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Jochum F, Dumas É, Gougis P, Hamy AS, Querleu D, Lecointre L, Gaillard T, Reyal F, Lecuru F, Laas E, Akladios C. Survival outcomes of primary vs interval cytoreductive surgery for International Federation of Gynecology and Obstetrics stage IV ovarian cancer: a nationwide population-based target trial emulation. Am J Obstet Gynecol 2024:S0002-9378(24)00818-4. [PMID: 39111517 DOI: 10.1016/j.ajog.2024.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND The effect of primary cytoreductive surgery vs interval cytoreductive surgery on International Federation of Gynecology and Obstetrics stage IV ovarian cancer outcomes remains uncertain and may vary depending on the stage and the location of extraperitoneal metastasis. Emulating target trials through causal assessment, combined with propensity score adjustment, has become a leading method for evaluating interventions using observational data. OBJECTIVE This study aimed to assess the effect of primary vs interval cytoreductive surgery on progression-free and overall survival in patients with International Federation of Gynecology and Obstetrics stage IV ovarian cancer using target trial emulation. STUDY DESIGN Using the comprehensive French national health insurance database, we emulated a target trial to explore the causal impacts of primary vs interval cytoreductive surgery on stage IV ovarian cancer prognosis (Surgery for Ovarian cancer FIGO 4: SOFI-4). The clone method with inverse probability of censoring weighting was used to adjust for informative censoring and to balance baseline characteristics between the groups. Subgroup analyses were conducted based on the stages and extraperitoneal metastasis locations. The study included patients younger than 75 years of age, in good health condition, who were diagnosed with stage IV ovarian cancer between January 1, 2014, and December 31, 2022. The primary and secondary outcomes were respectively 5-year progression-free survival and 7-year overall survival. RESULTS Among the 2772 patients included in the study, 948 (34.2%) were classified as having stage IVA ovarian cancer and 1824 (65.8%) were classified as having stage IVB ovarian cancer at inclusion. Primary cytoreductive surgery was performed for 1182 patients (42.6%), whereas interval cytoreductive surgery was conducted for 1590 patients (57.4%). The median progression-free survival for primary cytoreductive surgery was 19.7 months (interquartile range, 19.3-20.1) as opposed to 15.7 months (interquartile range, 15.7-16.1) for those who underwent interval cytoreductive surgery. The median overall survival was 63.1 months (interquartile range, 61.7-65.4) for primary cytoreductive surgery in comparison with 55.6 months (interquartile range, 53.8-56.3) for interval cytoreductive surgery. The findings of our study indicate that primary cytoreductive surgery is associated with a 5.0-month increase in the 5-year progression-free survival (95% confidence interval, 3.8-6.2) and a 3.9-month increase in 7-year overall survival (95% confidence interval, 1.9-6.2). These survival benefits of primary over interval cytoreductive surgery were observed in both the International Federation of Gynecology and Obstetrics stage IVA and IVB subgroups. Primary cytoreductive surgery demonstrated improved progression-free survival and overall survival in patients with pleural, supradiaphragmatic, or extra-abdominal lymph node metastasis. CONCLUSION This study advocates for the benefits of primary cytoreductive surgery over interval cytoreductive surgery for patients with stage IV ovarian cancer and suggests that extraperitoneal metastases like supradiaphragmatic or extra-abdominal lymph nodes should not automatically preclude primary cytoreductive surgery consideration in suitable patients.
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Affiliation(s)
- Floriane Jochum
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Gynaecology, Strasbourg University Hospital, Strasbourg, France.
| | - Élise Dumas
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Mathematics, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Paul Gougis
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Medical Oncology, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France; Clinical Investigation Center (CIC-1901) INSERM, Department of Pharmacology, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Anne-Sophie Hamy
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Medical Oncology, Institut Curie, Paris, France
| | - Denis Querleu
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Lise Lecointre
- Department of Gynaecology, Strasbourg University Hospital, Strasbourg, France
| | - Thomas Gaillard
- Department of Breast and Gynaecological Surgery, Institut Curie, Paris, France
| | - Fabien Reyal
- Residual Tumor & Response to Treatment Laboratory, Translational Research Department, INSERM, U932 Immunity and Cancer, Paris, France; Department of Breast and Gynaecological Surgery, Institut Curie, Paris, France
| | - Fabrice Lecuru
- Department of Breast and Gynaecological Surgery, Institut Curie, Paris, France
| | - Enora Laas
- Department of Breast and Gynaecological Surgery, Institut Curie, Paris, France
| | - Cherif Akladios
- Department of Gynaecology, Strasbourg University Hospital, Strasbourg, France
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Aytekin O, Kerinc SK, Tokalioglu AA, Ucar YO, Kilic F, Comert GK, Ucar G, Civelek B, Turan T. Does neoadjuvant chemotherapy reduce surgical complexity in patients with advanced-stage epithelial ovarian cancer? BMC Womens Health 2024; 24:435. [PMID: 39085835 PMCID: PMC11290156 DOI: 10.1186/s12905-024-03280-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND This study aimed to determine the effect of neoadjuvant chemotherapy (NACT) on the complex surgical procedures required in addition to staging surgery for the need to achieve a residual tumor 1 cm or less in a population of stage IIIC-IV epithelial ovarian cancer patients. METHODS Patients were referred for NACT if preoperative imaging and/or intraoperative evaluation confirmed that it was not possible to achieve a residual tumor size of 1 cm or less with cytoreductive surgery or if the patient had a poor performance status and a high American Society of Anesthesiologists (ASA) score. Surgical complexity was defined as complex or non-complex. RESULTS One hundred and twenty-six patients with stage IIIC-IV ovarian cancer were included in the study. Primary cytoreductive surgery was performed in 67 patients, and interval cytoreductive surgery was performed in 59 patients after NACT. At least one complex surgery was performed in 74.6% of the patients in the primary cytoreductive surgery group and in 61% of the patients in the NACT group, with no statistically significant difference between the groups. However, the NACT group showed significantly decreased rates of low-rectal resection, diaphragmatic peritoneal stripping, and peritonectomy. CONCLUSIONS The analyses showed no reduction in the requirement for at least one complex surgical procedure in the group of patients who underwent NACT. Nevertheless, this group exhibited a significant decrease in low-rectal resection, diaphragmatic peritoneal stripping, and peritonectomy due to their effectiveness in reducing peritoneal disease.
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Affiliation(s)
- Okan Aytekin
- Department of Gynecologic Oncology, Ankara Bilkent City Hospital, 06800, Ankara, Turkey.
| | | | | | - Yesim Ozkaya Ucar
- Department of Gynecologic Oncology, Ankara Bilkent City Hospital, 06800, Ankara, Turkey
| | - Fatih Kilic
- Department of Gynecologic Oncology, Ankara Bilkent City Hospital, 06800, Ankara, Turkey
| | - Gunsu Kimyon Comert
- Department of Gynecologic Oncology, Ankara Bilkent City Hospital, 06800, Ankara, Turkey
| | - Gokhan Ucar
- Department of Medical Oncology, Ankara Bilkent City Hospital, 06800, Ankara, Turkey
| | - Burak Civelek
- Department of Medical Oncology, Ankara Bilkent City Hospital, 06800, Ankara, Turkey
| | - Taner Turan
- Department of Gynecologic Oncology, Ankara Bilkent City Hospital, 06800, Ankara, Turkey
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Zhang K, Abdoli N, Gilley P, Sadri Y, Chen X, Thai TC, Dockery L, Moore K, Mannel RS, Qiu Y. Developing a novel image marker to predict the clinical outcome of neoadjuvant chemotherapy (NACT) for ovarian cancer patients. Comput Biol Med 2024; 172:108240. [PMID: 38460312 DOI: 10.1016/j.compbiomed.2024.108240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE Neoadjuvant chemotherapy (NACT) is one kind of treatment for advanced stage ovarian cancer patients. However, due to the nature of tumor heterogeneity, the clinical outcomes to NACT vary significantly among different subgroups. Partial responses to NACT may lead to suboptimal debulking surgery, which will result in adverse prognosis. To address this clinical challenge, the purpose of this study is to develop a novel image marker to achieve high accuracy prognosis prediction of NACT at an early stage. METHODS For this purpose, we first computed a total of 1373 radiomics features to quantify the tumor characteristics, which can be grouped into three categories: geometric, intensity, and texture features. Second, all these features were optimized by principal component analysis algorithm to generate a compact and informative feature cluster. This cluster was used as input for developing and optimizing support vector machine (SVM) based classifiers, which indicated the likelihood of receiving suboptimal cytoreduction after the NACT treatment. Two different kernels for SVM algorithm were explored and compared. A total of 42 ovarian cancer cases were retrospectively collected to validate the scheme. A nested leave-one-out cross-validation framework was adopted for model performance assessment. RESULTS The results demonstrated that the model with a Gaussian radial basis function kernel SVM yielded an AUC (area under the ROC [receiver characteristic operation] curve) of 0.806 ± 0.078. Meanwhile, this model achieved overall accuracy (ACC) of 83.3%, positive predictive value (PPV) of 81.8%, and negative predictive value (NPV) of 83.9%. CONCLUSION This study provides meaningful information for the development of radiomics based image markers in NACT treatment outcome prediction.
