Surgery may be used to stage the cancer, and as a form of therapy. The type of surgery offered will depend on several factors such as the stage of the disease, the patient’s age, performance status and desire or not to retain fertility.

Women with early-stage disease should have staging surgery that includes a hysterectomy and bilateral salpingo-oophorectomy (NCI 2019). In women who want to bear children but have apparent stage I tumours, unilateral salpingo-oophorectomy with comprehensive surgical staging may be a reasonable treatment option because this is associated with a low risk of cancer recurrence (NCI 2019).

Women diagnosed with more advanced stage (II and III) disease may benefit from a total abdominal hysterectomy and bilateral salpingo-oophorectomy and more extensive cytoreductive surgery before chemotherapy (NCI 2019).

Some patients with advanced disease (III and IV) who are deemed unlikely to achieve optimal debulking or who have medical contraindications to surgery may benefit from chemotherapy before surgery.

Timeframe for starting treatment

Surgery should be conducted within four weeks of the suspected or confirmed diagnosis and within two weeks of the MDM.

Training and experience required of the surgeon

Gynaecological oncologist (CGO) with adequate training and experience in gynaecological cancer surgery as well as institutional cross-credentialing and agreed scope of practice within this area.

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with ovarian cancer and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

• critical care support
• in-house access to radiology
• 24-hour medical staff availability
• 24-hour operating room access and intensive care unit
• diagnostic imaging
• pathology
• nuclear medicine imaging.

There is strong evidence to suggest that high-volume hospitals have better clinical outcomes for complex cancer surgery such as ovarian resections (Wright et al. 2017, 2019). Centres that do not have sufficient caseloads should establish processes to routinely refer surgical cases to a high-volume centre.

The appropriateness and type of chemotherapy or drug therapy will be determined by the multidisciplinary team. A number of patients may benefit from chemotherapy or drug therapy:

• before surgery (interval debulking) in suspected stage III or IV ovarian cancer, to reduce the volume of the tumour before surgery
• after surgery in all stages except where the cancer was clearly confined to one or both ovaries and considered low risk for recurring
• after surgery for stage III ovarian cancer where no residual disease has been left. Some patients may be considered for a combination of intraperitoneal and intravenous chemotherapy.

In selected cases, chemotherapy may be considered as part of primary treatment.

Intraperitoneal chemotherapy should be provided in a centre with appropriate expertise, and potential toxicities should be fully explained to the patient and her family (Cancer Australia 2014).

Timeframes for starting treatment

• Neoadjuvant chemotherapy should begin within two weeks of the MDM.
• Adjuvant chemotherapy should begin within four weeks of surgery.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

• Fellow of the Royal Australian College of Physicians (or equivalent)
• adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015)
• appropriate expertise if providing IP chemotherapy.

Cancer nurses should have accredited training in these areas:

• anti-cancer treatment administration
• specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
• the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

• adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

• a clearly defined path to emergency care and advice after hours
• access to diagnostic pathology including basic haematology and biochemistry, and imaging
• cytotoxic drugs prepared in a pharmacy with appropriate facilities
• occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019b)
• guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
• coordination for combined therapy with radiation therapy, especially where facilities are not co-located
• appropriate molecular pathology access

Some women with ovarian cancer may benefit from radiation therapy for symptomatic relief and palliation of metastatic or recurrent disease (Jiang et al. 2018). In selected cases, radiation may also be considered as part of primary treatment.

Timeframe for starting treatment

Radiation therapy should begin within four weeks of the MDM.

Training and experience required of the appropriate specialists

Radiation oncologist (FRANZCR or equivalent) with adequate training and experience that enables institutional credentialing and agreed scope of practice within this area. The radiation oncologist must also be a core member of a gynaecological oncology multidisciplinary team.

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics

To provide safe and quality care for patients having radiation therapy, health services should have these features:

• linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
• dedicated CT planning
• access to MRI and PET imaging
• automatic record-verify of all radiation treatments delivered
• a treatment planning system
• trained medical physicists, radiation therapists and nurses with radiation therapy experience
• coordination for combined therapy with systemic therapy, especially where facilities are not co-located
• participation in Australian Clinical Dosimetry Service audits
• an incident management system linked with a quality management system

Some women with ovarian cancer may benefit from the addition of targeted therapies:

• PARP inhibitors, which inhibit the enzyme poly ADP ribose polymerase – these may typically benefit patients with gene mutations
• angiogenesis inhibitors – these prevent the growth of blood vessels related to tumours

Emerging therapies showing promise for treating ovarian cancer include DNA-damaged pathway inhibitors. Other therapies may be considered within the confines of a clinical trial.

Immunotherapy has not been shown to be of benefit and should not be used outside of a clinical trial.