Commentary (Berek): Management of Intestinal Obstruction in the Patient With Ovarian Cancer

In their excellent review of intestinal obstruction in women with advanced and recurrent ovarian cancer, Drs. Randall and Rubin indicate that median survivals and quality of life for these patients have improved substantially. Data from the International Federation of Obstetrics and Gynecology (FIGO)[1] and the National Cancer Institute’s Survival, Epidemiology, and End Results (SEER) program[2] indicate that the 5-year disease-free survival for advanced-stage disease has risen over the past several decades from approximately 5% to 20%. Therefore, the palliation of intestinal obstruction secondary to metastatic ovarian cancer has become a more urgent issue. The management of recurrent or chronic intestinal obstruction is often complex, and the authors have carefully substantiated issues related to this complication of the malignancy.

Although the majority of patients with advanced disease ultimately relapse, many respond to the new agents that have become available recently, including topotecan (Hycamtin), liposomal doxorubicin (Doxil), gemcitabine (Gemzar), and etoposide. In addition, patients who initially responded to cisplatin (Platinol) and/or paclitaxel (Taxol) and sustained a response for 18 to 24 months are particularly likely to respond to retreatment with these agents.

First-Line Treatment

The authors point out correctly that conservative medical management is often successful and should be the first line of treatment. Most patients require only intravenous hydration and the designation of NPO (nothing by mouth) status. Occasionally, a nasogastric tube is useful, particularly in patients with severe and intractable nausea. I agree with the authors that long tubes, such as Cantor or Miller-Abbot tubes, should be avoided because they do not successfully palliate the obstruction and are quite uncomfortable.

In patients with chronic intermittent obstruction and occasional nausea and vomiting, the program recommended by St. Christopher’s Hospice in London would be appropriate.[3,5] This regimen entails the use of antiemetics but avoids both intravenous fluids and gastrointestinal intubation. Antiemetics such as ondansetron (Zofran) and metoclopramide can be helpful.

Occasionally, patients who require chronic intermittent nasogastric decompression benefit from placement of a percutaneous gastrostomy performed endoscopically-the so-called PEG procedure.[4,5] This tube permits intermittent proximal gastrointestinal decompression while avoiding irritation to the oropharynx and nasopharynx.

Selecting Patients for Exploratory Surgery

When conservative management fails, the clinician must determine which patients would benefit from exploratory surgery-a potentially difficult decision to make. Attempts to estimate expected survival are problematic and often imprecise. Experienced gynecologic oncologists evaluate the situation based on their knowledge of the particular patient and her overall status, eg, extent of disease and degree of functionality.

In general, patients who are otherwise thriving and have not experienced multiple organ failure would be considered appropriate candidates for surgical exploration to relieve intestinal obstruction. These patients tend to have chemosensitive tumors and usually have had a long disease-free interval (eg, longer than a year) after initial chemotherapy. I would not restrict selection to platinum-sensitive individuals alone, but suitable patients should have responded to initial chemotherapy.

In my personal experience, time to relapse after initial chemotherapy is one of the most valuable predictors of outcome of laparotomy to correct intestinal obstruction. The longer the time to relapse, the more indolent the tumor and the higher the probability that the tumor will continue to grow slowly, thereby allowing the patient to benefit from exploratory surgery.

Principal Goal

Nevertheless, the physician should always strive to relieve all suffering by using appropriate medications to control pain, nausea, and anxiety. The physician’s principal goal is to compre-

hensively address these issues and maintain the best possible quality of life for the patient, while avoiding measures that would inflict undue pain without the possibility of relieving symptoms associated with progressive disease.

The physician must be attentive and compassionate and communicate freely and openly with the patient. The patient’s wishes, desires, and the degree to which she is willing to accept the morbidity of the surgery and the possibility of its failure should be carefully discussed. After consideration of all the prognostic variables, the most important objective is to care for the patient in the way that the she prefers.

References:

1. Pecorelli S, Odicino F, Maisonneuve P, et al: Carcinoma of the ovary. Annual Report on the Results of Treatment of Gynaecological Cancer. J Epidemiol Biostat 3:75-102, 1999.

2. Trimble EL, Kosary CA, Cornelison TL, et al: Improved survival for women with ovarian cancer. Proceedings of the Society of Gynecologic Oncologists (abstract). 30:136, 1999.

3. Baines M, Oliver DJ, Carter RL: Medical management of intestinal obstruction in patients with advanced malignant disease: A clinical and pathological study. Lancet 2:990-993, 1985.

4. Berek JS: Epithelial ovarian cancer, in Berek JS, Hacker NF (eds): Practical Gynecologic Oncology , 3rd ed, pp 457-522. Philadelphia, Lippincott Williams & Wilkins, 2000.

5. Lickiss JN, Philip JAM: Palliative care and pain management, in Berek JS, Hacker NF (eds): Practical Gynecologic Oncology , 3rd ed, pp 863-885. Philadelphia, Lippincott Williams & Wilkins, 2000.