Arzt erläutert anhand eines Vagina Modelles

Ovarian Cancer — What Now? Therapy options today

Cli­nic for Gyneco­lo­gy with a Cen­ter for Onco­lo­gi­cal Surgery

Tho­se affec­ted and their rela­ti­ves often expe­ri­ence the dia­gno­sis of ova­ri­an can­cer as a deep tur­ning point in life: it is not uncom­mon for fear, stress and other psy­cho­lo­gi­cal stress to be the result. The­re are various opti­ons for sup­port and help — both in the direct envi­ron­ment and from various experts. With our con­tri­bu­ti­on to the tre­at­ment of ova­ri­an can­cer, we would like to show can­cer pati­ents, their fami­lies and fri­ends ways to bet­ter under­stand and deal with the dise­a­se In the fol­lo­wing you can read how a the­ra­py typi­cal­ly pro­ceeds from diagnosis.

1. Consultation hour

Do some rese­arch befo­re and after your visits to get ans­wers to all your questions.

First of all, your doc­tor will ask you what will lead you to him or her. He or she will want to know which exami­na­ti­ons have alre­a­dy been done and whe­ther you have writ­ten docu­ments for them, becau­se the­se can be very hel­pful. Plea­se bring all the docu­ments you have about your sta­te of health with you. You may also be asked about your com­plaints. Kno­wing about the sym­ptoms does not neces­s­a­ri­ly help to cla­ri­fy whe­ther it is ova­ri­an cancer.

Then a gyneco­lo­gi­cal spe­cu­lum and pal­pa­ti­on exami­na­ti­on of the vagi­na (vagi­nal), the abdo­men (abdo­mi­nal) and part­ly also the rec­tum (rec­tal) take place, as you alre­a­dy know from the gyneco­lo­gi­cal prac­ti­ce. This exami­na­ti­on is sup­ple­men­ted by a vagi­nal (and pos­si­bly abdo­mi­nal) ultra­sound and a deter­mi­na­ti­on of the tumor mar­kers (inclu­ding CA 125, CA 19–9, HE4). The tumor mar­kers only ser­ve as indi­ca­ti­ve fin­dings and are used to moni­tor the pro­gress, e.g. after an ope­ra­ti­on. They are not always sui­ta­ble as a spe­ci­fic indi­ca­tor of ova­ri­an can­cer, sin­ce inflamm­a­to­ry dise­a­ses, for exam­p­le, can also be asso­cia­ted with an increase in the tumor marker.

Your doc­tor may also order a com­pu­ted tomo­gra­phy (CT) scan. This pro­ce­du­re is used to assess the spread of the tumor and enables good pre­pa­ra­ti­on for the ope­ra­ti­on, which is almost always necessary.

The actu­al con­fir­ma­ti­on of the dia­gno­sis is only pos­si­ble by taking a tis­sue sam­ple. If ova­ri­an car­ci­no­ma is suspec­ted, this is obtai­ned during an ope­ra­ti­on; if ova­ri­an car­ci­no­ma is con­firm­ed, ano­ther major ope­ra­ti­on usual­ly has to be per­for­med. If ova­ri­an can­cer is very likely, this tis­sue sam­ple can also be taken right at the begin­ning of the major ope­ra­ti­on, which will only be pro­cee­ded after the final dia­gno­sis by the patho­lo­gist. After kno­wing all of the exami­na­ti­on results, your doc­tor will dis­cuss and plan this ope­ra­ti­on with you.

2. Diagnostics

The most important exami­na­ti­on if it is suspec­ted that ova­ri­an can­cer could be the case is the gyneco­lo­gi­cal exami­na­ti­on as you know it from prac­ti­ce, which is then car­ri­ed out by an expe­ri­en­ced ova­ri­an can­cer expert. In addi­ti­on, the anus is then usual­ly exami­ned from the rec­tum. This is fol­lo­wed by an ultra­sound exami­na­ti­on of the vagi­na and abdomen.

The next step is usual­ly a blood test to deter­mi­ne the tumor mar­ker for ova­ri­an can­cer in the blood. The result can help to make the dia­gno­sis but is not always meaningful.

