Stage 4 ovarian cancer

This page was reviewed under our medical and editorial policy by

Ruchi Garg, MD, Chair, Gynecologic Oncology, City of Hope Atlanta, Chicago and Phoenix

This page was updated on March 8, 2024.

Stage 4 ovarian cancer is an advanced disease that requires treatment.

The care team will assign an ovarian cancer stage based on the following tumor attributes:

  • Size
  • Whether it’s contained to its original site
  • The extent to which it’s spread to nearby tissue and lymph nodes or to more distant locations in the body

Ovarian cancer stages are numbered 1 through 4. Each number corresponds to increasing amounts and spread of cancer, with stage 4 referring to the most advanced cases of ovarian cancer.

Different systems of staging exist. The two most common systems for ovarian cancer are:

  • International Federation of Gynecology and Obstetrics (FIGO)
  • American Joint Committee on Cancer (AJCC)

AJCC criteria uses letters to represent qualities of the tumor:

T (tumor): This refers to the size of the primary tumor.

N (node): This describes the involvement of lymph nodes near the primary tumor. Lymph nodes are small, bean-shaped clusters of immune system cells that are crucial to fighting infections. They are usually one of the first sites in the body where cancer spreads.

M (metastasis): This indicates whether the cancer has spread (metastasized) to other areas of the body.

Each of these TNM qualities is assigned a number, referring to the degree of progression. These three qualities combined (T, N, M) create the stage grouping, which may be assigned after a surgeon has removed cancerous tissue for analysis. The stage grouping aligns with a FIGO or AJCC overall stage, such as IVA or IVB

This article will cover:

What is stage 4 ovarian cancer?

Stage 4 ovarian cancer is also referred to as metastatic ovarian cancer, meaning tumor cells have spread from the ovaries via the bloodstream or lymph-system vessels beyond nearby pelvic organs and lymph nodes to distant organs and tissues. Stage 4 is the most advanced stage of ovarian cancer.

Two subgroups comprise this stage.

Ovarian cancer stage 4A: Fluid containing cancer cells accumulates in the membranes between the chest wall and the lungs. These membranes are called the pleura, and the buildup of fluid is termed pleural effusion.

Ovarian cancer stage 4B: Cancer has spread to the spleen, liver or sites beyond the abdomen, which may include the lungs and groin-area lymph nodes.

Metastatic sites

Ovarian cancer may spread to neighboring organs in the pelvic area, such as the:

  • Uterus
  • Fallopian tubes
  • Bladder
  • Colon
  • Rectum
  • Peritoneum, which lines the abdominal cavity
  • Lymph nodes in the pelvis, abdomen, groin, lungs and other areas

Ovarian cancer may also metastasize to the:

  • Liver
  • Spleen
  • Lungs
  • Bones

As with other forms of cancer, ovarian cancer takes its name from the tissue where it originated. For example, when ovarian cancer cells create tumors elsewhere in the body, such as in the lungs, it’s considered metastatic ovarian cancer, not lung cancer. In other words, the cancer name is the original cancer and never changes, even if it becomes metastatic.

Stage 4 ovarian cancer symptoms

Symptoms of ovarian cancer may occur in any stage, but are more likely to be reported in advanced cases. They may include:

  • A feeling of being full, making it difficult to eat
  • Bloating, gas and constipation
  • Pain, pressure or swelling in the abdomen
  • The need to urinate urgently or more frequently

These symptoms may have many causes other than ovarian cancer. But when ovarian cancer is the cause, they tend to be more intense or frequent. If they occur for more than 12 days in a month, it’s important to contact a medical provider.

Other symptoms associated with ovarian cancer may include:

  • Indigestion (heartburn)
  • Pain during sexual intercourse
  • Back pain
  • Fatigue
  • Abdominal swelling accompanied by loss of weight
  • Menstrual changes

Stage 4 ovarian cancer treatment

Surgery and chemotherapy are the standard treatments for metastatic ovarian cancer. Other approaches, such as targeted therapy and immunotherapy, may also be used. Treatment for advanced ovarian cancer aims to extend a patient’s life, reduce symptoms and discomfort, while surgery seeks to remove as much cancerous tissue as possible.


Debulking, or cytoreductive surgery, removes cancer and may reduce pressure from cancerous growths on other organs. It may also make any future chemotherapy treatments work better. Surgical options for metastatic ovarian cancer may include:

Removal of the reproductive organs will make future pregnancy impossible, and the loss of sex hormones will start menopause. Women who want children in the future should discuss fertility-sparing options with the care team.

Not every patient is a candidate for up-front debulking surgery. Some patients may need neoadjuvant chemotherapy to shrink the cancer before they’re eligible for debulking surgery.

