Ovarian, fallopian tube and primary peritoneal cancer

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These cancers at a glance

• Epithelial cancers start in surface or lining cells. Ovarian, fallopian tube and primary peritoneal epithelial cancers are closely related and are usually staged and treated in the same way.
• Persistent bloating, pelvic or abdominal pain, feeling full quickly and urinary change deserve assessment, especially when new or frequent.
• For people at average risk who have no symptoms, routine screening has not been shown to reduce deaths from these cancers. Cancer antigen 125 (CA-125), a blood marker, and ultrasound can help investigate symptoms or a mass; neither can diagnose cancer on its own.
• A specialist in cancers of the female reproductive organs should plan the operation. The aim is often to remove all visible disease while protecting safety and function.
• Carboplatin plus paclitaxel is a common chemotherapy combination. Some people also receive a targeted medicine, explained under Treatment options.
• Testing for inherited gene changes, called germline testing, is recommended for epithelial ovarian, fallopian tube and primary peritoneal cancer regardless of age or family history. The results may guide treatment and help relatives understand their risk.
• If cancer returns (recurs), treatment depends on what you have already received, how long it helped, your symptoms and goals, and test results that may guide medicine choices. These treatment-guiding features are called biomarkers.

Understand

The ovaries, tubes and peritoneum

The ovaries sit on either side of the uterus (womb). The finger-like ends of the fallopian tubes, called fimbriae, lie close to the ovaries. The peritoneum is the thin lining inside the abdomen and pelvis.

• Ovaries release eggs and make hormones before menopause.
• The fallopian tubes extend from the upper uterus towards each ovary.
• Many high-grade serous cancers, the most common subtype, appear to start at the fimbrial end of a tube, even when the largest tumour is around an ovary.
• Primary peritoneal cancer begins in the lining itself and can occur even after ovaries have been removed.

What does 'ovarian cancer' include?

This guide covers epithelial ovarian, fallopian tube and primary peritoneal cancer together. When it says ovarian cancer in this shared treatment pathway, it usually includes all three. The cell type, stage and biomarker results still determine which treatments are suitable.

Germ-cell tumours start in egg-forming cells; stromal tumours start in supporting tissue. These and borderline tumours follow different pathways, explained below.

How these cancers spread

• Cancer cells can spread across the abdominal lining. Deposits may form on the omentum (a fatty apron over the abdominal organs), the bowel surface, the diaphragm (the breathing muscle below the lungs), or tissues in the pelvis.
• Fluid may collect in the abdomen (ascites) or around a lung (pleural effusion).
• Cancer may reach lymph nodes, small structures in the immune system, in the pelvis or beside the main artery in the abdomen. Less often, it spreads to distant organs.

The primary site may be assigned later

Examining the tissue helps identify whether a high-grade serous cancer began in an ovary, a fallopian tube or the peritoneum. Sometimes the starting site cannot be determined.

Primary peritoneal cancer can occur without an ovarian mass. It differs from cancer that has spread to the peritoneum from the bowel or another organ, and from peritoneal mesothelioma, a different cancer of the lining. Those diagnoses need their own treatment pathways.

The subtype changes the plan

Histology describes the cell type and pattern seen under the microscope. Different subtypes can grow and respond to treatment differently.

Symptoms are common - the pattern matters

Ovarian cancer symptoms often resemble digestive, urinary or hormonal problems. New, persistent or worsening symptoms deserve assessment.

Most people with these symptoms do not have ovarian cancer. The purpose of assessment is to find the cause, not to assume the worst.

Risk factors

Usually there is no single cause. A risk factor changes probability; it does not prove why one person developed cancer.

Factors that increase risk

• Increasing age and menopause
• An inherited harmful change in a gene such as BRCA1, BRCA2, RAD51C, RAD51D or BRIP1, or a change linked to Lynch syndrome, an inherited condition that increases the risk of several cancers
• A close family history of ovarian, fallopian-tube, breast, pancreatic, prostate, bowel or uterine cancer
• Endometriosis, particularly for clear-cell and endometrioid subtypes
• Never having been pregnant, and some reproductive or hormonal factors; these associations are modest and not anyone's fault

A tumour can have a change in BRCA1 or BRCA2 that is not inherited. These genes are often referred to together as BRCA. Blood or saliva testing checks inherited changes; tumour testing checks changes within the cancer.

