Ovarian cancer: current management and future directions

Of all the gynaecological malignancies ovarian cancer has the highest mortality. Different types of ovarian cancer vary significantly in their clinical and molecular characteristics and Epithelial ovarian cancer (EOC) is the most common subtype. Up to 20% of women with epithelial ovarian cancer have an inherited predisposition. The fallopian tubes are a potential source of high-grade serous cancer and risk reducing surgery can be an option. Routine screening with serum CA 125 and pelvic ultrasonography is still unproven. Diagnosis of ovarian tumours is usually made by pelvic ultrasonography and serum CA 125. The risk of malignancy index (RMI) is then calculated in order to decide where treatment takes place. Treatment of advanced ovarian cancer usually involves primary debulking surgery and adjuvant chemotherapy but neo-adjuvant chemotherapy with interval debulking surgery is equally effective. Survival is improved if surgery is performed by a specialist gynaecological oncologist. Recent evidence supports the value of radical surgery aiming to excise all macroscopic disease. Standard first line chemotherapy for epithelial ovarian cancer remains carboplatin with paclitaxel. BRAC mutation testing is frequently used to direct second line chemotherapy and molecular targeted treatments such as bevacizumab and PARP inhibitors have been added to the armoury against ovarian cancer. Treatment of advanced disease may prolong life and palliate symptoms but it is rarely curative. Novel drugs and approaches such as ultra-radical surgery, intra-peritoneal chemotherapy, and surgery for recurrent disease are being assessed.