Ovarian carcinoma: the role of chemotherapy

Maximum surgical effort will yield improved survival and response to subsequent therapy in patients with minimal residual disease (less than 2 cm diameter of any remaining nodule). Systemic therapy is the mainstay of later management. Studies have focused on single-agent v combination chemotherapy, optimal combination, dose intensity, and route of administration. In advanced disease, studies of the Gynecologic Oncology Group (GOG) demonstrate the superiority of cisplatin based combination chemotherapy over a single alkylating agent in regard to overall response, clinical complete response, response duration, and survival. Subsequent GOG and other studies suggest that a two-drug combination of cisplatin and cyclophosphamide is therapeutically equivalent to more toxic three- and four-drug combinations. Whether continued escalation of drug dose intensity beyond usual clinical schedules yields incremental gain in benefit remains under study. Administration of drug, particularly cisplatin, via the intraperitoneal (IP) route produces objective responses in patients who have progressed after prior cisplatin based therapy. Whether IP therapy is superior to IV therapy as first-line treatment is under investigation. In limited disease, patients can be assigned to low- and high-risk groups based on careful surgical staging. Patients with low-risk limited disease have a 5-year disease-free survival exceeding 95% with no adjuvant therapy. Those with high-risk disease, even with IP chromic phosphate or systemic melphalan, have a relapse rate of 20% or more after a similar period. The potential role of cisplatin based combination therapy in such patients is under study. Future improvement in results depends on current investigations of noninvasive methods for diagnosis and evaluation, better definition of the value of greater dose intensity and alternate route of administration, the value of methods for choosing appropriate drugs, the development of new agents, and methods to overcome drug resistance.