Surgery may also include removing portions of other organs, such as:

  • Intestines
  • Bladder
  • Spleen
  • Stomach
  • Liver
  • Gallbladder

If other organs are partially or fully removed, their functions may be affected.

Surgery carries such risks as:

  • Pain
  • Possible infection
  • Bleeding


Chemotherapy involves administering medicines that destroy tumor cells or block their ability to grow and reproduce. It’s considered a systemic treatment, as it spreads throughout the body. If the cancer has spread to distant sites, chemotherapy may be administered before surgery to help shrink tumors, called neoadjuvant therapy.

Chemotherapy or targeted therapy after surgery is called adjuvant therapy. In some cases, chemotherapy medication may be put directly into the abdomen during surgery or via a catheter and port placed during surgery for use afterward. Chemotherapy is usually administered intravenously, which may require a port. Some patients may qualify for oral therapy, which would start after the primary chemotherapy is completed.

Chemotherapy varies with the type of ovarian cancer. According to the American Cancer Society, an estimated 85 percent to 90 percent of ovarian cancers are epithelial ovarian cancer. Other forms include germ cell and stromal tumors. Chemotherapy for epithelial ovarian cancer often involves drugs given intravenously every three to six weeks such as:

  • The platinum-based drug cisplatin (Platinol®)
  • Carboplatin and a taxane, such as paclitaxel (Taxol®), and perhaps other medicines

Germ cell ovarian cancer may be treated with a combination of drugs, including a group called BEP (bleomycin, etoposide and cisplatin). Chemotherapy is seldom used for stromal ovarian cancer, but when it is, carboplatin and paclitaxel together—or the combination of bleomycin, etoposide and cisplatin—may be administered.

Chemotherapy side effects may include:

  • Nausea, vomiting and diarrhea
  • Hair loss
  • Mouth sores
  • Skin rashes
  • Peripheral neuropathy (damage to peripheral nerves)
  • Difficulties with memory or attention, nicknamed “chemo brain”

Effects of treatment on blood cell production in the bone marrow may cause:

  • Fatigue
  • Increased risk of infection
  • Bruising or bleeding more easily

Many side effects fade after treatment ends, but chemotherapy may cause long-term or permanent damage to:

  • Nerves
  • Kidneys
  • Bladder

Chemotherapy may also cause early menopause and infertility. However, these conditions may already be the result of the ovaries being removed. There’s a low chance that damage to bone marrow may lead to the development of a second cancer, such as myelodysplastic syndrome. The care team may suggest measures to help guard against some of these side effects.

Targeted therapy

Targeted therapies bind to specific targets in tumor cells, such as proteins, genes and other factors. They are not systemic, meaning they do not target the entire body. These drugs and antibody-drug combinations may:

  • Block vital processes in tumor cells
  • Help the immune system attack cancer cells
  • Prevent the surrounding tissue from feeding the tumor
  • Work to shrink tumors or slow their growth

Tests on tumor cells’ characteristics help the care team determine which therapy to use. Types of targeted therapy include the following:

Angiogenesis inhibitors, such as bevacizumab (Avastin®), are given by IV infusion and bind to a protein that signals surrounding tissue to create new blood vessels that allow tumors to grow and spread. The lack of a blood supply hinders tumor growth. Side effects of bevacizumab may include:

  • Fatigue
  • Headache
  • Low levels of white blood cells
  • High blood pressure
  • Lack of appetite
  • Diarrhea

Rare side effects may include:

  • Blood clots
  • Bleeding
  • Perforations in the colon
  • Fistulas (abnormal connections, such as blood vessels, that develop between the bowel and the bladder or the skin)

PARP inhibitors block tumor cells’ ability to repair damaged DNA, causing cell death and limiting tumor growth. They are given as pills or capsules. Side effects may include:

  • Fatigue
  • Nausea
  • Vomiting
  • Diarrhea
  • Low levels of red blood cells
  • Pain in the stomach, muscles and joints
  • More rarely, blood cancer 

Antibody-drug conjugates use monoclonal antibodies to deliver chemotherapy drugs directly to cancer cells and not to healthy tissue. These conjugates include mirvetuximab soravtansine (Elahere™), which may be used in patients for whom treatment with cisplatin or carboplatin is no longer appropriate. Side effects are considered more manageable than those of systemic chemotherapy drugs and include:

  • Liver impairment
  • Diarrhea
  • Peripheral neuropathy
  • Damage to the cornea
  • Blurry vision


Immunotherapy helps the immune system identify and destroy tumor cells. Pembrolizumab (Keytruda®) and dostarlimab-gxly (Jemperli) are checkpoint inhibitors that turn off a protein on tumor cells that tells the immune system to go away. They may be given if cancer returns (recurs), or to help control tumor growth after other therapies have been tried. Side effects may include:

  • Fatigue
  • Cough
  • Nausea
  • Constipation
  • Diarrhea
  • Skin rash
  • Joint pain

Infusion and autoimmune reactions occur less often, but are serious. Both are emergencies that need to be addressed immediately.

