites | Review
Websites Review
National Ovarian Cancer Coalition • A treatment plan can help you through
www.ovarian.org/ treatment and beyond.
• It covers many issues—test results,

Foundation for Women’s Cancer
treatments, and supportive programs.
www.foundationforwomenscancer.org/
• You can choose how active a role to have in
Ovarian Cancer National Alliance planning your treatment.
www.ovariancancer.org/
• You may wish to get a 2nd opinion on your
treatment plan.
American Cancer Society
www.cancer.org/cancer/ovariancancer/index
National Cancer Institute

www.cancer.gov/types/ovarian/patient/ovarian-
epithelial-treatment-pdq#section/_104
National Coalition for Cancer Survivorship

www.canceradvocacy.org/toolbox
NCCN
www.nccn.org/patients/

80
Glossary
Dictionary
Acronyms

81
Glossary Dictionary
Dictionary
abdomen cancer stage
The belly area between the chest and pelvis. A rating of the growth and spread of cancer in the body.
adjuvant treatment cancer staging

Treatment given after the main treatment used to rid the The process of rating and describing the extent of cancer in
body of disease. the body.
allergic reaction capsule

Symptoms caused when the body is trying to rid itself of A thin layer of tissue that surrounds an organ—like the skin
invaders. of an apple.
ascites cell subtype

Abnormal fluid buildup in the belly (abdomen) or pelvis. Smaller groups that at type of cancer is divided into based
on how the cancer cells look under a microscope.
bilateral salpingo-oophorectomy (BSO)
Surgery to remove both ovaries and both fallopian tubes. cervix
The lower part of the uterus that connects to the vagina.
biochemical relapse
A rise in CA-125 levels signals that cancer has come back chemotherapy
after treatment. Drugs that kill fast-growing cells throughout the body,
including normal cells and cancer cells.
biopsy
Removal of small amounts of tissue from the body to be chest x-ray
tested for disease. A test that uses x-rays to make pictures of the inside of the
chest.
bladder
An organ that holds and expels urine from the body. clear cell
One of the four main cell subtypes of ovarian cancer.
blood chemistry profile
A test that measures the amounts of many different clinical relapse
chemicals in a sample of blood. Physical signs or symptoms signal that cancer has come
back after treatment.
blood vessel
A tube that carries blood throughout the body. clinical trial
Research on a test or treatment to assess its safety or how
BRCA1 or BRCA2 genes well it works.
Coded information in cells that help to prevent tumor growth
by fixing damaged cells and helping cells grow normally. combination regimen
Abnormal changes within these genes increases the The use of two or more drugs.
chances of developing breast and ovarian cancer.
complete blood count (CBC)
cancer antigen 125 (CA-125) A test of the number of blood cells.
A protein with sugar molecules on it that is made by ovarian
cancer cells and normal cells.
complete response
All signs and symptoms of cancer are gone after treatment.
cancer grade
A rating of how much the cancer cells look like normal cells.

82
Glossary Dictionary
completion surgery follow-up test

Surgery to remove the remaining ovary, fallopian tube, Tests done after the start of treatment to check how well
uterus, and all cancer that can be seen. treatment is working.
computed tomography (CT) scan gastrointestinal (GI) evaluation

A test that uses x-rays from many angles to make a picture A test to view the organs that food passes through when you
of the inside of the body. eat.
contrast gastrointestinal tract

A dye put into your body to make clearer pictures during The group of organs that food passes through when you eat.
imaging tests.
general anesthesia
cycle A controlled loss of wakefulness from drugs.
Days of treatment followed by days of rest.
genes
cytoreductive surgery A set of coded instructions in cells for making new cells and
Surgery to remove as much cancer as possible. Also called controlling how cells behave.
debulking surgery.
genetic counseling
debulking surgery A discussion with a health expert about the risk for a disease
Surgery to remove as much cancer as possible. Also called caused by changes in genes.
cytoreductive surgery.
genetic counselor
deoxyribonucleic acid (DNA) A health expert that has special training to help patients
Molecules that contain coded instructions for making and understand changes in genes that are related to disease.
controlling cells.
genetic testing
diagnose Tests to look for changes in coded instructions (genes) that
To identify a disease. increase the risk for a disease.
diagnosis germ cell

