Should I Get Surgery First?

The plan of action largely comes down to the extensiveness of the disease, and whether or not doctors see viability in conducting surgery upfront. "I like to describe to patients that ovarian cancer starts on the ovaries, but then you have these little cells that flick off like dandelions and deposit all over the abdomen," says Dr. Jewell. These "dandelion seeds," as Dr. Jewell describes them, can start to grow in easy places to remove, but they can conversely grow in areas that are very difficult to remove.

The most challenging places these cells can land are in the bowels or intestines, liver, and lungs. "Those challenging locations are when the 'dandelions seeds' land on the small bowel or the intestines and you have hundreds of little tiny spots that need to be removed, or if those 'dandelion seeds' have landed inside the liver or perhaps up inside the lungs, and in those locations your chances of removing all the cancer become a lot smaller," says Dr. Jewell. The location and number of small cells can makes them extremely hard for doctors to remove during surgery, in turn complicating the task of getting to the desired number of less than five millimeters of residual disease post-surgery. These challenges often lead doctors and patients to conversations about the best course of treatment, and if chemotherapy should be implemented prior to surgery.

Beginning with chemotherapy can shrink the cancer down to a manageable level, allowing doctors to have a more manageable mass to address through surgery, when they can go in and remove as much of the cancerous cells as possible. Finally, they will put the patient through more rounds of chemotherapy. This chemotherapy-first approach is often the most effective route, but also lead to complications.

According to recent University of Michigan studies, ovarian cancer patients who were treated with chemotherapy first and surgery second were at a significantly higher risk of blood clots, possibly due to decreased mobility. "We all knew that the risk was high for women with ovarian cancer, but none of the existing literature has focused on patients who had chemotherapy prior to surgery," says Dr. Shitanshu Uppal of the University of Michigan Institute of Healthcare Policy and Innovation.

Because of all of these factors, beginning with chemotherapy is not the ideal treatment path, and there is compelling data that shows that, if possible, surgery should precede chemotherapy. "Data, particularly out of several big academic institutionsthe Mayo Clinic, Memorial Sloan-Kettering, UCI have shown that when we can take a patient to surgery first and remove all of that tumor that we are talking about, those patients do have a longer disease-free interval and a longer overall survival compared to those patients that you give chemotherapy first," says Dr. Jewell. Therefore, if at all possible, surgery should be implemented prior to the use of chemotherapy.

But doctors stress that surgery should not be attempted if there are issues with safety or if they won’t be able to remove enough of the cancerous tissue for the operation to be effective. That’s why starting with chemotherapy can still be a preferable course, especially if the disease’s “dandelion seeds” have spread to widely throughout the abdomen.

In sum, talking through the ordering of chemotherapy and surgery in treating ovarian cancer is an important conversation to have with your doctor.

 

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