Does Time-to-Chemotherapy Impact the Outcomes of Resected Ovarian Cancer? Meta-analysis of Randomized and Observational Data

Visual Peritoneal Evaluation of Residual Disease After Neoadjuvant Chemotherapy in Advanced Ovarian Cancer Patients: The VIPER Study

BACKGROUND

Chemotherapy induces histopathological tumor necrosis and fibrosis which results in macroscopic tissue changes, making surgeons' intraoperative visual evaluation of the disease distribution more difficult to interpret. The aim of the study was to assess the sensitivity, specificity, and accuracy of intraoperative laparoscopic visual evaluation of the diaphragmatic peritoneum and compare it with histopathological examination.

METHODS

Patients receiving diaphragmatic peritonectomy at time of IDS were retrospectively included. The population was grouped based on the surgeon's assessment of the diaphragmatic peritoneum during diagnostic laparoscopy. Group 1 included patients with a "visually pathologic" diaphragmatic peritoneum, and group 2 included patients with a "visually dubious" diaphragmatic peritoneum. Sensitivity, specificity, predictive values, and accuracy were calculated considering the final formalin-fixed pathology as the reference standard.

RESULTS

155 patients were included (92 in group 1 and 63 in group 2). The accuracy rate of visual examination was 67.1%, the negative predictive value was 19%, specificity was 100%, and sensitivity was 64.3%.

CONCLUSION

NACT strongly affects the ability of the surgeon to discern between peritoneal scars and truly pathologic peritoneum. The diaphragmatic laparoscopic visual examination showed a low overall accuracy. We propose an algorithm that can guide the surgeon towards a more tailored approach to diaphragmatic peritonectomy during IDS.

The impact of lag time to cancer diagnosis and treatment on clinical outcomes prior to the COVID-19 pandemic: A scoping review of systematic reviews and meta-analyses

Background

The COVID-19 pandemic has disrupted cancer care, raising concerns regarding the impact of wait time, or 'lag time', on clinical outcomes. We aimed to contextualize pandemic-related lag times by mapping pre-pandemic evidence from systematic reviews and/or meta-analyses on the association between lag time to cancer diagnosis and treatment with mortality- and morbidity-related outcomes.

Methods

We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library of Systematic Reviews for reviews published prior to the pandemic (1 January 2010-31 December 2019). We extracted data on methodological characteristics, lag time interval start and endpoints, qualitative findings from systematic reviews, and pooled risk estimates of mortality- (i.e., overall survival) and morbidity- (i.e., local regional control) related outcomes from meta-analyses. We categorized lag times according to milestones across the cancer care continuum and summarized outcomes by cancer site and lag time interval.

Results

We identified 9032 records through database searches, of which 29 were eligible. We classified 33 unique types of lag time intervals across 10 cancer sites, of which breast, colorectal, head and neck, and ovarian cancers were investigated most. Two systematic reviews investigating lag time to diagnosis reported different findings regarding survival outcomes among paediatric patients with Ewing's sarcomas or central nervous system tumours. Comparable risk estimates of mortality were found for lag time intervals from surgery to adjuvant chemotherapy for breast, colorectal, and ovarian cancers. Risk estimates of pathologic complete response indicated an optimal time window of 7-8 weeks for neoadjuvant chemotherapy completion prior to surgery for rectal cancers. In comparing methods across meta-analyses on the same cancer sites, lag times, and outcomes, we identified critical variations in lag time research design.

Conclusions

Our review highlighted measured associations between lag time and cancer-related outcomes and identified the need for a standardized methodological approach in areas such as lag time definitions and accounting for the waiting-time paradox. Prioritization of lag time research is integral for revised cancer care guidelines under pandemic contingency and assessing the pandemic's long-term effect on patients with cancer.

Funding

The present work was supported by the Canadian Institutes of Health Research (CIHR-COVID-19 Rapid Research Funding opportunity, VR5-172666 grant to Eduardo L. Franco). Parker Tope, Eliya Farah, and Rami Ali each received an MSc. stipend from the Gerald Bronfman Department of Oncology, McGill University.

Impact of surgery and chemotherapy timing on outcomes in older versus younger epithelial ovarian cancer patients: A nationwide Danish cohort study

INTRODUCTION

To explore differences in surgical complexity, chemotherapy administration, and treatment delays between younger and older Danish patients with epithelial ovarian cancer (EOC).

