It's understandably very distressing to hear that your cancer has come back. Knowing what questions to ask and ensuring that you get clear answers is extremely important.
When does treatment start?
Treatment for recurrent ovarian cancer usually begins when there is some evidence that the cancer has returned – most commonly when a woman begins experiencing symptoms of ovarian cancer, alongside confirmation usually from a CT scan that the tumour is growing.
Waiting until symptoms occur can be worrying if you want to start treatment as soon as possible; however, there are benefits to waiting.
- It lengthens the time period between platinum-based chemotherapy treatments, which may help the response to the drug, and reduce the chances of developing resistance to it.
- It may improve your quality of life, because over the course of time if there are a number of recurrences, there would be less time spent having treatment and dealing with the side effects.
- Research has shown that starting chemotherapy when a woman's CA125 level starts rising (but before there are any symptoms) does not have an effect on the success of treatment.
However, it's also perfectly acceptable to start treatment as soon as recurrence is detected. It's important to discuss your preferences with your clinical nurse specialist (CNS) or oncologist as you may have a particular reason for wanting to start treatment as soon as possible.
Once you begin treatment it's most likely that a CA125 test will be used to assess your response, unless you're among the small proportion of women whose CA125 level has never registered as abnormal. CT scans and ultrasounds may also be used to assess your response to treatment. Your CNS or oncologist will be able to explain your treatment plan in more detail.
Your treatment options
Chemotherapy and targeted therapy are the most common treatments offered for women with recurrent ovarian cancer. Surgery and hormone therapies are sometimes offered too. Increasingly, more targeted therapies are being researched. Your oncologist and CNS should discuss with you available and suitable treatments and your personal preference. The possibility of taking part in a clinical trial – where available – should also be discussed with you if this is something you would like to explore.
Different types of chemotherapy
Oncologists divide recurrent ovarian cancer into two groups, called 'platinum-sensitive' and 'platinum-resistant', depending on how long it has been since you finished your last platinum-based chemotherapy containing either carboplatin or cisplatin.
If it's been six months or more since your last treatment with carboplatin or cisplatin, your cancer is platinum-sensitive – this means that there is a greater chance it will respond to more platinum. In these circumstances, your oncologist will suggest giving you more carboplatin, usually in combination with another drug, such as paclitaxel (Taxol®) or pegylated liposomal doxorubicin hydrochloride (PLDH or Caelyx®).
Occasionally (in approximately 10 per cent of cases) women can become allergic to carboplatin. If this happens, it's sometimes possible to continue with carboplatin at a later date, using so-called ‘desensitisation regimes’, where the carboplatin is restarted at a very low dose and gradually increased. It's also sometimes possible to switch to cisplatin, which is very similar to carboplatin. However, if the allergy is severe, it's sometimes necessary to stop platinum chemotherapy altogether.
Sometimes the term 'partially platinum-sensitive' is used, and refers to when recurrence occurs between six and twelve months after the last treatment.
Some women will have very platinum-sensitive disease when they are diagnosed with recurrent ovarian cancer and have multiple courses of this treatment over many years. However the majority will develop resistance to the platinum-based chemotherapy over time.
If your cancer has returned within six months of your last treatment with platinum (either carboplatin or cisplatin), your cancer is called 'platinum-resistant'. In these circumstances, it is unlikely that it will respond to platinum chemotherapy again, and different drugs are used. These include paclitaxel (Taxol®) – often given once per week rather than every three weeks or pegylated liposomal doxorubicin hydrochloride (PLDH or Caelyx®). In platinum-resistant ovarian cancer, these drugs are usually given alone (as so-called ‘single agents’).
The term 'resistant' is only really true for first two relapses and new descriptions are likely to emerge. Always ask your oncologist if you are unclear about any terminology they are using.
Remember you and your cancer are unique. Your oncologist will suggest using the drugs that will have the best impact on your ovarian cancer.
You can also join our Facebook group to talk to women and find out about their hints and tips for chemo.
Surgery may be an option if your cancer has returned. We are still waiting for the results of large clinical trials to see if this surgery is effective, but surgery is often considered if certain criteria are met:
- All visible disease was removed at the first operation.
- It has been at least a year since previous treatment.
- Your surgeon believes that they will be able to operate successfully.
Surgery may also be recommended in certain circumstances to deal directly with certain symptoms such as a blocked bowel or bowel obstruction. This may involve the creation of a stoma.
You can always ask for a second opinion on whether surgery is an option or not.
