Should Surgery or Chemotherapy Come First?
- Most women with ovarian cancer will get a combination of chemotherapy and surgery, but the order can vary
- Doctors consider how far the cancer has spread, and a woman’s health, when making the decision
- Delaying surgery for chemotherapy first – neoadjuvant chemotherapy – may be a better option in areas hard-hit by COVID-19
- Data shows that the sequence of treatment doesn’t impact your outcome
"The decision process for me, at least, and I think for most gynecologic oncologists, is, can you get all the cancer out without chemotherapy?" says Dr. John Nakayama, gynecologic oncologist at University Hospitals in Cleveland, Ohio.
When to Consider Surgery First
Read MoreWhen to Consider Chemotherapy First
In some cases, the results of CT scans and other tests will steer doctors away from starting with surgery. Sometimes the cancer has already spread too far to make it realistic to remove right away.
"I try to assess, based on the patient’s imaging, how much cancer is there? Is it in a spot that I might not be able to take out surgically?" Dr. Nakayama says. "If that’s the case, I would consider chemotherapy first to try to make that go away, so that we could have an optimal debulking." Once your cancer has shrunk to a more manageable size, surgery will be a safer option.
Your overall health is also critical to the decision-making process. Ovarian cancer surgery takes several hours and can be quite extensive. The ovaries, fallopian tubes and uterus are removed, as well as portions of other organs that may be affected by the disease. Do you have any underlying conditions that might make an invasive medical procedure too risky? "If you’ve had a stroke or a heart attack recently, perhaps it’s more dangerous for you to undergo surgery. Then we can buy a little bit of time with chemo first, and potentially make your surgery significantly easier,” says Dr. Nakayama.
Waiting to have surgery has a particular advantage now, when COVID-19 has made many women concerned about the risks of visiting a hospital or cancer center. Opting for chemotherapy before surgery, called neoadjuvant chemotherapy, can minimize the risk of exposure to the virus for women with ovarian cancer, who may already have weakened immunity.
Neoadjuvant chemotherapy typically consists of three to four cycles of chemo drugs, often delivered through an IV infusion. That's followed by another round of tests to see if the cancer has been reduced enough for surgery to proceed. After the surgery, a woman will probably have another three cycles of chemotherapy to complete this initial treatment.
Which Approach is Best?
A number of studies have looked to see whether the outcome differs between women who have chemo first, and those who have surgery first. "There doesn’t seem to be a significant difference, which I find very reassuring," Dr. Nakayama says.
Because you can have good results from either approach, the decision of which treatmentsurgery or chemotherapyto have first should be based on your personal preferences, your health, and how significantly COVID-19 is spreading in your area.
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