Advances in treatment of advanced epithelial ovarian cancer include platinum and taxane agents and the use of surgery as an aggressive initial treatment. However, 70-80% of patients present with advanced disease, and the majority of patients who attain remission with chemotherapy relapse. Although patients who relapse after platinum-based therapy are not curable, Dr. Gore noted that some may survive for a lengthy period.

Dr. Gore's focus was on two groups of patients whom he considered equivalent clinically: patients with early stage disease who relapse after only surgical therapy and patients with advanced disease who relapse after surgery and adjuvant chemotherapy.

He noted that disease-free interval between completion of chemotherapy and relapse has been documented to correlate with response to second-line chemotherapy. He cited cumulative data from two studies:

Disease-free interval (months)	Number of patients	Response rate to 2nd-line Therapy
5-12	51	22%
12-24	29	31%
>24	46	59%

In the setting of second-line therapy after relapse, combination regimens seem to have a higher success rate than single agents. However, toxicity also seems to increase with combination regimens, and quality-of-life must be weighed given that treatment for this patient group is considered palliative.

Serum measurement of CA-125 is a sensitive marker of relapse. Although the median period is 3-9 months before development of clinically evident disease, there is wide variation among patients. Dr. Gore expressed concern that some physicians and patients become too dependent on a normal CA-125 level to control anxiety over possible relapse. An ongoing trial is examining whether there is a survival difference when treatment is initiated in asymptomatic patients with an increasing CA-125 level compared with treatment initiated at first clinical evidence of disease.

There is no consensus on the role of surgery for patients with relapsed disease, either as a direct palliative measure or as palliation of a complication such as bowel obstruction. Dr. Gore believes there are cases for which benefits outweigh surgical risks and morbidity, but he noted that no randomized, prospective trials have been conducted.

He urged that patients with relapsed disease be classed by disease-free interval and initial platinum sensitivity and offered entry into randomized clinical trials. Patients who relapse more than 6 months after chemotherapy may be the best target because the number of such patients is high and there is a good chance of response to second-line therapy.