Ovarian Cancer: Drug Therapy

Therapeutic target

Improvement of symptoms

Therapy recommendations

Therapy recommendations include the following groups:

  • Epithelial ovarian cancer.
  • Borderline tumors
  • Malignant germline tumors
  • Malignant germ cell tumors

See also under “Further therapy“.

Agents (main indication)

Chemotherapeutic agents

Epithelial ovarian cancer [S3 guideline]

Early “Epithelial Ovarian Carcinoma.”

  • Adjuvant therapy (therapy that follows surgical resection of a tumor):
    • Patients with previous stage IA, grade 1 ovarian cancer do not require adjuvant chemotherapy.
    • FIGO stages IA/B and grade 3 or IC should receive chemotherapy with carboplatin for 6 cycles.
    • FIGO stage IIIB and above are also indicated to receive antiangiogenic antibody therapy with bevacizumab 15 mg/kg bw i.v. on day 1 every 3 weeks.

Advanced “Epithelial Ovarian Carcinoma”.

  • In patients with advanced ovarian cancer (IIb-IV), carboplatin AUC 5 and paclitaxel 175 mg/m² over 3 h i.v. should be used for a total of 6 cycles every 3 weeks.
  • From FIGO stage IIIB, antiangiogenic antibody therapy with bevacizumab 15 mg/kgKG i.v. on day 1 every 3 weeks is also indicated.
  • Patients with stage III/IV high-grade ovarian cancer and proven BRCA mutation should receive maintenance therapy with a PARP inhibitor (olaparib) after response to platinum-containing first-line therapy [recommendation grade 3].
    • Treatment with olaparib in patients with newly diagnosed advanced ovarian cancer showed an unprecedented survival benefit in favor of PARP inhibitor versus placebo: after a median follow-up of 40.7 months, the median time to disease progression or death was not yet reached in olaparib group compared with 13.8 months on placebo.
  • No maintenance/consolidation therapies should be given after primary therapy.

Recurrences (recurrence) of “Epithelial Ovarian Carcinoma.”

  • Refractory ovarian cancer recurrence (platinum-resistant recurrence)* – monotherapy with gemcitabine, paclitaxel, pegylated liposomal doxorubicin, topotecan (no combination therapy, no endocrine therapy).
  • Platinum-sensitive ovarian cancer recurrence* * – platinum-containing combination therapy with
    • Carboplatin / Gemcitabine /Bevacizumab (monoclonal antibody which binds to VEGF and thus prevents binding to the VEGF surface receptor)* * * .
    • Carboplatin/pegylated liposomal doxorubicin,
    • Carboplatin/paclitaxel
    • Carboplatin / gemcitabine.
  • If repeat platinum therapy is not an option, platinum-free monochemotherapies are used. Effective substances are, in addition to pegylated liposomal doxorubicin (PLD) and gemcitabine, treosulfan and topotecan. As far as no therapy with bevacizumab has been done, a combination with the vascular-endothelial-growth-factor(VEGF)-inhibitor is also possible.

* No response to therapy, progression (progress) within 4 weeks after the end of therapy, recurrence within 6 months after the end of therapy* * Recurrence no earlier than 6 months after the end of primary therapy* * * * in patients with first recurrence and without prior VEGF (vascular endothelial growth factor)-directed therapy.

Additional notes

  • For patients with recurrent platinum-sensitive ovarian cancer and a proven mutation in the BRCA1 (chromosome 17q21) or BRCA2 (chromosome 13q12) gene, the first drug (olaparib) in the series of so-called PARP (poly-ADP-ribose polymerase) inhibitors has been available since December 2014. PARP inhibitors block an enzyme involved in DNA repair, improving progression-free survival.
  • Another PARP inhibitor was approved by the FDA in March 2017: Niraparib contributed to a prolongation from 5.5 to 21.0 months (hazard ratio 0.27; 95 percent confidence interval 0.17 to 0.41) in 203 BRCA-positive patients. Niraparib also improved progression-free survival from 3.9 to 9.3 months in 350 patients without a BRCA mutation. In 2020, niraparib was approved as first-line maintenance therapy for advanced ovarian cancer (epithelial (FIGO stages III and IV) high-grade carcinoma of the ovary).Another PARP inhibitor is rucaparib, which is also approved in advanced ovarian cancer.
  • Approval status of PARP inhibitors:
    • Olaparib: maintenance monotherapy for advanced (FIGO stage III and IV) BRCA 1/2-mutated (germline and/or somatic) high-grade epithelial ovarian, fallopian tube, or peritoneal Ca after first-line response to platinum-based chemo.
    • Niraparib: maintenance monotherapy for recurrence of platinum-sensitive poorly differentiated ovarian cancer in remission on platinum-based chemotherapy.
    • Rucaparib: monotherapy of relapsed or progressive platinum-sensitive high-grade ovarian cancer with BRCA mutation who have previously received two or more platinum-based chemotherapies and are now ineligible for further such therapy.
  • The efficacy of PARP inhibitors in first-line maintenance therapy for advanced ovarian cancer is now considered confirmed. Treatment is also an option for women without a BRCA mutation.

Borderline tumors [S3 guideline]

  • No adjuvant therapy

Malignant germline stromal tumors [S3 guideline]

  • The benefit of adjuvant radiotherapy, chemotherapy, or endocrine therapy in the setting of complete surgery is unproven and controversial.
  • From stage FIGO IC or with residual tumor, platinum-containing chemotherapy can be discussed

Malignant germ cell tumors [S3 guideline]

Primary chemotherapy (= neoadjuvant chemotherapy, NACT).

  • In advanced stages, primary chemotherapy may be possible with the goal of preserving fertility (fertility). After three to four cycles, resection of the tumor remnant or existing metastases may be targeted
  • Substances: platinum-containing therapeutic agents + etoposide + bleomycin or ifosfamide.

Adjuvant chemotherapy

  • Stage FIGO IA no adjuvant chemotherapy.
  • Stage > FIGO IA should be platinum-containing chemotherapy, risk-adapted consisting of two or three cytostatic drugs* and 2-4 courses.

* The chemotherapy should contain platinum and etoposide in any case. Bleomycin or ifosfamide may be considered as a third substance.

Other indications for ovarian cancer

  • Persistent activation of especially β 2-adrenergic receptors promotes ovarian cancer growth and also ovarian cancer metastasis. One study demonstrated for the first time that therapy with nonselective beta-blockers appeared to be associated with a significant prolongation of overall survival.Further studies are awaited.
  • A single course of hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin prolonged survival in patients with advanced ovarian cancer in a randomized clinical trial:
    • Median recurrence-free survival: from 10.7 months to 14.2 months
    • Median overall survival: from 33.9 months to 45.7 months

Hormone therapy after treatment of ovarian cancer S3 guideline]

  • No reliable statement can be made regarding the safety of hormone therapy after treatment of ovarian cancer.
  • Hormone therapy can be performed after appropriate education.