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Gynecological Cancer -7 Ovary Cancer Treatment Stage 4

Gynecological Cancer  – 7

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for highlighting some important points about ovary cancer treatment. 1. Most patients need chemotherapy after surgery, even if stage one. Most commonly used and first option is a carboplatin and paclitaxel combination for 6 courses. Addition of Intraperitoneal chemotherapy is also an established option with better results as per randomized trials. However, it is cumbersome, more side effects and not widely available. Hence most centers worldwide still prefer only IV chemotherapy. 2. Most patients benefit from chemotherapy even in stage 4. Platinum refractory patients have limited benefit however, and should be offered palliative care only or clinical trial as options.
Most patients in India think that stage 4 means absolutely terminal, and there is no point doing any effort. How true is that?
Answer: I think it is important to provide right information to patient and family and help them make the decision. We should not have our fixed opinions about what stage or patient must be treated and who must not be treated. That decision should be theirs. We have to give them balanced information about benefit, side effects, cost effectiveness, logistics etc and help them reach a decision.
I have been surprised many times by the perspective patient or family has, after I give them all the information. For example, an 80 year old would like to undergo treatment in stage 4 and a 65 year would say no. just personal choice. For some, it boils down to cost effectiveness, traveling for treatment, or fear of side effects.
It is difficult to comment on all cancers, but in general, breast ovary lung colon etc are cancers with many options even in stage 4. If we talk about ovary, even in stage 4, especially Platinum Sensitive disease, there are several options and fairly good life expectancy, with a good quality of life.
Que: Thank you for this clarity. Yes we have changing culture and expectations. We see this in other diseases too. And patients often take their decisions, unlike in past where doctor took all decisions. You mentioned last time that Platinum Refractory disease is one which relapses within six months after last postoperative chemotherapy. So I assume that those who relapse after six months are Platinum Sensitive.
Ans: Yes, absolutely. You are catching up fast. These are the patients who frequently respond well to several chemotherapy agents, including to same carboplatin paclitaxel again. Over few to several years, they also become resistant to all agents and do not survive beyond 5 years in general.
Que: How can we decide which agent is best for them in case of relapse? I have heard of chemosensitivity tests. How reliable are they?
Ans: As of now, these assays are not very reliable and not recommended as a routine. Choice of agent depends on time since last chemotherapy, comorbidities, patient choice, cost etc.
One important point is that relapse can be highly variable, from absolutely minimal symptoms and disease burden to florid relapse on other extreme. Also, if patient has no symptoms, and relapse is identified only by a rising CA 125, best is to leave them untreated and just monitor every few months. This is difficult for many patients to accept, but with adequate explanation and reassurance, they generally do. At some point of course, they all do need treatment.
I saw a follow up patient in my clinic yesterday, with CA 125 now 533, rising steadily for last six months, but with no symptoms, and stable very small 2 nodes on sonography. She is only on observation, no medicines at all. And that is the right way to treat such patients. Some may give them hormone therapy tablets which is a reasonable option too. However chemotherapy should be avoided, even oral agents like capecitabine.
Patients who need active treatment, have many options, including oral agents like capecitabine or UFT. And several intravenous options.
Rare patients have single metastatic site which can be clearly resected.
A new form of therapy, known as HIPEC is also available now, but is controversial. It involves extensive surgery to remove all obvious disease, followed by heated intraperitoneal chemotherapy. There are no good randomized trials but it can be considered in young, very fit and motivated patients. It is also expensive.

June 14th 2017.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com

Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com

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