Treatment for relapsed ovarian cancer

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. 

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. 

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', a webinar with Professor Gordon Jayson

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 support@ovacome.org.uk for information about current trials.

You can read more about clinical trials here.

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.

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