Screening and prevention

For people at average risk and without symptoms, CA-125 and transvaginal ultrasound (a scan using a probe in the vagina) have not been shown to reduce ovarian-cancer deaths.

If inherited risk is high

• See a genetic counsellor to interpret the exact gene, family history and personal risks.
• Removing both fallopian tubes and ovaries after completing plans for children substantially lowers the risk for people with a harmful inherited BRCA change. It does not remove every risk, including the risk of primary peritoneal cancer. Timing depends on the gene and individual circumstances.
• Surgery causes infertility and, before natural menopause, sudden menopause. Discuss symptoms, bone/heart health, sexual health and whether hormone therapy is appropriate.
• Screening may sometimes be used while surgery is deferred, but it is not a proven substitute for risk-reducing surgery.

Tests and diagnosis

The first assessment

No single test diagnoses ovarian cancer. Each part answers a different question.

CA-125: useful, but not a verdict

CA-125 is a protein measured in blood. It helps most when interpreted with symptoms, scans, menopause status and the tumour's own behaviour.

What CA-125 can do

• Support assessment of a suspicious mass, particularly after menopause
• Provide a baseline before treatment if the cancer produces CA-125
• Help track response when the starting value was raised
• Contribute to follow-up discussions, alongside symptoms and examination

What it cannot do

• Diagnose or exclude ovarian cancer by itself
• Distinguish cancer from every benign cause: menstruation, pregnancy, endometriosis, fibroids, infection, liver disease and fluid around organs can raise it
• Show exactly where cancer is or whether surgery is possible

Biopsy and tissue diagnosis

A scan or CA-125 result alone cannot confirm the cancer type. Examining tissue, taken in a small sample called a biopsy or during surgery, establishes the diagnosis and guides treatment.

If surgery is planned first

The tumour and other samples removed during surgery provide the diagnosis and help establish the stage. A rapid tissue check during the operation, called a frozen section, may help guide surgery. The final laboratory examination gives a more complete result.

If chemotherapy is planned first

The team usually takes a core biopsy, a small cylinder of tissue, from an accessible tumour or a deposit on the abdominal lining or omentum. Examining cells in fluid can help, but a tissue biopsy usually gives more information about the cancer type and provides material for biomarker tests.

What the pathologist reports

• Primary site and histological subtype
• Grade and tests for proteins that help identify the subtype
• Whether the cancer could have started elsewhere, especially in the digestive tract
• Whether there is enough cancer tissue for BRCA, HRD or other treatment-guiding tests

Biomarkers: tests that can change treatment

Germline testing looks for inherited risk. Tumour testing looks for changes within the cancer. Some results overlap, but they are not interchangeable.

Preparing for your appointment

For your consultation or a second opinion, bring a compact disc (CD) containing your scan images in Digital Imaging and Communications in Medicine (DICOM) format and the software needed to view them, along with the written scan reports.

Bring the biopsy report, treatment summaries and a list of medicines and allergies. Ask whether tissue slides or blocks are needed for review or further testing. A family member or caregiver can help you take notes if you wish. If a record is missing, ask the team how to obtain it; you can still discuss the next steps.

Planning your treatment

Understanding your stage

International Federation of Gynecology and Obstetrics (FIGO) staging for ovarian, fallopian tube and primary peritoneal cancer

These cancers share a staging framework. Primary peritoneal cancer starts in the lining of the abdomen and has no stage 1. Surgery, tissue examination and scans establish the stage. The pictures show examples; an individual cancer may meet other criteria within the same stage.

Lymph nodes are small immune-system structures. Regional nodes are those near or draining the cancer’s starting area; distant spread means cancer has reached a site outside that regional area. Stages describe findings, not a sequence that everyone will pass through.

Purple represents cancer. Each picture shows one example.

Stage 1 (I)

Cancer is confined to one or both ovaries or fallopian tubes. The substage also considers capsule rupture, surface cancer and cancer cells in abdominal fluid or washings. Primary peritoneal cancer does not have stage 1.

Stage 2 (II)

Cancer has spread within the pelvis, for example to the uterus or other pelvic tissue. Primary peritoneal cancer confined to the pelvis can be stage 2.

