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Jochum F, Dumas É, Gougis P, Hamy AS, Querleu D, Lecointre L, Gaillard T, Reyal F, Lecuru F, Laas E, Akladios C. Survival outcomes of primary vs interval cytoreductive surgery for International Federation of Gynecology and Obstetrics stage IV ovarian cancer: a nationwide population-based target trial emulation. Am J Obstet Gynecol 2024:S0002-9378(24)00818-4. [PMID: 39111517 DOI: 10.1016/j.ajog.2024.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND The effect of primary cytoreductive surgery vs interval cytoreductive surgery on International Federation of Gynecology and Obstetrics stage IV ovarian cancer outcomes remains uncertain and may vary depending on the stage and the location of extraperitoneal metastasis. Emulating target trials through causal assessment, combined with propensity score adjustment, has become a leading method for evaluating interventions using observational data. OBJECTIVE This study aimed to assess the effect of primary vs interval cytoreductive surgery on progression-free and overall survival in patients with International Federation of Gynecology and Obstetrics stage IV ovarian cancer using target trial emulation. STUDY DESIGN Using the comprehensive French national health insurance database, we emulated a target trial to explore the causal impacts of primary vs interval cytoreductive surgery on stage IV ovarian cancer prognosis (Surgery for Ovarian cancer FIGO 4: SOFI-4). The clone method with inverse probability of censoring weighting was used to adjust for informative censoring and to balance baseline characteristics between the groups. Subgroup analyses were conducted based on the stages and extraperitoneal metastasis locations. The study included patients younger than 75 years of age, in good health condition, who were diagnosed with stage IV ovarian cancer between January 1, 2014, and December 31, 2022. The primary and secondary outcomes were respectively 5-year progression-free survival and 7-year overall survival. RESULTS Among the 2772 patients included in the study, 948 (34.2%) were classified as having stage IVA ovarian cancer and 1824 (65.8%) were classified as having stage IVB ovarian cancer at inclusion. Primary cytoreductive surgery was performed for 1182 patients (42.6%), whereas interval cytoreductive surgery was conducted for 1590 patients (57.4%). The median progression-free survival for primary cytoreductive surgery was 19.7 months (interquartile range, 19.3-20.1) as opposed to 15.7 months (interquartile range, 15.7-16.1) for those who underwent interval cytoreductive surgery. The median overall survival was 63.1 months (interquartile range, 61.7-65.4) for primary cytoreductive surgery in comparison with 55.6 months (interquartile range, 53.8-56.3) for interval cytoreductive surgery. The findings of our study indicate that primary cytoreductive surgery is associated with a 5.0-month increase in the 5-year progression-free survival (95% confidence interval, 3.8-6.2) and a 3.9-month increase in 7-year overall survival (95% confidence interval, 1.9-6.2). These survival benefits of primary over interval cytoreductive surgery were observed in both the International Federation of Gynecology and Obstetrics stage IVA and IVB subgroups. Primary cytoreductive surgery demonstrated improved progression-free survival and overall survival in patients with pleural, supradiaphragmatic, or extra-abdominal lymph node metastasis. CONCLUSION This study advocates for the benefits of primary cytoreductive surgery over interval cytoreductive surgery for patients with stage IV ovarian cancer and suggests that extraperitoneal metastases like supradiaphragmatic or extra-abdominal lymph nodes should not automatically preclude primary cytoreductive surgery consideration in suitable patients.
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Affiliation(s)
- Floriane Jochum
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Gynaecology, Strasbourg University Hospital, Strasbourg, France.
