Ovarian, Fallopian Tube and Peritoneal Cancer: How Treatment Is Planned

Ovarian, fallopian tube and primary peritoneal cancers behave as one clinical group: they spread within the abdominal cavity, are usually diagnosed after spread has begun, and are treated with a combination of surgery and platinum-based chemotherapy. Because outcomes depend heavily on how complete the first operation is and on tumour biology, the plan must be individualised. This guide summarises the 2020 JSGO guidelines, which cover initial treatment, recurrent disease, borderline tumours, malignant germ cell tumours and sex cord–stromal tumours.

How the diagnosis is reached

Symptoms are vague — bloating, abdominal or pelvic discomfort, early satiety, urinary frequency, increasing abdominal girth — which is why many cases are found late. Assessment combines a pelvic examination, transvaginal and abdominal ultrasound, CA125 (and often HE4, with the ROMA index) and a CT of the chest, abdomen and pelvis to map disease. A tissue diagnosis may be obtained before surgery by biopsy, or the diagnosis may be made at operation; the guideline allows histological confirmation from the ovary or from a metastatic site. Genetic testing matters: BRCA1/BRCA2 status — and broader homologous recombination deficiency testing — influences both treatment and family risk.

Initial treatment: surgery first or chemotherapy first

Standard primary treatment is cytoreductive (debulking) surgery aiming to remove all visible disease, because residual tumour is the strongest modifiable predictor of survival. Total hysterectomy, removal of both tubes and ovaries, omentectomy and assessment — often removal — of affected lymph nodes and peritoneal deposits are typical; fertility-sparing surgery preserving the uterus and one ovary can be considered in selected young patients with early-stage disease. Where extensive disease makes complete removal unlikely up front, or where the patient is not fit for immediate major surgery, neoadjuvant chemotherapy followed by interval debulking surgery is an accepted alternative with equivalent survival in appropriately selected patients. The decision belongs in a multidisciplinary meeting with a gynaecologic oncologist present.

Chemotherapy and maintenance

Adjuvant platinum–taxane chemotherapy — carboplatin with paclitaxel, usually six cycles — is standard after surgery, with dose-dense or intraperitoneal schedules considered in specific settings. Maintenance therapy has transformed the field: PARP inhibitors (olaparib, niraparib) benefit patients with BRCA mutations or homologous recombination deficiency and increasingly those without, while bevacizumab is another option. Genetic results should therefore be available early rather than at relapse.

Recurrence and less common types

Recurrent disease is classified by the treatment-free interval: platinum-sensitive relapse (typically beyond six months) is re-treated with a platinum doublet, often followed by maintenance; platinum-resistant relapse uses non-platinum agents such as pegylated liposomal doxorubicin, weekly paclitaxel, gemcitabine or topotecan. Secondary cytoreductive surgery is considered in selected platinum-sensitive relapses. Separately, borderline tumours are often cured by surgery alone even in young women; malignant germ cell tumours — seen in adolescents and young women — are treated with fertility-sparing surgery plus bleomycin–etoposide–cisplatin chemotherapy and are highly curable; sex cord–stromal tumours are managed surgically with chemotherapy reserved for advanced cases.

After treatment

Follow-up typically combines symptom review, examination, CA125 and imaging at intervals that are closest in the first two years, when recurrence is most likely. Discuss genetic testing for family members, manage menopausal symptoms and bone health after ovary removal, and ask about the survivorship issues specific to this disease — fatigue, neuropathy and the psychological impact of a diagnosis whose course is often unpredictable.