Recurrent or Persistent Ovarian Epithelial Cancer
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Local Modalities: Surgery and Radiation Therapy
Cytoreduction is often employed,[1] but such intervention only now is being studied in the setting of a randomized clinical trial (GOG-0213). The role of radiation therapy in patients with recurrent ovarian cancer has not been defined.
Systemic treatment options for patients with recurrent disease are subdivided as follows:
- Platinum-sensitive recurrence: for patients whose disease recurs more than 6 months after cessation of the induction (usually retreated with a platinum-cisplatin or carboplatin- and referred to as potentially platinum sensitive).
- Platinum-refractory or platinum-resistant recurrence: for patients who progress prior to cessation of induction (platinum refractory) or within 6 months after cessation (platinum resistant); in these patients, platinums are generally deemed toxic and not sufficiently useful to be part of the treatment plan.
Platinum-Sensitive Recurrence
Table 2. Outcome in Patients With "Platinum-Sensitive" Ovarian Cancer Recurrence
| Eligibility (mo) | Platinum Regimen | Patient Number | Comparator | Comments on Outcome (mo) |
| Platinum sensitive (>6) | Carboplatin + pegylated-liposomal doxorubicin | 104 | None | PFS median 9; OS median 31[2] |
| Platinum sensitive (>6) | Carboplatin + epirubicin | 190 | Carboplatin | Powered for response differences; OS 17 vs. 15 [3] |
| Platinum sensitive (=12) | Cisplatin + doxorubicin + cyclophosphamide | 97 | Paclitaxel | PFS 15.7 vs. 9; OS 34.7 vs. 25.8 [4] |
| Platinum sensitive (>6) | Carboplatin + gemcitabine | 356 | Carboplatin | PFS 8.6 vs. 5.8*; OS 18 vs. 17 [5] |
| Platinum sensitive (>6) | Cisplatin or carboplatin + paclitaxel | 802 | Single or nontaxane + platinums | PFS 11 vs. 9; OS 24 vs. 19 [6] |
Carboplatin was approved in 1987 for the treatment of patients with ovarian cancer whose disease recurred after treatment with cisplatin, based on improved survival with etoposide or 5-fluorouracil.[7] In a randomized phase II trial of paclitaxel, a currently used second-line drug, the cisplatin-containing combination of cisplatin plus doxorubicin plus cyclophosphamide (CAP) yielded a superior survival outcome. This, and subsequent studies (see Table 2), have reinforced using carboplatin as the treatment core for patients with platinum-sensitive recurrences. Cisplatin is occasionally used, particularly in combination with other drugs, because of its lesser myelosuppression, but this advantage over carboplatin is counterbalanced by its greater intolerance. Oxaliplatin, initially introduced with the hope that it would overcome platinum resistance, has activity mostly in platinum-sensitive patients [8] but has not been compared with carboplatin alone or in combinations. With all platinums, outcome is generally better the longer the initial interval without recurrence from the initial platinum-containing regimens.[9] Therefore, on occasion, patients with platinum-sensitive recurrences relapsing within 1 year have been included in trials of nonplatinum drugs. In one such trial, comparing the pegylated liposomal doxorubicin (PLD) to topotecan, the subset of patients who were platinum sensitive had better outcomes with either drug (and in particular with PLD) relative to the platinum-resistant cohort.[10]
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