| | - Élise Dumas
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Mathematics, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Paul Gougis
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Medical Oncology, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France; Clinical Investigation Center (CIC-1901) INSERM, Department of Pharmacology, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Anne-Sophie Hamy
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Medical Oncology, Institut Curie, Paris, France
| | - Denis Querleu
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Lise Lecointre
- Department of Gynaecology, Strasbourg University Hospital, Strasbourg, France
| | - Thomas Gaillard
- Department of Breast and Gynaecological Surgery, Institut Curie, Paris, France
| | - Fabien Reyal
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Breast and Gynaecological Surgery, Institut Curie, Paris, France
| | - Fabrice Lecuru
- Department of Breast and Gynaecological Surgery, Institut Curie, Paris, France
| | - Enora Laas
- Department of Breast and Gynaecological Surgery, Institut Curie, Paris, France
| | - Cherif Akladios
- Department of Gynaecology, Strasbourg University Hospital, Strasbourg, France
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Baldewpersad Tewarie NMS, van Ham M, Wouters M, Kruitwagen R, van Driel W. Guideline adherence in ovarian cancer for surgical staging in the Netherlands. Int J Gynecol Cancer 2022; 32:1592-1598. [PMID: 36270772 DOI: 10.1136/ijgc-2022-003666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE Previous studies have shown low adherence to surgical staging guidelines in patients with clinical early-stage ovarian carcinoma. The aim of this study was to identify guideline adherence for surgical staging and to show the distribution of each surgical item within the study population. In addition, we examined whether regional variation in the Netherlands exists for complete surgical staging. METHODS Patients with ovarian cancer and surgical staging registered in the Dutch Gynecological Oncology Audit between January 1, 2015 and December 31, 2019 in the Netherlands were included. Complete surgical staging was defined according to the Dutch evidence-based guideline. Surgical items were ranked and illustrated. Variation in complete surgical staging for eight regional cancer networks was shown in funnel plots. Manual validation of registered data was performed in three gynecological oncology centers. RESULTS 604 patients underwent surgical staging, 365 (60%) underwent an incomplete staging procedure, 295 (81%) were registered with early-stage disease (International Federation of Gynecology and Obstetrics I-IIA) and, of these patients, 115 (39%) received adjuvant chemotherapy. Patients with incomplete surgical staging were operated more often with minimal invasive techniques (laparoscopy or robot) compared with patients in the complete staging group (p<0.001). Sampling of cytology/ascites was the most frequently lacking factor (29%). Manual validation of data in three gynecological oncology centers identified reasons for incomplete staging, the most common being 'perioperative findings' such as dense adhesions between tumor and peritoneum, consistent with advanced stage disease (≥IIA). Regional variation for complete surgical staging showed two regions performing outside the confidence intervals (12.5% and 25.5%, mean 40%). CONCLUSION Guideline adherence for staging was lower than expected and validation of data gave additional insights into the reasons that were contributing to incomplete surgical staging. Moreover, this analysis showed that regional variation for surgical staging exists, which forms a starting point to improve and harmonize staging procedures for these patients nationwide.
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Affiliation(s)
- Nishita M S Baldewpersad Tewarie
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands .,Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, The Netherlands
| | - Maaike van Ham
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michel Wouters
- Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, The Netherlands.,Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Roy Kruitwagen
- Department of Obstetrics and Gynecology, and GROW- School for Oncology and Reproduction, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Willemien van Driel
- Department of Gynecology, Amsterdam, Center of Gynecological Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Drouin L, Guani B, Balaya V, Azaïs H, Betrian S, Bolze PA, Dabi Y, Kerbage Y, Sanson C, Zaccarini F, Mathevet P, Lécuru F, Guyon F, Akladios C, Bendifallah S, Deluche E. Results of a 2021 French National Survey on Management of Patients with Advanced Stage Epithelial Ovarian Cancer. J Clin Med 2021; 10:4829. [PMID: 34768353 PMCID: PMC8585030 DOI: 10.3390/jcm10214829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 09/29/2021] [Accepted: 10/02/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of this study was to assess current French practices in the management of patients with advanced epithelial ovarian cancer. METHOD a 58-question electronic survey was distributed anonymously to the members of the SFOG (French Society of Gynaecological Oncology), GINECO-ARCAGY (National Investigators Group for Ovarian and Breast Cancer Studies in France) and FRANCOGYN (French research group in oncological and gynaecological surgery). Initial diagnostic workup and staging, pathological data, surgical data, treatments and follow-up strategies were assessed. RESULTS a total of 107 participants responded to emailed surveys. Most of the respondents were obstetrician-gynaecologists (37.4%), surgical oncologists (34.6%) and medical oncologists (17.8%). According to most (76.8%) participants, less than 50% of patients were eligible for primary debulking surgery (PDS). The LION study criteria were applied in 69.5% of cases during PDS and 39% after chemotherapy. The timing of BRCA testing was very heterogeneous and ranged from 1 to 6 months. The use of bevacizumab as an adjuvant schedule was lower in cases of no residual disease (for 54.5% of respondents) compared to cases of residual disease (for 63.6% of respondents). In cases of BRCA1-2 mutations, olaparib was given by 75.8-84.8% of respondents, whereas niraparib was given in cases of BRCA wild-type diseases. CONCLUSION this survey provides an extensive and a unique review of current French practices in the management of patients with advanced epithelial ovarian cancer in 2021.
