Treatments for relapsed ovarian cancer

Content

Why has my cancer come back?
How is a relapse treated?
Can I have more surgery?
Are other treatments available?
Getting a second opinion
Support for you

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 those whose ovarian cancer has come back after initial treatment. It describes what further treatments may be available and how to get a second opinion.

Why has my cancer come back?

Ovarian cancer is usually treated with surgery and chemotherapy. Some people may also be treated with targeted therapies such as a PARP inhibitor and/or bevacizumab (Avastin). These are first line treatments.

Sometimes this is not completely successful, and the cancer does not respond, or it comes back. This is called a relapse or a recurrence, and you will need further treatment to keep the cancer under control.

We do not know what causes cancers to return. You may have signs that your cancer has come back, such as a rising level of the cancer marker CA125, or there may be signs of disease on a scan.

Sometimes you might have symptoms that are like the original symptoms you noticed, such as bloating. But you might have no symptoms at all. In this situation your medical team may suggest waiting until you do experience symptoms before starting any treatment. This is because research has shown that starting treatment before symptoms develop does not improve the treatment’s results.

Waiting for symptoms to begin can allow you to maximise the time between treatments and have a longer time of feeling well. If you find it too worrying to wait for symptoms to show before beginning treatment, you can discuss this with your medical team.

Recent evidence has suggested that in some cases a second operation might be helpful to you. This is described below. If your cancer has returned you might wish to discuss this with your oncology team, even if you don’t have symptoms yet.

How is a relapse treated?

Your second treatment will depend on how successful the first treatment was. This is judged by how long the cancer has taken to come back. Relapsed ovarian cancer is put into one of two different groups, depending on how well it responded to the first line of treatment.

The groups are:

1. Cancer that has come back less than six months after finishing platinum-based chemotherapy, such as carboplatin or cisplatin.

This is called platinum resistant cancer. Your oncologist will explain whether they think you will benefit from further treatment with platinum chemotherapy, or not.

If the cancer never responded to platinum-based chemotherapy this is called platinum refractory ovarian cancer.

In these situations, your oncologist will discuss treatment options with you such as paclitaxel (Taxol) or liposomal doxorubicin (Caelyx), or suggest you try new treatments that may be available in a clinical trial. Some centres offer weekly chemotherapy treatments for platinum- resistant ovarian cancer.

2. Cancer that has responded to platinum chemotherapy, which has come back more than six months after the end of treatment.

This is platinum sensitive ovarian cancer. Usually, cancer that returns more than six months after chemotherapy is treated with platinum- based chemotherapy plus another drug such as paclitaxel (Taxol) or liposomal doxorubicin (Caelyx). Your doctor may suggest adding additional drugs that are available in a clinical trial.

These groups will be considered alongside other issues when you and your oncologist decide which treatment is best for you now.

These issues are:

Does your illness need to be treated now, or can it be monitored by scans and blood tests?
How did your illness respond to the drugs before?
What are the drug’s possible side effects? You may prefer to avoid drugs that cause numbness in your fingers and toes (neuropathy) or which can cause hair loss.
Do you have an allergy to particular chemotherapy drugs? What are the likely benefits of the recommended drug?

If you have completed treatment for platinum-sensitive ovarian cancer and tests show the tumour has shrunk and your CA125 has gone down, you may be offered a PARP inhibitor to keep the cancer under control if you did not have a PARP inhibitor previously. These are drugs that stop damaged cancer cells repairing themselves. They can be taken at home as maintenance therapy.

Research shows that PARP inhibitors are helpful when they are used once. If you have already used them after your first line chemotherapy, you may be offered an alternative maintenance therapy.

There are currently clinical trials to see if a second treatment with a PARP inhibitor may be effective in certain circumstances. There is more information here.

PARP inhibitors such as olaparib and niraparib are most effective in people whose tumours contain a BRCA gene mutation or whose tumours contain a similar genetic mistake, called HRD. You can learn more about BRCA and these drugs here.

You can find out about HRD here.

Can I have more surgery?

Some patients whose ovarian cancer has recurred have secondary surgery. A research trial called DESKTOP 3 looked at the benefits of having another operation and found that it can help patients in certain circumstances.

The people in the trial had platinum-sensitive ovarian cancer which had recurred. They were otherwise fit and well. Their initial surgery had completely removed all visible cancer and they did not have ascites (fluid in the abdomen).

One group was treated with chemotherapy alone, a second group had surgery followed by chemotherapy. Results showed that those who had surgery and chemotherapy lived an average of eight months longer than those who had chemotherapy alone.

However, this benefit was seen only when the second surgery removed all the recurrent tumour. There was no benefit to people whose tumours were partly removed.

This means surgery for recurrent ovarian cancer may be considered if:

The cancer has come back at least six months after previous treatment. This is platinum-sensitive recurrent ovarian cancer.
You feel fit and well.
You have little or no ascites (fluid) in your abdomen. Your first surgery removed all visible tumour.
Your surgeon expects a further operation to be able to remove all the visible tumour.

Are other treatments available?

Hormonal treatments

If you don’t want to have chemotherapy again you may want to discuss hormonal treatments with your oncologist. We know some drugs such as tamoxifen and letrozole can control cancer by blocking hormones.

These drugs can cause menopause symptoms such as hot flushes and vaginal dryness. Letrozole can thin bones and your bone density needs to be monitored if you use this drug for a long time. You can ask your GP to arrange a dual-energy X-ray absorptiometry (DEXA) scan to measure your bone density.

Targeted therapies: bevacizumab (Avastin)

Avastin works by interfering with the cancer’s blood supply. It is available to people being treated for advanced (stage 3 or stage 4) ovarian cancer and can be taken alongside carboplatin and Taxol chemotherapy.