Other drugs and clinical trials
Radiotherapy is not routinely used to treat a recurrence of ovarian cancer. However, it can be used to control symptoms in certain circumstances. Your oncologist will be able to speak to you about whether radiotherapy is suitable for you.
Hormone therapy, using drugs such as tamoxifen and letrozole, is best known as a treatment for breast cancer. However, it appears it can also be useful in recurrent ovarian cancer, especially if the cancer is growing very slowly or you do not wish to receive more chemotherapy.
However, there have not been any large scale trials to see how hormone therapy compares to standard treatments and who might benefit most from such an approach.
Targeted (biological) therapies
Targeted therapies, sometimes known as biological therapies, are drugs that encourage the body to attack the cancer itself through strengthening the immune system or interfering with the cancer cells' growth.
Bevacizumab (also known by brand name Avastin®) is a targeted therapy. It targets a protein called vascular endothelial growth factor (VEGF) that helps cancer cells develop a new blood supply. It's given through a drip in combination with chemotherapy and as a maintenance drug after the chemotherapy course is completed. Maintenance drugs seek to ensure that the benefits received from the chemotherapy are continued after the chemotherapy course is completed.
Olaparib (also known as Lynparza®) is a biological therapy known as a PARP inhibitor that has been shown to be effective in some women with ovarian cancer who have a mutation in their BRCA1 or BRCA2 gene. It targets the DNA of the tumour, so it can’t repair itself. It's given as a maintenance drug following platinum-containing chemotherapy.
Funding and access to bevacizumab and olaparib differs across the UK.
Clinical trials are research studies that investigate potential new drugs, new ways of giving treatments or different types of treatments and compare them to the current standard treatments.
Read more about clinical trials – what they are, how they work and how you can find out more.
Funding and access to drugs across the UK
Standard drugs and treatments
Most women with recurrent ovarian cancer will be offered standard treatments by their oncologist. This means drugs that are licensed for treating women with ovarian cancer in the UK and approved for use within the NHS on the grounds of clinical and cost-effectiveness. This includes the chemotherapy drugs discussed earlier. However, for some drugs, access differs across the UK because of the way they are approved.
In England and Wales, drugs are approved by the National Institute of Health and Care Excellence (NICE). NICE has approved the use of olaparib (Lynparza®) as a maintenance therapy for relapsed, platinum-sensitive ovarian cancer for women with a mutation in their BRCA1 or BRCA2 gene, if they have had three or more courses of platinum-based chemotherapy. NICE does not fund the use of bevacizumab (Avastin®) in women with platinum-sensitive recurrent ovarian cancer.
Northern Ireland tends to follow NICE guidance.
In Scotland, drugs are approved by the Scottish Medicines Consortium (SMC). The SMC has approved the use of bevacizumab (Avastin®) in combination with paclitaxel for the treatment of advanced platinum-resistant recurrent ovarian cancer in eligible women. Speak to your oncologist about whether you are eligible for this. The SMC has also approved the use of olaparib (Lynparza®) as a maintenance treatment for relapsed, platinum-sensitive ovarian cancer for women with a mutation in their BRCA1 or BRCA2 gene, if they have responded to platinum-based chemotherapy.
In addition, within England only, certain cancer drugs that are not approved for routine use on the NHS by NICE can be accessed via a special fund called the Cancer Drugs Fund (CDF), designed to improve access to cancer drugs. However, there are currently no drugs for women with recurrent ovarian cancer available through the CDF.
Non-standard drugs and treatments
Some women may wish to ask about other ways to access different drugs, not yet licensed or approved. Sometimes oncologists prescribe drugs to treat women with ovarian cancer outside the clinical trial setting that are not yet licensed for ovarian cancer if they believe a patient may benefit. This is referred to as prescribing 'off license' or 'off-label'.
An oncologist may also choose to prescribe a drug that is licensed but not yet approved for NHS funding. In either case the oncologist may well have to make a special application for funding for the drug which may or may not be accepted.
Occasionally manufacturers of the drugs in question will run a compassionate access scheme for patients who meet certain criteria, meaning the drug company meet the cost; however, approaches to the drug company must be made by your oncologist.
It's important to note it can be quite stressful going through this process at a time when you are unwell. If your oncologist is reluctant or unsure about discussing other drugs, you can always ask for a second opinion. You will always need the support of an oncologist, as they have to make the applications for funding on your behalf.
This information is reviewed regularly and is in line with accepted national and international guidelines. All of our publications undergo an expert peer review and are reviewed by women with ovarian cancer to ensure that we provide accurate and high-quality information. To find out more take a look at our information standards.