**3. Palliative care for ovarian cancer patients**

Generally, it is called as the silent killer and it is the dominant gynecological cancer worldwide. Long-term survival of more than 5 years for those with advanced disease is realized in approximately 25% of patients [50–52]. Ovarian cancer's early-stage signs and symptoms are usually vague and similar to other genitourinary or gastrointestinal illnesses. The recurrence is about 70% of ovarian cancer patients. Nearly all of the parenteral cytotoxic drugs indicated for recurrent ovarian cancer have massive side effects that decrease the therapeutic benefit and consequently patients' acceptance of therapy. The less toxic alternative is altretamine which works to enhance the outcome of these patients.

Altretamine is an oral alkylating activity drug that has been prescribed for advanced ovarian carcinoma, it is prescribed for patients with recurrent ovarian cancer or who had undergone surgery and failed one or more chemotherapy regimen. It works as palliation for those with recurrent disease or as a maintenance drug to enhance and increase progression-free survival for these patients. Most benefit of altretamine is the decrease of physical and psychological discomfort came with the parenteral therapies and its oral use decreases the need for hospitalization [53, 54].

Besides altretamine, palliative therapy is used to minimize the symptoms of ovarian cancer. Women with ovarian cancer can have *ascites*. It can be very annoying but can be treated with *paracentesis*. It is a procedure where skin is numbed, a needle is inserted to withdraw the fluid. Another therapeutic option is a catheter which placed into the abdomen and the fluid can be eliminated as often as is needed. Bevacizumab (Avastin) can also help by slow fluid buildup, it is injected directly into the abdomen. These treatments can decrease symptoms, but rarely, might aide some women live longer. After all, their effects are temporary, and the cancer persists.

Another symptom is intestinal tract *obstruction*. That can cause nausea, vomiting, and abdominal pain, another procedure to allow the stomach juices to drain so that the digestive tract isn't completely blocked, this is done by placing a tube through the skin and into the stomach [55, 56]. Other therapies to facilitate bowel movements include, drinking adequate fluids, and gentle exercise. To manage the symptoms of constipation some medications can be prescribed including ondansetron as antiemitting, Miralax as laxatives, and steroids to reduce inflammation [57].

#### **3.1 Pelvic or abdominal pain**

At the beginning of ovarian cancer, pain can be easily ignored, hard to diagnose, or missed with other conditions. But, later in advance stage of ovarian cancer, it may cause a lot of pain and discomfort in the abdominal parts of your body. Over-thecounter (OTC) pain medications such as acetaminophen or anti-inflammatory pain relievers ibuprofen (Motrin, Advil). If your pain isn't controlled by OTC medications, an opioid indicated in such cases, can help minimize stronger pain such as morphine, fentanyl patch, hydromorphone, and methadone. Also find an alternative therapy to decrease abdominal pain, for example, massage, try: acupuncture, relaxation techniques, such as guided imagery, meditation, and chiropractic treatment.

Ovarian cancer can expand and affect the urinary system. Its tumor can block the ureters that prevent the urine from reaching the bladder, which results in swelling, pain, and kidney damage if don't treat. To relieve this pressure and pain, a special tube may utilize to drain the urine during cancer treatment. The tube can be placed inside the body to excrete urine from the kidney into the bladder, or outside of the body to excrete urine directly from the kidney.

Bloating and swelling can be seen at any stage of ovarian cancer. OTC remedies may not decrease this discomfort; octreotide may decrease these symptoms. Additionally, decreasing secondary bloating by staying away from carbonated beverages, processed foods, and gas-producing foods such as cabbage, beans, and broccoli [58–61].