Infusion reactions happen while receiving the drug and resemble an allergic reaction, including such possible symptoms as:

  • Itchiness
  • Wheezing
  • Breathing difficulties
  • Fever
  • Chills

Autoimmune reactions occur when the immune system attacks healthy organs and tissue.

Hormone therapy

Hormone therapy may be used to treat stromal cancer, a rare form of ovarian cancer, if it recurs. It’s seldom used to treat epithelial ovarian cancer. These drugs include:

  • Aromatase inhibitors, including letrozole (Femara®), anastrozole (Arimidex®) and exemestane (Aromasin®)
  • Luteinizing-hormone-releasing hormone (LHRH) agonists, including goserelin (Zoladex®) and leuprolide (Lupron®)
  • Tamoxifen

These drugs interfere with estrogen production or block its use in the body. Side effects may be similar to those of menopause:

  • Hot flashes
  • Vaginal dryness
  • Bone thinning

Tamoxifen may increase the risk of blood clots in the legs.

Radiation therapy

Radiation therapy may be used to treat the sites where ovarian cancer has spread to an isolated region. External beam radiation therapy focuses X-rays on the affected spot. Treatment sessions may be given several days a week for a few weeks. Side effects may include:

  • Fatigue
  • Skin irritation (similar to sunburn)
  • Gastrointestinal upset

Clinical trials

Clinical trials are considered along every step of treatment. They may be indicated in certain situations as a way to get therapies that have shown good responses in ovarian cancer, but aren’t yet approved for this cancer type. Clinical trials also test new drugs or combinations of therapies that researchers are studying in hopes of getting approval for use by the federal Food and Drug Administration.

What to expect with metastatic stage 4 ovarian cancer

According to research in the American Cancer Society journal Cancer, stage 4 ovarian cancer will recur in many patients.

After initial surgery and chemotherapy, doctors will monitor symptoms of any remaining cancer and look for signs of cancer returning. One indicator used is a tumor marker called CA-125. According to the American Society of Clinical Oncology, blood levels of this marker rise in 95 percent of patients who experience a recurrence of ovarian cancer.

Imaging with computed tomography (CT) or positron emission tomography (PET) may be used if symptoms occur or CA-125 levels increase.

Further treatment with chemotherapy—alone or in combination with other therapies—may be done to hinder tumor growth and help alleviate symptoms. Other medications may be prescribed to reduce side effects of treatment.

Palliative care aims to help patients not only with medical needs, but also with supporting quality of life, including:

Palliative care differs from hospice care and may be employed at any stage of cancer.

Hospice care is offered when cancer is no longer being directly treated. Instead, only the cancer’s symptoms and side effects are treated. It may begin in the final portion of stage 4 ovarian cancer. Hospice may include palliative care and may be offered at home or in a hospice facility.

Stage 4 ovarian cancer survival rate

Cancer survival rates represent estimates of what percentage of people with a particular form of cancer remain alive after a specific amount of time after diagnosis, compared to those without cancer. The National Cancer Institute Surveillance, Epidemiology and End Results (SEER) Program estimates that 49.7 percent of patients with all types and stages of ovarian cancer have at least a five-year relative survival rate post-diagnosis compared to individuals without ovarian cancer.

The NCI SEER program uses the following stages to describe cancer’s progression:

  • Localized: Contained at the original site
  • Regional: Spread to nearby lymph nodes
  • Distant: Spread beyond neighboring organs and lymph nodes
  • Unknown, or not staged

Stage 4 ovarian cancer has spread to distant sites in the body. According to SEER data, the five-year relative survival rate for patients with distant ovarian cancer of all types is 30.8 percent.

According to the American Cancer Society, based on SEER data, five-year relative survival rates for distant ovarian cancer by types are:

  • Invasive epithelial ovarian cancer: 31 percent
  • Ovarian stromal tumors: 70 percent
  • Germ cell tumors of the ovary: 74 percent

Survival rates are only estimates; they aren’t predictions of an individual’s life expectancy. They do take into consideration factors that influence a patient’s prognosis, such as their general health, age and what treatments they’re receiving. They also don’t reflect recent advancements in treatment, as five-year relative survival rates are at least five years old.

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