Stage 3 (III)

Cancer involves the abdominal lining beyond the pelvis, regional lymph nodes behind the abdominal lining, or both. Cancer on the outer surface of the liver or spleen can be stage 3; this differs from cancer inside those organs.

Stage 4A (IVA)

Cancer cells are found in fluid around a lung. Fluid alone does not establish stage 4A; the fluid must contain cancer cells.

Stage 4B (IVB)

Cancer is found inside liver or spleen tissue, in another distant organ, or in distant lymph nodes outside the abdomen. Spread along the abdominal lining alone is not stage 4.

Advanced stage does not mean that surgery or active treatment has no role. The subtype, amount and location of disease, overall health and likelihood of removing visible tumour are central to treatment planning.

Clinical stage comes from examination, biopsies and scans. Pathological stage can add information from surgery; a prefix such as yp means the tissue was assessed after treatment. A revised assessment does not necessarily mean the cancer grew while you were waiting. Grade describes the cells’ behaviour and is different from stage.

Your care team

Care works best when specialists review scans, tissue results, surgery, medicines and support needs together. This is called a multidisciplinary team discussion.

How your treatment plan is chosen

Good decisions combine clinical evidence with what is realistically achievable and what matters to you.

1. 1

   Confirm the diagnosis

   Tissue review defines the cancer type. Check whether this is epithelial ovarian, fallopian-tube, primary peritoneal, borderline, germ-cell or stromal disease.

2. 2

   Map the disease and fitness

   CT of the chest, abdomen and pelvis, PET-CT when it will help guide treatment, CA-125 where useful, nutrition and medical fitness. The goal is to judge whether complete surgery is likely and safe.

3. 3

   Choose the starting route

   Start with surgery if all visible cancer appears safely removable. If that is unlikely, or surgery would be too risky, a biopsy is usually followed by carboplatin plus paclitaxel before surgery. Chemotherapy given before surgery is called neoadjuvant chemotherapy.

4. 4

   Plan after chemotherapy

   Complete the planned chemotherapy course. Discuss maintenance based on the BRCA and HRD results, whether bevacizumab was used, the stage, response, side effects and treatment availability.

Surgery first or chemotherapy first?

Both routes are established options for stage 3–4 epithelial cancer. The team recommends the route most likely to allow safe removal of all visible cancer, taking your subtype and general health into account.

A gynaecological oncologist should assess the safest starting route with you. The aim is complete removal of visible disease with an acceptable risk of complications.

Fertility and treatment-induced menopause

Raise fertility before treatment, even when time is short. Options depend on age, stage, subtype and safety.

Fertility-sparing treatment

Selected people with a carefully staged cancer confined to one ovary, or certain borderline, germ-cell or stromal tumours, may be able to keep the uterus and an unaffected ovary. Eligibility depends on the exact stage, subtype and grade.

This is not a routine option for high-grade or advanced epithelial cancer and should not be assumed suitable for fallopian tube or primary peritoneal cancer. Discuss fertility wishes with a gynaecological oncologist before treatment.

If both ovaries are removed

• If you have not reached menopause, removing both ovaries causes an immediate menopause. You can no longer produce eggs for a natural pregnancy.
• Hot flushes, sleep disturbance, mood change, vaginal dryness, pain during sex and urinary symptoms can occur.
• Long-term bone and cardiovascular health deserve attention.
• Hormone therapy may be suitable for some subtypes and unsuitable or uncertain for others. The team considers your cancer type, age and other health conditions before recommending it.

Treatment options

Surgery to remove visible cancer

The aim is to remove all visible cancer whenever safely possible. This can be a long abdominal operation and should be planned by a specialist team.

The operation may include

• Removal of uterus, cervix, both tubes and ovaries
• Removal of the omentum and visible peritoneal deposits
• Sampling or removal of selected lymph nodes when indicated
• Removal of disease from bowel, diaphragm, spleen, liver surface, bladder or other organs when necessary and safe
• Fluid washings and tissue samples that help establish the final FIGO stage

Before consenting, ask

• How likely is complete removal? Could I need bowel surgery, a stoma (an opening in the abdomen to collect stool in a bag), spleen removal, a blood transfusion or intensive care? If a stoma is needed, might it be temporary or permanent?
• What is the recovery plan, including pain relief, eating, movement and prevention of blood clots?
• How will fertility, menopause, bladder, bowel and sexual function be affected?

