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Download our booklet on secondary surgery

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Content

Ovacome is a national charity providing support to those affected by ovarian cancer. We give information about symptoms, diagnosis, treatments and research. Ovacome runs a telephone and email support line and works to raise awareness and give a voice to all those affected by ovarian cancer.

This page is for people whose ovarian cancer has recurred and who want to find out more about secondary debulking surgery.

If your ovarian cancer has recurred you may have the option of further surgery to remove it.  This is secondary debulking surgery.

When your ovarian cancer was first diagnosed it was probably treated with surgery and chemotherapy.  Since then, you may have been using a maintenance therapy to control the cancer and keep you well, or you may not have needed this.

Ovarian cancer does often come back, which is called relapse or recurrence. If your cancer has recurred you may have experienced the same symptoms as when you were first diagnosed such as bloating; or there may have been no symptoms at all, and the recurrence was found at a follow-up clinic appointment.

A recurrence can be treated with chemotherapy and other drugs.  Sometimes surgery may be needed to relieve symptoms, for example to remove a cancerous tumour that has spread to the bowel and created a blockage.

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What is secondary surgery?

For some people with recurrent ovarian cancer there can be an option of further surgery which aims to remove all the visible cancer.  This is secondary surgery, or secondary debulking. The techniques used in these operations are sometimes termed radical or ultra-radical surgery.

Secondary surgery is not widely available in the UK but is more common in Europe.  Secondary debulking operations should be carried out in larger cancer centres with a specialised and experienced medical team. 

To be considered for this type of surgery you need to meet certain conditions.

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How can I access secondary surgery and what do I need to know?

You can ask your consultant or GP to refer you to a larger cancer centre where this surgery is carried out, for a second opinion to see if you could be considered.

At the cancer centre the specialist team will see and assess you. They will look at your cancer treatment so far and how fit you are.

The team will see where the cancer has come back and how long after your initial diagnosis this happened.  They will look at what surgery you have had. Then they will discuss with you whether secondary debulking would be an option.

The specialist team will only discuss secondary debulking with you if they believe that they can remove all the cancer during the operation. Research studies have shown that if this won’t be possible, then there is no benefit from operating.

The specialist team will look at your individual circumstances and will carefully consider the risks and benefits for you from secondary debulking surgery.

Secondary debulking surgery works best when it is used with other treatments such as chemotherapy, targeted therapies and hormonal therapies. 

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Lesley’s story

Lesley was diagnosed with stage 3c clear cell ovarian cancer when she was 65.  She had secondary surgery when the cancer recurred one year after she had finished chemotherapy.

Her operation in 2013 removed cancer next to major blood vessels.  She experienced no post-operative complications.

“My CA125 had gone up to 110 and a scan showed two tumours.  The oncologist recommended further chemotherapy and radiotherapy and stated that surgery was very inadvisable. 

“I felt in a deep dilemma because the cancer was still in distinct tumours.  I had no symptoms, and I would probably never again be in such a good position to consider more surgery.  If my timid streak had taken charge I would have backed off and I wouldn’t be alive now.

“I knew I had one chance, one window of opportunity and I had to take it.

“My GP supported me and referred me to a different cancer centre for a second opinion.  There the consultant said that secondary surgery might be possible – and it was in my best interests to try. 

“My family was very supportive, but they thought the surgery was a great risk and that if I opted for more chemotherapy then at least we would all have a few more months together.

“But it was my risk to take – and the surgery was successful.”

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What are the benefits?

Some research studies have shown that secondary surgery can extend ovarian cancer patients’ lives.

Desktop 3 is a randomised clinical trial of 407 women who were given either chemotherapy alone or secondary surgery then chemotherapy. The results were presented in 2020 and showed that secondary surgery followed by second line chemotherapy extended survival – but this benefit was only seen when the cancer was completely removed.

Another trial, SOC1, randomly assigned 356 women in their first relapse to either secondary surgery then chemotherapy or chemotherapy alone.  It found that secondary surgery improved progression-free survival at the first recurrence compared to chemotherapy alone.  Again, this benefit was only seen in cases where all visible cancer was removed.

However, a third study GOG-0213 of 485 ovarian cancer patients published in 2019 did not show an overall survival benefit for secondary surgery.

Research results are mixed, but some show that some ovarian cancer patients can benefit from secondary surgery but only if all their visible cancer is removed. 

Successful secondary surgery depends on identifying the patients most likely to benefit and having a team of specialised and experienced clinicians.

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What are the risks?

Secondary surgery includes similar procedures to the first debulking surgery.  This includes the stripping of the peritoneum from different sites in your abdomen (peritonectomy), removal of the spleen (splenectomy), bowel resection and lymph node resection. The Desktop study has shown  that a stoma is needed in less than 10 per cent (one in 10) of patients.

Possible complications of secondary debulking surgery are also similar to those of first debulking surgery.  They are: thrombosis, needing further surgery, infection, fluid collections that need to be drained and injury to organs that are close to the cancer.

Research studies have, so far, shown very low death rates from secondary debulking surgery which is performed by experienced clinical teams.

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Clinical guidance

Special guidance on secondary debulking surgery is necessary to ensure safety standards and the best possible outcomes for patients.

NICE (National Institute for Health and Care Excellence) states that ultra-radical surgery should be done only within specialised teams trained in extensive surgery.  NICE states that the operations should be carried out in specialised units where there is regular practice of this type of surgery.

It goes onto say that the clinicians must inform the clinical governance leads in their NHS trust about planned secondary surgeries. 

When patients are being asked to consent to the treatment, they must be told about alternative treatment options and about their risks and benefits compared to those of the secondary surgery. Patients must also be given clear written information about secondary surgery.

The British Gynaecological Cancer Society (BGCS) guidance says that the careful consideration of cases within a specialist multi-disciplinary team can identify patients who may benefit from further surgery.

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The future

Secondary surgery can work well for a very carefully selected group of ovarian cancer patients.  It is part of the progress towards individualised treatment. 

More large, specialised centres are needed to train clinicians and provide them with the experience they need so that more people can make this treatment choice.

Patients need to be more aware of the right to ask for a second opinion within the NHS to explore all their treatment options.

If you would like more information about secondary surgery and other treatment choices, please call Ovacome’s support line on 0800 008 7054 Monday to Friday 10am-5pm.  You may also want to talk to your clinical team.

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If you would like more information on the sources and references for this booklet, please call us on 0800 008 7054. If you would like to discuss anything about ovarian cancer, please phone our support line on 0800 008 7054 Monday to Friday between 10am and 5pm.

Reviewed by Professor Christina Fotopoulou PhD M.D, Professor of Practice (Gynaecological Oncology), Faculty of medicine, Dept of surgery and cancer, Imperial College London. Consultant gynaecological oncologist, Queen Charlotte’s and Chelsea Hospital. Professor of Surgery, Hammersmith Hospital.

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Disclaimer

Ovacome booklets provide information and support. We make every effort to ensure the accuracy and reliability of the information at the time of printing. The information we give is not a substitute for professional medical care. If you suspect you have cancer you should consult your doctor as quickly as possible. Ovacome cannot accept liability for any inaccuracy in linked sources. Rights reserved.

Date last updated April 2021
Date for review April 2023

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