A meta-analysis of prognostic factors in advanced ovarian cancer with median survival and overall survival (measured with the log (relative risk)) as main objectives

Primary surgery in ovarian cancer: current opinions

There have been no controlled clinical trials supporting the use of primary cytoreductive surgery. The question remains as to whether the observed survival benefits for patients subjected to primary cytoreductive surgery are an effect of surgical skill or tumour biology. The proponents of tumour biology claim that cytoreductive surgery is a selective procedure, choosing patients with better prognosis. This paper discusses indirect evidence in the literature in support of, or in contradiction to, this hypothesis.

Management of ovarian cancer: referral to a multidisciplinary team matters

Differences in survival outcome for patients with ovarian cancer in Scotland led to an investigation of whether these differences were due to variation in presenting prognostic features or to the organisation and delivery of cancer services. A retrospective study of all 533 cases of ovarian cancer registered in Scotland in 1987 was carried out. After adjustment for age, stage, pathology, degree of differentiation and presence of ascites, survival improved when patients (1) were first seen by a gynaecologist (P < 0.05); (2) were operated on by a gynaecologist (P < 0.05); (3) had residual disease of less than 2 cm post-operatively (P < 0.001); (4) were prescribed platinum chemotherapy (P < 0.05); and (5) were referred to a joint clinic (P < 0.001). When gynaecologists operated the likelihood of smaller residual disease increased (P < 0.001). The improved survival from management by a multidisciplinary team at a joint clinic was not solely due to the prescription of platinum chemotherapy. The results of this study support the contents of the 1991 Department of Health report on present acceptable practice in the management of ovarian cancer, circulated to gynaecologists and surgeons in Scotland in 1992. The new finding that in a common cancer management by a multidisciplinary team at a joint clinic directly affects survival requires urgent attention.

Meta-analysis of failure-time data with adjustment for covariates

The objective of this study was to present and illustrate a technique for combining failure-time data from various sources, adjusting for differences in case-mix among studies. Based on the proportional-hazards model and the actuarial life-table approach, the method used assumes that the variation across studies is in part due to heterogeneity of the case-mix and adjusts for the case-mix before pooling results. As an example, the technique is applied to life-table data from six selected papers reporting patency of affected arteries following femoropopliteal angioplasty. Published 4- and 5-year patency results ranged from 25% to 58%, with a pooled five-year cumulative patency rate (without adjustment for case-mix) of 45% (+/- 2%). The populations in these studies, however, differed markedly in the prevalence of factors with prognostic value: type of lesion and distal runoff vessels. After adjustment for these differences in case-mix, the pooled five-year patency rates ranged from 60% (+/- 2%) for patients with stenotic lesions and good runoff to 24% (+/- 9%) for those with occlusion and poor runoff. The authors conclude that pooling studies without considering the effect of case-mix yields an average result with inappropriately narrow confidence intervals that does not reflect the variability across subgroups. The presented technique provides a method for combining failure-time data, adjusting for case-mix.

Neoadjuvant carboplatin and ifosfamide chemotherapy for inoperable FIGO stage III and IV ovarian carcinoma

Thirty patients aged 34-69 years (median 56) with previously untreated FIGO Stage III and IV ovarian carcinoma were given carboplatin (400 mg/m2) and ifosfamide (5 g/m2) with mesna every 28 days for a median of 3 cycles, followed, where possible, by laparotomy. Objective responses were observed in 13 (43%) patients, 11 of whom proceeded to laparotomy. Nine were successfully debulked, and two of these had removal of all macroscopic disease. Three cycles of chemotherapy were found to achieve the optimum response for the least toxicity. After a minimum follow-up of 32 months, two patients who had had debulking surgery remain alive. The median response duration was 13.9 months in the debulked group compared with 3 months in those who remained inoperable, while the corresponding median survivals were 23.4 and 6.4 months. This study suggests that neoadjuvant chemotherapy given over 8 weeks may render debulking surgery feasible in a proportion of patients presenting with unresectable ovarian cancer and can result in an improved median survival.

Advanced ovarian cancer. An overview of multi-variate analyses of prognostic variables with special reference to the role of cytoreductive surgery

BACKGROUND

Cytoreductive surgery is still widely believed to be a cornerstone in the management of advanced ovarian cancer. In the absence of data from prospective randomized trials, multi-variate analysis can assist in evaluating the role of optimal surgical cytoreduction relative to other possible prognostic variables.

MATERIALS AND METHODS

Published analyses of prognostic variables have been reviewed and the consistency and reproducibility of variables have been considered.

RESULTS

When reviewing the most recent literature it is obvious that there is a need to develop a consensus as to the most important patient characteristics which should be reported. Furthermore, these characteristics need to be standardized as do definitions such as toxicity, grading, and response criteria and duration. Subjective variables such as performance status, histological grading and typing, present a special problem as these lack reproducibility. The overview of multi-variate analyses for prognostic variables such as residual tumour size, tumour size prior to cytoreductive surgery, cisplatin therapy, grade, stage, histology, and performance status demonstrates that the impact of individual prognosticators depends on the indicators included in the analysis and that the importance of these variables could change as new technologies and treatments are introduced.