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Affiliation(s)
- Ke Zhang
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK, USA, 73019; School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, USA, 73019
| | - Neman Abdoli
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, USA, 73019
| | - Patrik Gilley
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, USA, 73019
| | - Youkabed Sadri
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, USA, 73019
| | - Xuxin Chen
- School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, USA, 73019
| | - Theresa C Thai
- Department of Radiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA, 73104
| | - Lauren Dockery
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA, 73104
| | - Kathleen Moore
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA, 73104
| | - Robert S Mannel
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA, 73104
| | - Yuchen Qiu
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK, USA, 73019; School of Electrical and Computer Engineering, University of Oklahoma, Norman, OK, USA, 73019.
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Żak K, Satora M, Skrabalak I, Tarkowski R, Ostrowska-Leśko M, Bobiński M. The Potential Influence of Residual or Recurrent Disease on Bevacizumab Treatment Efficacy in Ovarian Cancer: Current Evidence and Future Perspectives. Cancers (Basel) 2024; 16:1063. [PMID: 38473419 DOI: 10.3390/cancers16051063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
There were high hopes for the new antiangiogenic medicament, bevacizumab, which could inhibit the creation of new blood vessels through binding to isoform A of vascular endothelial growth factor (VEGF). However, it is not only blood vessels that are responsible for tumor cell spread. During the process of tumor growth, lymphangiogenesis is mediated by other members of the VEGF family, specifically VEGF-C and VEGF-D, which act independent to bevacizumab. Therefore, based on the mechanism of bevacizumab action and the processes of angio- and lymphangiogenesis, we formed three hypotheses: (1) if the lymph nodes in primary ovarian cancers are metastatic, the outcome of bevacizumab treatment is worsened; (2) concerning the second-line treatment, bevacizumab will act in a weakened manner if recurrence occurs in lymph nodes as opposed to a local recurrence; (3) patients treated by bevacizumab are more likely to have recurrences in lymph nodes. These hypotheses raise the issue of the existing knowledge gap, which concerns the effect of bevacizumab on metastatic lymph nodes.
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Affiliation(s)
- Klaudia Żak
- Department of Medical Chemistry, Medical University of Lublin, 20-059 Lublin, Poland
| | - Małgorzata Satora
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-059 Lublin, Poland
| | - Ilona Skrabalak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Rafał Tarkowski
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Marta Ostrowska-Leśko
- Chair and Department of Toxicology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Marcin Bobiński
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-059 Lublin, Poland
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Liu H, Luo M, Peng C, Huang J, Wang D, Huang J, Zhang G. A retrospective analysis for investigating the relationship between FIGO stage IVA/IVB and cytoreductive surgery with prognosis in epithelial ovarian cancer. Front Oncol 2023; 13:1103357. [PMID: 37564940 PMCID: PMC10411534 DOI: 10.3389/fonc.2023.1103357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 07/07/2023] [Indexed: 08/12/2023] Open
Abstract
Objective To investigate the effect of primary debulking surgery (PDS), NACT followed by interval debulking surgery (NACT-IDS), and chemotherapy alone on the prognosis of FIGO stage IV epithelial ovarian cancer (EOC) with different metastatic patterns. Methods We retrospectively analyzed 133 cases of FIGO stage IV EOC with pleural effusion (stage IVA), parenchymal metastases (stage IVB), or extra-abdominal lymph node metastases (stage IVB) at our Hospital between January 2014 and July 2021. Results Among 133 cases with stage IV disease, 16.5% (n=22) presented with pleural effusion, 46.6% (n=62) with parenchymal metastases, and 36.9% (n=49) with extra-abdominal lymph node metastases. Regardless of the metastatic patterns, the 90.2% (n=120) of cases who underwent PDS/NACT-IDS exhibited a significantly superior overall survival (OS) compared to the 9.8% cases (n=13) who received chemotherapy alone (32 vs 17 months, p=0.000). The cohort was further stratified into 58 cases (48.3%) with R0, 41 cases (34.2%) with R1, and 21 cases (17.5%) with R2. The median OS of cases with R0 was significantly better than that of cases with R1/R2 (74 vs 27 months, p=0.000). There was no significant difference in median OS between PDS and NACT-IDS (43 vs 31 months, p=0.676), as well as between FIGO IVA and IVB (35 vs 31 months, p=0.582). Additionally, the metastatic patterns and the number of neoadjuvant chemotherapy cycles (≤4 or >4) did not demonstrate any prognostic significance for median OS (p=0.820 and 33 vs 26 months, p=0.280, respectively). Conclusion Regardless of FIGO IVA and IVB stages or metastatic patterns, patients diagnosed with stage IV EOC may benefit from cytoreductive surgery with abdominal R0, compared with chemotherapy alone.
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Affiliation(s)
- Hong Liu
- Gynecologic Oncology Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Min Luo
- Gynecologic Oncology Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Chunrong Peng
- Gynecologic Oncology Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Jianmei Huang
- Gynecologic Oncology Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Dengfeng Wang
- Gynecologic Oncology Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Jianming Huang
- Department of Biochemistry & Molecular Biology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Guonan Zhang
- Gynecologic Oncology Center, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
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Nagao S, Tamura J, Shibutani T, Miwa M, Kato T, Shikama A, Takei Y, Kamiya N, Inoue N, Nakamura K, Inoue A, Yamamoto K, Fujiwara K, Suzuki M. Neoadjuvant chemotherapy followed by interval debulking surgery for advanced epithelial ovarian cancer: GOTIC-019 study. Int J Clin Oncol 2023; 28:804-815. [PMID: 37140771 DOI: 10.1007/s10147-023-02329-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 03/15/2023] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Three randomized controlled trials have resulted in extremely extensive application of the strategy of using neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS) for patients with advanced epithelial ovarian cancer in Japan. This study aimed to evaluate the status and effectiveness of treatment strategies using NAC followed by IDS in Japanese clinical practice. PATIENTS AND METHODS We conducted a multi-institutional observational study of 940 women with Federation of Gynecology and Obstetrics (FIGO) stages III-IV epithelial ovarian cancer treated at one of nine centers between 2010 and 2015. Progression-free survival (PFS) and overall survival (OS) were compared between 486 propensity-score matched participants who underwent NAC followed by IDS and primary debulking surgery (PDS) followed by adjuvant chemotherapy. RESULTS Patients with FIGO stage IIIC receiving NAC had a shorter OS (median OS: 48.1 vs. 68.2 months, hazard ratio [HR]: 1.34; 95% confidence interval [CI] 0.99-1.82, p = 0.06) but not PFS (median PFS: 19.7 vs. 19.4 months, HR: 1.02; 95% CI: 0.80-1.31, p = 0.88). However, patients with FIGO stage IV receiving NAC and PDS had comparable PFS (median PFS: 16.6 vs. 14.7 months, HR: 1.07 95% CI: 0.74-1.53, p = 0.73) and OS (median PFS: 45.2 vs. 35.7 months, HR: 0.98; 95% CI: 0.65-1.47, p = 0.93). CONCLUSIONS NAC followed by IDS did not improve survival. In patients with FIGO stage IIIC, NAC may be associated with a shorter OS.
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Affiliation(s)
- Shoji Nagao
- Department of Obstetrics and Gynecology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, Japan.
- Department of Gynecologic Oncology, Hyogo Cancer Center, 13-70 Kitaoji-cho, Akashi, Hyogo, 673-8558, Japan.