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Affiliation(s)
- Leonor Drouin
- Department of Gynecology, CHU de Limoges, 87000 Limoges, France;
| | - Benedetta Guani
- Department of Gynecology and Obstetrics, 1700 Fribourg, Switzerland;
| | - Vincent Balaya
- Department of Gynecology, CHU Vaudois, 1011 Lausanne, Switzerland; (V.B.); (P.M.)
| | - Henri Azaïs
- Gynecologic and Breast Oncologic Surgery Department, Georges-Pompidou European Hospital, 75015 Paris, France;
| | - Sarah Betrian
- Department of Medical Oncology, IUCT Oncopole, 31100 Toulouse, France;
| | - Pierre-Adrien Bolze
- Department of Gynaecologic and Oncologic Surgery and Obstetrics, Centre Hospitalier Universitaire Lyon Sud, Hospices Civils de Lyon, Université Lyon 1, 69100 Villeurbanne, France;
| | - Yohann Dabi
- Department of Gynecology, Sorbonnes University, Tenon Hospital, AP-HP, 75020 Paris, France; (Y.D.); (S.B.)
| | - Yohan Kerbage
- Department of Obstetrics and Gynecology, Lille University Hospital, 59000 Lille, France;
| | - Claire Sanson
- Surgical Oncology Department, Gustave Roussy Institute, 94805 Villejuif, France; (C.S.); (F.Z.)
| | - François Zaccarini
- Surgical Oncology Department, Gustave Roussy Institute, 94805 Villejuif, France; (C.S.); (F.Z.)
| | - Patrice Mathevet
- Department of Gynecology, CHU Vaudois, 1011 Lausanne, Switzerland; (V.B.); (P.M.)
| | - Fabrice Lécuru
- Breast, Gynecology and Reconstructive Surgery Unit, Curie Institute, 75005 Paris, France;
| | - Fréderic Guyon
- Surgical Oncology Department, Bergonié Institute, 33000 Bordeaux, France;
| | - Cherif Akladios
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, 67091 Strasbourg, France;
| | - Sofiane Bendifallah
- Department of Gynecology, Sorbonnes University, Tenon Hospital, AP-HP, 75020 Paris, France; (Y.D.); (S.B.)
| | - Elise Deluche
- Department of Medical Oncology, CHU de Limoges, 87000 Limoges, France
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Said SA, Bretveld RW, Koffijberg H, Sonke GS, Kruitwagen RFPM, de Hullu JA, van Altena AM, Siesling S, van der Aa MA. Clinicopathologic predictors of early relapse in advanced epithelial ovarian cancer: development of prediction models using nationwide data. Cancer Epidemiol 2021; 75:102008. [PMID: 34509380 DOI: 10.1016/j.canep.2021.102008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/03/2021] [Accepted: 08/08/2021] [Indexed: 12/09/2022]
Abstract
OBJECTIVE To identify clinicopathologic factors predictive of early relapse (platinum-free interval (PFI) of ≤6 months) in advanced epithelial ovarian cancer (EOC) in first-line treatment, and to develop and internally validate risk prediction models for early relapse. METHODS All consecutive patients diagnosed with advanced stage EOC between 01-01-2008 and 31-12-2015 were identified from the Netherlands Cancer Registry. Patients who underwent cytoreductive surgery and platinum-based chemotherapy as initial EOC treatment were selected. Two prediction models, i.e. pretreatment and postoperative, were developed. Candidate predictors of early relapse were fitted into multivariable logistic regression models. Model performance was assessed on calibration and discrimination. Internal validation was performed through bootstrapping to correct for model optimism. RESULTS A total of 4,557 advanced EOC patients were identified, including 1,302 early relapsers and 3,171 late or non-relapsers. Early relapsers were more likely to have FIGO stage IV, mucinous or clear cell type EOC, ascites, >1 cm residual disease, and to have undergone NACT-ICS. The final pretreatment model demonstrated subpar model performance (AUC = 0.64 [95 %-CI 0.62-0.66]). The final postoperative model based on age, FIGO stage, pretreatment CA-125 level, histologic subtype, presence of ascites, treatment approach, and residual disease after debulking, demonstrated adequate model performance (AUC = 0.72 [95 %-CI 0.71-0.74]). Bootstrap validation revealed minimal optimism of the final postoperative model. CONCLUSION A (postoperative) discriminative model has been developed and presented online that predicts the risk of early relapse in advanced EOC patients. Although external validation is still required, this prediction model can support patient counselling in daily clinical practice.