Chemotherapy

Carboplatin plus paclitaxel every three weeks for about six cycles is common for stage 2–4 and higher-risk stage 1 epithelial cancer. A cycle is one treatment period followed by a recovery interval. The exact plan depends on the subtype, stage, earlier treatment and your health.

During treatment

• Blood counts and organ function are checked before cycles.
• CA-125 and imaging may help assess response when they were informative at baseline.
• Tell the team early about tingling, numbness, hearing change, allergy symptoms, uncontrolled nausea or reduced intake.
• Dose adjustment or delay can protect safety without meaning treatment has failed.

Additional treatments for selected patients

These approaches can help selected people, but they are not automatic additions for everyone.

Bevacizumab

Bevacizumab blocks signals that help cancers grow new blood vessels. It may be given with the first chemotherapy course or with treatment for recurrence, then continued as maintenance. The team checks bowel involvement, wound healing, blood pressure, urine protein and the risk of bleeding or blood clots before recommending it.

Intraperitoneal (IP) chemotherapy

Intraperitoneal means inside the abdomen. Chemotherapy is delivered there through a small implanted access device called a port. It may be discussed for selected people with stage 2–3 disease who are well enough for treatment and have little or no visible cancer left after surgery. Side effects and treatment arrangements limit its routine use.

Hyperthermic intraperitoneal chemotherapy (HIPEC)

HIPEC circulates heated chemotherapy inside the abdomen during surgery. It may be considered at interval cytoreductive surgery, after chemotherapy, for selected patients with stage 3 disease, good general fitness and adequate kidney function in an experienced centre. It is not a routine addition for every stage or operation.

Maintenance after first treatment

Maintenance aims to keep cancer controlled for longer after platinum chemotherapy has worked. A complete response means no cancer is detectable on the assessment used; a partial response means the cancer has shrunk. The choice depends on the biomarker results, earlier treatment, side effects and your preferences.

PARP inhibitors are not suitable for every recurrence. Your team checks current treatment criteria, biomarkers and any previous PARP treatment before recommending them.

If the cancer persists or returns

Recurrence is common in advanced high-grade epithelial cancer. Further treatment can often control disease, relieve symptoms and maintain quality of life.

The new plan considers

• How well platinum chemotherapy worked and the time from its last dose until the cancer returned
• Previous surgery, chemotherapy, bevacizumab and maintenance
• Current symptoms, sites and pace of disease
• Ongoing neuropathy, blood counts, kidney and liver function, and overall health
• BRCA and HRD results; FR-alpha, PD-L1, HER2, MMR, MSI and TMB; changes in KRAS or BRAF; and other relevant tumour features
• Goals: symptom relief, longer control, treatment-free time, or a clinical trial

For selected people with a first recurrence, another operation may be considered if all visible cancer appears removable. This is called secondary cytoreductive surgery and needs assessment in an experienced centre.

When platinum may still help

If the cancer responded to platinum before, the time from the last platinum dose to recurrence helps guide whether to use it again. A gap of 12 months or longer generally favours a better chance of benefit, but platinum can also be considered after 6–12 months.

The previous response, side effects, symptoms and overall health matter as well; the interval is not the only deciding factor. This is not a reason to delay treatment once it is needed.

Platinum allergy

The risk of a platinum allergy rises with repeated treatment. Tell the infusion team immediately about flushing, itching, chest tightness, breathlessness or dizziness. An experienced unit may be able to give the drug through a closely monitored gradual reintroduction process called desensitisation, or use a different medicine.

When platinum no longer works well

Platinum-resistant disease usually means cancer has grown during platinum treatment or returned within six months of its last dose. This helps guide choices, alongside the previous response and your health. Treatment may use one chemotherapy medicine, sometimes with bevacizumab, or a suitable biomarker-guided option. The selected combinations below are for adults with epithelial ovarian, fallopian tube or primary peritoneal cancer.

Your oncologist and pharmacist should review the indication, previous treatments, safety requirements and treatment arrangements.

Low-grade, mucinous and other uncommon tumours

A treatment plan built for high-grade serous cancer should not be copied automatically to a rare subtype.

