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Coleridge SL, Bryant A, Kehoe S, Morrison J. Neoadjuvant chemotherapy before surgery versus surgery followed by chemotherapy for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2021; 7:CD005343. [PMID: 34328210 PMCID: PMC8406953 DOI: 10.1002/14651858.cd005343.pub6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require a combination of surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases up to 9 October 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. We extracted data of overall (OS) and progression-free survival (PFS), adverse events, surgically-related mortality and morbidity and quality of life outcomes. We used GRADE methods to determine the certainty of evidence. MAIN RESULTS We identified 2227 titles and abstracts through our searches, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1774 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the four studies where data were available and found little or no difference with regard to overall survival (OS) (Hazard Ratio (HR) 0.96, 95% CI 0.86 to 1.08; participants = 1692; studies = 4; high-certainty evidence) or progression-free survival in four trials where we were able to pool data (Hazard Ratio 0.98, 95% CI 0.88 to 1.08; participants = 1692; studies = 4; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were variably and incompletely reported across studies. There are probably clinically meaningful differences in favour of NACT compared to PDS with regard to overall postoperative serious adverse effects (SAE grade 3+): 6% in NACT group, versus 29% in PDS group, (risk ratio (RR) 0.22, 95% CI 0.13 to 0.38; participants = 435; studies = 2; heterogeneity index (I2) = 0%; moderate-certainty evidence). NACT probably results in a large reduction in the need for stoma formation: 5.9% in NACT group, versus 20.4% in PDS group, (RR 0.29, 95% CI 0.12 to 0.74; participants = 632; studies = 2; I2 = 70%; moderate-certainty evidence), and probably reduces the risk of needing bowel resection at the time of surgery: 13.0% in NACT group versus 26.6% in PDS group (RR 0.49, 95% CI 0.30 to 0.79; participants = 1565; studies = 4; I2 = 79%; moderate-certainty evidence). NACT reduces postoperative mortality: 0.6% in NACT group, versus 3.6% in PDS group, (RR 0.16, 95% CI 0.06 to 0.46; participants = 1623; studies = 5; I2 = 0%; high-certainty evidence). QoL on the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) scale produced inconsistent and imprecise results in three studies (MD -0.29, 95% CI -2.77 to 2.20; participants = 524; studies = 3; I2 = 81%; very low-certainty evidence) but the evidence is very uncertain and should be interpreted with caution. AUTHORS' CONCLUSIONS The available high to moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT probably reduces the risk of serious adverse events, especially those around the time of surgery, and reduces the risk of postoperative mortality and the need for stoma formation. These data will inform women and clinicians (involving specialist gynaecological multidisciplinary teams) and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sean Kehoe
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
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Coleridge SL, Bryant A, Kehoe S, Morrison J. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2021; 2:CD005343. [PMID: 33543776 PMCID: PMC8094177 DOI: 10.1002/14651858.cd005343.pub5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases on 11 February 2019: CENTRAL, Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. MAIN RESULTS We found 1952 potential titles, with a most recent search date of February 2019, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1713 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the three studies where data were available and found little or no difference with regard to overall survival (OS) (1521 women; Hazard Ratio (HR) 0.95, 95% CI 0.84 to 1.07; I2 = 0%; moderate-certainty evidence) or progression-free survival in four trials where we were able to pool data (1631 women; HR 0.97, 95% CI 0.87 to 1.07; I2 = 0%; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were poorly and incompletely reported across studies. There may be clinically meaningful differences in favour of NACT compared to PDS with regard to serious adverse effects (SAE grade 3+). These data suggest that NACT may reduce the risk of need for blood transfusion (risk ratio (RR) 0.80; 95% CI 0.64 to 0.99; four studies,1085 women; low-certainty evidence), venous thromboembolism (RR 0.28; 95% CI 0.09 to 0.90; four studies, 1490 women; low-certainty evidence), infection (RR 0.30; 95% CI 0.16 to 0.56; four studies, 1490 women; moderate-certainty evidence), compared to PDS. NACT probably reduces the need for stoma formation (RR 0.43, 95% CI 0.26 to 0.72; two studies, 581 women; moderate-certainty evidence) and bowel resection (RR 0.49, 95% CI 0.26 to 0.92; three studies, 1213 women; moderate-certainty evidence), as well as reducing postoperative mortality (RR 0.18; 95% CI 0.06 to 0.54:five studies, 1571 women; moderate-certainty evidence). QoL on the EORTC QLQ-C30 scale produced inconsistent and imprecise results in two studies (MD -1.34, 95% CI -2.36 to -0.32; participants = 307; very low-certainty evidence) and use of the QLQC-30 and QLQC-Ov28 in another study (MD 7.60, 95% CI 1.89 to 13.31; participants = 217; very low-certainty evidence) meant that little could be inferred. AUTHORS' CONCLUSIONS The available moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT may reduce the risk of serious adverse events, especially those around the time of surgery, and the need for bowel resection and stoma formation. These data will inform women and clinicians and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Obstetrics and Gynaecology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sean Kehoe
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
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Harrison RF, Cantor SB, Sun CC, Villanueva M, Westin SN, Fleming ND, Toumazis I, Sood AK, Lu KH, Meyer LA. Cost-effectiveness of laparoscopic disease assessment in patients with newly diagnosed advanced ovarian cancer. Gynecol Oncol 2021; 161:56-62. [PMID: 33536126 DOI: 10.1016/j.ygyno.2021.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/19/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To determine if laparoscopy is a cost-effective way to assess disease resectability in patients with newly diagnosed advanced ovarian cancer. METHODS A cost-effectiveness analysis from a health care payer perspective was performed comparing two strategies: (1) a standard evaluation strategy, where a conventional approach to treatment planning was used to assign patients to either primary cytoreduction (PCS) or neoadjuvant chemotherapy with interval cytoreduction (NACT), and (2) a laparoscopy strategy, where patients considered candidates for PCS would undergo laparoscopy to triage between PCS or NACT based on the laparoscopy-predicted likelihood of complete gross resection. A microsimulation model was developed that included diagnostic work-up, surgical and adjuvant treatment, perioperative complications, and progression-free survival (PFS). Model parameters were derived from the literature and our published data. Effectiveness was defined in quality-adjusted PFS years. Results were tested with deterministic and probabilistic sensitivity analysis (PSA). The willingness-to-pay (WTP) threshold was set at $50,000 per year of quality-adjusted PFS. RESULTS The laparoscopy strategy led to additional costs (average additional cost $7034) but was also more effective (average 4.1 months of additional quality-adjusted PFS). The incremental cost-effectiveness ratio (ICER) of laparoscopy was $20,376 per additional year of quality-adjusted PFS. The laparoscopy strategy remained cost-effective even as the cost added by laparoscopy increased. The benefit of laparoscopy was influenced by mitigation of serious complications and their associated costs. The laparoscopy strategy was cost-effective across a range of WTP thresholds. CONCLUSIONS Performing laparoscopy is a cost-effective way to improve primary treatment planning for patients with untreated advanced ovarian cancer.
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Affiliation(s)
- Ross F Harrison
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1362, Houston, TX 77030, United States of America
| | - Scott B Cantor
- Department of Health Services Research, Cancer Prevention and Population Sciences Division, The University of Texas MD Anderson Cancer Center, 1400 Pressler St. FCT 9.5000, Houston, TX 77030, United States of America
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1362, Houston, TX 77030, United States of America
| | - Mariana Villanueva
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1362, Houston, TX 77030, United States of America
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1362, Houston, TX 77030, United States of America
| | - Nicole D Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1362, Houston, TX 77030, United States of America
| | - Iakovos Toumazis
- Department of Health Services Research, Cancer Prevention and Population Sciences Division, The University of Texas MD Anderson Cancer Center, 1400 Pressler St. FCT 9.5000, Houston, TX 77030, United States of America
| | - Anil K Sood
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1362, Houston, TX 77030, United States of America
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1362, Houston, TX 77030, United States of America
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1362, Houston, TX 77030, United States of America; Department of Health Services Research, Cancer Prevention and Population Sciences Division, The University of Texas MD Anderson Cancer Center, 1400 Pressler St. FCT 9.5000, Houston, TX 77030, United States of America.