The process of identifying or confirming a disease. Reproductive cells that become eggs in women and sperm
in men.
diaphragm
The muscles below the ribs that help a person to breathe. gynecologic oncologist
A surgeon who’s an expert in cancers that start in a woman’s
epithelial cells reproductive organs.
Cells that form the outer layer of tissue around organs in the
body. hereditary ovarian cancer
Ovarian cancer caused by abnormal coded information in
epithelial ovarian cancer cells that is passed down from parent to child.
Cancer that starts in the cells that form the outer layer of
tissue around the ovaries. hormone
Chemicals in the body that activate cells or organs.
fallopian tube
A thin tube through which an egg travels from the ovary to hormone therapy
the uterus. Treatment that stops the making or action of hormones in the
body.
fatigue
Severe tiredness despite getting enough sleep. hot flashes
A health condition of intense body heat and sweat for short
fertility-sparing surgery periods.
Surgery that only removes one ovary and fallopian tube so
that a woman can still have babies.

83
Glossary Dictionary
hysterectomy liver function test

Surgery to remove the uterus. A blood test that measures chemicals that are made or
processed by the liver to check how well the liver is working.
imaging test
Tests that make pictures (images) of the inside of the body. low malignant potential (LMP) tumor
A tumor formed by abnormal cells that aren’t clearly cancer
implant cells because, while they can spread and grow on the
Cancer cells that broke away from the first tumor and formed
surface of organs in the belly, they do not invade these
new tumors on the surface of nearby organs and tissues.
organs.
infusion lymph
A method of giving drugs slowly through a needle into a vein.
A clear fluid containing white blood cells that fight infection
intestine and disease.
The organ that eaten food passes through after leaving the
lymph nodes
stomach.
Small groups of special disease-fighting cells located
intraperitoneal (IP) chemotherapy throughout the body.
Chemotherapy drugs given directly into the belly (abdomen)
lymph vessels
through a small tube.
Small tubes that carry lymph—a clear fluid with white blood
intraperitoneal (IP) cells that fight infection and disease—throughout the body.
Given directly into the belly (abdomen) through a small tube.
magnetic resonance imaging (MRI) scan
intravenous (IV) chemotherapy A test that uses radio waves and powerful magnets to make
Chemotherapy drugs given through a needle or tube inserted pictures of the inside of the body.
into a vein.
maintenance treatment
intravenous (IV) Treatment given to continue (maintain) good results of prior
Given by a needle or tube inserted into a vein. treatment.
invasion medical history

When one kind of cell grows into organs or tissues where it All health events and medications taken to date.
doesn’t belong.
medical oncologist
invasive implant A doctor who is an expert in treating cancer with drugs such
Cancer cells that broke away from the first tumor and are as chemotherapy.
growing into (invading) supporting tissue of nearby organs.
menopause
kidneys The point in time when menstrual periods end.
A pair of organs that filter blood and remove waste from the
menstrual cycle
body through urine.
Changes in the womb and ovaries that prepare a woman’s
laparotomy body for pregnancy.
Surgery with a long, up-and-down cut through the wall of the
metastases
belly (abdomen).
Tumors formed by cancer cells that have spread from the
large intestine first tumor to other parts of the body.
The organ that prepares unused food for leaving the body.
metastasis
liver The spread of cancer cells from the first tumor to another
An organ that removes waste from blood and makes a liquid body part.
that helps to digest food.