Ima­ging with com­pu­ted tomo­gra­phy (CT) may be neces­sa­ry, but by no means always. In the case of very small, unclear herds, posi­ti­on emis­si­on tomo­gra­phy (PET-CT) may also be used, but this is very rare­ly only necessary.

For this pur­po­se, you will recei­ve an appoint­ment at the Charité’s radio­lo­gy depart­ment via our pati­ent manage­ment; the results of the exami­na­ti­on can usual­ly be view­ed by the doc­tors in our depart­ment after 5 days.

Final cer­tain­ty can only be obtai­ned through a fine tis­sue exami­na­ti­on. For this, a tis­sue sam­ple must be obtai­ned from the abdo­men in an ope­ra­ti­on and sent to the patho­lo­gist. You look at the tis­sue under the micro­scope and can tell whe­ther it is a benign or mali­gnant growth.

3. Operation

The stan­dard tre­at­ment for ova­ri­an can­cer is almost always sur­gery first. This should be done within 2–3 weeks of the dia­gno­sis. The aim of the ope­ra­ti­on is to con­firm the dia­gno­sis, deter­mi­ne the ext­ent of the tumor and com­ple­te­ly remo­ve (visi­ble) tumor tis­sue. If this is not com­ple­te­ly pos­si­ble, an attempt is made to remo­ve as much tumor tis­sue as pos­si­ble, becau­se the smal­ler the remai­ning tumor, the bet­ter the pro­gno­sis (long-term survival).

The ope­ra­ti­on has three objectives:

  1. Con­fir­ma­ti­on and scope of the dia­gno­sis (through his­to­lo­gi­cal ana­ly­sis of tumor tissue)
  2. Deter­mi­na­ti­on of tumor spread
  3. Maxi­mum tumor reduc­tion or removal

The ope­ra­ti­on is car­ri­ed out via a lon­gi­tu­di­nal abdo­mi­nal incis­i­on (lon­gi­tu­di­nal lapa­roto­my) from the pubic bone to the navel and, depen­ding on the ext­ent of the ope­ra­ti­on, even to the lower edge of the ster­num. Sur­gery for ova­ri­an can­cer usual­ly takes 3–6 hours. Among other things, due to the con­fir­ma­ti­on of the dia­gno­sis using a tis­sue sam­ple. The patho­lo­gist exami­nes this direct­ly (quick sec­tion) and com­mu­ni­ca­tes the result to the sur­ge­on over the pho­ne, who then deci­des on the fur­ther ext­ent of the ope­ra­ti­on. The sur­gery usual­ly includes:

  • Com­ple­te pal­pa­ti­on of the abdo­mi­nal cavi­ty with rem­oval of parts of the peri­to­ne­um if necessary
  • Rem­oval of the ute­rus (hys­terec­to­my), fallo­pian tubes, and ova­ries (adne­xec­to­my)
  • Rem­oval of the lar­ge net­work, a lymph organ han­ging from the intesti­ne (omen­tec­to­my) and the enlar­ged lymph nodes (lympha­denec­to­my) in the small pel­vis and along the lar­ge ves­sels (main artery, lar­ge infe­ri­or vena cava)
  • If neces­sa­ry, appen­dec­to­my (appen­dec­to­my), if it is a mucus-pro­du­cing tumor

In addi­ti­on, if neces­sa­ry, all other are­as affec­ted by the tumor are remo­ved. Organs or parts of organs may also have to be remo­ved. For exam­p­le, the spleen, part of the liver, part of the dia­phragm or, more often, part of the intesti­ne. If part of the intesti­ne has to be remo­ved, the affec­ted part is usual­ly cut out and the healt­hy ends sewn back tog­e­ther direct­ly. But some­ti­mes it can also be neces­sa­ry to crea­te an arti­fi­ci­al anus, usual­ly when the healt­hy bowel is too short to crea­te a direct con­nec­tion or other sutures first need rest from the bowel move­ment. In this case, the arti­fi­ci­al anus can be relo­ca­ted back after a heal­ing phase.