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de Fréminville Q, Licaj I, Frenel JS, Hamel-Senecal L, Thomas G, Brachet PE, Coquan E, Leconte A, Classe JM, Joly F. [Retrospective study: Late surgery post chemotherapy versus after 3-4 cures in treatment of advanced ovarian cancer]. Bull Cancer 2019; 107:157-170. [PMID: 31858981 DOI: 10.1016/j.bulcan.2019.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/30/2019] [Accepted: 10/02/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Treatment in locally advanced ovarian cancer is optimal surgery followed by chemotherapy. Patients with significant tumor spread, OMS>2, age>75 years old are poor candidates for aggressive primary surgery. Interval surgery, after neo-adjuvant chemotherapy, aims to achieve more complete surgery, increase survival, and reduce surgical morbidity. The primary endpoint was progression-free survival. Secondary outcomes were overall survival and postoperative morbidity and mortality. METHOD This is a retrospective study conducted in 2 French referral centers between January 2000 and December 2015. Patients who could not benefit from a complete initial surgery were operated after 3 cures of chemotherapy at the François Baclesse center and after least 5 cures at the center René Gauducheau. RESULTS The population analyzed included 104 patients, 43 (41.0%) patients treated at the René Gauducheau center (group 1) and 61 (59.0%) patients treated at the François Baclesse center (group 2). Progression-free and overall survival were similar between the 2 groups, they were, respectively, 15.9 months and 34 months in group 1 vs. 15.4 months and 37.6 months in group 2 (P=0.72; P=0.65). Mean hospital stay and postoperative morbidity were similar in both groups. CONCLUSION For weak patients, to limit invasive surgery, doing more than 5 courses of chemotherapy may be a reasonable option.
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Affiliation(s)
| | - Idlir Licaj
- Centre François-Baclesse, 2, avenue du Général-Harris, 14000 Caen, France
| | | | - Lea Hamel-Senecal
- Centre François-Baclesse, 2, avenue du Général-Harris, 14000 Caen, France
| | - Guy Thomas
- Centre François-Baclesse, 2, avenue du Général-Harris, 14000 Caen, France
| | | | - Elodie Coquan
- Centre François-Baclesse, 2, avenue du Général-Harris, 14000 Caen, France
| | - Alexandra Leconte
- Centre François-Baclesse, 2, avenue du Général-Harris, 14000 Caen, France
| | - Jean-Marc Classe
- Department Medical Oncology, Centre R-Gauducheau, Nantes, France
| | - Florence Joly
- Centre François-Baclesse, 2, avenue du Général-Harris, 14000 Caen, France
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Coleridge SL, Bryant A, Lyons TJ, Goodall RJ, Kehoe S, Morrison J. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2019; 2019:CD005343. [PMID: 31684686 PMCID: PMC6822157 DOI: 10.1002/14651858.cd005343.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases on 11 February 2019: CENTRAL, Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. MAIN RESULTS We found 1952 potential titles, with a most recent search date of February 2019, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1713 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the three studies where data were available and found little or no difference with regard to overall survival (OS) (1521 women; hazard ratio (HR) 1.06; 95% confidence interval (CI) 0.94 to 1.19, I2 = 0%; moderate-certainty evidence) or progression-free survival in four trials where we were able to pool data (1631 women; HR 1.02; 95% CI 0.92 to 1.13, I2 = 0%; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were poorly and incompletely reported across studies. There may be clinically meaningful differences in favour of NACT compared to PDS with regard to serious adverse effects (SAE grade 3+). These data suggest that NACT may reduce the risk of need for blood transfusion (risk ratio (RR) 0.80; 95% CI 0.64 to 0.99; four studies,1085 women; low-certainty evidence), venous thromboembolism (RR 0.28; 95% CI 0.09 to 0.90; four studies, 1490 women; low-certainty evidence), infection (RR 0.30; 95% CI 0.16 to 0.56; four studies, 1490 women; moderate-certainty evidence), compared to PDS. NACT probably reduces the need for stoma formation (RR 0.43, 95% CI 0.26 to 0.72; two studies, 581 women; moderate-certainty evidence) and bowel resection (RR 0.49, 95% CI 0.26 to 0.92; three studies, 1213 women; moderate-certainty evidence), as well as reducing postoperative mortality (RR 0.18; 95% CI 0.06 to 0.54:five studies, 1571 women; moderate-certainty evidence). QoL on the EORTC QLQ-C30 scale produced inconsistent and imprecise results in two studies (MD -1.34, 95% CI -2.36 to -0.32; participants = 307; very low-certainty evidence) and use of the QLQC-30 and QLQC-Ov28 in another study (MD 7.60, 95% CI 1.89 to 13.31; participants = 217; very low-certainty evidence) meant that little could be inferred. AUTHORS' CONCLUSIONS The available moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT may reduce the risk of serious adverse events, especially those around the time of surgery, and the need for bowel resection and stoma formation. These data will inform women and clinicians and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Taunton and Somerset NHS Foundation TrustObstetrics and GynaecologyMusgrove Park HospitalTauntonUKTA1 5DA
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Thomas J Lyons
- University of BristolSchool of Medical Sciences38 Kings Parade AvenueBristolUKBS8 2RB
| | - Richard J Goodall
- Imperial College LondonDepartment of Surgery and CancerKensingtonLondonUKSW7 2AZ
| | - Sean Kehoe
- University of BirminghamInstitute of Cancer and GenomicsBirminghamUKB15 2TT
| | - Jo Morrison
- Musgrove Park HospitalDepartment of Gynaecological OncologyTaunton and Somerset NHS Foundation TrustTauntonSomersetUKTA1 5DA
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Iura A, Takita M, Kawano A, Imai K, Konnai K, Onose R, Kato H. Negative peritoneal washing cytology during interval debulking surgery predicts overall survival after neoadjuvant chemotherapy for ovarian cancer. J Gynecol Oncol 2018; 29:e70. [PMID: 30022634 PMCID: PMC6078894 DOI: 10.3802/jgo.2018.29.e70] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/30/2018] [Accepted: 04/19/2018] [Indexed: 11/30/2022] Open
Abstract
Objective Optimal debulking in interval debulking surgery (IDS) after neoadjuvant chemotherapy (NAC) has been reported as a prognostic factor for patients with ovarian cancer. However, the identification of microscopic residual disease (MRD) using visualization and palpation is subjective. Peritoneal washing cytology (PWC) during IDS is an easy-to-implement, objective approach for assessing disease status, although its clinical relevance and association with MRD is not known. The aim of this study was to evaluate the efficacy of PWC during IDS. Methods In total, 164 patients diagnosed with ovarian cancer at our institution were retrospectively evaluated, including 64 who had received NAC. Seventeen patients had undergone an exploratory laparotomy followed by NAC, while the remaining patients were diagnosed based on imaging, peritoneal cytology, and tumor markers. The PWC was performed before intraperitoneal observation at laparotomy during IDS. Results NAC-treated patients had stage III–IV disease. IDS was performed in 78.1% of NAC-treated patients. Seventeen patients (26.6%) were PWC-negative and 33 patients (51.6%) were PWC-positive. Fourteen patients (21.9%) had progressive disease and were ineligible for IDS. The median overall survival of the PWC-negative, PWC-positive, and non-IDS groups was 47, 18, and 5 months, respectively. The differences were significant (p<0.01). PWC was an independent prognostic factor in the multivariate Cox regression analysis (p<0.001). Conclusion PWC during IDS may be a prognostic factor for NAC-treated patients with ovarian cancer. PWC may be more useful than visualization and palpation in IDS for determining the presence of MRD.