| | - Jun Tamura
- Department of Biostatistics, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Takashi Shibutani
- Department of Gynecologic Oncology, Hyogo Cancer Center, 13-70 Kitaoji-cho, Akashi, Hyogo, 673-8558, Japan
| | - Maiko Miwa
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Yamane, Hidaka, 1397-1, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Ayumi Shikama
- Department of Obstetrics and Gynecology, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Japan
| | - Yuji Takei
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Japan
| | - Natsuko Kamiya
- Department of Obstetrics and Gynecology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Naoki Inoue
- Department of Obstetrics and Gynecology, Gunma University, 3-39-15 Showa-cho, Maebashi, Japan
| | - Kazuto Nakamura
- Department of Gynecologic Oncology, Gunma Prefectural Cancer Center, 617-1 Takabayashi-cho, Ota, Japan
| | - Aya Inoue
- Department of Obstetrics and Gynecology, Ehime University School of Medicine, 454 Shitsukawa, Toon, Japan
| | - Koji Yamamoto
- Department of Biostatistics, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Keiichi Fujiwara
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Yamane, Hidaka, 1397-1, Japan
| | - Mitsuaki Suzuki
- Department of Obstetrics and Gynecology, Shin-Yurigaoka General Hospital, 255 Furusawatsuko, Asao-ku, Kawasaki, Japan
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Jorgensen K, Melamed A, Wu CF, Nitecki R, Pareja R, Fagotti A, Schorge JO, Ramirez PT, Rauh-Hain JA. Minimally invasive interval debulking surgery for advanced ovarian cancer after neoadjuvant chemotherapy. Gynecol Oncol 2023; 172:130-137. [PMID: 36977622 PMCID: PMC10192032 DOI: 10.1016/j.ygyno.2023.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Assess outcomes of interval debulking surgery (IDS) after neoadjuvant chemotherapy via minimally invasive surgery (MIS) compared with laparotomy in patients with advanced epithelial ovarian cancer. METHODS Patients diagnosed with stage IIIC or IV epithelial ovarian cancer between 2013 and 2018 who received neoadjuvant chemotherapy and IDS were identified in the National Cancer Database. Primary outcome was overall survival. Secondary outcomes were 5-year survival, 30- and 90-day postoperative mortality, extent of surgery, residual disease, hospitalization duration, surgical conversions, and unplanned readmissions. Propensity score matching was used to compare MIS and laparotomy for IDS. Association of treatment approach with overall survival was assessed using Kaplan-Meier method and Cox regression. Sensitivity analysis was conducted for effect of unmeasured confounders. RESULTS A total of 7897 patients met inclusion criteria; 2021 (25.6%) underwent MIS. Percentage undergoing MIS increased from 20.3%-29.0% over the study period. After propensity score matching, median overall survival was 46.7 months in the MIS group versus 41.0 months in the laparotomy group [hazard ratio (HR) 0.86 (95%CI 0.79-0.94)]. Five-year survival probability was higher in MIS versus laparotomy (38.3% vs 34.8%, p < 0.01). There was lower 30- and 90-day mortality (0.3% vs 0.7% [p = 0.04] and 1.4% vs 2.5% [p = 0.01], respectively), shorter length of stay (median 3 vs 5 days, p < 0.01), lower residual disease (23.9% vs 26.7%, p < 0.01), and lower additional cytoreductive procedures (59.3% vs 70.8%, p < 0.01) in MIS compared to laparotomy, with similar rates of unplanned readmission (2.7% vs 3.1%, p = 0.39). CONCLUSIONS Patients who undergo IDS by MIS have similar overall survival and decreased morbidity compared with laparotomy.
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Affiliation(s)
- Kirsten Jorgensen
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States
| | - Chi-Fang Wu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Roni Nitecki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rene Pareja
- Gynecologic Oncology, Instituto Nacional de Cancerología, Bogota, Colombia
| | - Anna Fagotti
- Department of Woman's and Child Health and Public Health Sciences, Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - John O Schorge
- Department of Obstetrics and Gynecology, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jose Alejandro Rauh-Hain
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Huepenbecker SP, Fu S, Sun CC, Zhao H, Primm KM, Giordano SH, Meyer LA. Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis. Ann Surg Oncol 2023; 30:1508-1519. [PMID: 36310311 PMCID: PMC10466211 DOI: 10.1245/s10434-022-12663-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/28/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid. METHODS We searched the National Cancer Database for women aged 40-64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010-2013) and post-2014 (2014-2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest. RESULTS Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.67) and ovarian cancer (OR 0.67, 95% CI 0.46-0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12-13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31-0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05-0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50-0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26-0.91). CONCLUSIONS State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Becton, Dickinson and Company, Franklin Lakes, NJ, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristin M Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA.
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9
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Xiao Y, Linghu H. Survival Outcomes of Patients with International Federation of Gynecology and Obstetrics Stage IV Ovarian Cancer: Cytoreduction Still Matters. Cancer Control 2023; 30:10732748231159778. [PMID: 36815671 PMCID: PMC9969442 DOI: 10.1177/10732748231159778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
PURPOSE There is still no consensus on the therapeutic strategies for patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV ovarian cancer (OC). We aim to outline the clinical characteristics and optimal therapeutic strategies of patients with FIGO stage IV OC. METHODS This single center retrospective study analyzed the clinical features and survival of patients with FIGO stage IV OC that underwent cytoreduction or received at least one course of chemotherapy between January 2014 and December 2020. RESULTS One hundred and twenty patients were included. Surgery, especially optimal cytoreduction without residual mass improved the overall survival of patients in surgery group (P = .047, HR .432, 95% CI .181-.987). Secondly, the completion of chemotherapy improved median overall survival of patients either with (53.0 months vs 25.0 months, P < .001, HR 7.015, 95% CI 1.372-35.881) or without cytoreduction (43.0 months vs 6.0 months, P = .006, HR 5.969, 95% CI 1.115-31.952). In patients with FIGO stage IVB, those with only extra-abdominal lymph node metastases had better survival. CONCLUSIONS In patients with FIGO stage IV, complete resection of intra-abdominal tumor foci and completion of chemotherapy provided considerable survival benefits to patients with FIGO stage IV OC. Among patients with FIGO stage IVB, those with only extra-abdominal lymph node metastases had a better prognosis.
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Affiliation(s)
- Yao Xiao
- Department of Gynecology, The First Affiliated Hospital of
Chongqing Medical University, Chongqing, China
| | - Hua Linghu
- Department of Gynecology, The First Affiliated Hospital of
Chongqing Medical University, Chongqing, China,Hua Linghu, PHD, Department of Gynecology,
The First Affiliated Hospital of Chongqing Medical University, No.1 Medical
College Road, Yuzhong District, Chongqing 400016, China.
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10
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Cummings M, Nicolais O, Shahin M. Surgery in Advanced Ovary Cancer: Primary versus Interval Cytoreduction. Diagnostics (Basel) 2022; 12:988. [PMID: 35454036 PMCID: PMC9026414 DOI: 10.3390/diagnostics12040988] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 12/01/2022] Open
Abstract
Primary debulking surgery (PDS) has remained the only treatment of ovarian cancer with survival advantage since its development in the 1970s. However, survival advantage is only observed in patients who are optimally resected. Neoadjuvant chemotherapy (NACT) has emerged as an alternative for patients in whom optimal resection is unlikely and/or patients with comorbidities at high risk for perioperative complications. The purpose of this review is to summarize the evidence to date for PDS and NACT in the treatment of stage III/IV ovarian carcinoma. We systematically searched the PubMed database for relevant articles. Prior to 2010, NACT was reserved for non-surgical candidates. After publication of EORTC 55971, the first randomized trial demonstrating non-inferiority of NACT followed by interval debulking surgery, NACT was considered in a wider breadth of patients. Since EORTC 55971, 3 randomized trials-CHORUS, JCOG0602, and SCORPION-have studied NACT versus PDS. While CHORUS supported EORTC 55971, JCOG0602 failed to demonstrate non-inferiority and SCORPION failed to demonstrate superiority of NACT. Despite conflicting data, a subset of patients would benefit from NACT while preserving survival including poor surgical candidates and inoperable disease. Further randomized trials are needed to assess the role of NACT.
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Affiliation(s)
- Mackenzie Cummings
- Department of Obstetrics and Gynecology, Jefferson Abington Hospital, Abington, PA 19001, USA; (M.C.); (O.N.)
| | - Olivia Nicolais
- Department of Obstetrics and Gynecology, Jefferson Abington Hospital, Abington, PA 19001, USA; (M.C.); (O.N.)
| | - Mark Shahin
- Asplundh Cancer Pavilion, Sidney Kimmel Cancer Center, Hanjani Institute for Gynecologic Oncology, Thomas Jefferson University, Willow Grove, PA 19090, USA
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11
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Sørensen SM, Høgdall C, Mosgaard BJ, Dalgaard MIR, Jensen MP, Fuglsang K, Schnack TH. Residual tumor and primary debulking surgery vs interval debulking surgery in stage IV epithelial ovarian cancer. Acta Obstet Gynecol Scand 2022; 101:334-343. [PMID: 35187660 DOI: 10.1111/aogs.14319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION It is debated whether women with FIGO (International Federation of Gynecology and Obstetrics) Stage IV epithelial ovarian cancer should be offered primary debulking surgery (PDS) or interval debulking surgery (IDS). Furthermore, the impact of complete resection of intra-abdominal disease (R0) despite their extra-abdominal metastases is questioned. The objective of this study was to investigate the impact of intra-abdominal residual tumor, Stage IVA vs IVB, the localization and number of metastases defining Stage IV disease on overall survival (OS) comparing PDS and IDS in FIGO Stage IV epithelial ovarian cancer. MATERIAL AND METHODS We included 2091 women registered with Stage IIIC-IV ovarian cancer in the Danish Gynecological Cancer Database during 2009-2016. The impact of residual tumor was evaluated using univariate and multivariate analyses. RESULTS In total, 681 patients had stage IV disease, of whom 26% underwent PDS, 38% IDS, and 36% chemotherapy only. Overall survival for PDS and IDS were similar. Patients achieving R0 at PDS showed a tendency towards a higher OS than patients achieving R0 at IDS, though the difference was non-significant. In women with Stage IVA and IVB disease there was a survival benefit in achieving R0 both when treated with PDS and IDS. Women with Stage IVB disease treated with chemotherapy only had a significantly lower OS than patients achieving R0 at both PDS and IDS. Malignant pleural effusion and having five metastatic sites compared with having one was associated with a poorer OS. CONCLUSIONS Our study shows similar OS in patients with Stage IV disease treated with IDS compared with PDS. Complete intra-abdominal tumor resection improves the prognosis in both PDS and IDS in Stage IV ovarian cancer. Malignant pleural effusion seems to be a negative prognostic factor and should have more focus in future studies.
