Seminars in oncology
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In women with recurrent epithelial ovarian cancer, secondary treatment options include surgery and chemotherapy. Surgery should be considered in patients with persistent disease at the time of second-look laparotomy and before chemotherapy in those whose disease recurs following long-term remission. With regard to secondary chemotherapy, active agents include cisplatin, carboplatin, ifosfamide, and paclitaxel. ⋯ Patients who receive platinum therapy initially and relapse after long periods of remission often respond to second-line platinum treatment. Ifosfamide may be effective in patients receiving one or two prior cisplatin-containing regimens, but is contraindicated in those with hepatic or renal insufficiency. Paclitaxel is the drug of choice for patients who have developed primary resistance to platinum therapy.
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Third-party payer reimbursement policies have undergone significant changes in recent years and will probably continue to do so as the nation's health care system is reformed. These changes will have important implications for oncologists, similar to those that have arisen as a result of Medicare's payment system changing from one of "reasonable charges" to a fixed-fee schedule. The likely growth of managed competition as part of health care reform may prove to be disadvantageous to the oncologist without laws or rules guaranteeing cancer patients the right to treatment by a specialist and to tertiary care. Other areas of importance that will probably be affected include reimbursement of patient care costs associated with clinical trials and of drug costs when the drug is used for off-label indications.