After the ope­ra­ti­on you will first spend a few hours in the reco­very room, whe­re you will be asked whe­ther you are in pain and will be given addi­tio­nal pain medi­ca­ti­on imme­dia­te­ly if neces­sa­ry. As a rule, the anes­the­tists also put a peri­du­al cathe­ter (PDA) befo­re the ope­ra­ti­on, as is also the case with child­birth, which makes it pos­si­ble for you to expe­ri­ence as litt­le pain as pos­si­ble. You will likely be trans­fer­red from the reco­very room to an inten­si­ve care unit for a day or two. After most­ly 2 days, you will then con­ti­nue to be cared for in a nor­mal hos­pi­tal ward until you can usual­ly be dischar­ged home after 10 days.

While you are reco­ve­ring from the ope­ra­ti­on and with the help of the phy­sio­the­ra­pists and nur­ses on the ward, get back on your feet as quick­ly as pos­si­ble and, for exam­p­le, get your own tea, the results of the ope­ra­ti­on and the tis­sue exami­na­ti­on are dis­cus­sed in a tumor con­fe­rence . In the tumor con­fe­rence, experts from onco­lo­gy, gyneco­lo­gy, radio­lo­gy and radia­ti­on the­ra­py meet and deci­de tog­e­ther which fur­ther tre­at­ment steps are neces­sa­ry and recom­men­ded to you.

After the ope­ra­ti­on — check­list ques­ti­ons to ask my doctor:

  • Do I have a high-gra­de or a low-gra­de carcinoma?
  • What stage is my ill­ness at?
  • What other tre­at­ments do you recommend?
  • What tre­at­ment opti­ons are available for me and why?
  • What are their advan­ta­ges or disadvantages?
  • How much time do I have to make a decis­i­on? Would you recom­mend that I get a second opinion?
  • When is my next appointment?

4. Genetic testing

Breast can­cer is the most com­mon form of can­cer in women. Around every 10th woman will deve­lop it in the cour­se of her life. The majo­ri­ty of the­se dise­a­ses occur spo­ra­di­cal­ly, only about 5 to a maxi­mum of 10% of the dise­a­ses can be tra­ced back to indi­vi­du­al gene­tic chan­ges and thus occur more fre­quent­ly in fami­lies. The­se gene­tic chan­ges can also be asso­cia­ted with an increased risk of deve­lo­ping ova­ri­an cancer. 

Test­ing for this gene­tic chan­ge (BRCA 1 or 2 muta­ti­on) can also be decisi­ve for tre­at­ment plan­ning in ova­ri­an can­cer, as the­re are drugs that can only be used if the­re is a gene­tic change.

The sus­pi­ci­on of a her­edi­ta­ry cau­se of breast can­cer can­not be rai­sed on the basis of an indi­vi­du­al dise­a­se, but is made taking fami­ly histo­ry into account. If you have one of the fol­lo­wing cri­te­ria, the­re could be a gene­tic pre­dis­po­si­ti­on. In this case, plea­se speak to your doc­tor. Gene­tic coun­seling should be offe­red to all women with ova­ri­an, fallo­pian tube, or peri­to­ne­al cancer.

Fami­lies with:

  • at least three women are or have had breast can­cer, regard­less of age.
  • at least two women have or were dia­gno­sed with breast can­cer, one of them befo­re the age of 51.
  • at least one woman is or has had breast can­cer and one woman has ova­ri­an cancer.
  • at least two women have or were dia­gno­sed with ova­ri­an cancer.
  • at least a woman has or has had breast or ova­ri­an cancer.
  • at least a woman has or was dia­gno­sed with breast can­cer when she was 35 years or younger.
  • at least a woman has or has had bila­te­ral breast can­cer, the first time when she was 50 years old or younger.
  • A man has had breast can­cer and a woman has breast or ova­ri­an can­cer, regard­less of age.
  • A woman has or has had tri­ple nega­ti­ve breast cancer.
  • A woman has or was dia­gno­sed with ova­ri­an cancer.

Source: Cen­ter for Fami­li­al Breast and Ova­ri­an Can­cer Con­sul­ta­ti­on Hours

Gene­tic test­ing can be car­ri­ed out with a blood sam­ple and also with a tumor sam­ple. You can read about the BRCA muta­ti­on / gene­tic breast and / or ova­ri­an can­cer on this page in a few weeks.