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Affiliation(s)
- Sarah Mejer Sørensen
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus Høgdall
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Berit Jul Mosgaard
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Mai Partridge Jensen
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Katrine Fuglsang
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Tine Henrichsen Schnack
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
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12
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Winarto H, Welladatika A, Habiburrahman M, Purwoto G, Kusuma F, Utami TW, Putra AD, Anggraeni T, Nuryanto KH. Overall Survival and Related Factors of Advanced-stage Epithelial Ovarian Cancer Patients Underwent Debulking Surgery in Jakarta, Indonesia: A Single-center Experience. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM: The worrisome prognosis of advanced-stage epithelial ovarian cancer (EOC) needs a new perspective from developing countries. Thus, we attempted to study the 5-year overall survival (OS) of advanced-stage EOC patients who underwent debulking surgery in an Indonesian tertiary hospital.
METHODS: A retrospective study recruited forty-eight subjects between 2013 and 2015. We conducted multiple logistic regression analyses to predict risk factors leading to unwanted disease outcomes. The OS was evaluated through the Kaplan–Meier curve and Log-rank test. Cox proportional hazards regression examined prognostic factors of patients.
RESULTS: Prominent characteristics of our patients were middle age (mean: 51.9 ± 8.9 years), obese, with normal menarche onset, multiparous, not using contraception, premenopausal, with serous EOC, and FIGO stage IIIC. The subjects mainly underwent primary debulking surgery (66.8%), with 47.9% of all individuals acquiring optimal results, 77.1% of patients treated had the residual disease (RD), and 52.1% got adjuvant chemotherapy. The risk factor for serous EOC was menopause (odds ratio [OR] = 4.82). The predictors of suboptimal surgery were serous EOC (OR = 8.25) and FIGO stage IV (OR = 11.13). The different OS and median survival were observed exclusively in RD, making it an independent prognostic factor (hazard ratio = 3.50). 5-year A five year OS and median survival for patients with advanced-stage EOC who underwent debulking surgery was 37.5% and 32 months, respectively. Optimal versus suboptimal debulking surgery yielded OS 43.5% versus 32% and median survival of 39 versus 29 months. Both optimal and suboptimal debulking surgery followed with chemotherapy demonstrated an OS 40% lower than those not administered (46.2% and 20%, respectively). The highest 5-year OS was in serous EOC (50%). Meanwhile, the most extended median survival was with mucinous EOC (45 months).
CONCLUSION: Chemotherapy following optimal and suboptimal debulking surgery has the best OS among approaches researched in this study. RD is a significant prognostic factor among advanced-stage EOC. Suboptimal surgery outcomes can be predicted by stage and histological subtype.
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13
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Ray MD, Deo SSV, Kumar L, Gaur MK. Upfront cytoreductive surgery versus neoadjuvant chemotherapy in advanced epithelial ovarian cancer in Indian patients. Future Oncol 2021; 17:3607-3614. [PMID: 34263662 DOI: 10.2217/fon-2021-0077] [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] [Indexed: 01/17/2023] Open
Abstract
In cases of ovarian carcinoma, primary cytoreductive surgery (CRS) is the standard treatment up to stage IIIB, but patient selection for neoadjuvant chemotherapy (NACT) in selected cases is controversial. A total of 200 patients with advanced ovarian cancer were analyzed retrospectively, according to specific selection criteria. Primary CRS was performed in 95 patients (47.5%) and interval CRS after 3-6 cycles of NACT was performed in 105 patients (52.5%). After median follow-up of 35 months, 5-year overall survival was 53.7% in the upfront CRS group and 42.2% in the NACT group. Primary CRS is the standard in advanced stages of ovarian carcinoma, but in certain subset of patients, NACT is preferred. Identifying that group is challenging but feasible. Proper selection of patients is key to successful outcomes.
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Affiliation(s)
- Mukur Dipi Ray
- Department of Surgical Oncology, DR BRA-IRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Suryanarayana S V Deo
- Department of Surgical Oncology, DR BRA-IRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Lalit Kumar
- Department of Medical Oncology, DR BRA-IRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Manish Kumar Gaur
- Department of Surgical Oncology, DR BRA-IRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
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14
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Computational modeling of ovarian cancer dynamics suggests optimal strategies for therapy and screening. Proc Natl Acad Sci U S A 2021; 118:2026663118. [PMID: 34161278 DOI: 10.1073/pnas.2026663118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
High-grade serous tubo-ovarian carcinoma (HGSC) is a major cause of cancer-related death. Treatment is not uniform, with some patients undergoing primary debulking surgery followed by chemotherapy (PDS) and others being treated directly with chemotherapy and only having surgery after three to four cycles (NACT). Which strategy is optimal remains controversial. We developed a mathematical framework that simulates hierarchical or stochastic models of tumor initiation and reproduces the clinical course of HGSC. After estimating parameter values, we infer that most patients harbor chemoresistant HGSC cells at diagnosis and that, if the tumor burden is not too large and complete debulking can be achieved, PDS is superior to NACT due to better depletion of resistant cells. We further predict that earlier diagnosis of primary HGSC, followed by complete debulking, could improve survival, but its benefit in relapsed patients is likely to be limited. These predictions are supported by primary clinical data from multiple cohorts. Our results have clear implications for these key issues in HGSC management.
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15
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Patel A, Iyer P, Matsuzaki S, Matsuo K, Sood AK, Fleming ND. Emerging Trends in Neoadjuvant Chemotherapy for Ovarian Cancer. Cancers (Basel) 2021; 13:cancers13040626. [PMID: 33562443 PMCID: PMC7915369 DOI: 10.3390/cancers13040626] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Epithelial ovarian cancer is one of the most lethal cancers in women and is typically diagnosed at an advanced-stage. Historically, primary tumor reductive surgery was attempted followed by postoperative chemotherapy in most patients diagnosed with advanced ovarian cancer. However, neoadjuvant chemotherapy followed by interval tumor reductive surgery is an alternative approach for patients with advanced-stage ovarian cancer where primary tumor reductive surgery is not feasible. Here, we review proposed models that can assist in selecting patients who would benefit most from neoadjuvant chemotherapy followed by surgery. Abstract Epithelial ovarian cancer remains a leading cause of death amongst all gynecologic cancers despite advances in surgical and medical therapy. Historically, patients with ovarian cancer underwent primary tumor reductive surgery followed by postoperative chemotherapy; however, neoadjuvant chemotherapy followed by interval tumor reductive surgery has gradually become an alternative approach for patients with advanced-stage ovarian cancer for whom primary tumor reductive surgery is not feasible. Decision-making about the use of these approaches has not been uniform. Hence, it is essential to identify patients who can benefit most from neoadjuvant chemotherapy followed by interval tumor reductive surgery. Several prospective and retrospective studies have proposed potential models to guide upfront decision-making for patients with advanced ovarian cancer. In this review, we summarize important decision-making models that can improve patient selection for personalized treatment. Models based on clinical factors (clinical parameters, radiology studies and laparoscopy scoring) and molecular markers (circulating and tumor-based) are useful, but laparoscopic staging is among the most informative diagnostic methods for upfront decision-making in patients medically fit for surgery. Further research is needed to explore more reliable models to determine personalized treatment for advanced epithelial ovarian cancer.
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Affiliation(s)
- Ami Patel
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.P.); (P.I.); (A.K.S.)
| | - Puja Iyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.P.); (P.I.); (A.K.S.)
| | - Shinya Matsuzaki
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan; (S.M.); (K.M.)
| | - Koji Matsuo
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan; (S.M.); (K.M.)
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Anil K. Sood
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.P.); (P.I.); (A.K.S.)
| | - Nicole D. Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.P.); (P.I.); (A.K.S.)
- Correspondence: ; Tel.: +1-(281)-566-1900
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16
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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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17
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Llueca A, Serra A, Climent MT, Segarra B, Maazouzi Y, Soriano M, Escrig J. Outcome quality standards in advanced ovarian cancer surgery. World J Surg Oncol 2020; 18:309. [PMID: 33239057 PMCID: PMC7690155 DOI: 10.1186/s12957-020-02064-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/26/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Advanced ovarian cancer surgery (AOCS) frequently results in serious postoperative complications. Because managing AOCS is difficult, some standards need to be established that allow surgeons to assess the quality of treatment provided and consider what aspects should improve. This study aimed to identify quality indicators (QIs) of clinical relevance and to establish their acceptable quality limits (i.e., standard) in AOCS. MATERIALS AND METHODS We performed a systematic search on clinical practice guidelines, consensus conferences, and reviews on the outcome and quality of AOCS to identify which QIs have clinical relevance in AOCS. We then searched the literature (from January 2006 to December 2018) for each QI in combination with the keywords of advanced ovarian cancer, surgery, outcome, and oncology. Standards for each QI were determined by statistical process control techniques. The acceptable quality limits for each QI were defined as being within the limits of the 99.8% interval, which indicated a favorable outcome. RESULTS A total of 38 studies were included. The QIs selected for AOCS were complete removal of the tumor upon visual inspection (complete cytoreductive surgery), a residual tumor of < 1 cm (optimal cytoreductive surgery), a residual tumor of > 1 cm (suboptimal cytoreductive surgery), major morbidity, and 5-year survival. The rates of complete cytoreductive surgery, optimal cytoreductive surgery, suboptimal cytoreductive surgery, morbidity, and 5-year survival had quality limits of < 27%, < 23%, > 39%, > 33%, and < 27%, respectively. CONCLUSION Our results provide a general view of clinical indicators for AOCS. Acceptable quality limits that can be considered as standards were established.