84
Glossary Dictionary
microscope pelvis
A tool that uses lenses to see very small things the eyes The body area between the hip bones.
can’t.
peritoneal cavity
microscopic metastases The space inside the belly (abdomen) that contains
Cancer cells that have spread from the first tumor to another abdominal organs such as the intestines, stomach, and liver.
body part and are too small to be seen with the naked eye.
peritoneal washing
mutation A test in which a special liquid is used to wash the inside of
An abnormal change in the instructions in cells for making the belly (peritoneal cavity) to check for cancer cells.
and controlling cells.
peritoneal washings
neuropathy Sample of liquid that is tested for cancer cells after it is used
A nerve problem that causes pain, tingling, and numbness in to “wash” the inside of the belly (peritoneal cavity).
the hands and feet.
peritoneum
noninvasive implant The layer of tissue that lines the inside of the belly
Cancer cells that broke away from the first tumor and are (abdomen) and pelvis and covers most organs in this space.
growing on the surface of nearby organs, but are not growing
into (invading) tissue.
persistent disease
Cancer that stayed the same—didn’t get better or worse—
observation during treatment.
A period of testing to watch for cancer growth.
physical exam
omentum A review of the body by a health expert for signs of disease.
The layer of fatty tissue that covers organs in the belly
(abdomen).
platinum agent
A cancer drug that is made with platinum. These drugs
ovarian cancer of low malignant potential damage DNA in cells, which stops them from making new
A tumor in the ovary formed by abnormal cells that aren’t cells and causes them to die.
clearly cancer cells because, while they can spread and
grow on the surface of organs in the belly, they do not invade
platinum-based chemotherapy
Treatment with two or more chemotherapy drugs and
these organs.
the main drug is made with platinum. Such drugs include
ovaries cisplatin and carboplatin.
The pair of organs in women that make eggs for reproduction
(making babies) and make hormones.
platinum-resistant
When cancer drugs made with platinum, such as cisplatin
ovary and carboplatin, do not work well against the cancer.
One of a pair of organs in women that make eggs for
reproduction (making babies) and make hormones.
platinum-sensitive
When cancer drugs made with platinum, such as cisplatin
partial response and carboplatin, work well against the cancer.
Cancer improved as a result of treatment—tests show a
decrease in the amount of cancer, tumor size, or CA-125
poly ADP-ribose polymerase (PARP)
A protein that helps repair damaged DNA in cells.
levels—but it’s not completely gone.
pathologist positron emission tomography (PET) scan

A test that uses a sugar radiotracer—a form of sugar that is
A doctor who’s an expert in testing cells and tissue to find
put into your body and lets off a small amount of energy that
disease.
is absorbed by active cells—to view the shape and function
pelvic exam of organs and tissues inside your body.
A medical exam of the female organs in the pelvis.

85
Glossary Dictionary
positron emission tomography (PET)/computed reproductive system

tomography (CT) scan The group of organs that work together to make babies. In
A test that uses a sugar radiotracer and x-rays from many women, this includes the ovaries, fallopian tubes, uterus,
angles to view the shape and function of organs and tissues cervix, and vagina.
inside the body.
serous
primary chemotherapy The most common cell subtype of ovarian cancer.
The first or main chemotherapy drugs given to treat cancer.
side effect
primary treatment An unhealthy or unpleasant condition caused by treatment.
The main treatment used to rid the body of cancer.
sigmoid colon
primary tumor The last part of the colon—organ that changes unused food
The first mass of cancer cells in the body. from a liquid to a solid form—that connects to the rectum,
which hold stool until it leaves the body.
prognosis
The likely or expected course and outcome of a disease. small intestine
The digestive organ that absorbs nutrients from eaten food.
progressive disease
Cancer that continued to grow (progress) during or after spleen
treatment. An organ to the left of the stomach that helps protect the
body from disease.
radiographic relapse
Imaging tests show signs that cancer has come back after stromal cell
treatment. Cells that form the connective and supporting tissues that
hold the ovary together.
radiologist
A doctor who’s an expert in reading imaging tests—tests that sugar radiotracer
make pictures of the inside of the body. A form of sugar that is put into your body and lets off a small
amount of energy that is absorbed by active cells.
rectum
The last part of the large intestine that holds stool until it’s supportive care
expelled from the body. Treatment given to relieve the symptoms of a disease. Also
called palliative care.
recurrence
The return of cancer after treatment. Also called a relapse. surgeon
A doctor who is an expert in operations to remove or repair a
recurrence treatment part of the body.
Treatment that is given after prior treatments failed to kill all
the cancer or keep it away. surgery
An operation to remove or repair a part of the body.
regimen
A treatment plan that specifies the drug(s), dose, schedule, surgical staging
and length of treatment. The process of finding out how far cancer has spread by
performing tests and procedures during surgery to remove
relapse the cancer.
The return of cancer after treatment. Also called a
recurrence. surgical treatment
Treatment with surgery—an operation to remove or repair a
reproductive organs part of the body.
Organs that help make babies.
symptom
A new or changed health problem a person experiences that
may indicate a certain disease or health condition.

