Ovarian cancer is expected to occur in 22,000 women and cause 14,030 deaths in the United States. This fatality rate makes this tumor the leading cause of gynecologic cancer mortality. Epithelial ovarian cancer typically spreads in a logical fashion to involve the peritoneal cavity and lymph nodes as well as outside the abdomen. The most common site of extra-abdominal spread is the pleural space and thought to occur through the lymphatics. Hematologic also spreads to the liver, spleen, or lung occurs.

Most patients with ovarian cancer experience no signs or symptoms of the disease until it spreads to the upper abdomen—approximately 70% of patients with this tumor present with advanced stage III or stage IV. Abdominal discomfort, bloating, and early satiety are the most common symptoms, occasionally found as a pelvic mass during physical examination.

The tumor marker CA 125 is only elevated in approximately 50% of patients presenting with ovarian cancer. This limits this test as a screening tool. Postoperatively it is a useful screening tool. Transvaginal ultrasound is an essential diagnostic: Transvaginal ultrasound is more sensitive than screening by CAT scanning. New genomic analysis and evaluation of peripheral blood circulating cancer cells can make an early diagnosis which allows for advanced treatment and eradication.

Management of advanced-stage disease is by debulking surgery, which includes the removal of large, necrotic tumors with the inadequate blood supply that might lead to impaired chemotherapy delivery. Primary debulking surgery is surgery before chemotherapy and is the standard of care. Postoperatively we use systemic chemotherapy and intraperitoneal chemotherapy.

We are now able to profile through genomic testing to evaluate the “tumor drivers,” which are the pathways causing cancer to multiply and divide. These factors include genetic mutations, growth factors, hormone factors, and other factors causing new blood vessel growth and the metastasis of cancer. Various pathways are blocked to stop the growth of the tumor. By evaluating the circulating cancer cells, we can predict remission prognosis and recurrence. New chemosensitivity testing to find out which chemotherapy will be most effective in your cancer as well as testing for natural substances performed. The patient’s underlying immune system is of critical importance and is evaluated and optimized in all cases.

The recent approval of immunotherapy with checkpoint inhibitors have changed the management of advanced ovarian cancer. Anti-PD–1, anti-PD–L1 and CT LA–4 checkpoint inhibitors currently used. They are synergistic with other treatments. The patient’s tumor mutational burden and microsatellite instability are assessed before treatment. Also, before treatment, the patient’s underlying immune function is of critical importance and is optimized.

Personalized Vaccines are currently made for your stage 4 ovarian cancer. These vaccines have taken from the patient’s circulating cancer cell in their blood and made in the laboratory. They are injected directly back into the bloodstream to attack cancer and administered several times a year. Optimization of your immune function is critical to their effectiveness.