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Affiliation(s)
- Antoni Llueca
- Department of Obstetrics and Gynecology, University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain. .,Multidisciplinary Unit of Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain. .,Department of Medicine, University Jaume I (UJI), Castellón, Spain.
| | - Anna Serra
- Department of Obstetrics and Gynecology, University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain.,Multidisciplinary Unit of Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain.,Department of Medicine, University Jaume I (UJI), Castellón, Spain
| | - Maria Teresa Climent
- Department of Obstetrics and Gynecology, University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain.,Multidisciplinary Unit of Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain.,Department of Medicine, University Jaume I (UJI), Castellón, Spain
| | - Blanca Segarra
- Department of Obstetrics and Gynecology, University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain.,Multidisciplinary Unit of Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain
| | - Yasmine Maazouzi
- Department of Obstetrics and Gynecology, University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain.,Multidisciplinary Unit of Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain
| | - Marta Soriano
- Multidisciplinary Unit of Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain.,Department of Anesthesiology, University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain
| | - Javier Escrig
- Multidisciplinary Unit of Abdominal Pelvic Oncology Surgery (MUAPOS), University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain.,Department of Medicine, University Jaume I (UJI), Castellón, Spain.,Department of General Surgery, University General Hospital of Castellón, Av Benicasim s/n, 12004, Castellón, Spain
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18
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Nakamura K, Kitahara Y, Nishimura T, Yamashita S, Kigure K, Ito I, Kanuma T. Nadir CA-125 serum levels during neoadjuvant chemotherapy and no residual tumor at interval debulking surgery predict prognosis in advanced stage ovarian cancer. World J Surg Oncol 2020; 18:200. [PMID: 32791996 PMCID: PMC7427056 DOI: 10.1186/s12957-020-01978-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 07/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent phase III randomized trials have suggested that neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) is a treatment option for patients with advanced epithelial ovarian cancer. This study aimed to use CA-125 and computed tomography (CT) scanning to generate a simple and clinically applicable model of predicting complete cytoreduction by interval debulking surgery (IDS) and the overall survival in patients who receive taxane/platinum-based chemotherapy as neoadjuvant chemotherapy (NACT). METHODS Patients with stage IIIc or IV epithelial ovarian cancer who underwent taxane/platinum-based NACT followed by IDS in Gunma Prefectural Cancer Center, Takasaki General Medical Center, and Gunma University from April 2009 to March 2015 were included. Patients underwent a CT scan to confirm confirm tumors unresectable by standard surgery before NACT. CA-125 levels were measured pre-NACT, after each cycle of NACT, and before IDS. CT was also performed before IDS to evaluate tumor metastasis. Data were collected retrospectively and analyzed to determine the predictive factors of complete resection and overall survival. RESULTS Among 63 patients who received NACT-IDS, 43 and 20 patients had stages IIIc and IV epithelial ovarian cancer at diagnosis, respectively. CT predictors of residual tumors after IDS such as extra-ovarian implants (P = 0.009) and omental cakes (P = 0.038) were not present. Univariate analysis revealed that the independent factors for overall survival were no residual tumor by IDS (P = 0.0016) and CA125 ≤ 20 U/ml before IDS (P = 0.0011). CONCLUSIONS Although this study had a small sample size, NACT-IDS used to completely remove macroscopic disease which significantly improved the prognosis of patients with preoperative CA-125 ≤ 20 U/ml. Results from this study provide useful information for future studies on the management of patients with advanced epithelial ovarian cancer.
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Affiliation(s)
- Kazuto Nakamura
- Department of Gynecology, Gunma Prefectural Cancer Center, 617-1, Takabayashinishi, Ota, Gunma, 373-8550, Japan.
| | - Yoshikazu Kitahara
- Department of Obstetrics and Gynecology, Gunma University Hospital, Maebashi, Gunma, 371-8511, Japan
| | - Toshio Nishimura
- Department of Obstetrics and Gynecology, Gunma University Hospital, Maebashi, Gunma, 371-8511, Japan
| | - Soichi Yamashita
- Department of Gynecology, Gunma Prefectural Cancer Center, 617-1, Takabayashinishi, Ota, Gunma, 373-8550, Japan
| | - Keiko Kigure
- Department of Gynecology, Gunma Prefectural Cancer Center, 617-1, Takabayashinishi, Ota, Gunma, 373-8550, Japan
| | - Ikuro Ito
- Department of Obstetrics and Gynecology, Takasaki General Medical Center, Takasaki, Gunma, 370-0829, Japan
| | - Tatsuya Kanuma
- Department of Gynecology, Gunma Prefectural Cancer Center, 617-1, Takabayashinishi, Ota, Gunma, 373-8550, Japan
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Feng LY, Li L. Low expression of NCALD is associated with chemotherapy resistance and poor prognosis in epithelial ovarian cancer. J Ovarian Res 2020; 13:35. [PMID: 32228639 PMCID: PMC7106630 DOI: 10.1186/s13048-020-00635-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/12/2020] [Indexed: 12/13/2022] Open
Abstract
Background Low expression of NCALD(neurocalcin delta) in peripheral blood of ovarian cancer patients predicts poor prognosis. However, the molecular mechanism of NCALD in ovarian cancer and its relationship with chemotherapy outcomes is unclear. The aim of this study was to investigate the potential signaling pathways of NCALD and to evaluate its ability to predict chemotherapy outcomes and prognosis. Methods High-throughput RNA sequencing data were downloaded from TCGA. GSEA explored the potential signaling pathways of NCALD. The expression of NCALD in chemotherapy sensitive and chemotherapy resistant ovarian cancer patients was detected by TCGA data and clinical samples. ROC analysis confirmed the ability of NCALD to predict chemotherapy outcomes. The association between NCALD expression and prognosis in ovarian cancer patients was assessed using Kaplan-Meier plotter. Results In patients with NCALD overexpression, genes expression related to ERK1 / 2 signaling pathway, NF-kappaB signaling pathway, TGF-β signaling pathway and immune response pathway was increased, especially ERK1 / 2 signaling pathway. The expression of NCALD in chemoresistant patients was significantly lower than chemosensitive patients. In TCGA data and immunohistochemical samples, the AUC of NCALD expression predicting chemotherapy outcome was 0.59 and 0.64, respectively. In clinical samples, low expression of NCALD was associated with poor OS and PFS. Conclusions NCALD may activate the ERK1 / 2 signaling pathway in ovarian cancer. As a new biomarker of chemotherapy sensitivity, NCALD was significantly down-regulated in chemotherapy resistance ovarian cancer patients. Low expression of NCALD in ovarian cancer is associated with poor OS and PFS. In the future, further research will be needed on the potential mechanism and clinical application value of NCALD in ovarian cancer.
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Affiliation(s)
- Li-Yuan Feng
- Department of Gynecologic oncology, Guangxi Medical University Cancer Hospital, 71 Hedi Road, Nanning, Guangxi, 530021, P.R. China
| | - Li Li
- Department of Gynecologic oncology, Guangxi Medical University Cancer Hospital, 71 Hedi Road, Nanning, Guangxi, 530021, P.R. China.
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Dabi Y, Huchon C, Ouldamer L, Bendifallah S, Collinet P, Bricou A, Daraï E, Ballester M, Lavoue V, Haddad B, Touboul C. Patients with stage IV epithelial ovarian cancer: understanding the determinants of survival. J Transl Med 2020; 18:134. [PMID: 32293460 PMCID: PMC7087387 DOI: 10.1186/s12967-020-02295-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/11/2020] [Indexed: 01/10/2023] Open
Abstract
Background The most appropriate management for patients with stage IV ovarian cancer remains unclear. Our objective was to understand the main determinants associated with survival and to discuss best surgical management. Methods Data of 1038 patients with confirmed ovarian cancer treated between 1996 and 2016 were extracted from maintained databases of 7 French referral gynecologic oncology institutions. Patients with stage IV diseases were selected for further analysis. The Kaplan–Meier method was used to estimate the survival distribution. A Cox proportional hazards model including all the parameters statistically significant in univariable analysis, was used to account for the influence of multiple variables. Results Two hundred and eight patients met our inclusion criteria: 65 (31.3%) never underwent debulking surgery, 52 (25%) underwent primary debulking surgery (PDS) and 91 (43.8%) neoadjuvant chemotherapy and interval debulking surgery (NACT-IDS). Patients not operated had a significantly worse overall survival than patients that underwent PDS or NACT–IDS (p < 0.001). In multivariable analysis, three factors were independent predictors of survival: upfront surgery (HR 0.32 95% CI 0.14–0.71, p = 0.005), postoperative residual disease = 0 (HR 0.37 95% CI 0.18–0.75, p = 0.006) and association of Carboplatin and Paclitaxel regimen (HR 0.45 95% CI 0.25–0.80, p = 0.007). Conclusions Presence of distant metastases should not refrain surgeons from performing radical procedures, whenever the patient is able to tolerate. Maximal surgical efforts should be done to minimize residual disease as it is the main determinant of survival.