MATERIALS AND METHODS

We included a nationwide cohort diagnosed with EOC from 2013 to 2018. We described surgical complexity and outcomes, the extent of chemotherapy and treatment delays stratified by age (<70 and ≥ 70 years), and surgical modality (primary, interval, or no debulking surgery).

RESULTS

In total, we included 2946 patients. For patients with advanced-stage disease, 52% of the older patients versus 25% of the younger patients did not undergo primary debulking surgery (PDS) or interval debulking surgery (IDS). For patients undergoing PDS or IDS, older patients underwent less extensive surgery and more often had residual disease after surgery >0 cm compared to younger patients. Furthermore, older patients were less often treated with chemotherapy. Older patients had PDS later than younger. We did not find any differences between age groups concerning treatment delays. Two-year cancer-specific survival differed significantly between age groups regardless of curatively intended treatment.

DISCUSSION

This study demonstrates that older patients are treated less actively concerning surgical and oncological treatment than younger patients, leading to worse cancer-specific survival. Older patients do not experience more treatment delays than younger ones.

The impact of interval between primary cytoreductive surgery with bowel resection and initiation of adjuvant chemotherapy on survival of women with advanced ovarian cancer: a multicenter cohort study

Objective

Our aim was to determine if the time interval between bowel resection and initiation of adjuvant chemotherapy impacts survival in advanced ovarian cancers.

Methods

This was a retrospective cohort study using data from two cancer centers, Princess Margaret Cancer Centre in Toronto, Ontario, Canada and Samsung Comprehensive Cancer Center in Seoul, South Korea. Patients with International Federation of Gynecology and Obstetrics (FIGO) stage III or IV ovarian cancer that underwent large bowel resection during primary cytoreductive surgery (PCS) were included.

Results

Ninety-one women were eligible of which the majority (90.1%) were diagnosed with high-grade serous cancer. The median interval from PCS to chemotherapy for all patients was 21 days (7–86 days). Patients were stratified into 3 groups: 1) Interval ≤14 days, 32 (35.2%) patients; 2) Interval between 15–28 days, 27 (29.6%) patients; and 3) Interval between 29–90 days, 32 (35.2%) patients. Surgical procedures and postoperative outcomes were similar between groups. Multivariate analysis indicated that PCS to chemotherapy interval of 2–4 weeks, younger age, and completion of 4 or more adjuvant chemotherapy cycles were independent prognostic factors of favorable overall survival.

Conclusion

Initiation of adjuvant chemotherapy between 2 to 4 weeks after PCS with bowel resection may improve survival outcomes in women with advanced ovarian cancer by maximizing the benefit of PCS plus adjuvant chemotherapy.

Optimal waiting time for adjuvant chemotherapy after bowel resection during surgery in advanced ovarian cancer is unclear. Two to 4 weeks after surgery showed best survival outcomes which is similar in colorectal cancer. Stoma formation and intraperitoneal chemotherapy are associated with delayed waiting time.

Prognostic influence of an early time to chemotherapy following primary cytoreductive surgery for advanced epithelial ovarian cancer

Objective

The current investigation analyzes the prognostic role of the time to chemotherapy (TTC) interval following primary cytoreductive surgery for patients with advanced epithelial ovarian cancer.

Methods

Characteristics and outcome data for 509 consecutive patients with stage IIIB–IVB ovarian, fallopian tube, and peritoneal cancer who had primary cytoreductive surgery between January 2000 and December 2019 are utilized. A univariate Cox regression determined the association of categorical variables with progression-free survival (PFS) and overall survival (OS). Significant variables (p≤0.05) on univariate analysis were applied to Cox proportional hazard regression.

Results

The median TTC was 19 days and overall follow-up was 62.2 months. The PFS and OS were 25.5 months and 78.4 months for the study cohort plus 28.4 months and OS 84.5 months for patients rendered grossly disease-free. An early TTC (7–14 vs. 15–21 vs. 22–28 vs. >28 days) was associated with an improved PFS (41.7 vs. 30.6 vs. 18.9 vs. 17.9 months; p<0.001) and OS (132.7 vs. 104.6 vs. 56.5 vs. 48.0 months; p<0.001). The performance status, histology, disease distribution, dimension of residual disease, and categorical plus continuous TTC were predictors of PFS and OS. The use of maintenance therapy was also a predictor of PFS, and the route of chemotherapy administration was a predictor of OS.

Conclusions

For advanced epithelial ovarian cancer, a TTC of less than 21-days was observed to independently improve the PFS and OS. A 7–14 days TTC trended towards a further extension of the OS.