CONCLUSIONS

The collection of a single data base including all known variables reported for each patient with appropriate attention to the careful evaluation of subjective indicators should be undertaken, with a view to establishing a prognostic index. This would allow the relative risk for individual patients to be assessed.

What have we learnt from meta-analyses in ovarian cancer?

BACKGROUND

Meta-analyses aim to provide an overview of certain key questions such as optimal chemotherapy, dose-response relationships, and factors predicting long-term survival.

MATERIALS AND METHODS

A review was done of recently published meta-analyses trying to answer the above questions.

RESULTS

Two studies suggest that platinum containing combination chemotherapy is superior with regard to survival. Both show the limitation of all meta-analyses with variations in terms of follow-up and in trial details, and the conclusions must be regarded as tentative. Prospective studies which have attempted to confirm the importance of cisplatin dose-intensity (as opposed to total dose) have actually failed to do so. Two meta-analyses found a strong correlation between surgical complete response and survival. In a Dutch long-term follow-up study of about 400 cases cisplatin combination, pathologically documented complete remission, optimal debulking, and grade all were associated with a significant survival benefit. The results of other analyses, suggesting that the treatment centre involved, and adherence to study protocols, are independent prognostic factors are particularly provocative.

CONCLUSIONS

Recognizing their limitations, meta-analyses are intended to stimulate ideas for future trials and as such have a positive impact.

The prognostic value of nuclear roundness and neopterin in ovarian cancer

The prognostic value of clinical factors, morphometric features and neopterin, a marker for macrophage activation, was investigated retrospectively in 68 ovarian carcinoma patients. Nuclear roundness was a good predictor of patient survival. About 50% of our patients showed neopterin concentrations above the cut-off level of 275 mumol/mol creatinine. Interestingly, those patients with elevated urinary neopterin concentration, and thus displaying a sign of activation of cell-mediated immunity, had a shorter survival than those with normal concentration. Applying a multivariate Cox regression analysis, the only independent parameters predicting patient survival were FIGO stage, residual disease, nuclear roundness and neopterin.

Long-term survival with advanced ovarian cancer: an analysis of 5-year survivors in the Australian trial comparing combination versus sequential chlorambucil and cisplatin therapy

Of 369 patients with apparent advanced ovarian cancer entered on a randomized trial between September 1979 and June 1983, 56 survived more than 5 years. Central pathology review confirmed the diagnosis in 318 cases (15 cases not ovarian primary, 36 slides did not reach central review). Two hundred ninety-eight were invasive cancer and 34 of these (11.4%) patients were alive at 5 years. The remaining 20 cases were tumors of low malignant potential and 17 (85%) were alive at 5 years. The clinical, pathological, and treatment characteristics of these long-term survivors has been ascertained. No significant difference in survival has emerged between the two treatment arms being compared--combination chlorambucil and cisplatin versus sequential chlorambucil followed by cisplatin on treatment failure. Of 298 cases of invasive cancer there were 133 with residuum less than 2 cm after initial surgery and 20 of these (15%) survived 5 years compared with 14/165 (8.5%) of those with more tumor residuum. Clinical response was a poor indicator of survival. Only 7 of 46 (15%) patients with complete clinical response survived 5 years; however, of 44 patients with complete surgical response, 29 (65.9%) were alive at 5 years. These results highlight the improved survival prospects of women with low-potential malignancy, even in advanced stage, compared to those with invasive tumors and make a strong case for central pathology review of all cases of apparent ovarian cancer entered on randomized trials.

Advanced epithelial ovarian carcinoma: long-term survival experience at the community hospital

OBJECTIVE

The purpose of this study was to determine prognostic factors that could be altered to increase survival of patients with advanced ovarian cancer treated at the community hospital.

STUDY DESIGN

This study is a retrospective analysis of 101 patients with stage III and IV epithelial ovarian carcinoma who underwent primary surgery at two private hospitals from 1970 to 1990.

RESULTS

Primary laparotomy was done by a general surgeon in 54 cases. The tumors in 23% of stage IIIC cases were debulked to less than or equal to 2 cm residuum. The survival rate decreased as stage or postoperative tumor residual increased. Patients with stage IIIA and IIIB disease had similar survival rates, significantly better than those with stage IIIC disease. Cytoreduction of stages IIIB and IIIC to microscopic disease resulted in a survival curve equal to the "natural optimal" stage IIIA. Patients with cytoreduction of stage IIIC disease to less than or equal to 2 cm did not obtain survival rates equal to those with stage IIIB disease with visible tumor remaining. Patients with stage IIIC disease achieved a significant increase in survival rate if their tumors were cytoreduced to microscopic disease. Platinum-based combination chemotherapy compared with alkylating agents improved survival in patients with stage IIIC disease who had greater than 2 cm tumor residual. Seven patients survived greater than 5 years, with three patients currently free of disease. Three prognostic categories predict decreasing survival: (1) stage IIIC if tumor is cytoreduced to no visible residual, stage IIIA or stage IIIB; (2) stage IIIC with visible tumor residual; (3) stage IV.