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Affiliation(s)
- Yohann Dabi
- Department of Obstetrics and Gynecology, Centre Hospitalier Intercommunal, Faculté de médecine de Créteil UPEC-Paris XII, Créteil, France
| | - Cyrille Huchon
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy - Saint Germain - en - Laye, 78103, Poissy, France
| | - Lobna Ouldamer
- Department of Obstetrics and Gynecology, Centre hospitalier régional universitaire de Tours, hôpital Bretonneau, Tours, France
| | - Sofiane Bendifallah
- Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique, Hôpitaux de Paris (AP-HP) des, University Pierre and Marie Curie, Paris 6, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Pierre Collinet
- Department of Obstetrics and Gynecology, Centre Hospitalier Régional Universitaire, Lille, France
| | - Alexandre Bricou
- Department of Obstetrics and Gynecology, Jean-Verdier University Hospital, Assistance Publique, Hôpitaux de Paris (AP-HP) des, Paris, France
| | - Emile Daraï
- Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique, Hôpitaux de Paris (AP-HP) des, University Pierre and Marie Curie, Paris 6, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Marcos Ballester
- Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique, Hôpitaux de Paris (AP-HP) des, University Pierre and Marie Curie, Paris 6, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Vincent Lavoue
- CRLCC Eugène-Marquis, Department of Gynecology, CHU de Rennes, Université de Rennes 1, Rennes, France
| | - Bassam Haddad
- Department of Obstetrics and Gynecology, Centre Hospitalier Intercommunal, Faculté de médecine de Créteil UPEC-Paris XII, Créteil, France
| | - Cyril Touboul
- Department of Obstetrics and Gynecology, Centre Hospitalier Intercommunal, Faculté de médecine de Créteil UPEC-Paris XII, Créteil, France. .,Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique, Hôpitaux de Paris (AP-HP) des, University Pierre and Marie Curie, Paris 6, Institut Universitaire de Cancérologie (IUC), Paris, France. .,Service de Gynécologie Obstétrique, Hôpital Intercommunal de Créteil, 40 Avenue de Verdun, Créteil, 94000, France.
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Manning-Geist BL, Hicks-Courant K, Gockley AA, Clark RM, Del Carmen MG, Growdon WB, Horowitz NS, Berkowitz RS, Muto MG, Worley MJ. A novel classification of residual disease after interval debulking surgery for advanced-stage ovarian cancer to better distinguish oncologic outcome. Am J Obstet Gynecol 2019; 221:326.e1-326.e7. [PMID: 31082382 DOI: 10.1016/j.ajog.2019.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Complete surgical resection affords the best prognosis at the time of interval debulking surgery. When complete surgical resection is unachievable, optimal residual disease is considered the next best alternative. Despite contradicting evidence on the survival benefit of interval debulking surgery if macroscopic residual disease remains, the current definition of "optimal" in patients undergoing interval debulking surgery is defined as largest diameter of disease measuring ≤1.0 cm, independent of the total volume of disease. OBJECTIVE To examine the relationship between volume and anatomic distribution of residual disease and oncologic outcomes among patients with advanced-stage epithelial ovarian/fallopian tube/primary peritoneal carcinoma undergoing neoadjuvant chemotherapy then interval debulking surgery. For patients who did not undergo a complete surgical resection, a surrogate for volume of residual disease was used to assess oncologic outcomes. STUDY DESIGN Patient demographics, operative characteristics, anatomic site of residual disease, and outcome data were collected from medical records of patients with International Federation of Gynecology and Obstetrics stage IIIC and IV epithelial ovarian cancer undergoing interval debulking surgery from January 2010 to July 2015. Among patients who did not undergo complete surgical resection but had ≤1 cm of residual disease, the number of anatomic sites (single location vs multiple locations) with residual disease was used as a surrogate for volume of residual disease. The effect of residual disease volume on progression-free survival and overall survival was evaluated. RESULTS Of 270 patients undergoing interval debulking surgery, 173 (64.1%) had complete surgical resection, 34 (12.6%) had ≤1 cm of residual disease in a single anatomic location, 47 (17.4%) had ≤1 cm of residual disease in multiple anatomic locations, and 16 (5.9%) were suboptimally debulked. Median progression-free survival for each group was 14, 12, 10, and 6 months, respectively (P<.001). Median overall survival for each group was: 58, 37, 26, and 33 months, respectively (P<.001). CONCLUSION Following interval debulking surgery, patients with complete surgical resection have the best prognosis, followed by patients with ≤1 cm single-anatomic location disease. In contrast, despite being considered "optimally debulked," patients with ≤1 cm multiple-anatomic location disease have a survival similar to suboptimally debulked patients.
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Bartels HC, Rogers AC, McSharry V, McVey R, Walsh T, O'Brien D, Boyd WD, Brennan DJ. A meta-analysis of morbidity and mortality in primary cytoreductive surgery compared to neoadjuvant chemotherapy in advanced ovarian malignancy. Gynecol Oncol 2019; 154:622-630. [DOI: 10.1016/j.ygyno.2019.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 01/27/2023]
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Economic Analysis of Neoadjuvant Chemotherapy Versus Primary Debulking Surgery for Advanced Epithelial Ovarian Cancer Using an Aggressive Surgical Paradigm. Int J Gynecol Cancer 2019; 28:1077-1084. [PMID: 29683880 DOI: 10.1097/igc.0000000000001271] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced epithelial ovarian cancer (AEOC) remains controversial in the United States. Generalizability of existing trial results has been criticized because of less aggressive debulking procedures than commonly used in the United States. As a result, economic evaluations using input data from these trials may not accurately reflect costs and outcomes associated with more aggressive primary surgery. Using data from an ongoing trial performing aggressive debulking, we investigated the cost-effectiveness and cost-utility of NACT versus PDS for AEOC. METHODS A decision tree model was constructed to estimate differences in short-term outcomes and costs for a hypothetical cohort of 15,000 AEOC patients (US annual incidence of AEOC) treated with NACT versus PDS over a 1-year time horizon from a Medicare payer perspective. Outcomes included costs per cancer-related death averted, life-years and quality-adjusted life-years (QALYs) gained. Base-case probabilities, costs, and utilities were based on the Surgical Complications Related to Primary or Interval Debulking in Ovarian Neoplasms trial. Base-case analyses assumed equivalent survival; threshold analysis estimated the maximum survival difference that would result in NACT being cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds. Probabilistic sensitivity analysis was used to characterize model uncertainty. RESULTS Compared with PDS, NACT was associated with $142 million in cost savings, 1098 fewer cancer-related deaths, and 1355 life-years and 1715 QALYs gained, making it the dominant treatment strategy for all outcomes. In sensitivity analysis, NACT remained dominant in 99.3% of simulations. Neoadjuvant chemotherapy remained cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds if survival differences were less than 2.7 and 1.4 months, respectively. CONCLUSIONS In the short term, NACT is cost-saving with improved outcomes. However, if PDS provides a longer-term survival advantage, it may be cost-effective. Research is needed on the role of patient preferences in tradeoffs between survival and quality of life.
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Chiofalo B, Bruni S, Certelli C, Sperduti I, Baiocco E, Vizza E. Primary debulking surgery vs. interval debulking surgery for advanced ovarian cancer: review of the literature and meta-analysis. Minerva Med 2019; 110:330-340. [PMID: 31081304 DOI: 10.23736/s0026-4806.19.06078-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Epithelial ovarian cancer (EOC) is the seventh most common cancer among women in the world and the leading cause of death from gynecological malignancies. The standard treatment for advanced EOC consists of optimal primary debulking surgery (PDS) associated with an adjuvant chemotherapy. Neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) have been proposed in the management of advanced EOC to increase the rate of complete citoreductive surgery and to reduce morbidity and mortality. This systematic review and meta-analysis is conducted to compare the oncologic and postoperative outcomes of NACT and IDS with PDS followed by chemotherapy in patients with ovarian cancer. EVIDENCE ACQUISITION We conducted a search on the electronic databases PubMed/Medline, Cochrane and Scopus. All randomized controlled trials, cohort and case-control studies comparing PDS and IDS in ovarian cancer published in English until 28 February 2019 were considered eligible. EVIDENCE SYNTHESIS Twenty studies were included in the systematic review. As regards the meta-analysis, only studies that allowed the data we needed to be extracted were included: five were included for the evaluation of overall survival (OS) and PFS and 9 for the evaluation of major postoperative complications and days of hospital stay. CONCLUSIONS From the meta-analysis of the current available literature, none of the two investigated procedures has proven to be superior in terms of OS and PFS in the treatment of advanced ovarian cancer. However surgical complexity and postoperative complications are reduced in the IDS group.