86
Glossary Dictionary
targeted therapy unilateral salpingo-oophorectomy (USO)

Treatment with drugs that target a specific or unique feature Surgery that removes one ovary and the attached fallopian
of cancer cells. tube.
taxane uterus
A type of cancer drug that blocks certain cell parts to stop a The female organ where babies grow during pregnancy. Also
cell from dividing into two cells. called womb.
treatment plan vagina

A written course of action through cancer treatment and The hollow, muscular tube in women through which babies
beyond. are born.
treatment response vein

An outcome or improvement related to treatment. A blood vessel that carries blood back to the heart from all
parts of the body.
tumor
An abnormal mass formed by the overgrowth of cells. washings
Sample of liquid that is tested for cancer cells after it is used
tumor marker to “wash” the inside of the belly (peritoneal cavity).
A substance found in body tissue or fluid that may be a sign
of cancer. white blood cell
A type of blood cell that helps fight infections in the body.
U.S. Food and Drug Administration
A federal government agency that regulates drugs and food
in the United States.
ultrasound
A test that uses sound waves to take pictures of the inside of
the body.

87
Glossary Acronyms
Acronyms
BSO MRI
bilateral salpingo-oophorectomy magnetic resonance imaging
CA-125 PARP
cancer antigen 125 poly ADP-ribose polymerase
CAM PET
complementary and alternative medicine positron emission tomography
CBC PET/CT
complete blood count positron emission tomography/computed tomography
cm TAH
centimeter total abdominal hysterectomy
CT USO
computed tomography unilateral salpingo-oophorectomy
DNA
deoxyribonucleic acid
NCCN Abbreviations and Acronyms
FDA
U.S. Food and Drug Administration NCCN®
National Comprehensive Cancer Network®
FIGO
International Federation of Gynecology and Obstetrics NCCN Patient Guidelines
FNA
fine-needle aspiration
NCCN Guidelines®
GI NCCN Clinical Practice Guidelines in Oncology®
gastrointestinal
IP
intraperitoneal
IV
intravenous
LHRH
luteinizing hormone-releasing hormone
LMP
low malignant potential
mm
millimeter

88
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90
NCCN Panel Members
NCCN Panel Members for

Ovarian Cancer
Robert J. Morgan, Jr., MD/Chair Ardeshir Hakam, MD Paul Sabbatini, MD
City of Hope Comprehensive Cancer Center Moffitt Cancer Center Memorial Sloan Kettering Cancer Center
Deborah K. Armstrong, MD/Vice Chair Laura J. Havrilesky, MD Joseph T. Santoso, MD

The Sidney Kimmel Comprehensive Duke Cancer Institute St. Jude Children’s Research Hospital/
Cancer Center at Johns Hopkins The University of Tennessee
Carolyn Johnston, MD Health Science Center
Ronald D. Alvarez, MD University of Michigan
University of Alabama at Birmingham Comprehensive Cancer Center Theresa L. Werner, MD
Comprehensive Cancer Center Huntsman Cancer Institute
Shashikant Lele, MD at the University of Utah
Jamie N. Bakkum-Gamez, MD Roswell Park Cancer Institute
Mayo Clinic Cancer Center
Lainie Martin, MD
Kian Behbakht, MD Fox Chase Cancer Center
University of Colorado Cancer Center
Ursula A. Matulonis, MD
Lee-may Chen, MD Dana-Farber/Brigham and Women’s
UCSF Helen Diller Family Cancer Center
Comprehensive Cancer Center
David M. O’Malley, MD
Larry Copeland, MD The Ohio State University Comprehensive
The Ohio State University Comprehensive Cancer Center - James Cancer Hospital
Cancer Center - James Cancer Hospital and Solove Research Institute
and Solove Research Institute
Richard T. Penson, MD, MRCP
Marta Ann Crispens, MD Massachusetts General Hospital
Vanderbilt-Ingram Cancer Center Cancer Center
Oliver Dorigo, MD, PhD Steven C. Plaxe, MD

Stanford Cancer Institute UC San Diego Moores Cancer Center
David M. Gershenson, MD Matthew A. Powell, MD

The University of Texas Siteman Cancer Center at Barnes-
MD Anderson Cancer Center Jewish Hospital and Washington
University School of Medicine
Heidi J. Gray, MD
University of Washington Medical Center/ Elena Ratner, MD
Seattle Cancer Care Alliance Yale Cancer Center/Smilow Cancer Hospital
Rachel Grisham, MD Steven W. Remmenga, MD

Memorial Sloan Kettering Cancer Center Fred & Pamela Buffett Cancer Center
For disclosures, visit www.nccn.org/about/disclosure.aspx.

