In 2016, estimated 21,580 women will be diagnosed with epithelial ovarian, fallopian tube, or primary peritoneal cancer in the United States; and approximately 14,300 of them will die from the disease [1]. The vast majority of patients with these cancers present with advanced malignancy, stage III or IV disease, with widespread tumor dissemination within the abdominal cavity, with or without tumor spread to the liver, lungs, or distant organs [1]. This is the deadliest of all gynecologic cancers. Though it accounts for only 3% of all cancer cases in women, ovarian cancer is the ffth leading cause of cancer-related death [2]. Although more than 70% of women with advanced disease respond to the initial chemotherapy, most become subject to recurrent disease within the peritoneal cavity and eventually become resistant to chemotherapy [3]. Once the disease recurs, it usually becomes incurable despite further chemotherapy and surgery, and patients eventually die of their disease. Symptom management of patients with ovarian cancer is performed along a continuum: beginning at diagnosis, continuing through curative treatment and for some will continue when disease recurs. For patients with end-stage ovarian cancer, palliative services, including actively setting achievable patient-centered goals for medical care and aggressive symptom management, should be routinely ofered, alongside curative and disease-modifying treatments. At the recurrence setting, ovarian cancer patients may have a variety of symptoms, including emotional and psychological issues, as well as physical symptoms including pain, bowel symptoms (chronic constipation, obstructions, and diarrhea), abdominal bloating due to recurrent ascites, dyspnea due to pleural efusion or pulmonic congestion, and deterioration in quality of life. In this review, we address issues related to end-stage ovarian cancer patients and review the options for treatment aimed to improve pain control and quality of life.

Ovarian cancer end‑stage disease

The primary intervention for patients with ovarian cancer is complete/optimal surgical cytoreduction. In the case of advanced disease, either debulking surgery followed by chemotherapy using paclitaxel plus carboplatin, with or without biologic agents, or neoadjuvant chemotherapy with interval debulking is performed [2]. In cases of recurrence, most women eventually become resistant to the frst-line therapies and require treatment with second-, third-, and possibly fourth-line chemotherapy regimens. Advanced ovarian cancer runs a chronic course. By the end of the second to the fourth line of chemotherapy, a time comes when patients are left without any available cancer-specifc treatment options despite the presence of a progressive disease. At this point, only palliative and supportive care can be ofered. The goal in end-of-life care is to provide maximum palliation of symptoms and maximal psychological support. End-of-life care should emphasize the shift from curing the disease to major eforts for palliation and control of symptoms that are caused by the disease. Achieving this dramatic change in attitude entails the incorporation of palliative care teams for patients and their caregiving network, family, and friends.