If your cancer comes back.
If your ovarian cancer was at an advanced stage when you were first diagnosed, it means that the cancer had already spread beyond the ovaries to other areas within your pelvis, and possibly to organs outside the pelvis.
Initial surgery removes the ovaries, other affected organs and as much visible cancer as possible, and chemotherapy then helps to ‘mop up’ remaining cancer cells. But in advanced cancer, where the cancer cells have already been deposited in other parts of the body, there is a high chance that they will begin to grow again. This is called a recurrence.
When ovarian cancer recurs it is increasingly being seen and treated as a chronic illness: where the cancer recurs a number of times and can be treated and stabilised — and there may be long periods in- between where no treatment is needed. While a cure may not be possible, it does mean that you can live for an extended time with a good quality of life.
How will I know if the cancer has come back?
You and your doctor may suspect that your cancer has come back if you begin to experience symptoms similar to those when you were first diagnosed or if you notice other changes in your health. Always tell your doctor about any symptoms that are new or have returned.
Your doctor may also suspect that your cancer has come back based on changes found in your follow-up physical examination or if your CA125 level has been rising (please see pages xx–xx for more about rising CA125 levels).
Some women may have signs that the cancer has come back even though their CA125 isn’t rising.
If tests or symptoms suggest that your cancer has recurred, it may then be confirmed by an ultrasound or CT scan. It is important to remember that your follow-up plan is designed by you and your doctor to check on you and ensure you get the care you need.
Many women say that finding out their cancer has come back is more stressful than their initial diagnosis. Ask for all the support you need at this time. You may want a family member or close friend to come to appointments with you, and this may be a time when you need to talk to someone such as a counsellor or psychologist who can provide you with extra emotional support.
Treatment for recurrent ovarian cancer
If a recurrence has been confirmed, or your CA125 is rising and you have decided to begin treatment, your doctor will usually recommend another round of chemotherapy — this is often called second-line treatment.
You and your healthcare team will work together to treat and manage the cancer using the type of chemo that is likely to be most effective for you while minimising side effects and helping you to maintain the best possible quality of life.
The type of second-line treatment that may be best for you will depend on many different factors including:
How long it has been since your last chemo treatment finished
The period between completing your first-line chemo and starting second-line treatment is known as your treatment-free interval.
Generally, if you have had a treatment-free interval of 6 months or longer, it means your tumour responded well to the initial treatment and is called ‘platinum-sensitive’. This usually means that a recurrent tumour is likely to respond well again to a platinum-based chemo. A longer treatment-free interval also means that your body has been able to recover from initial chemo and so your body is usually better able to tolerate the side effects.
If you have had a shorter treatment-free interval and your tumour has not responded well to the initial treatment, your tumour is called ‘platinum-resistant’ and your healthcare team will usually suggest re-treatment with a different agent. There are many different chemo drugs that you and your treatment team can choose from — your oncologists will discuss which ones may be the best choice to try next.
Depending on your response to previous chemo, your oncologist may also talk to you about using the hormonal therapy tamoxifen.
When you think about recurrent ovarian cancer as a chronic illness that can go into remission, but may not completely go away, it means that planning the sequence of future treatments with your oncologist becomes especially important. Sometimes the treatment choices you make today can affect treatment options later on. Talk to your doctor about your treatment goals and how this might affect the order in which different chemo drugs are used.
The side effects you experienced with first-line chemo and the possible side effects of new treatment
You and your healthcare team will need to consider the side effects that you had with previous chemo and how you may be affected by second-line treatment.
As well as side effects impacting on your quality of life, some of the toxic effects of chemo can affect your overall health and some are cumulative (continue to get worse over time). If you previously had problems with lowered white blood cell counts or neuropathy, your oncologist will try to choose a chemo agent that is less likely to cause these problems.
Chemo schedule and delivery method
You should also talk to your oncologist about the schedule and delivery method for second-line chemo as this may affect what is most suitable for you. Considerations may include whether IV access is a problem for you or whether nausea and vomiting may make oral chemo less suitable.
If there is a suitable clinical trial
Always ask your medical oncologist if there is a current clinical trial that may be suitable for you. Most of the improvements we have in the treatment of ovarian cancer today are based on the results of previous clinical trials, and these trials are used to assess new treatments and quality of life for both initial and recurrent ovarian cancer.
Is surgery an option?
Surgery is an important part of the initial treatment for ovarian cancer, but its role in treating recurrent ovarian cancer is not so clear. When ovarian cancer recurs, it is not usually a single tumour that can be easily removed. But occasionally, your gynaecological oncologist may consider further surgery if it has been some time since your original surgery and there is good evidence that the new cancer or a significant part of it can be removed. Usually, surgery would not take place if it is less than 12 months since you went into remission.
There are a number of US websites where you can find more detailed information about treatment for recurrent ovarian cancer. Keep in mind that the types of chemo available and the recommendations for women in the US may be different from those in Australia. If you read anything of interest, print the information and discuss it with your healthcare team.
NOCC — The US National Ovarian Cancer Coalition has produced a comprehensive booklet for women with recurrent ovarian cancer. Go to www.ovarian.org and choose the ‘Resources’ tab and then choose ‘Resource Guide — Recurrent Ovarian Cancer’ from the list of publications.
The Johns Hopkins Pathology Ovarian Cancer website includes a detailed section on recurrence, which you will find under ‘Understanding OvCa’.
Working in partnership with your healthcare team and playing an active role in making treatment decisions can help to give you a greater sense of control over your illness and your life.
Our Ovarian Cancer Australia Connect online forum gives you access to a community of compassionate and supportive women who have been affected by ovarian cancer. The forum has a group specifically for women who have experienced a recurrence; click here to explore further.