Low-grade serous ovarian cancer

• Surgery is important. For selected recurrent disease, options include hormone treatment such as an aromatase inhibitor, which lowers oestrogen production, or trametinib. Trametinib blocks a growth-signalling protein called mitogen-activated protein kinase kinase (MEK).
• For adults whose low-grade serous ovarian cancer has returned after previous systemic treatment and has a KRAS mutation, avutometinib with defactinib is another targeted-treatment option approved in the US. The team checks the tumour result, previous treatments, likely benefits, side effects and local approval and availability before recommending it.

Mucinous carcinoma

Specialist tissue review and assessment of the digestive tract help check that the cancer has not spread from the appendix, bowel, stomach or pancreas. The medicines may follow an ovarian-cancer or digestive-tract-cancer treatment plan, depending on where the cancer started and its features.

Germ-cell and sex-cord stromal tumours

Ovarian germ-cell tumours often affect younger people and may produce AFP, beta-hCG or LDH. Surgery that preserves fertility may be possible.

Their chemotherapy and follow-up differ substantially from epithelial ovarian cancer and broadly follow principles used for testicular germ-cell tumours. The exact drugs, number of cycles, surgery and follow-up depend on the subtype and stage; discuss the differences with your treating team.

Sex-cord stromal tumours are a separate group. Some produce inhibin, and their surgery, medicines and follow-up are planned according to that subtype. Fertility-preserving surgery may be possible in selected situations.

Managing side effects

Managing treatment side effects

Report problems early. Many effects improve with prevention, dose adjustment and supportive care.

Supportive and palliative care

Supportive care is active treatment of symptoms and quality of life. It can be given from diagnosis, alongside surgery and anticancer therapy.

When to seek urgent help

Your treatment team should give you a 24-hour contact route. When in doubt, call early.

Bring useful information

• Cancer diagnosis and current treatment
• Date of last chemotherapy/infusion/tablet dose
• Your medicines, allergies and details of any implanted port or treatment line
• Oncology team and hospital contact numbers

Do not drive yourself if you are faint, severely breathless, confused or in uncontrolled pain. Use local emergency services.

Live well

Follow-up after treatment

Follow-up looks for symptoms, supports recovery and decides when tests would change care. A scan at every visit is not always helpful.

Schedules vary by stage, treatment and centre. A common pattern is closer review during the first two years, then gradually less often, with individual adjustment.

Recovery, food, movement and sexual health

There is no special diet that cures ovarian cancer. The goal is enough energy, protein, fluid and movement to support recovery and independence.

Practical recovery

• After surgery, increase walking and activity gradually; follow lifting, wound and driving advice.
• Choose small frequent meals if early fullness persists. Eggs, dairy, pulses, soy, nuts and supplements recommended by a dietitian can raise protein intake.
• Ask for help with constipation, diarrhoea, stoma care, taste change or persistent nausea rather than restricting many foods.
• Pelvic-floor physiotherapy, vaginal moisturisers/lubricants, menopause care and sexual counselling can help. Discuss vaginal oestrogen or systemic hormone therapy with the oncology team before use.
• Fatigue often improves with regular light-to-moderate activity, sleep support and correction of pain, anaemia or mood problems.

Emotional and practical support

Fear of recurrence, grief, anger, low mood, changed body image and uncertainty are common. Support is part of good cancer care.

For patients

• Tell the team if anxiety, low mood or poor sleep is persistent or limits daily life.
• Ask about counselling or psychology support for people with cancer, peer groups, help with recovery and daily activities, palliative care and spiritual support.
• Discuss work, travel, fertility, menopause, sexuality and finances directly; these are clinical issues, not extras.

For caregivers

• With the patient’s agreement, keep a shared medicines and contact list and write down questions. Let them decide how much help they want.
• Before going home, ask the team to show you how to manage any drains, stoma, feeding needs or symptom medicines. Make sure you know which problems need a call and who to contact out of hours.
• Protect your own sleep, health and breaks. Caregiver burnout is not a failure.

Related care

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Meet our doctors

Dr (Prof) Vijay Agarwal

Professor and Lead Consultant – Medical Oncology

Dr Prathyush V

Senior Consultant – Medical Oncology & Haemato-Oncology

Dr Darshan R S

Consultant – Medical Oncology & Haemato-Oncology

Where to get care

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Apollo Hospitals
Bengaluru

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Apollo Hospitals
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