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Affiliation(s)
- Sherin A Said
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; Department of Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Reini W Bretveld
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - Hendrik Koffijberg
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Roy F P M Kruitwagen
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, the Netherlands; GROW - School for Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | - Joanne A de Hullu
- Department of Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anne M van Altena
- Department of Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Maaike A van der Aa
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
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den Ouden JE, The R, Myren BJ, Boll D, Driel WJV, Lalisang RI, Kruitwagen RF, van Altena AM. Development of a decision aid for primary treatment of patients with advanced-stage ovarian cancer. Int J Gynecol Cancer 2020; 30:837-844. [PMID: 32276940 DOI: 10.1136/ijgc-2019-001095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/03/2020] [Accepted: 02/18/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Despite renewed treatment options for advanced epithelial ovarian cancer, survival remains poor. The Patient Association and the Gynecological Oncology Working Party in the Netherlands have identified a need for a tool to improve shared decision-making. The aim of this study was to develop an evidence-based online decision aid for patients with advanced epithelial ovarian cancer and their medical team. METHODS First, we identified the patients' and clinicians' needs using surveys and in-depth interviews. Second, we conducted multidisciplinary face-to-face meetings with representatives from all stakeholders (clinicians and patient representatives) to determine the content of the decision aid. Third, we developed the decision aid using standardized criteria and national guidelines. Finally, we tested the usability of the tool with patients and clinicians who participated in the needs assessment. RESULTS Patients and clinicians indicated the need for more sources of reliable information that include all treatment options available in the Netherlands. Although most interviewees were satisfied with the level of information available at the time of their own treatment, the majority (90%) of the patients stated that no choice of treatment was offered. We developed a consultation sheet and an online decision aid based on patient interviews and team discussions. The sheet contains a summary of all treatment options and login codes for the decision aid; it will be offered to patients at their first consultation. The decision aid can be used at home and includes information about epithelial ovarian cancer and all available treatment options and questions about quality of life and treatment preferences, delivering a personalized summary for discussion during the following consultation about the primary treatment choices. DISCUSSION In cooperation with patients and clinicians, we developed a decision aid for advanced-stage epithelial ovarian cancer patients and their medical team to support shared decision-making, based on a confirmed need for more extensive information sources. The decision aid is currently under assessment in a multicenter implementation trial.
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Affiliation(s)
- Judith E den Ouden
- Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
| | - Regina The
- Development and Implementation of Decision Aids, ZorgKeuzeLab, Delft, Netherlands
| | - Britt J Myren
- Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
| | - Dorry Boll
- Obstetrics and Gynecology, Catharina Hospital, Eindhoven, Netherlands
| | - Willemien J van Driel
- Center for Gynecological Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Roy I Lalisang
- Internal Medicine, Division Medical Oncology, Maastricht University Medical Center, Maastricht, Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht, Netherlands
| | - Roy Fpm Kruitwagen
- GROW, School for Oncology and Developmental Biology, Maastricht, Netherlands.,Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Anne M van Altena
- Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
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