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Affiliation(s)
- Ayaka Iura
- Department of Gynecologic Oncology, Kanagawa Cancer Center, Kanagawa, Japan.
| | - Morihito Takita
- Clinical Management Office, Kanagawa Cancer Center, Kanagawa, Japan
| | - Aiko Kawano
- Department of Gynecologic Oncology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Kazuaki Imai
- Department of Gynecologic Oncology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Katsuyuki Konnai
- Department of Gynecologic Oncology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Ryo Onose
- Department of Gynecologic Oncology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Hisamori Kato
- Department of Gynecologic Oncology, Kanagawa Cancer Center, Kanagawa, Japan
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Xiao Y, Xie S, Zhang N, Wang J, Lv C, Guo J, Yang Q. Platinum-Based Neoadjuvant Chemotherapy versus Primary Surgery in Ovarian Carcinoma International Federation of Gynecology and Obstetrics Stages IIIc and IV: A Systematic Review and Meta-Analysis. Gynecol Obstet Invest 2017; 83:209-219. [PMID: 29402804 DOI: 10.1159/000485618] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 11/21/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM This study aimed to compare neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS) with primary debulking surgery (PDS) followed by chemotherapy in patients with advanced ovarian carcinoma International Federation of Gynecology and Obstetrics (FIGO) stages IIIc and IV. METHODS PubMed, the Cochrane Library, and manual searches were applied to discriminate potentially eligible studies published before June 30, 2016. RESULTS A total of 12 comparative studies were finally included; 1,372 patients underwent NAC followed by IDS, and 2,680 patients underwent PDS followed by chemotherapy. For overall pooled estimates, significant between-trial differences were found in the optimal debulking rate, grade 3-5 postoperative adverse reactions, and median overall survival (OS), but no difference was found in the median progression-free survival (PFS). Moreover, a significantly higher incidence was identified in major infections, vascular events, and wound complications for patients in the PDS group. CONCLUSIONS This study suggested that NAC followed by IDS could improve the optimal debulking rate and decrease the postoperative adverse reactions for the current studies, but whether it could improve the OS and PFS compared with PDS followed by chemotherapy in patients with ovarian carcinoma FIGO stages IIIc and IV were still needed to be verified by conducting more randomized controlled trials.
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Affiliation(s)
- Yunyun Xiao
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shuang Xie
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ningning Zhang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jiao Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Chao Lv
- Department of Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jiao Guo
- Department of Surgery, The Fourth Hospital of China Medical University, Shenyang, China
| | - Qing Yang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
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Vermeulen CKM, Tadesse W, Timmermans M, Kruitwagen RFPM, Walsh T. Only complete tumour resection after neoadjuvant chemotherapy offers benefit over suboptimal debulking in advanced ovarian cancer. Eur J Obstet Gynecol Reprod Biol 2017; 219:100-105. [PMID: 29078115 DOI: 10.1016/j.ejogrb.2017.10.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/14/2017] [Accepted: 10/17/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The aim of this study was to compare surgical results and survival outcome of advanced ovarian cancer patients who were treated with primary versus interval debulking surgery. STUDY DESIGN In this retrospective study stage III and IV ovarian cancer patients who received debulking surgery from 2006 to 2015 were included. Surgical results were described as complete, optimal or suboptimal debulking and chi-square test was used to assess significant differences. Overall survival was measured using Kaplan-Meier curves, the log-rank test and uni- and multivariable Cox regression analyses. RESULTS Of 146 patients included in the study, 55 patients were treated with primary debulking surgery (PDS) followed by adjuvant chemotherapy and 91 patients received neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS). Complete or optimal debulking (0-10mm of residual disease) was achieved in 76.4% (n=42) of the PDS group and in 79.1% (n=72) of the IDS group. Overall median survival was 38 months for PDS and 31 months for IDS, which was not significantly different (p=0.181). In the IDS group, a significant difference was found in OS between complete and optimal resection (p=0.013). Besides that, no difference in survival outcome was found in the IDS group between patients with optimal or suboptimal debulking (median survival were 20 and 19 months respectively). CONCLUSION Complete debulking surgery is of utmost importance, both in case of PDS and IDS. Achieving optimal interval debulking of 1-10mm residual disease did not show any survival benefit over suboptimal interval debulking.
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Affiliation(s)
- Carolien K M Vermeulen
- Department of Gynaecologic Oncology, Mater Misericordiae University Hospital, Dublin, Ireland; Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands, The Netherlands.
| | - Workineh Tadesse
- Department of Gynaecologic Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Maite Timmermans
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands, The Netherlands; GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands; Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Roy F P M Kruitwagen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands, The Netherlands; GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Tom Walsh
- Department of Gynaecologic Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
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Stewart JM, Tone AA, Jiang H, Bernardini MQ, Ferguson S, Laframboise S, Murphy KJ, Rosen B, May T. The optimal time for surgery in women with serous ovarian cancer. Can J Surg 2017; 59:223-32. [PMID: 27240134 DOI: 10.1503/cjs.014315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Advanced high-grade serous ovarian carcinoma (HGSC) is commonly treated with surgery and chemotherapy. We investigated the survival of patients treated with primary or interval surgery at different times following neoadjuvant chemotherapy. Their survival was compared with that of patients treated with primary cytoreductive surgery and adjuvant chemotherapy. METHODS Patients with stage III or IV HGSC were included in this retrospective cohort study. Clinical data were obtained from patient records. Patients were divided into 2 groups based on treatment with neoadjuvant chemotherapy and interval cytoreductive surgery (NAC) or with primary cytoreductive surgery and adjuvant chemotherapy (PCS). Study groups were stratified by several clinical variables. RESULTS We included 334 patients in our study: 156 in the NAC and 178 in the PCS groups. Survival of patients in the NAC group was independent of when they underwent interval cytoreductive surgery following initiation of neoadjuvant chemotherapy (p < 0.001). Optimal surgical cytoreduction had no impact on overall survival in the NAC group (p < 0.001). Optimal cytoreduction (p < 0.001) and platinum sensitivity (p < 0.001) were independent predictors of improved survival in the PCS but not in the NAC group. Patients in the NAC group had significantly worse overall survival than those in the PCS group (31.6 v. 61.3 mo, p < 0.001). CONCLUSION Women with advanced HGSC who underwent PCS had better survival than those who underwent interval NAC, regardless of the number of cycles of neoadjuvant therapy. Optimal cytoreduction did not provide a survival advantage in the NAC group.
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Affiliation(s)
- Jocelyn M Stewart
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Alicia A Tone
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Haiyan Jiang
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Marcus Q Bernardini
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Sarah Ferguson
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Stephane Laframboise
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - K Joan Murphy
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Barry Rosen
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Taymaa May
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
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Melis MH, Elagwany AMS. WITHDRAWN: Adjuvant chemotherapy followed by interval debulking surgery versus upfront surgery followed by chemotherapy in advanced epithelial ovarian carcinoma. Hematol Oncol Stem Cell Ther 2016:S1658-3876(16)30004-8. [PMID: 27013277 DOI: 10.1016/j.hemonc.2016.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 01/22/2016] [Accepted: 02/17/2016] [Indexed: 11/22/2022] Open
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Mahmoud Hanafy Melis
- Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Ahmad SZ, Rajanbabu A, Vijaykumar DK, Haji AG, Pavithran K. A prospective comparison of perioperative morbidity in advanced epithelial ovarian cancer: Primary versus interval cytoreduction - experience from India. South Asian J Cancer 2016; 4:107-10. [PMID: 26942138 PMCID: PMC4756482 DOI: 10.4103/2278-330x.173171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objectives: The objective was to compare perioperative morbidity and mortality of patients with advanced epithelial ovarian cancer (EOC) treated with either of the two treatment approaches; neoadjuvant chemotherapy (NACT) followed by interval debulking versus upfront surgery. Design: Prospective comparative observational study. Participants: In total, 51 patients were included in the study. All patients with diagnosed advanced EOC (International Federation of Gynecology and Obstetrics IIIC and IV) presenting for the 1st time were included in the study. Interventions: Patients were either operated upfront (n = 19) if deemed operable or were subjected to NACT followed by interval debulking (n = 32). Primary and Secondary Outcomes: Intra- and postoperative morbidity and mortality were the primary outcome measures. Results: Patients with interval cytoreduction were noted to have significantly lesser operative time, blood loss, and extent of surgery. Their discharge time was also significantly earlier. However, they did not differ from the other group vis. a vis. postoperative complications or mortality. Conclusions: Neoadjuvant chemotherapy although has a positive impact on various intraoperative adverse events, fails to show any impact on immediate postoperative negative outcomes.