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Affiliation(s)
- Benito Chiofalo
- Unit of Gynecologic Oncology, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy -
| | - Simone Bruni
- Division of Obstetrics and Gynecology, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Camilla Certelli
- Unit of Gynecologic Oncology, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Isabella Sperduti
- Unit of Biostatistical, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Ermelinda Baiocco
- Unit of Gynecologic Oncology, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Enrico Vizza
- Unit of Gynecologic Oncology, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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Wang M, Zhou J, Zhang L, Zhao Y, Zhang N, Wang L, Zhu W, He X, Zhu H, Xu W, Pan Q, Mao A, Li Q, Wang L. Surgical treatment of ovarian cancer liver metastasis. Hepatobiliary Surg Nutr 2019; 8:129-137. [PMID: 31098360 DOI: 10.21037/hbsn.2018.12.06] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In addition to hepatocellular carcinoma, metastatic liver cancer (MLC) is another focus of hepatic surgeon. Good outcome of patients with liver metastasis (LM) from colorectal cancer or neuroendocrine tumor have been achieved. Ovarian cancer liver metastasis (OCLM) has its unique oncological characteristics and a variety of metastasis patterns, which brings a challenge to hepatic surgeon. Hepatic surgeons hold different views and techniques from gynecologists, which makes differences in the evaluation and treatment of the disease. We reviewed recent studies and, in combination with our own clinical experience, attempted to introduce the progress of surgical treatment of liver metastases from OC. In our experience, both preoperative imaging and surgical procedures are based on the assurance of R0 resection. R0 cytoreductive surgery (CRS) is the most favorable determinant for the prognosis of OC patients, and R0 liver resection (LR) is a component of R0 CRS. Gynecologists and hepatic surgeons should do their own preoperative and intraoperative evaluation for the extrahepatic and intrahepatic metastasis respectively. During the operation, regardless of the miliary nodules dissemination between the right hemidiaphragm and liver capsule, liver parenchymal infiltration (LPI) or liver parenchymal metastasis (LPM), 1-2 cm resection margin should be emphasized. For patients with liver portal lymph node metastasis (LPLNM), hepatic portal skeletonization should be performed, rather than portal lymph node dissection. The operation should be as radical as possible to ensure the patients to achieve good prognosis.
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Affiliation(s)
- Miao Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Jiamin Zhou
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Lyu Zhang
- Research Center for Translational Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Yiming Zhao
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Ning Zhang
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Longrong Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiping Zhu
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xigan He
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Hongxu Zhu
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiqi Xu
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qi Pan
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Anrong Mao
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qinchuan Li
- Department of Cardiothoracic Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Lu Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
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Ferron G, Narducci F, Pouget N, Touboul C. [Surgery for advanced stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:197-213. [PMID: 30792175 DOI: 10.1016/j.gofs.2019.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Indexed: 01/10/2023]
Abstract
Debulking surgery is the key step of advanced stage ovarian cancer treatment with chemotherapy. The quality of surgical resection is the main prognosis factor, thus a complete resection must be achieved (grade A) in an expert center (grade B). Surgery for stage IV is possible and has a benefit in case of complete peritoneal resection (LoE3). Pelvic and aortic lymphadenectomies are recommended in case of clinical or radiological suspicious lymph nodes (grade B). In absence of clinical or radiological suspicious lymph nodes and in case of complete peritoneal resection during initial debulking surgery, lymphadenectomy can be omitted because it won't change nor medical treatment nor overall survival (grade B). Neoadjuvant chemotherapy can be proposed in case of: impossibility to perform initial complete surgical resection (grade B) ; alteration of general state or co-morbidities or elderly patient (in order to decrease morbidity and increase quality of life) (grade B); stage IV with multiple intra-hepatic or pulmonary metastasis or important ascites with miliary (grade B). In case of stage III or IV ovarian cancer diagnosed on a biopsy during prior laparotomy, a neoadjuvant chemotherapy and interval debulking surgery should be preferred (gradeC). In case of palliative surgery or peroperative impossibility to perform a complete resection, no data regarding the type of surgery to perform influencing survival or quality of life is available. Peritoneal carcinosis description before resection and residual disease at the end of the surgery should be reported (size, location and reason of non-extirpability) (grade B). A score of peritoneal carcinosis such as Peritoneal Carcinosis Index (PCI) should be used in order to objectively evaluate the tumoral burden (gradeC). A standardized operative report is recommended (gradeC).
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Affiliation(s)
- G Ferron
- Inserm CRCT 19, département de chirurgie oncologique, institut Claudius Regaud, institut universitaire du cancer, 31000 Toulouse, France
| | - F Narducci
- Inserm U1192, département de chirurgie oncologique, centre Oscar Lambret, 59000 Lille, France
| | - N Pouget
- Département de chirurgie oncologique, chirurgie gynécologique et mammaire, institut Curie, site Saint-Cloud, 75005 Paris, France
| | - C Touboul
- IMRB, U955 Inserm, service de gynécologie obstétrique et médecine de la reproduction, centre hospitalier intercommunal de Créteil, institut Mondor de recherche biomédicale, 94000 Créteil, France.
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Rubello D, Marzola MC, Colletti PM. Re: The Prognostic Value of 18F-FDG PET/CT in Monitoring Chemotherapy in Ovarian Cancer Both at Initial Diagnosis and at Recurrent Disease. Clin Nucl Med 2018; 44:342-344. [PMID: 30371573 DOI: 10.1097/rlu.0000000000002318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Domenico Rubello
- Nuclear Medicine and PET Unit Department of Molecular Imaging Radiology, and Clinical Pathology Rovigo Hospital Rovigo,
| | - Maria Cristina Marzola
- Nuclear Medicine and PET Unit Department of Molecular Imaging Radiology, and Clinical Pathology Rovigo Hospital Rovigo,
| | - Patrick M Colletti
- Department of Nuclear Medicine University of Southern California Los Angeles, CA
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Cole AL, Austin AE, Hickson RP, Dixon MS, Barber EL. Review of methodological challenges in comparing the effectiveness of neoadjuvant chemotherapy versus primary debulking surgery for advanced ovarian cancer in the United States. Cancer Epidemiol 2018; 55:8-16. [PMID: 29758492 PMCID: PMC6054914 DOI: 10.1016/j.canep.2018.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 12/20/2022]
Abstract
Randomized trials outside the U.S. have found non-inferior survival for neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced ovarian cancer (AOC). However, these trials reported lower overall survival and lower rates of optimal debulking than U.S. studies, leading to questions about generalizability to U.S. practice, where aggressive debulking is more common. Consequently, comparative effectiveness in the U.S. remains controversial. We reviewed U.S. comparative effectiveness studies of NACT versus PDS for AOC. Here we describe methodological challenges, compare results to trials outside the U.S., and make suggestions for future research. We identified U.S. studies published in 2010 or later that evaluated the comparative effectiveness of NACT versus PDS on survival in AOC through a PubMed search. Two independent reviewers abstracted data from eligible articles. Nine of 230 articles were eligible for review. Methodological challenges included unmeasured confounders, heterogeneous treatment effects, treatment variations over time, and inconsistent measurement of treatment and survival. Whereas some limitations were unavoidable, several limitations noted across studies were avoidable, including conditioning on mediating factors and immortal time introduced by measuring survival beginning from diagnosis. Without trials in the U.S., non-randomized studies are an important source of evidence for the ideal treatment for AOC. However, several methodological challenges exist when assessing the comparative effectiveness of NACT versus PDS in a non-randomized setting. Future observational studies must ensure that treatment is consistent throughout the study period and that treatment groups are comparable. Rapidly-evolving oncology data networks may allow for identification of treatment intent and other important confounders.
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Affiliation(s)
- Ashley L Cole
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, 27599, USA.
| | - Anna E Austin
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Ryan P Hickson
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Matthew S Dixon
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Emma L Barber
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, 60611 USA
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Neoadjuvant chemotherapy or primary debulking surgery in FIGO IIIC and IV patients; results from a survey study in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2018. [PMID: 29525755 DOI: 10.1016/j.ejogrb.2018.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Primary debulking surgery (PDS) followed by adjuvant chemotherapy is historically recommended as first line treatment for advanced stage ovarian cancer. Two randomized controlled trials, however, showed similar efficacy and reduced toxicity with neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS). Nevertheless, uptake of NACT-IDS varies widely between hospitals, which cannot be explained by difference in patient populations. In this survey, we therefore aimed to evaluate the views on NACT-IDS among all Dutch gynaecologists and medical oncologists involved in the treatment of ovarian cancer. STUDY DESIGN An e-mail link to the online questionnaire was sent to all medical oncologists and gynaecologists in the Netherlands, regardless of their (sub)specializations. The data was analysed using descriptive statistics and chi-square tests were used to analyse differences between groups. RESULTS Three-hundred-forty physicians were invited to fill out the questionnaire. After two reminders, 167 of them responded (49%). Among the responders, 82% of the gynaecologists versus 93% of the medical oncologists considered the available evidence sufficiently convincing to treat advanced stage ovarian cancer patients with NACT-IDS (p = 0.076). Moreover, 33% of gynaecologists and 62% of medical oncologists preferred NACT-IDS to PDS as first line treatment (p = 0.001). While most responders (86%) indicated that selecting the right patients for NACT-IDS is difficult, those with bulky disease, FIGO stage IV or metastases near the porta hepatica were most likely to undergo NACT-IDS. CONCLUSION The majority of Dutch gynaecologists and medical oncologists adopted NACT-IDS as an alternative treatment approach for advanced stage primary ovarian cancer. About two-thirds of medical oncologists and one-third of gynaecologists prefer NACT-IDS to PDS as first line treatment in this setting. Improving patient selection is considered of paramount importance.