Chemotherapy was administered as early as possible after extensive primary cytoreductive surgery for patients with stage IIIB-IV epithelial ovarian cancer. Early time to chemotherapy improved survival. Complete recovery from surgery before chemotherapy is not essential.

CA125 normalization within 60 days as an independent prognostic factor for patients with advanced epithelial ovarian cancer

BACKGROUND

CA125 level normalization at different chemotherapy cycles has been reported to be a prognosticator in advanced epithelial ovarian cancer.

OBJECTIVE

In the present study, we investigated whether the time (in days) to CA125 normalization or nadir during treatment could be used as markers to predict survival.

METHODS

Patients with FIGO stage III-IV epithelial ovarian cancer treated with cytoreductive surgery followed by adjuvant chemotherapy between 2008 and 2016 were enrolled in this retrospective study. Clinicopathological characteristics, changes in CA125 level during treatment, and survival outcomes were analyzed. Time-dependent receiver operating characteristic curve analysis was used to determine the optimal cut-off values of the time to normalization and time to nadir of CA125 levels to predict survival. Univariate and multivariate Cox regression analysis were used to examine the impact of each variable on survival.

RESULTS

A total of 106 patients were included in the analysis. The optimal cut-off values for the time to normalization and nadir for predicting survival were 60 and 194 days, respectively. In Kaplan-Meier survival analysis, CA125 level normalization ⩽ 60 days and CA125 ⩽ 35 u/mL after the third cycle, and CA125 level ⩽ 10 u/mL after the sixth cycle of chemotherapy were associated with significantly better 5-year progression-free survival (PFS) and overall survival (OS). In multivariate analysis, only CA125 level normalization > 60 days was significantly associated with poor survival outcomes (PFS, HR 2.62 [95% CI: 1.54, 4.45], p= 0.004; OS, HR 2.40 [95% CI: 1.19, 4.81], p= 0.014).

CONCLUSIONS

Normalization of CA125 level within 60 days after cytoreductive surgery followed by adjuvant chemotherapy in patients with advanced ovarian epithelial cancer could be used as a marker to predict survival.

Impact of the Time Interval Between Primary Debulking Surgery and Start of Adjuvant Chemotherapy in Advanced Epithelial Ovarian Cancer

Aim

To investigate whether the time interval between primary debulking surgery (PDS) and initiating adjuvant chemotherapy affects survival in patients with epithelial ovarian cancer (EOC).

Methods

We retrospectively reviewed FIGO stage IIB to IV EOC patients who received PDS followed by adjuvant chemotherapy in our hospital between January 2008 and December 2016. The optimal cut-off time interval to chemotherapy related to survival was determined using the Contal and O’Quigley method and Cox hazard models. Cox regression analysis was used to identify the independent effect of time interval on survival.

Results

A total of 152 patients were identified and divided into three groups based on the time interval between PDS and initiating adjuvant chemotherapy: early (<23 days), intermediate (23–43 days) and late (>43 days). The intermediate group had a significantly better median progression-free survival (PFS, 35.5 months) compared to the early (20 months) and late (22.6 months) groups. After adjustments for confounding factors, time interval was still an independent variable affecting PFS. The intermediate group was associated with a better PFS compared with the early and late groups (hazard ratio 0.27, 95% CI 0.10–0.83, p=0.002). There was no statistical significance in overall survival (OS) in univariate or multivariate analysis, although there was a trend towards better OS in the intermediate group.

Conclusion

Our results provide evidence that the time interval from PDS to chemotherapy influences PFS in patients with advanced EOC. The optimal time to initiate chemotherapy was between 23 and 43 days, within 3–6 weeks post-operatively. Initiating chemotherapy early (<23 days) did not appear to benefit PFS.

Does Time-to-Chemotherapy after Primary Complete Macroscopic Cytoreductive Surgery Influence Prognosis for Patients with Epithelial Ovarian Cancer? A Study of the FRANCOGYN Group

To determine if the time-to-chemotherapy (TTC) after primary macroscopic complete cytoreductive surgery (CRS) influences recurrence-free survival (RFS) and overall survival (OS) in patients with epithelial ovarian cancer (EOC). We conducted an observational multicenter retrospective cohort analysis of women with EOC treated from September 2006 to November 2016 in nine institutions in France (FRANCOGYN research group) with maintained EOC databases. We included women with EOC (all FIGO stages) who underwent primary complete macroscopic CRS prior to platinum-based adjuvant chemotherapy. Two hundred thirty-three patients were included: 73 (31.3%) in the early-stage group (ESG) (FIGO I-II), and 160 (68.7%) in the advanced-stage group (ASG) (FIGO III-IV). Median TTC was 43 days (36–56). The median OS was 77.2 months (65.9–106.6). OS was lower in the ASG when TTC exceeded 8 weeks (70.5 vs. 59.3 months, p = 0.04). No impact on OS was found when TTC was below or above 6 weeks (78.5 and 66.8 months, respectively, p = 0.25). In the whole population, TTC had no impact on RFS or OS. None of the factors studied were associated with an increase in TTC. Chemotherapy should be initiated as soon as possible after CRS. A TTC greater than 8 weeks is associated with poorer OS in patients with advanced stage EOC.