5. Chemotherapy

Almost wit­hout excep­ti­on, che­mo­the­ra­py fol­lows the ope­ra­ti­on to com­bat mali­gnant cells that have remain­ed in the body (adju­vant the­ra­py). In addi­ti­on, che­mo­the­ra­py can be used befo­re a plan­ned major ope­ra­ti­on to redu­ce the size of the tumor (neoad­ju­vant) or, in the case of incura­ble tumor dise­a­ses, to reli­e­ve sym­ptoms (pal­lia­ti­ve).

The first che­mo­the­ra­py should be given within 4 to 6 weeks from the day of surgery.

Che­mo­the­ra­peu­tic drugs (cyto­sta­tics) are able to kill tumor cells or at least inhi­bit their growth. They are usual­ly given intra­ve­nous­ly (into a vein) and are dis­tri­bu­ted throug­hout the body and also act throug­hout the body. Che­mo­the­ra­peu­tic agents (cyto­sta­tic agents) attack cells that are gro­wing or divi­ding par­ti­cu­lar­ly quick­ly. A pro­per­ty that is par­ti­cu­lar­ly true of can­cer cells. Howe­ver, healt­hy body cells are also affec­ted, which explains the side effects of che­mo­the­ra­py. For­t­u­na­te­ly, unli­ke can­cer cells, our healt­hy body cells have repair mecha­nisms to repair the dama­ge cau­sed by cyto­sta­tic drugs.

Howe­ver, as a side effect of this high­ly effec­ti­ve the­ra­py, all of your body hair will fall out. But after the end of the the­ra­py they grow back imme­dia­te­ly. Even if most pati­ents get through the the­ra­py with almost no other side effects thanks to sup­port­i­ve medi­ca­ti­on, nau­sea and vomi­ting and a wea­k­en­ed immu­ne defen­se and blood clot­ting can occur. The fin­ger­tips and palms of the hands may also ting­le due to the effect on the fine ner­ve cells the­re; this side effect, as well as unsight­ly dis­co­lo­ra­ti­on of the fin­ger­nails, usual­ly regress after the the­ra­py. Stay in touch with your doc­tor and nur­ses about your side effects. They can cer­tain­ly offer you fur­ther sup­port­i­ve mea­su­res befo­re it beco­mes neces­sa­ry to redu­ce or dis­con­ti­nue the therapy.

Che­mo­the­ra­py for ova­ri­an can­cer con­sists of 2 drugs, name­ly car­bo­pla­tin and pacli­ta­xel. The drugs are given 6 times with a mini­mum inter­val of 3 weeks. A the­ra­py ses­si­on lasts about 4–6 hours and this is what doc­tors call che­mo­the­ra­py, the peri­od of 3 weeks after che­mo­the­ra­py is cal­led a cycle. In total, che­mo­the­ra­py takes place in 6 cycles.

Befo­re the che­mo­the­ra­py, your doc­tor will inform you and you must also sign that you con­sent to the tre­at­ment. You can also ask your own ques­ti­ons during this conversation.

Befo­re each medi­ca­ti­on, a blood test is neces­sa­ry to deter­mi­ne whe­ther your kid­neys and immu­ne sys­tem are fit enough for the the­ra­py. This blood sam­ple can also be taken in a prac­ti­ce near you, in which case the results of the blood test must be faxed to the che­mo out­pa­ti­ent depart­ment 2 days befo­re the che­mo­the­ra­py appoint­ment. Thanks a lot for this. We also need infor­ma­ti­on about your height and cur­rent weight, as the dose of the­ra­py is adapt­ed to your body.

Che­mo­the­ra­py is best given through a port. A port is a small metal cham­ber that is pla­ced under the skin on the base of the breast and is con­nec­ted to the blood sys­tem. This requi­res a very small ope­ra­ti­on, which is usual­ly car­ri­ed out by the doc­tors in radio­lo­gy under local anesthesia.