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Affiliation(s)
- Sheikh Zahoor Ahmad
- Department of Surgical Oncology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Anupama Rajanbabu
- Department of Gynecologic Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - D K Vijaykumar
- Department of Surgical Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Altaf Gauhar Haji
- Department of Surgical Oncology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - K Pavithran
- Department of Medical Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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Meleis MH, El-Agwany AS. Neo-adjuvant Chemotherapy Followed by Interval Debulking Surgery Versus Upfront Surgery Followed by Chemotherapy in Advanced Epithelial Ovarian Carcinoma. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2016. [DOI: 10.1007/s40944-016-0038-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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The Effect of the Interval from the Third Cycle of Neoadjuvant Chemotherapy to Interval Debulking Surgery on the Surgical Results in Advanced Epithelial Ovarian Cancer. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2016. [DOI: 10.1007/s40944-016-0037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Poonawalla IB, Lairson DR, Chan W, Piller LB, Du XL. Cost-Effectiveness of Neoadjuvant Chemotherapy versus Primary Surgery in Elderly Patients with Advanced Ovarian Cancer. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:387-395. [PMID: 26091592 DOI: 10.1016/j.jval.2015.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 01/13/2015] [Accepted: 01/26/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND The use of neoadjuvant chemotherapy (NAC) in the treatment of advanced ovarian cancer has increased in recent years. There is uncertainty about NAC's effectiveness and no study of its cost-effectiveness compared with that of standard primary debulking surgery (PDS). OBJECTIVES To seek answers to three important questions: 1) What is the lifetime cost of treating elderly patients with advanced ovarian cancer, based on the primary treatment received? 2) Are the extra costs expended by the NAC group worth any extra survival advantage? 3) Would NAC potentially benefit a particular subgroup and serve as a cost-effective first-line treatment approach? METHODS A cohort of elderly women (≥65 years) with stage III/IV ovarian cancer was identified from the Surveillance, Epidemiology and End Results-Medicare linked database from January 1, 2000, to December 31, 2009. Cost analysis was conducted from a payer perspective, and direct medical costs incurred by Medicare were integrated for each patient. Cumulative treatment costs were estimated with a phase-of-care approach, and effectiveness was measured as years of survival. Incremental cost-effectiveness ratio (ICER) and propensity-score-adjusted net monetary benefit regression was used to estimate the cost-effectiveness of NAC per life-year gained. Analyses were further stratified by risk group categorization on the basis of tumor stage, patient age, and comorbidity score. RESULTS Average lifetime cost for treatment with NAC was $17,417 more than with PDS. With only 0.1 incremental life-year gained, the ICER estimate was $174,173. Stratification, however, helped to delineate the treatment effect. Patients in the high-risk subgroup incurred $34,390 and 0.8 life-years more than did patients in the PDS subgroup, with a corresponding ICER of $42,987. In the non-high-risk subgroup, NAC use was dominated by PDS (more costly, less effective). CONCLUSIONS Administering NAC before surgery to patients in the high-risk subgroup was cost-effective at "normal" levels of willingness to pay, but not for the overall sample or for patients in the non-high-risk subgroup.
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Affiliation(s)
- Insiya B Poonawalla
- Department of Epidemiology, Human Genetics, and Environmental Science, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - David R Lairson
- Department of Management Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Wenyaw Chan
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Linda B Piller
- Department of Epidemiology, Human Genetics, and Environmental Science, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Xianglin L Du
- Department of Epidemiology, Human Genetics, and Environmental Science, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
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Onda T, Yoshikawa H. Neoadjuvant chemotherapy for advanced ovarian cancer: overview of outcomes and unanswered questions. Expert Rev Anticancer Ther 2014; 11:1053-67. [DOI: 10.1586/era.11.24] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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PET/CT in the staging of patients with a pelvic mass suspicious for ovarian cancer. Gynecol Oncol 2013; 131:694-700. [DOI: 10.1016/j.ygyno.2013.08.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 08/16/2013] [Accepted: 08/17/2013] [Indexed: 11/19/2022]
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17
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Tangjitgamol S, Hanprasertpong J, Cubelli M, Zamagni C. Neoadjuvant chemotherapy and cytoreductive surgery in epithelial ovarian cancer. World J Obstet Gynecol 2013; 2:153-166. [DOI: 10.5317/wjog.v2.i4.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 02/06/2013] [Indexed: 02/05/2023] Open
Abstract
Ovarian cancer is one of the leading causes of death among gynecological cancers. This is because the majority of patients present with advanced stage disease. Primary debulking surgery (PDS) followed by adjuvant chemotherapy is still a mainstay of treatment. An optimal surgery, which is currently defined by leaving no gross residual tumor, is the goal of PDS. The extent of disease as well as the operative setting, including the surgeon’s skill, influences the likelihood of successful debulking. With extensive disease and a poor chance of optimal surgery or high morbidity anticipated, neoadjuvant chemotherapy (NACT) prior to primary surgery is an option. Secondary surgery after induction chemotherapy is termed interval debulking surgery (IDS). Delayed PDS or IDS is offered to patients who show some clinical response and are without progressive disease. NACT or IDS has become more established in clinical practice and there are numerous publications regarding its advantages and disadvantages. However, data on survival are limited and inconsistent. Only one large randomized trial could demonstrate that NACT was not inferior to PDS while the few randomized trials on IDS had inconsistent results. Without a definite benefit of NACT prior to surgery over PDS, one must carefully weigh the chances of safe and successful PDS against the morbidity and risks of suboptimal surgery. Appropriate selection of a patient to undergo PDS followed by chemotherapy or, preferably, to have NACT prior to surgery is very important. Some clinical characteristics from physical examination, serum tumor markers and/or findings from imaging studies may be predictive of resectability. However, no specific features have been consistently identified in the literature. This article will address the clinical data on prediction of surgical outcomes, the role of NACT, and the role of IDS.
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Dai-yuan M, Bang-xian T, Xian-fu L, Ye-qin Z, Hong-Wei C. A meta-analysis: neoadjuvant chemotherapy versus primary surgery in ovarian carcinoma FIGO stageIII and IV. World J Surg Oncol 2013; 11:267. [PMID: 24112995 PMCID: PMC3852916 DOI: 10.1186/1477-7819-11-267] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 09/30/2013] [Indexed: 11/28/2022] Open
Abstract
Background The purpose of the current study is to analyze the existing data comparing neoadjuvant chemotherapy with primary debulking surgery (PDS) in patients with advanced ovarian carcinoma. Methods Patients with stage IIIC and IV ovarian cancer were identified from articles in Medline, PubMed, Cochrane Library, and EMBASE database (1989 to February 2013). Two authors independently extracted the data. To assess the risk of bias of included literatures, Cochrane Collaboration’s risk of bias tool was used. Meta-analysis on literatures was conducted by using RevMan 5.2 software. Results Two high-quality randomized controlled trials (RCTs) met the inclusion criteria. These multicenter trials randomized 1,220 women with stage IIIc/IV ovarian cancer to NACT or PDS followed by chemotherapy. There were no significant differences between the study groups with regard to overall survival (OS) (1,120 women; HR 0.98; 95% CI 0.85 to 1.14) or progression-free survival (PFS) (1,120 women; HR 1.03; 95% CI 0.91 to 1.16). Conclusion There was no statistical difference in median OS and PFS between the two treatment groups. With regard to selecting who will benefit from NACT, treatment should be tailored to the patient and should take into account respectability, age, histology, stage, and performance status.