91
NCCN Member Institutions
NCCN Member Institutions

Fred & Pamela Buffett The Sidney Kimmel St. Jude Children’s
Cancer Center Comprehensive Cancer Research Hospital/
Omaha, Nebraska Center at Johns Hopkins The University of Tennessee
800.999.5465 Baltimore, Maryland Health Science Center
nebraskamed.com/cancer 410.955.8964 Memphis, Tennessee
hopkinskimmelcancercenter.org 888.226.4343 • stjude.org
Case Comprehensive Cancer Center/ 901.683.0055 • westclinic.com
University Hospitals Seidman Robert H. Lurie Comprehensive
Cancer Center and Cleveland Clinic Cancer Center of Northwestern Stanford Cancer Institute
Taussig Cancer Institute University Stanford, California
Cleveland, Ohio Chicago, Illinois 877.668.7535
800.641.2422 • UH Seidman Cancer Center 866.587.4322 cancer.stanford.edu
uhhospitals.org/seidman cancer.northwestern.edu
866.223.8100 • CC Taussig Cancer Institute University of Alabama at Birmingham
my.clevelandclinic.org/services/cancer Mayo Clinic Cancer Center Comprehensive Cancer Center
216.844.8797 • Case CCC Phoenix/Scottsdale, Arizona Birmingham, Alabama
case.edu/cancer Jacksonville, Florida 800.822.0933
Rochester, Minnesota www3.ccc.uab.edu
City of Hope Comprehensive 800.446.2279 • Arizona
Cancer Center 904.953.0853 • Florida UC San Diego Moores Cancer Center
Los Angeles, California 507.538.3270 • Minnesota La Jolla, California
800.826.4673 mayoclinic.org/departments-centers/mayo- 858.657.7000
cityofhope.org clinic-cancer-center cancer.ucsd.edu
Dana-Farber/Brigham and Memorial Sloan Kettering UCSF Helen Diller Family

Women’s Cancer Center Cancer Center Comprehensive Cancer Center
Massachusetts General Hospital New York, New York San Francisco, California
Cancer Center 800.525.2225 800.689.8273
Boston, Massachusetts mskcc.org cancer.ucsf.edu
877.332.4294
dfbwcc.org Moffitt Cancer Center University of Colorado Cancer Center
massgeneral.org/cancer Tampa, Florida Aurora, Colorado
800.456.3434 720.848.0300
Duke Cancer Institute moffitt.org coloradocancercenter.org
Durham, North Carolina
888.275.3853 The Ohio State University University of Michigan
dukecancerinstitute.org Comprehensive Cancer Center - Comprehensive Cancer Center
James Cancer Hospital and Ann Arbor, Michigan
Fox Chase Cancer Center Solove Research Institute 800.865.1125
Philadelphia, Pennsylvania Columbus, Ohio mcancer.org
888.369.2427 800.293.5066
foxchase.org cancer.osu.edu The University of Texas
MD Anderson Cancer Center
Huntsman Cancer Institute Roswell Park Cancer Institute Houston, Texas
at the University of Utah Buffalo, New York 800.392.1611
Salt Lake City, Utah 877.275.7724 mdanderson.org
877.585.0303 roswellpark.org
huntsmancancer.org Vanderbilt-Ingram Cancer Center
Siteman Cancer Center Nashville, Tennessee
Fred Hutchinson Cancer at Barnes-Jewish Hospital 800.811.8480
Research Center/ and Washington University vicc.org
Seattle Cancer Care Alliance School of Medicine
Seattle, Washington St. Louis, Missouri Yale Cancer Center/
206.288.7222 • seattlecca.org 800.600.3606 Smilow Cancer Hospital
206.667.5000 • fredhutch.org siteman.wustl.edu New Haven, Connecticut
855.4.SMILOW
yalecancercenter.org