6. Antibody therapy / conservation therapy

In addi­ti­on to che­mo­the­ra­py, the anti­bo­dy beva­ci­zu­mab (Ava­stin) is used for tre­at­ment in addi­ti­on to che­mo­the­ra­py in ova­ri­an can­cer, which also affects the upper part of the abdo­men. This anti­bo­dy the­ra­py inhi­bits can­cer growth by sup­pres­sing the for­ma­ti­on of new blood ves­sels. As a result, the can­cer, which needs a lot of blood to grow, is no lon­ger ade­qua­te­ly sup­pli­ed with oxy­gen and nutrients.

This the­ra­py is usual­ly given from the 2nd cycle of che­mo­the­ra­py along with che­mo­the­ra­py. After che­mo­the­ra­py, anti­bo­dy the­ra­py should be con­tin­ued every 3 weeks for a total of 15 months. The hair will grow back again during this time and the other pos­si­ble side effects of che­mo­the­ra­py will alre­a­dy subside.

Con­ser­va­tio­nal therapy:

The PARP inhi­bi­tors are also slow­ly fin­ding their way into the­ra­py, even with the first occur­rence of ova­ri­an can­cer and are not only used for rel­ap­ses, as they have been for seve­ral years PARP inhi­bi­tors inhi­bit the DNA repair mecha­nisms of tumors.

You pro­ba­b­ly know that cell divi­si­on crea­tes two iden­ti­cal copies of a cell, each with a com­ple­te set of genes (DNA). During this doubling pro­cess, mista­kes can natu­ral­ly ari­se spon­ta­neous­ly in the dou­ble-stran­ded DNA, e.g. in which pie­ces of the gene­tic infor­ma­ti­on of a sin­gle strand break off. The­se errors in the copy­ing pro­cess are also one of the reasons why can­cer can deve­lop in the first place. Nor­mal­ly, the­se errors are cor­rec­ted by genes (for exam­p­le BRCA1 / 2) that are respon­si­ble for the for­ma­ti­on of repair enzy­mes (such as poly-ADP-ribo­se poly­me­ra­se (PARP)). Howe­ver, if the­se genes are modi­fied in such a way that the enzy­mes can­not pro­du­ce them, the repair pro­cess can­not take place. This would be fatal for healt­hy cells, but not so bad for can­cer cells, sin­ce the DNA dama­ge can ulti­m­ate­ly bring tumor growth to a standstill.

So rese­ar­chers have taken the­se pro­ces­ses in the cel­lu­lar micro­c­osm as a model and deve­lo­ped drugs that spe­ci­fi­cal­ly inhi­bit the cancer’s own repair mecha­nisms: the so-cal­led PARP inhi­bi­tors. The­se enzy­me inhi­bi­tors bind to the com­plex of DNA and repair enzy­me of the tumor, so that, among other things, the enti­re dou­ble strand breaks. What is pos­si­ble with nor­mal body cells is not pos­si­ble with can­cer cells: name­ly, repai­ring dou­ble-strand breaks. Ins­tead, the can­cer tri­es to find alter­na­ti­ve ways to repair DNA in order to sur­vi­ve. This also leads to the desta­bi­liza­ti­on of the DNA until the cell is prac­ti­cal­ly dri­ven into “sui­ci­de” and tumor growth comes to a com­ple­te standstill.

The­se rela­tively new PARP inhi­bi­tors work hand in hand with che­mo­the­ra­peu­tic agents that spe­ci­fi­cal­ly cau­se DNA dama­ge in the tumor. If the trea­ting phy­si­ci­ans have deter­mi­ned that the tumor has chan­ges (muta­ti­ons) in spe­ci­fic tumor-sup­pres­sing genes, the inhi­bi­tor can be used in com­bi­na­ti­on with che­mo­the­ra­py or as main­ten­an­ce the­ra­py after the che­mo­the­ra­py cycles. This is par­ti­cu­lar­ly important when the­re is a high pro­ba­bi­li­ty that the tumor will return despi­te stan­dard the­ra­py, e.g. if it is dis­co­ver­ed late. The the­ra­py curr­ent­ly seems to be actual­ly effec­ti­ve in various can­cers, such as breast, fallo­pian tube, peri­to­ne­um and espe­ci­al­ly ova­ri­an can­cer. Stu­dies show that PARP inhi­bi­tors in such can­cers increase the time it takes for the tumor to recur from an avera­ge of one to around four years.