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Affiliation(s)
- Ma Dai-yuan
- Department of Oncology, the First Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, People's Republic of China.
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Morrison J, Haldar K, Kehoe S, Lawrie TA. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2012; 2012:CD005343. [PMID: 22895947 PMCID: PMC4050358 DOI: 10.1002/14651858.cd005343.pub3] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment is to perform surgery first and then give chemotherapy. However, it is not yet clear whether there are any advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before cytoreductive surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows maximal cytoreductive surgery. SEARCH METHODS For the original review we searched, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2006), MEDLINE (Silver Platter, from 1966 to 1 Sept 2006), EMBASE via Ovid (from 1980 to 1 Sept 2006), CANCERLIT (from 1966 to 1 Sept 2006), PDQ (search for open and closed trials) and MetaRegister (most current search Sept 2006). For this update randomised controlled trials (RCTs) were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2011) and the Cochrane Gynaecological Cancer Specialised Register (2011), MEDLINE (August week 1, 2011), EMBASE (to week 31, 2011), PDQ (search for open and closed trials) and MetaRegister (August 2011). SELECTION CRITERIA RCTs of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Data were extracted by two review authors independently, and the quality of included trials was assessed by two review authors independently. MAIN RESULTS One high-quality RCT met the inclusion criteria. This multicentre trial randomised 718 women with stage IIIc/IV ovarian cancer to NACT followed by interval debulking surgery (IDS) or primary debulking surgery (PDS) followed by chemotherapy. There were no significant differences between the study groups with regard to overall survival (OS) (670 women; HR 0.98; 95% CI 0.82 to 1.18) or progression-free survival (PFS) (670 women; HR 1.01; 95% CI 0.86 to 1.17).Significant differences occurred between the NACT and PDS groups with regard to some surgically related serious adverse effects (SAE grade 3/4) including haemorrhage (12 in NACT group vs 23 in PDS group; RR 0.50; 95% CI 0.25 to 0.99), venous thromboembolism (none in NACT group vs eight in PDS group; RR 0.06; 95% CI 0 to 0.98) and infection (five in NACT group vs 25 in PDS group; RR 0.19; 95% CI 0.07 to 0.50). Quality of life (QoL) was reported to be similar for the NACT and PDS groups.Three ongoing RCTs were also identified. AUTHORS' CONCLUSIONS We consider the use of NACT in women with stage IIIc/IV ovarian cancer to be a reasonable alternative to PDS, particularly in bulky disease. With regard to selecting who will benefit from NACT, treatment should be tailored to the patient and should take into account resectability, age, histology, stage and performance status. These results cannot be generalised to women with stage IIIa and IIIb ovarian cancer; in these women, PDS is the standard. We await the results of three ongoing trials, which may change these conclusions.
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Affiliation(s)
- Jo Morrison
- Department of Obstetrics and Gynaecology, Musgrove Park Hospital, Taunton, UK.
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Chang SJ, Bristow RE. Evolution of surgical treatment paradigms for advanced-stage ovarian cancer: redefining 'optimal' residual disease. Gynecol Oncol 2012; 125:483-92. [PMID: 22366151 DOI: 10.1016/j.ygyno.2012.02.024] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 02/10/2012] [Accepted: 02/16/2012] [Indexed: 12/14/2022]
Abstract
Over the past 40 years, the survival of patients with advanced ovarian cancer has greatly improved due to the introduction of combination chemotherapy with platinum and paclitaxel as standard front-line treatment and the progressive incorporation of increasing degrees of maximal cytoreductive surgery. The designation of "optimal" surgical cytoreduction has evolved from residual disease ≤ 1 cm to no gross residual disease. There is a growing body of evidence that patients with no gross residual disease have better survival than those with optimal but visible residual disease. In order to achieve this, more radical cytoreductive procedures such as radical pelvic resection and extensive upper abdominal procedures are increasingly performed. However, some investigators still suggest that tumor biology is a major determinant in survival and that optimal surgery cannot fully compensate for tumor biology. The aim of this review is to outline the theoretical rationale and historical evolution of primary cytoreductive surgery, to re-evaluate the preferred surgical objective and procedures commonly required to achieve optimal cytoreduction in the platinum/taxane era based on contemporary evidence, and to redefine the concept of "optimal" residual disease within the context of future surgical developments and analysis of treatment outcomes.
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Affiliation(s)
- Suk-Joon Chang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
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Rauh-Hain JA, Rodriguez N, Growdon WB, Goodman AK, Boruta DM, Horowitz NS, del Carmen MG, Schorge JO. Primary debulking surgery versus neoadjuvant chemotherapy in stage IV ovarian cancer. Ann Surg Oncol 2011; 19:959-65. [PMID: 21994038 DOI: 10.1245/s10434-011-2100-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Indexed: 12/14/2022]
Abstract
PURPOSE Primary debulking surgery (PDS) has historically been the standard treatment for advanced ovarian cancer. Recent data appear to support a paradigm shift toward neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS). We hypothesized that stage IV ovarian cancer patients would likely benefit from NACT-IDS by achieving similar outcomes with less morbidity. METHODS Patients with stage IV epithelial ovarian cancer who underwent primary treatment between January 1, 1995 and December 31, 2007, were identified. Data were retrospectively extracted. Each patient record was evaluated to subclassify stage IV disease according to the sites of tumor dissemination at the time of diagnosis. The Kaplan-Meier method was used to compare overall survival (OS) data. RESULTS A total of 242 newly diagnosed stage IV epithelial ovarian cancer patients were included in the final analysis; 176 women (73%) underwent PDS, 45 (18%) NACT-IDS, and 21 (9%) chemotherapy only. The frequency of achieving complete resection to no residual disease was significantly higher in patients with NACT-IDS versus PDS (27% vs. 7.5%; P < 0.001). When compared to women treated with NACT-IDS, women with PDS had longer admissions (12 vs. 8 days; P = 0.01), more frequent intensive care unit admissions (12% vs. 0%; P = 0.01), and a trend toward a higher rate of postoperative complications (27% vs. 15%; P = 0.08). The patients who received only chemotherapy had a median OS of 23 months, compared to 33 months in the NACT-IDS group and 29 months in the PDS group (P = 0.1). CONCLUSIONS NACT-IDS for stage IV ovarian cancer resulted in higher rates of complete resection to no residual disease, less morbidity, and equivalent OS compared to PDS.
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Affiliation(s)
- J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Ramirez I, Chon HS, Apte SM. The Role of Surgery in the Management of Epithelial Ovarian Cancer. Cancer Control 2011; 18:22-30. [DOI: 10.1177/107327481101800104] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Epithelial ovarian cancer is the most deadly gynecologic cancer in the United States. Multiple modalities of therapy are utilized in the management of the disease. The role of surgery remains important in the treatment of this disease and is described herein. Methods Medline and PubMed were utilized to search the English language medical literature up to March 2010. A broad range of studies and quality of data were analyzed, including prospective studies, case control analyses, and meta-analyses. When possible, the highest level of evidence was reviewed and presented. Results For the medically fit patient, optimal cytoreductive surgery positively impacts survival. For some highly selected patients, there is a role for a minimally invasive approach. In the recurrent setting, factors such as interval to recurrence and the distribution of disease will determine the utility of secondary cytoreductive surgery. A subgroup of patients may benefit from palliative surgical procedures in the recurrent setting. Conclusions Despite advances in the use of chemotherapy and biologic agents, surgery remains an important modality in the diagnosis and treatment of ovarian cancer.