Evaluation of delay in time to adjuvant chemotherapy after HIPEC and its impact on oncological outcome in advanced epithelial ovarian cancer

Obejectives

Optimal cytoreductive surgery (CRS), followed by adjuvant chemotherapy, is a major predictor of oncological outcome in patients with advanced epithelial ovarian carcinoma (EOC). It is not clear if a delayed start of adjuvant chemotherapy negatively impacts on the oncological outcome.

Methods

Prospective registry study on 75 patients treated with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC). Adjuvant chemotherapy was started within 42 days in 41 patients (55%), later on in 34 patients (45%). Multivariate analyses of preoperative factors were done on survival outcome. Outcomes were recurrence-free survival (RFS) and overall survival (OS).

Results

There was no difference in RFS after early introduction (median 35 months) vs. late introduction of chemotherapy (median 32 months), p = 0.17. Median OS in patients with late introduction of chemotherapy was 46 months and was not yet reached in early introduction group.

Conclusions

In this exploratory study in a small group of women with advanced EOC, starting adjuvant chemotherapy more than 6 weeks after CRS and HIPEC did not deteriorate significantly RFS or OS. Well-designed clinical studies are still needed to evaluate the interplay of HIPEC and the point of time of postoperative adjuvant chemotherapy in this indication.

Impact of time to radiation therapy in adjuvant settings in endometrial carcinoma: A multicentric retrospective study

OBJECTIVE

Time to adjuvant treatment could have an impact on cancer prognosis. It is possible that robotic surgery lengthens the healing time of vaginal cuff after minimally invasive hysterectomy. The objective of this study was to state the impact of time to RT (TTR) on prognosis in endometrial carcinoma (EC) patients and to assess variables associated with TTR.

STUDY DESIGN

We conducted a multicentric retrospective study in two cancer centers. We included EC patients, between January 1996 and January 2016. We searched variables associated with TTR and impact of TTR on end-points: local recurrence-free survival, metastatic-free survival, event-free survival and overall survival.

RESULTS

329 patients were included and 279 were analyzed for TTR impact. Robotic surgery was associated with shorter TTR (8 weeks, 8.9 w for laparotomy, 9.2 w for laparoscopy). Pelvic lymphadenectomy, para-aortic lymphadenectomy, discussion in multidisciplinary meeting and treatment center was independently associated with TTR. No impact of TTR was shown on metastatic-free survival, event-free survival and overall survival but there was a trend of a decreased local recurrence rate in case of prolonged TTR (HR_{continuous variable} = 1.08; CI95 %: 0.97-1.2).

CONCLUSION

Our study did not show any impact of treatment delay on survival end-points although prolonged TTR could moderate the benefit of radiotherapy on local control rate. Surgical route was not associated with TTR, particularly robot-associated laparoscopy did not lengthen treatment delay. TTR seems dependent of health-care organization and could represent a quality criterion of EC care for institutions.

Interval between secondary cytoreductive surgery and adjuvant chemotherapy is not associated with survivals in patients with recurrent ovarian cancer

Background

Secondary cytoreductive surgery (SCS) is possible in selected patients with recurrent epithelial ovarian cancer (EOC). The goal of SCS is complete resection, although chemotherapy is always followed. Delayed intervals between primary debulking surgery and adjuvant chemotherapy was reported to be associated with poorer survivals, however, the role of intervals in recurrent disease is still unknown.

Materials and methods

This retrospective cohort study reviewed data from electronic medical records of women with recurrent EOC treated at Samsung Medical Centre, Seoul, Korea, between January 1, 2002, and December 31, 2015. Patients who underwent SCS with adjuvant chemotherapy for recurrent EOC were eligible. We defined intervals as the period between the day of SCS and the first cycle of adjuvant chemotherapy.