Side effects

Unfort­u­na­te­ly, side effects can­not always be avo­ided with this the­ra­py eit­her. Tired­ness, nau­sea, vomi­ting, diar­rhea and abdo­mi­nal pain, wor­sening liver and kid­ney values, anemia and a lack of blood plate­lets can affect your well-being to a grea­ter or les­ser ext­ent. Under cer­tain cir­cum­s­tances, the side effects can be so seve­re that the the­ra­py has to be inter­rupt­ed or redu­ced. If such a the­ra­py is car­ri­ed out on you, your atten­ding doc­tor will cer­tain­ly always remain in dia­lo­gue with you and choo­se the most pro­mi­sing opti­on for you. If you have any ques­ti­ons about this, don’t hesi­ta­te to ask.

The health insu­rance com­pa­ny will assu­me the costs

Not all health insu­ran­ces have yet to cover the cos­ts of tre­at­ment with PARP inhi­bi­tors when ova­ri­an can­cer first occurs. Howe­ver, you can ask your doc­tor to app­ly for reim­bur­se­ment if the tre­at­ment is sui­ta­ble for you. Alter­na­tively, your doc­tor may be able to find a cli­ni­cal stu­dy in which you can bene­fit from free tre­at­ment with the inhi­bi­tor and inten­si­ve medi­cal super­vi­si­on at the same time.

7. Follow-up care

After can­cer tre­at­ment, we recom­mend that you take part in regu­lar medi­cal fol­low-up care. Here, not only are exami­na­ti­ons car­ri­ed out to detect a recur­rence of the can­cer at an ear­ly stage, but also

You should also be sup­port­ed and accom­pa­nied in your reco­very. Fol­low-up care rough­ly covers the peri­od in which the pati­ent is still deal­ing with the con­se­quen­ces of the dise­a­se and its treatment.

Exami­na­ti­on intervals:

Sin­ce the risk of a rel­ap­se (recur­rence of the dise­a­se) in ova­ri­an can­cer is hig­hest within the first 3 years after the ope­ra­ti­on, clo­se fol­low-up exami­na­ti­ons are car­ri­ed out during this time:

  • Up to 3 years after sur­gery: Fol­low-up exami­na­ti­ons every 10–12 weeks
  • From the 3rd year after the ope­ra­ti­on: Fol­low-up exami­na­ti­ons every 6 months
  • From the 5th year after the ope­ra­ti­on: Fol­low-up exami­na­ti­ons every 6–12 months

The­se are gene­ral recom­men­da­ti­ons that ser­ve as a gui­de. Your doc­tors will work with you to crea­te an indi­vi­du­al after­ca­re plan based on your indi­vi­du­al situation.


The fol­low-up exami­na­ti­on for ova­ri­an can­cer con­sists of a con­ver­sa­ti­on in which you are asked about typi­cal sym­ptoms that could be a sign of a recur­rence of the dise­a­se, as well as a gyneco­lo­gi­cal exami­na­ti­on with rec­tal pal­pa­ti­on and a gyneco­lo­gi­cal ultra­sound of the vagi­na and an ultra­sound of the abdo­men.
In addi­ti­on, the tumor mar­ker Ca125 is deter­mi­ned, the cour­se of which, not the indi­vi­du­al value, can also be meaningful. 

A CT exami­na­ti­on is only neces­sa­ry if the exami­na­ti­on reve­a­led unclear abnor­ma­li­ties. After the exami­na­ti­on, the­re is also the oppor­tu­ni­ty to speak to your doc­tor about topics that con­cern you or about which you have ques­ti­ons. The best thing to do is to prepa­re and make a few notes before­hand about what you want to talk about.

Pos­si­ble topics for your fol­low-up consultation:

  • Nut­ri­ti­on
  • Sexua­li­ty
  • Pre­ven­ti­on
  • Reha­bi­li­ta­ti­on
  • Deal­ing with my family
  • Addi­tio­nal psycho-onco­lo­gi­cal support
  • Crea­ti­ve therapies
  • Healt­hy living
  • Social pro­blems
  • Gene­tic predisposition

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