The benefit of adjuvant chemotherapy in most cases of true stage I ovarian cancer remains uncertain because of the lack of complete surgical staging in randomized

Box 8-5. Summary of Early-Stage Ovarian Cancer Treatment

All patients should have thorough surgical staging at the initial operation.

Patients with Complete Surgical Staging

1. Low-risk Stage I (see Box 8-2): No adjuvant therapy

a. Three cycles IV carboplatin-paclitaxel (3-6 cycles = NCCN option); or b. Consider observation if not clear cell (not an NCCN guideline)

a. Six cycles IV carboplatin-paclitaxel; or b. IP chemotherapy if <1 cm residual disease (see Fig. 8-8); or

Patients without Complete Surgical Staging

1 . Low-risk patients:

a. Re-operate for staging if patient accepts, or suspect residual disease; or b. Six cycles IV carboplatin/paclitaxel

2. High-risk patients:

a. Six cycles IV carboplatin-paclitaxel if no suspicion of resectable disease; otherwise, re-operate; or b. Re-operate for staging if considering observation (not an NCCN guideline)

3. Stage II: Same as completely staged patients

IP, intraperitoneal; NCCN, National Comprehensive Care Network practice guidelines, v.1, 2007.


Paclitaxel 175 mg/m2 IV over 3 hours and carboplatin AUC 5.0-7.5 q 3 weeks x 6 cycles


Intravenous management: Docetaxel 60-75 mg/m2 IV over 1 hour and carboplatin AUC 5-6 q 3 weeks x 6 cycles

Intraperitoneal (IP) management: Paclitaxel 135 mg/m2 IV 24-hour infusion on day 1; cisplatin 100 mg/m2 IP on day 2; paclitaxel 60 mg/m2 IP on day B (max. BSA 2.0 m2). Repeat q 3 weeks x 6 cycles

Figure 8-9. The National Comprehensive Cancer Network (NCCN) guidelines for chemotherapy of advanced ovarian cancer. BSA, body surface area. (From NCCN practice guidelines, v. 1, 2007.)

controlled trials that used no-treatment control arms. The largest European trials (ICON-1 and ACTION) have demonstrated that adjuvant chemotherapy definitely benefits patients who have "apparent," or grossly visible, stage I disease. Data suggest that treatment of completely staged patients may not significantly reduce the cancer recurrence rate.9,16 A randomized controlled trial to prove this concept may not be feasible because of both the sample size necessary for adequate power and the challenge of multiple institutions performing standardized complete surgical staging operations.

Observation rather than adjuvant chemotherapy in patients who have had complete surgical staging is appropriate for low-risk stage I disease and may be an option for high-risk stage I disease if the patient is fully counseled (see Box 8-5).

Complete surgical staging should be performed at the original operation if possible, and should be offered as a re-operation under certain circumstances to patients who have had incomplete staging.

When adjuvant chemotherapy is indicated, carboplatin and paclitaxel constitute the most commonly used regimen, but alternatives exist. Three to six cycles are recommended for those with completely staged high-risk stage I disease, and six cycles are recommended for incompletely staged patients with apparent stage I disease and for all those with stage II disease (see Box 8-5).

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