92
Notes
My notes

93
Index
Index
adjuvant treatment 35, 54, 60 surgical staging 21, 24, 25, 30, 32, 34, 46, 47, 50–53,
biopsy 15, 21, 22, 25, 47, 50–53, 56–58 55–58, 67
CA-125 15, 20, 48, 49, 55, 61, 62, 64, 66 symptom 6, 11, 12, 14, 34, 38, 49, 62, 63, 66, 67, 73, 74,
77
cancer grade 24, 29, 30, 52, 53, 55
targeted therapy 32, 37, 42, 68
cancer stage 24, 26–28, 30, 45, 50, 52–56, 58, 60, 72
treatment response 61, 62, 69
chemotherapy 32, 35–37, 42, 46, 47, 49, 52–62, 66–69,
73, 74
clinical trial 32, 39, 40, 42, 62, 62, 66, 67, 73, 78
completion surgery 46–48, 52, 53, 58, 59, 65
computed tomography (CT) 15, 17–19, 64, 66
debulking surgery 33, 34, 49, 57
fertility-sparing surgery 33, 46, 48, 50, 65
follow-up test 44, 46–49, 54, 55, 62–64, 66
genetic counseling 14, 15, 22, 64, 65
hormone therapy 32, 38, 42, 68
imaging test 14–19, 22, 49, 55, 61, 62, 64–66
implant 10, 27, 46, 47, 49
IP chemotherapy 36, 60, 61
IV chemotherapy 36, 55, 60, 61
low malignant potential (LMP) tumor 9, 10, 12, 44–49
primary chemotherapy 35, 54, 60–62
primary treatment 32, 35, 42, 46–54, 56–60
recurrence 49, 62, 63, 66
recurrence treatment 62, 63, 66–69
relapse 49, 64, 66, 67, 69
reproductive 7, 24, 32, 73
side effect 20, 34, 36–39, 55, 61, 63, 64, 67, 73
supportive care 62, 63, 66, 67
surgery 21, 24, 25, 27, 29, 30, 32–36, 42, 46–50, 52–61,
65–67, 73, 74

94
Ü
Ovarian
Cancer
Version 1.2015
NCCN Foundation® gratefully acknowledges our advocacy supporter National Ovarian Cancer Coalition. NCCN independently
develops and distributes the NCCN Guidelines for Patients®. Our industry supporters do not participate in the development of the
NCCN Guidelines for Patients and are not responsible for the content and recommendations contained therein.
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NCCN Guidelines for Patients®

The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit

NCCN Guidelines for Patients®

Supported by NCCN Foundation®

National Comprehensive Cancer Network (NCCN)

NCCN Guidelines for Patients®

NCCN Guidelines for Patients®

Who should read this book? Making sense of medical

The recommendations in this book are based

NCCN Guidelines for Patients®

NCCN Guidelines for Patients®

Learning that you have cancer can

NCCN Guidelines for Patients®

NCCN Guidelines for Patients®

Figure 1.2 Normal cell growth Cancer cell growth

Normal cells divide to make Cell death

NCCN Guidelines for Patients®

Most ovarian cancers

NCCN Guidelines for Patients®

How does ovarian cancer

Second, cancer cells can grow into (invade) other

Third, cancer cells don’t stay in one place as they

Cancer cells can also spread through blood or lymph

The uncontrolled growth, invasion, and spread of

NCCN Guidelines for Patients®

If this describes you, tell your doctor about your

Your doctor may also think you have ovarian cancer

NCCN Guidelines for Patients®

NCCN Guidelines for Patients®

NCCN Guidelines for Patients®

General health tests

NCCN Guidelines for Patients®

Chart 2.1 Tests for ovarian cancer

Type of test Recommended tests

• Family and medical history

NCCN Guidelines for Patients®

This test uses a hand-held device called an

For a transabdominal ultrasound, a gel will be spread

NCCN Guidelines for Patients®

Figure 2.1 Ultrasound

Transabdominal ultrasound Transvaginal ultrasound

Ultrasound picture Ultrasound picture

NCCN Guidelines for Patients®

Before the CT scan, you may be given a contrast dye

A CT scan machine is large and has a tunnel in the

One x-ray scan is completed in about 30 seconds.

An MRI scan of your abdomen and pelvis may be

Getting an MRI scan is similar to getting a CT scan.

NCCN Guidelines for Patients®

PET is very good at showing small groups of cancer

NCCN Guidelines for Patients®

Blood tests Liver function tests

Blood chemistry profile

NCCN Guidelines for Patients®

However, a biopsy may be done before treatment in