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Affiliation(s)
- Ingrid Ramirez
- Department of Obstetrics and Gynecology at the University of South Florida, Tampa, Florida
| | - Hye Sook Chon
- Department of Women's Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Sachin M. Apte
- Department of Women's Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Shyamala G. Conservative Approach in Gynecologic Malignancies. J Gynecol Surg 2010. [DOI: 10.1089/gyn.2009.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Guruvare Shyamala
- Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal, India
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Weinberg LE, Rodriguez G, Hurteau JA. The role of neoadjuvant chemotherapy in treating advanced epithelial ovarian cancer. J Surg Oncol 2010; 101:334-43. [PMID: 20187069 DOI: 10.1002/jso.21482] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The current management of advanced ovarian cancer consists of aggressive primary cytoreductive surgery (PCS) followed by combination platinum based chemotherapy. Recent studies have suggested that platinum-based chemotherapy may be of benefit in patients with advanced ovarian cancer prior to cytoreductive surgery (neoadjuvant chemotherapy, NACT). The concept of NACT has not been completely validated in the treatment of ovarian cancer. This review will discuss the role of NACT in patients with advanced epithelial ovarian cancer.
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Affiliation(s)
- Lori E Weinberg
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Martinek IE, Kehoe S. When should surgical cytoreduction in advanced ovarian cancer take place? JOURNAL OF ONCOLOGY 2009; 2010:852028. [PMID: 19859583 PMCID: PMC2766504 DOI: 10.1155/2010/852028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 09/13/2009] [Indexed: 11/17/2022]
Abstract
Initial surgical management is commonly accepted to date as paramount in the treatment of women presenting with epithelial ovarian cancer and permits the assessment of the disease (staging), the histological confirmation of disease type and grade, and the practice of maximal debulking preceding platinum-based chemotherapy. Many studies have shown that the volume of residual disease after initial surgical cytoreduction inversely correlates with survival. Thus, women with optimal debulking performed by a trained specialist have improved median survival. In this review, we will focus on the answers gleaned from clinical trials on primary and interval surgery, which prompts the question on the timing of surgery in respect to chemotherapy. Interval debulking surgery (IDS) is secondary cytoreduction following primary debulking and is carried out in between the courses of chemotherapy. The major clinical trials and the latest systematic reviews seem unable to give any definitive guidance or recommendation for clinical practice. The choice of aggressive primary cytoreduction or upfront chemotherapy followed by second line surgical cytoreduction seems among others to have to be individualized according to tumour load, prediction of its resectability, and response to chemotherapy. The role of tumour biology must also be kept in mind. Finally, concrete answers are awaited on the timing of surgery from the ongoing prospective randomized control trials (CHORUS and EORTC 55971) though preliminary data from the latter have already been presented at major meetings (IGCS 2008; SGO 2009) and ignited strong debate.
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Affiliation(s)
- Igor E. Martinek
- Oxford Gynaecological Cancer Centre Surgery and Diagnostics, Level 0, Churchill Hospital, Oxford OX3 7JL, UK
| | - Sean Kehoe
- Oxford Gynaecological Cancer Centre Surgery and Diagnostics, Level 0, Churchill Hospital, Oxford OX3 7JL, UK
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Onda T, Yoshikawa H. A phase III randomized trial comparing neoadjuvant chemotherapy and upfront debulking surgery is indispensable as a basis for changing the standard treatment of advanced Müllerian cancer. Gynecol Oncol 2009. [DOI: 10.1016/j.ygyno.2009.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kang S, Nam BH. Does neoadjuvant chemotherapy increase optimal cytoreduction rate in advanced ovarian cancer? Meta-analysis of 21 studies. Ann Surg Oncol 2009; 16:2315-20. [PMID: 19517192 DOI: 10.1245/s10434-009-0558-6] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Revised: 05/13/2009] [Accepted: 05/13/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND The purpose of the current study is to analyze the existing data regarding neoadjuvant chemotherapy (NAC) in advanced epithelial ovarian cancer (EOC) using a random-effects model and to determine whether NAC can improve the rate of optimal cytoreduction. METHODS Between 1989 and 2008, data of 21 studies were retrieved via a MEDLINE search. Meta-regression analysis based on a random-effects model was performed to assess the prognostic value of clinical variables. RESULTS The patients who received NAC had a lower risk of suboptimal cytoreduction than the patients with favorable conditions (pooled odds ratio, 0.50; 95% confidence interval, 0.29-0.86; P = 0.012 with DerSimonian-Laird model). Meta-regression analysis revealed that heterogeneity in year of publication, taxane use, and optimal cytoreduction rate influenced median overall survival significantly (P = 0.002, P = 0.007, and P = 0.012, respectively). However, the between-studies variation of the number of NAC cycles did not influence survival (P = 0.701). CONCLUSION The current meta-analysis showed that NAC helped the gynecologic oncologist achieve an increased rate of optimal cytoreduction.
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Affiliation(s)
- Sokbom Kang
- Branch of Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea.
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Le T, Faught W, Hopkins L, Fung-Kee-Fung M. Importance of CA125 normalization during neoadjuvant chemotherapy followed by planned delayed surgical debulking in patients with epithelial ovarian cancer. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2008; 30:665-670. [PMID: 18786288 DOI: 10.1016/s1701-2163(16)32914-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the prognostic significance, in patients with ovarian cancer, of normalization of CA125 levels in serum during neoadjuvant chemotherapy treatment combined with delayed primary surgical debulking. METHODS We carried out a retrospective chart review to identify ovarian cancer patients treated between 1997 and 2005 with neoadjuvant chemotherapy and delayed surgical debulking. Serum levels of CA125 were measured at baseline, prior to each cycle of chemotherapy, and before surgery. "CA125 normalization" was defined as a reduction in serum CA125 levels, in patients with elevated levels at diagnosis, to less than 35 kU/L. Cox proportional hazard models were built to model progression-free survival and overall survival. RESULTS Ninety patients met the inclusion criteria. Sixteen patients (17.8%) had CA125 normalization before surgery, and 52 patients (57.8%) had normalization at the conclusion of all primary chemotherapy. Cox regression showed that CA125 normalization from neoadjuvant chemotherapy before surgery did not significantly predict survival. Patients who failed to normalize CA125 after finishing primary chemotherapy had shortened progression-free survival (HR 3.1; 95% CI 1.9-5.1, P < 0.001) and overall survival (HR 2.6; 95% CI 1.0-6.9, P < 0.05). The estimated median survival was 72 months (95% CI 64.6-79.40) in patients with normal CA125 at the end of chemotherapy, whereas in those with persistently elevated CA125 the corresponding estimated median survival was 46.8 months (95% CI 38.2-55.3). CONCLUSION CA125 normalization after neoadjuvant chemotherapy is not an independent predictor of either progression-free or overall survival. Patients with persistently elevated CA125 after completing primary treatment had significantly inferior survivals compared with those who normalized CA125.
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Affiliation(s)
- Tien Le
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Ottawa, Ottawa ON
| | - Wylam Faught
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Ottawa, Ottawa ON
| | - Laura Hopkins
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Ottawa, Ottawa ON
| | - Michael Fung-Kee-Fung
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Ottawa, Ottawa ON
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Vergote I, van Gorp T, Amant F, Leunen K, Neven P, Berteloot P. Timing of debulking surgery in advanced ovarian cancer. Int J Gynecol Cancer 2008; 18 Suppl 1:11-9. [PMID: 18336393 DOI: 10.1111/j.1525-1438.2007.01098.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
It is clear that primary debulking remains the standard of care within the treatment of advanced ovarian cancer (FIGO stage III and IV). This debulking surgery should be performed by a gynecological oncologist without any residual tumor load, or so-called "optimal debulking." Over the last decades, interest in the use of neoadjuvant chemotherapy together with an interval debulking has increased. Neoadjuvant therapy can be used for patients who are primarily suboptimally debulked due to an extensive tumor load. In this situation, based on the randomized European Organization for Research and Treatment of Cancer-Gynaecological Cancer Group trial, interval debulking by an experienced surgeon improves survival in some patients who did not undergo optimal primary debulking surgery. Based on the GOG 152 data, interval debulking surgery does not seem to be indicated in patients who underwent primarily a maximal surgical effort by a gynecological oncologist. Neoadjuvant chemotherapy can also be used as an alternative to primary debulking. In retrospective analyses, neoadjuvant chemotherapy followed by interval debulking surgery does not seem to worsen prognosis compared to primary debulking surgery followed by chemotherapy. However, we will have to wait for the results of future randomized trials to know whether neoadjuvant chemotherapy followed by interval debulking surgery is a good alternative to primary debulking surgery in stage IIIc and IV patients. Open laparoscopy is probably the most valuable tool for evaluating the operability primarily or at the time of interval debulking surgery.