CONCLUSION

Survival of community hospital-treated advanced ovarian carcinoma patients can be improved by early diagnosis, adjuvant platinum-based combination chemotherapy, and surgical cytoreduction to minimal disease. This treatment requires a team approach and education of the medical staff, including nongynecologists.

An independent evaluation of the potential clinical usefulness of proposed CA-125 indices previously shown to be of prognostic significance in epithelial ovarian cancer

CA-125 levels were assessed prior to each of the first three cycles of chemotherapy, in 81 patients with epithelial ovarian cancer receiving first-line chemotherapy. All patients have at least 1 year's follow-up. Thirty-nine patients (48%) have progressed clinically or have died within 1 year of treatment (treatment 'failures'). Three CA-125 indices previously shown to be of prognostic value are assessed for their ability to pick-out these 'failures'. When the indices examined are modified to obtain a specificity for picking out failures just exceeding 90%, the maximum sensitivity obtained was 46%. The use of CA-125 for clinical decision making in ovarian cancer requires further investigation to determine and validate a prognostic index with acceptable sensitivity and specificity, and to determine the clinical impact of treatment decisions made using such an index.

Sequential cisplatin-doxorubicin, early debulking surgery and intraperitoneal chemotherapy in advanced ovarian cancer. Groupe d'Etude et de Recherche sur les Cancers de l'Ovaire et Digestifs (GERCOD)

40 patients with advanced ovarian cancer were treated with immediate debulking followed by sequential cisplatin and doxorubicin every 4 weeks, followed by second-look laparotomy (SLL). Six courses were given when residual disease (RD) was under 2 cm. When RD was over 2 cm, three courses were followed by early debulking and six more courses before SLL. Immediate debulking was optimal in 15 patients (38%) and early debulking in an additional 15 (38%). Pathological complete responses (34 evaluable cases) were observed in 14 cases (41%), partial response in 13 (38%), stable disease in 3 (9%) and progression in 5 (15%). Toxicity was mainly haematological. 11 patients with negative SLL and 15 with RD under 2 cm received intraperitoneal cisplatin 200 mg/m2 alone or with cytarabine. Median survival was 45 months: 58 months for RD under 2 cm at initial laparotomy and 31 months for RD over 2 cm. Median survival was 46 months when early debulking was successful. 5 year disease-free survival was only 16%. However, this multimodal treatment offers prolonged survival, especially in patients optimally debulked either at initial laparotomy or at early debulking surgery.

Improved prognosis of ovarian cancer in The Netherlands during the period 1975-1985: a registry-based study

Survival of 568 patients with ovarian cancer, diagnosed in 1975-1985, was studied by means of a population-based registry in the Southeast Netherlands. Patients diagnosed in the period 1981-1985 had a significantly better prognosis than patients diagnosed in 1975-1980. This improvement of survival declined with advancing age of the patients. In women younger than 60 years, mortality from ovarian cancer decreased, while incidence remained stable. Apart from the effect of new treatment methods, consisting of more extensive tumor reduction and cisplatin-based combination chemotherapy, advances in supportive care as well as a trend toward earlier diagnosis, possibly in combination with an increasing proportion of less malignant tumors, may explain the improvement in prognosis. Survival was strongly related to stage at diagnosis and to age, the prognosis of younger patients being more favorable. Patients with tumors of either germ cell or stromal origin generally survived longer than patients with epithelial tumors, but this difference disappeared after adjustment for stage and age. Patients still alive after 6 years did not have a survival significantly different from that of the general female population.

The role of chemotherapy including ifosfamide for ovarian carcinoma. Austrian Collab. Ovarian Cancer Study Group

On the basis of the results of earlier studies, 30 departments of gynecology have been cooperating nationwide in Austria since 1980 to promote the use of adjuvant chemotherapy after surgery for cure of ovarian carcinoma in early stages and the role of lymph node dissection and of second-look operation. Results recorded in more than 160 patients treated with adjuvant chemotherapy after so-called radical surgery performed in disease stages I and II demonstrate that only highly differentiated tumours in stage Ia can be cured by surgery only with no further adjuvant treatment. This underlines the necessity for staging. More than 200 patients with TNM stages III and IV were randomized after debulking surgery to receive treatment with different kinds of drug combinations to compare the therapeutic efficacy of a sequential alternating drug regimen consisting of Adriamycin-cisplatin + vincristine-cyclophosphamide + high-dose methotrexate with that of the combination of Adriamycin-cyclophosphamide and that of Adriamycin-cisplatin. High-dosed ifosfamide was also used in pilot studies.