Debulking Basics
- For ovarian cancer, the decision-making around whether or not to proceed with debulking surgery often revolves around whether the surgeon will be able to remove all visible tumor
- The incision usually extends from the pubic bone to above the belly button
- The stage and extent of disease dictate the organs (ovaries, fallopian tubes, etc.) and other tissue that may need to be removed during a debulking procedure
“Surgery is a nerve wracking process,” says Dr. Gillian Hsieh, gynecologic oncologist at Sutter Bay Medical Foundation in the San Francisco Bay Area. “Sometimes we do surgery for ovarian cancer before chemotherapy to remove as much of the tumor as possible.” Called primary debulking surgery, this approach is associated with positive outcomes, particularly when doctors expect to be able to remove all visible signs of disease at the time of surgery.
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“Primary debulking surgery can be very difficult for frail patients or for those who have health problems,” Dr. Hsieh says. In those cases, it’s important for patients to talk to their physician about alternatives.
Interval Debulking Surgery
Ovarian cancer usually requires extensive surgery. And while the doctor’s goal is to remove as much of the disease as possible to improve your outcome, they also have to consider the patient’s health and quality of life.
So, for example, if you have evidence of disease in several areas of the liver, doctors are not going to remove the liver to get rid of the tumor. Similarly, if you’re over 70 and suffering from comorbid conditions, your doctor may not want to put you through a large procedure.
In cases like these, patients may receive chemotherapy preoperatively. Called neoadjuvant chemotherapy, this chemo-first approach can help reduce the volume of disease, so doctors may not have to remove as much tissue during surgery.
“When we give patients chemotherapy first to shrink the tumor, the surgery doesn’t have to be as big or as long,” Dr. Hsieh says. “We find that those surgeries have fewer complications and patients don’t stay in the hospital as long.”
While studies are at odds about whether neoadjuvant chemotherapy improves survival for patients with ovarian cancer, the “chemo-first-protocol” does reduce the risk of surgical complications by 25 to 30 percent. Still, if you’re a good candidate for surgery without pre-treatment with chemotherapy, doctors usually prefer to recommend that route.
Open Surgery
Whether you undergo primary debulking surgery or interval debulking surgery, most procedures require open surgery (called a laparotomy). “With this approach, we typically do a midline vertical incision that can extend from the pubic bone to slightly above the belly button, or if we’re doing a more aggressive surgery can go all the way to the sternum,” Dr. Hsieh says.
As part of the procedure, doctors open the belly and collect something called “pelvic washings.” This fluid from inside the belly can help doctors spot microscopic rogue cancer cells that are floating in the fluid. In some cases, doctors also remove lymph nodes from inside of the hip bones all the way up to the major blood vessels of the body as part of their routine staging process.
The goal, in every case, is to find any remaining disease. Of course, surgery and disease staging is a complicated process that requires insight from a variety of professionals ranging from radiologists and surgeons to oncologists and supportive care professionals. Conversations with your health care team and careful planning can help you navigate the experience.
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