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Affiliation(s)
- I Vergote
- Department of Obstetrics and Gynaecology, Division of Gynaecological Oncology, University Hospitals, Katholieke Universiteit Leuven, Leuven, Belgium.
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Le T, Williams K, Senterman M, Hopkins L, Faught W, Fung-Kee-Fung M. Omental chemotherapy effects as a prognostic factor in ovarian cancer patients treated with neoadjuvant chemotherapy and delayed primary surgical debulking. Ann Surg Oncol 2007; 14:2649-53. [PMID: 17562112 DOI: 10.1245/s10434-007-9460-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2007] [Accepted: 04/08/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND We sought to assess the prognostic significance of chemotherapy effect on upper abdominal metastatic disease. METHODS Retrospective chart reviews were carried out from 1997 to 2005 to identify ovarian cancer patients treated with neoadjuvant chemotherapy. Pathologic examinations of resected omental and ovarian tumors for the presence of chemotherapy effect were performed. Cox proportional hazard models were built to model time to progression and death by using predictor variables of age, tumor grade, amount and location of largest residual disease, and the presence of chemotherapy effects on resected tumors. RESULTS Sixty-six patients with available slides and clinical information were identified. The presence of omental chemotherapy effects was observed in 58 patients (88%). Identified independent statistically significant predictors for progression-free survival included presence of omental chemotherapy effect (hazard ratio [HR], .38; 95% confidence interval [95% CI], .17-.89; P = .026) and suboptimal tumor residuals in upper abdominal location compared with pelvic location (HR, 2.41; 95% CI, 1.06-5.48; P = .035). The presence of omental chemotherapy effect was the only statistically significant predictor of disease specific survival (HR, .21; 95% CI, .068-.639; P = .006). The estimated median survival for the group with positive omental chemotherapy effect was 84.45 months (95% CI, 69.63-99.28). The corresponding statistic in patients with no observed response to chemotherapy was 31.15 months (95% CI, 21.84-40.47). CONCLUSIONS Upper abdominal disease location and its response to chemotherapy were independent prognostic factors for progression-free survival. Aggressive upper abdominal debulking procedures are recommended to improve oncologic outcomes.
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Affiliation(s)
- Tien Le
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Ottawa General Hospital, University of Ottawa, K1H 8L6, Ottawa, Ontario, Canada.
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Histopathologic assessment of chemotherapy effects in epithelial ovarian cancer patients treated with neoadjuvant chemotherapy and delayed primary surgical debulking. Gynecol Oncol 2007; 106:160-3. [PMID: 17490737 DOI: 10.1016/j.ygyno.2007.03.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2006] [Revised: 03/15/2007] [Accepted: 03/20/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess the prognostic significance of pathologic tumour response to neoadjuvant chemotherapy. METHODS Retrospective chart reviews were carried out from 1997 to 2005 to identify ovarian cancer cases treated with neoadjuvant chemotherapy. Pathologic assessments of the extent of: tumour necrosis, fibrosis, macrophage infiltration, and tumour induced inflammation were graded on an ordinal scale of 0 to 2 (none/minimal, moderate, extensive). All pathology slides were reviewed and graded by one gynecologic pathologist. A composite pathologic tumour response score was calculated by summing all above pathologic assessments for each sample. Cox proportional hazard models were built to model time to clinical progression and death using predictor variables of: age, tumour grade, residual disease, and pathologic tumour response score. All p values less than 0.05 were considered to be statistically significant. RESULTS Sixty-two cases with available slides for reviews were identified retrospectively. Optimal debulking was achieved in 46 cases (74%). Significant predictors for prolonged progression free survival included: younger age (p=0.05), optimal tumour residual status (p=0.016), and higher composite pathologic tumour response score (HR 0.848, 95% CI 0.742-0.970, p=0.0016). Cox regression modeling revealed only one significant predictive variable of time to disease related death being the composite pathologic tumour response score (HR 0.695, 95% CI=0.515-0.938, p=0.017). CONCLUSION Pathologic assessments of tumour response to chemotherapy are helpful in determining prognosis and could be used to guide subsequent therapeutic decisions. The proposed composite pathologic tumour response score warrants further studies and validation.
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Le T, Hopkins L, Faught W, Fung-Kee-Fung M. The lack of significance of Ca125 response in epithelial ovarian cancer patients treated with neoadjuvant chemotherapy and delayed primary surgical debulking. Gynecol Oncol 2007; 105:712-5. [PMID: 17400284 DOI: 10.1016/j.ygyno.2007.02.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2006] [Revised: 02/07/2007] [Accepted: 02/08/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To examine the prognostic significance of Ca125 response to neoadjuvant chemotherapy and delayed primary surgical debulking in epithelial ovarian cancer patients. METHODS Retrospective chart reviews were carried out from 1997 to 2005 to identify ovarian cancer patients treated with neoadjuvant chemotherapy. Ca125 response was defined as being a decrease of at least 50% from baseline assessment. Ca125 response was assessed in two phases: prior to surgical debulking to reflect the response to neoadjuvant chemotherapy and at the end of primary chemotherapy to assess the response to debulking surgery and further chemotherapy. Cox proportional hazard models were built to model progression-free intervals using predictor variables of: age, cancer stage, tumour grade, residual disease, and Ca125 response. RESULTS Ninety-one patients were included. About 83% had a positive Ca125 response following three cycles of neoadjuvant chemotherapy preoperatively. Cox regressions revealed two significant predictive variables of prolonged time to first progression: younger age (p=0.002) and microscopic residual disease compared to suboptimal residual disease (p=0.003). Ca125 response to neoadjuvant chemotherapy was not significantly predictive of progression-free survivals. The estimated median survival was 71.42 months (95% CI: 44.34-78.50) in patients with >50% Ca125 decrease from surgery and further chemotherapy whereas in those with no response, the corresponding survival estimate was 44.02 months (95% CI: 33.26-54.79). CONCLUSION The lack of Ca125 response from neoadjuvant chemotherapy is not an independent prognostic factor. All patients treated with neoadjuvant chemotherapy should undergo radical debulking surgery.
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Affiliation(s)
- T Le
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Ottawa, Ottawa General Hospital, Ottawa, Ontario, Canada K1H 8L6.
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Bristow RE, Eisenhauer EL, Santillan A, Chi DS. Delaying the primary surgical effort for advanced ovarian cancer: a systematic review of neoadjuvant chemotherapy and interval cytoreduction. Gynecol Oncol 2006; 104:480-90. [PMID: 17166564 DOI: 10.1016/j.ygyno.2006.11.002] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Revised: 10/29/2006] [Accepted: 11/06/2006] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To summarize the existing data on interval cytoreductive surgery and neoadjuvant chemotherapy as alternative treatment strategies for patients with advanced-stage ovarian cancer. METHODS All investigational studies with evaluable survival data on interval cytoreductive surgery and neoadjuvant chemotherapy for ovarian cancer reported in the English language literature between 1989 and 2006 were systematically reviewed. RESULTS Three randomized trials and six non-randomized studies of interval cytoreduction following suboptimal initial surgery were identified. Twenty-six studies, including a total of 1336 patients, reporting on neoadjuvant chemotherapy administered in lieu of primary cytoreductive surgery were analyzed according to the survival outcome achieved, the degree of surgical effort or success, and the particular selection criteria employed to justify deferring an attempt at primary cytoreductive surgery. CONCLUSIONS Interval surgery following a concerted but suboptimal attempt at up-front cytoreduction does not appear to have an appreciable impact on survival outcome. Maximal primary cytoreductive surgery remains the standard of care for the majority of women with suspected advanced ovarian cancer. Neoadjuvant chemotherapy represents a viable alternative management strategy for the limited number of patients felt to be optimally unresectable by an experienced ovarian cancer surgical team; however, currently available data suggest that the survival outcome achievable with initial chemotherapy is inferior to successful up-front cytoreductive surgery. Additional research is needed to devise universal selection criteria for neoadjuvant chemotherapy, determine the most efficacious treatment program, and characterize the appropriate proportion of patients in which an attempt at primary surgery should be abandoned in favor of initial chemotherapy.