It is given every two to three weeks and can be used for 12 months. Avastin is currently only available through the NHS as a first line treatment for ovarian cancer, although research has shown it can be effective as a second line treatment too. You may have to pay for it or use insurance to access it for this and further treatments.

A protein biomarker called Tie2 can show when Avastin is working in patients with recurrent ovarian cancer. It is hoped this can be used as evidence that Avastin can be an effective treatment for recurrent disease, and so lead to it becoming available on the NHS for this use. A study called VALTIVE is looking at this.

Watch Treating ovarian cancer with anti-angiogenic agents, an Ovacome webinar with Professor Gordon Jayson on treatments such as bevacizumab (Avastin)

Clinical trials

Clinical trials research new treatments for ovarian cancer. Most trials have strict guidelines on who can take part. You might want to talk to your oncologist to see if there is a trial that is suitable for you. You will need to discuss the risks and benefits of taking part. You can also call Ovacome’s free support line on 0800 008 7054 or email [email protected] for information about current trials.

Immune therapy

There is on-going research into immunotherapy drugs that can boost the immune system to resist cancer. So far, the results for ovarian cancer have not been promising. Further trials are testing combinations of immunotherapies with Avastin. This has been shown to be effective for treating other cancers, but not ovarian cancer.

Getting a second opinion

A second opinion is when you see another doctor for their opinion on your diagnosis and treatment. Usually it means you’ll see a different hospital specialist from your current one.

You might seek a second opinion if you are concerned about your diagnosis or the treatment you’ve been recommended. Anyone can ask for a second opinion. You can have one on the NHS so you don’t have to pay, or you can choose to have one privately.

Access to second opinions may be affected by hospital measures to control COVID 19.

Some of the reasons for requesting a second opinion:

You may have doubt about your diagnosis.
You may not understand the information you've been given.
You may not be happy with the treatment that is recommended.
You may not feel you can talk to your doctor or specialist about your diagnosis and treatment.
You may need to confirm that the treatment you are receiving is the right treatment for you.
You have been told that there are no further treatments for you and would like to have that opinion checked.

Before asking for a second opinion, it’s worth asking your consultant to go over your diagnosis and explain anything you don't understand. If you're unhappy with your diagnosis or would like to consider a different course of treatment, discuss this with them. Your consultant should be happy to explain things and in many cases, there may be no need for a second opinion.

Here are some of the advantages and disadvantages to think about before you decide about a second opinion:

Possible advantages:

If both doctors agree about your diagnosis and treatment this will help you feel more confident about their decision.
You may find that you get on better with a different doctor and have more confidence in what they say.
You may be offered a treatment that has not been suggested before, or a newer treatment that’s part of a clinical trial.
You may be offered a wider choice of treatments by the second doctor, so you can decide which treatment to have.

Possible disadvantages:

Having a second opinion doesn't mean you'll be seen or treated more quickly than anyone else. Your treatment may be delayed by waiting to see another consultant. The person you see for a second opinion will also need to get information from your first doctor, which can delay treatment. You may need to think carefully about having a second opinion if a delay is likely to be harmful to you or reduce your chances of successful treatment.
You may find it upsetting being told the same or different news about your diagnosis and treatment if it’s not what you were hoping for.
If you're offered a different treatment, you may be asked to decide which treatment to have. Some people find this difficult and worry about whether they will make the right decision. However, it’s important to remember that there’s no right or wrong decision.
You may have to travel some distance to a different hospital to see another specialist and you may then need to have your treatment at that hospital. This might not be easy for you or your family and may mean you have extra travelling costs.

How to get a second opinion

There are different ways of seeking a second opinion from a hospital consultant or specialist. You can ask your GP to refer you to another consultant or specialist, either on the NHS or privately. Or you can ask your current consultant or specialist to refer you for a second opinion.

People often worry that this will upset the specialist or that you would be seen as a bad patient. However, many doctors, consultants or other specialists will be happy to refer you for a second opinion if it will be helpful. They will be used to being asked for second opinions themselves.

Relatives and carers can also request a second opinion on your behalf, but only with your consent. Some people do their own research to find the name of a consultant they would like to see.

When you are referred for a second opinion, relevant medical information will be sent to the new doctor or specialist. This information will include your scans, test results and any previous treatments.

If, after your second opinion, you want the second doctor, consultant, or specialist to treat you, this will have to be formally arranged with them.

It can help to prepare for your appointment by thinking about what you want to gain from it. You could write questions to take with you. It can help to have a friend with you.

Here are some questions you may want to ask:

If the second opinion differs from the original one, why?

Are there other treatments I could have?

What are the side effects of these other treatments?

What impact might the treatments have on my life?

How long will I need to be treated for?

Will I need to have my treatment at another hospital?

Difficulty getting a referral for a second opinion

If you find it difficult to get a referral for a second opinion, the Patient Advice and Liaison Service (PALS) in your local hospital may be able to help. You can get the phone number of your PALS team from the hospital switchboard.

Alternatively, your local Citizens Advice Bureau (CAB) may be able to advise you. Other organisations include: Macmillan Cancer Support, NHS choices and The Patients Association.

Support for you

Ovacome is the UK 's national ovarian cancer support charity. We've been providing emotional support and personalised, expert information since 1996. Contact our support line by phone, email or text if you have questions about a diagnosis, or if you just want to talk things through.

We support anyone affected by ovarian cancer, including family members, carers, those with an inherited risk, and health professionals working in the field.

We run support group and events, both in person and online, providing an opportunity to connect with others. Find out more about our groups and events here.

Booklet text reviewed by Professor Gordon Jayson PhD FRCP Professor of Medical Oncology, Christie Hospital and University of Manchester

Disclaimer
Ovacome information 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.

Version 2.6. Last updated August 2022, due for review August 2024.

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