Results

Seventy-nine patients were eligible for this study. Their median age was 48 (range, 18–69) years and median interval between the date of SCS and initiation of adjuvant chemotherapy was 10 (range, 4–115) days. The rate of complete resection was 72.2% (57/79). Division of the patients by interval (Group 1, interval ≤ 10 days; Group 2, interval > 10 days) revealed no difference in clinical parameters. No gross residual disease after SCS (no vs. any gross residual, p = 0.002) and longer platinum-free survival (over 12 vs. 6–12 months, p = 0.023) were independent favorable prognostic factors in Cox model; however, the intervals did not affect survival.

Conclusions

Delayed intervals to adjuvant chemotherapy after secondary cytoreductive surgery is not associated with decreased survivals. It is important to identify recurrent EOC patients who might have no gross residual disease following SCS. Moreover, surgeons should strive for complete resection.

Secondary cytoreductive surgery in recurrent uterine leiomyosarcoma: a multi-institutional study

INTRODUCTION

Uterine leiomyosarcoma (uLMS) represents a rare gynecological malignancy with high incidence of recurrence. Evidence in literature about the management of recurrent uLMS is limited, and the role of secondary cytoreduction has been evaluated in small and heterogeneous populations. The objective of this study is to assess the prognostic role of secondary cytoreductive surgery and its related complications in a large and homogeneous group of patients.

METHODS

All consecutive patients who underwent surgery for recurrent uLMS between 01/2010-01/2018 at four Italian tertiary referral centers, were included. Relevant demographic and clinico-pathologic data were retrieved. Survival curves were estimated by Kaplan-Meier method and compared by log-rank test. Cox-proportional hazard model was used to assess the effect of the most predictive prognostic variables.

RESULTS

38 patients with recurrent uLMS were treated with secondary cytoreductive surgery in the study period. Recurrence presented as isolated disease in 17 (44.7%) cases. Bowel, bladder and upper abdominal surgery was performed in 50.0%, 18.4% and 28.9% of the cases, respectively. No residual tumor was the final surgical result in 35 (92.1%) patients. Median hospital stay was 7 days (range, 1-24). No women had major intra-operative and 4 (33.3%) had major post-operative complications. No patient died within 30-days from the secondary cytoreduction. Median time to the first cycle of adjuvant chemotherapy was 41-days (range, 29-78). Median recurrence-free survival was 16.0months (95%CI,11.6 to 26.1). 5-year overall survival (OS) was 76% (95%CI,53 to 89%). Time to first recurrence >12months significantly affected OS (p=0.04).

DISCUSSION

Secondary cytoreduction in recurrent uLMS often requires complex and extensive surgical procedures. Referral to tertiary centers guarantees low peri-operative morbidity, short length of hospitalization and median time to chemotherapy within the standard of care. Therefore, secondary cytoreduction to no residual disease is an option that may be considered in recurrent uLMS, especially in patients with time to first recurrence >12months.

Systematic Review of Cytoreductive Surgery and Bevacizumab-Containing Chemotherapy in Advanced Ovarian Cancer: Focus on Safety

BACKGROUND

Initial experiences reported increased surgical morbidities in patients receiving cytoreductive surgery for colorectal cancer after bevacizumab-containing chemotherapy; however, more recent literature suggests a favorable toxicity profile in patients with advanced ovarian cancer (AOC). With the aim of providing a more objective point of view on this controversial issue, we present here a systematic literature review.

METHODS

Systematic revision of the available literature was conducted using the PubMed, MEDLINE, and EMBASE electronic databases. All studies reporting safety data regarding cytoreductive surgery performed before or after bevacizumab-containing chemotherapy have been analyzed for the purposes of this study. The study has been prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Forty-eight studies were retrieved from the electronic databases, with 23 (47.9%) being excluded due to an unsatisfactory study design. Among the remaining 25 manuscripts, 16 did not report data regarding surgical morbidities after cytoreductive surgery, therefore only 9 studies were included in the final analysis. Overall, 198 AOC patients received bevacizumab-containing neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in the context of five studies, among whom 21 women experienced grade 3/4 postoperative complications (10.6%), which appears to be in line with data reported in patients receiving IDS after carboplatin-paclitaxel NACT. Results from phase I-II clinical trials, and dataset analysis from GOG-0218, did not observe an increased incidence of complications in AOC patients receiving bevacizumab-containing adjuvant chemotherapy after cytoreductive surgery.

CONCLUSIONS

The incorporation of bevacizumab into first-line chemotherapy was not associated with increased morbidities before and after cytoreductive surgery in women with AOC.