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Affiliation(s)
- Robert E Bristow
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Phipps #281, Baltimore, MD 21287, USA.
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Bristow RE, Chi DS. Platinum-based neoadjuvant chemotherapy and interval surgical cytoreduction for advanced ovarian cancer: a meta-analysis. Gynecol Oncol 2006; 103:1070-6. [PMID: 16875720 DOI: 10.1016/j.ygyno.2006.06.025] [Citation(s) in RCA: 293] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Revised: 06/17/2006] [Accepted: 06/19/2006] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine the overall survival and relative effect of multiple prognostic variables in cohorts of patients with advanced-stage ovarian cancer treated with platinum-based neoadjuvant chemotherapy in lieu of primary cytoreductive surgery. METHODS Twenty-two cohorts of patients with Stage III and IV ovarian cancer (835 patients) were identified from articles in MEDLINE (1989-2005). Linear regression models, with weighted correlation calculations, were used to assess the effect on median survival time of the proportion of each cohort undergoing maximum interval cytoreduction, proportion of patients with Stage IV disease, median number of pre-operative chemotherapy cycles, median age, and year of publication. RESULTS The mean weighted median overall survival time for all cohorts was 24.5 months. The weighted mean proportion of patients in each cohort undergoing maximal interval cytoreduction was 65.0%. Each 10% increase in maximal cytoreduction was associated with a 1.9 month increase in median survival time (p=0.027). Median overall survival was positively correlated with platinum-taxane chemotherapy (p<0.001) and increasing year of publication (p=0.004) and negatively correlated with the proportion of Stage IV disease (p=0.002). Each incremental increase in pre-operative chemotherapy cycles was associated with a decrease in median survival time of 4.1 months (p=0.046). CONCLUSIONS Neoadjuvant chemotherapy in lieu of primary cytoreduction is associated with inferior overall survival compared to initial surgery. Increasing percent maximal cytoreduction is positively associated with median cohort survival; however, the negative survival effect of increasing number of chemotherapy cycles prior to interval surgery suggests that definitive operative intervention should be undertaken as early in the treatment program as possible.
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Affiliation(s)
- Robert E Bristow
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Phipps #281, Baltimore, MD 21287, USA.
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Inciura A, Simavicius A, Juozaityte E, Kurtinaitis J, Nadisauskiene R, Svedas E, Kajenas S. Comparison of adjuvant and neoadjuvant chemotherapy in the management of advanced ovarian cancer: a retrospective study of 574 patients. BMC Cancer 2006; 6:153. [PMID: 16759398 PMCID: PMC1533845 DOI: 10.1186/1471-2407-6-153] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Accepted: 06/08/2006] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There is a lack of clinical data on the validity of neoadjuvant chemotherapy in the treatment of ovarian cancer. The aim of this study was to compare the impact of the adjuvant and neoadjuvant chemotherapy regimens on the clinical outcomes in patients with advanced ovarian cancer. METHODS We performed a retrospective analysis of 574 patients with advanced ovarian cancer admitted to four Lithuanian oncogynaecology departments during 1993-2000. The conventional combined treatment of cytoreductive surgery and platinum-based chemotherapy was applied to both the group that underwent neoadjuvant chemotherapy (n = 213) and to the control group (n = 361). The selection criterion for neoadjuvant chemotherapy was large extent of the disease. Overall and progression-free survival rates and survival medians were calculated using life tables and the Kaplan-Meier method. RESULTS There was no difference in median overall survival between stage III patients treated with adjuvant chemotherapy and neoadjuvant chemotherapy (25.9 months vs. 29.3 months, p = 0.2508) and stage IV patients (15.4 months vs. 14.9 months, p = 0.6108). Similarly, there was no difference in median progression-free survival between stage III patients treated with adjuvant chemotherapy and neoadjuvant chemotherapy (15.7 months vs. 17.5 months, p = 0.1299) and stage IV patients (8.7 months vs. 8.2 months, p = 0.1817). There was no difference in the rate of the optimal cytoreductive surgery between patients who underwent the neoadjuvant chemotherapy and patients primarily treated with surgery (n = 134, 63% vs. n = 242, 67%, respectively). CONCLUSION There was no difference in progression-free or overall survival and in the rate of optimal cytoreductive surgery between the neoadjuvant and adjuvant chemotherapy groups despite the fact that patients receiving neoadjuvant chemotherapy had a more extensive disease. Multivariate analysis failed to prove that neoadjuvant chemotherapy could be considered as an independent prognostic factor for survival, and the findings need to be investigated in the future prospective randomised studies.
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Affiliation(s)
- Arturas Inciura
- Kaunas university of Medicine, Eiveniu 2, LT-50009 Kaunas, Lithuania
| | - Andrius Simavicius
- Clinic of Obstetrics and Gynaecology, Šiauliai hospital, Architektu 75, LT-78170 Šiauliai, Lithuania
| | - Elona Juozaityte
- Kaunas university of Medicine, Eiveniu 2, LT-50009 Kaunas, Lithuania
| | | | | | - Eimantas Svedas
- Kaunas university of Medicine, Eiveniu 2, LT-50009 Kaunas, Lithuania
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Carey MS, Victory R, Stitt L, Tsang N. Factors That Influence Length of Stay for In-Patient Gynaecology Surgery: Is The Case Mix Group (CMG) or Type of Procedure More Important? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2006; 28:149-55. [PMID: 16643718 DOI: 10.1016/s1701-2163(16)32057-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To compare the association between the Case Mix Group (CMG) code and length of stay (LOS) with the association between the type of procedure and LOS in patients admitted for gynaecology surgery. METHODS We examined the records of women admitted for surgery in CMG 579 (major uterine/adnexal procedure, no malignancy) or 577 (major surgery ovary/adnexa with malignancy) between April 1997 and March 1999. Factors thought to influence LOS included age, weight, American Society of Anesthesiologists (ASA) score, physician, day of the week on which surgery was performed, and procedure type. Procedures were divided into six categories, four for CMG 579 and two for CMG 577. Data were abstracted from the hospital information costing system (T2 system) and by retrospective chart review. Multivariable analysis was performed using linear regression with backwards elimination. RESULTS There were 606 patients in CMG 579 and 101 patients in CMG 577, and the corresponding median LOS was four days (range 1-19) for CMG 579 and nine days (range 3-30) for CMG 577. Combined analysis of both CMGs 577 and 579 revealed the following factors as highly significant determinants of LOS: procedure, age, physician, and ASA score. Although confounded by procedure type, the CMG did not significantly account for differences in LOS in the model if procedure was considered. Pairwise comparisons of procedure categories were all found to be statistically significant, even when controlled for other important variables. CONCLUSION The type of procedure better accounts for differences in LOS by describing six statistically distinct procedure groups rather than the traditional two CMGs. It is reasonable therefore to consider changing the current CMG codes for gynaecology to a classification based on the type of procedure.
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Affiliation(s)
- Mark S Carey
- Department of Obstetrics and Gynecology, University of Western Ontario, London ON; London Health Sciences Centre, London ON
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