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Qin M, Jin Y, Ma L, Zhang YY, Pan LY. The role of neoadjuvant chemotherapy followed by interval debulking surgery in advanced ovarian cancer: a systematic review and meta-analysis of randomized controlled trials and observational studies. Oncotarget 2018; 9:8614-8628. [PMID: 29492221 PMCID: PMC5823572 DOI: 10.18632/oncotarget.23808] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 11/15/2017] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE We aimed to performed a meta-analysis and systematic review on the role of neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) in advanced ovarian cancer (AOC) patients. MATERIALS AND METHODS We searched PubMed, EMBASE, and the Cochrane Library for relevant articles. All statistical analyses were performed in Review Manager 5.3.5. RESULTS In two randomized controlled trials (RCTs), there was no significant difference in overall survival (OS) (HR = 0.93, 95% CI: 0.81-1.06) or progression-free survival (PFS) (HR = 0.97, 95% CI: 0.86-1.09). Few adverse events (HR = 0.37, 95% CI: 0.19-0.72) and a high optimal debulking surgery rate (HR = 1.69, 95% CI: 1.50-1.91) were observed with NACT. In 22 observational studies, primary debulking surgery (PDS) yielded better OS (HR = 1.38, 95% CI: 1.19-1.60) but not progression-free survival (PFS) (HR = 1.03, 95% CI: 0.86-1.23). An increased optimal cytoreduction rate (HR = 1.17, 95% CI: 1.12-1.22) was observed with NACT. Irrespective of the degree of residual disease, OS was longer in the PDS group than that in the NACT group. Patients with FIGO stage III (HR = 1.43, 95% CI: 1.05-1.95) and IV (HR = 1.14, 95% CI: 1.06-1.23) disease had better survival with PDS. CONCLUSIONS Treatment with NACT-IDS improves perioperative outcomes and optimal cytoreduction rates, but it may not improve OS. NACT-IDS is not inferior to PDS-CT in terms of survival outcomes in selected AOC patients. Future studies should focus on candidate selection for NACT.
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Affiliation(s)
- Meng Qin
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ying Jin
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Li Ma
- Department of Interventional Radiology and Vascular Surgery, Taiyuan Center Hospital, Taiyuan 030009, China
| | - Yan-Yan Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ling-Ya Pan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Marzola MC, Chondrogiannis S, Rubello D. Fludeoxyglucose F 18 PET/CT Assessment of Ovarian Cancer. PET Clin 2018; 13:179-202. [PMID: 29482749 DOI: 10.1016/j.cpet.2017.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ovarian cancer is one of the most common gynecologic cancers and one of the leading causes of cancer death in women. It is often asymptomatic in early stages, and thus most patients are diagnosed when it is of advanced stage. For these reasons, the role of biomarkers and tomographic imaging is crucial. Fludeoxyglucose F 18 PET/CT is a useful imaging modality in different clinical settings of the disease, overcoming some limits of conventional imaging and influencing prognosis and therapeutic approaches. PET/MR imaging is an emerging modality, and its potential role remains to be explored.
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Affiliation(s)
- Maria Cristina Marzola
- Department of Nuclear Medicine PET/CT Centre, S. Maria della Misericordia Hospital, Viale 3 Martiri, 140, Rovigo 45100, Italy.
| | - Sotirios Chondrogiannis
- Department of Nuclear Medicine PET/CT Centre, S. Maria della Misericordia Hospital, Viale 3 Martiri, 140, Rovigo 45100, Italy
| | - Domenico Rubello
- Department of Nuclear Medicine PET/CT Centre, S. Maria della Misericordia Hospital, Viale 3 Martiri, 140, Rovigo 45100, Italy
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Esmat M, Ashour M. A comparison between primary debulking surgery and primary chemotherapy in patients with advanced ovarian cancer: a retrospective study. AL-AZHAR ASSIUT MEDICAL JOURNAL 2018. [DOI: 10.4103/azmj.azmj_7_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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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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Subtypes of stage IV ovarian cancer; response to treatment and patterns of disease recurrence. Gynecol Oncol 2017; 146:273-278. [DOI: 10.1016/j.ygyno.2017.05.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 05/16/2017] [Accepted: 05/17/2017] [Indexed: 11/20/2022]
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Management of advanced ovarian cancer in South West Wales - a comparison between primary debulking surgery and primary chemotherapy treatment strategies in an unselected, consecutive patient cohort. Cancer Epidemiol 2017; 49:85-91. [PMID: 28599137 DOI: 10.1016/j.canep.2017.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 04/26/2017] [Accepted: 05/29/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study represents the first reported outcomes for patients with advanced ovarian cancer (AOC) in South-West Wales undergoing treatment with primary debulking surgery or primary chemotherapy respectively. METHODS This is a retrospective study of consecutive, unselected patients with advanced ovarian, fallopian tube or primary peritoneal cancer (FIGO III/IV) presenting to a regional cancer centre between October 2007 and October 2014. Patients were identified from Welsh Cancer Services records and relevant data was extracted from electronic National Health Service (NHS) databases. Main outcome measures were median overall survival (OS), progression free survival (PFS) and perioperative adverse events. Hazard ratio estimation was carried out with Cox Regression analysis and survival determined by Kaplan-Meier plots. RESULTS Of 220 women with AOC, 32.3% underwent primary debulking surgery (PDS) and 67.7% primary chemotherapy and interval debulking (PCT-IDS). Patients were often elderly (median age 67 years) with a poor performance status (26.5% PS >1). Complete cytoreduction (0cm residual) was achieved in 32.4% of patients in the PDS group and in 50.0% of patients undergoing IDS. Median OS for all patients was 21.9 months (PDS: 27.0 and PCT-IDS: 19.2 months; p >0.05) and median PFS was 13.1 months (PDS: 14.3 months and PCT-IDS: 13.0 months; p >0.05). Median overall and progression free survival for patients achieving complete cytoreduction were 48.0 and 23.2 months respectively in the PDS group and 35.4 months and 18.6 months in the IDS group (p >0.05). CONCLUSION This retrospective study of an unselected, consecutive cohort of women with AOC in South West Wales shows comparable survival outcomes with recently published trials, despite the relatively advanced age and poor performance status of our patient cohort. Over the seven-year study period, our data also demonstrated a non-significant trend towards improved survival following primary surgery in patients who achieved maximal cytoreduction. Our future aim therefore is to examine and develop the role of extended surgery in these patients.
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Barber EL, Dusetzina SB, Stitzenberg KB, Rossi EC, Gehrig PA, Boggess JF, Garrett JM. Variation in neoadjuvant chemotherapy utilization for epithelial ovarian cancer at high volume hospitals in the United States and associated survival. Gynecol Oncol 2017; 145:500-507. [PMID: 28366545 PMCID: PMC5503107 DOI: 10.1016/j.ygyno.2017.03.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/19/2017] [Accepted: 03/21/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To estimate variation in the use of neoadjuvant chemotherapy by high volume hospitals and to determine the association between hospital utilization of neoadjuvant chemotherapy and survival. METHODS We identified incident cases of stage IIIC or IV epithelial ovarian cancer in the National Cancer Database from 2006 to 2012. Inclusion criteria were treatment at a high volume hospital (>20 cases/year) and treatment with both chemotherapy and surgery. A logistic regression model was used to predict receipt of neoadjuvant chemotherapy based on case-mix predictors (age, comorbidities, stage etc). Hospitals were categorized by the observed-to-expected ratio for neoadjuvant chemotherapy use as low, average, or high utilization hospitals. Survival analysis was performed. RESULTS We identified 11,574 patients treated at 55 high volume hospitals. Neoadjuvant chemotherapy was used for 21.6% (n=2494) of patients and use varied widely by hospital, from 5%-55%. High utilization hospitals (n=1910, 10 hospitals) had a median neoadjuvant chemotherapy rate of 39% (range 23-55%), while low utilization hospitals (n=2671, 14 hospitals) had a median rate of 10% (range 5-17%). For all ovarian cancer patients adjusting for clinical and socio-demographic factors, treatment at a hospital with average or high neoadjuvant chemotherapy utilization was associated with a decreased rate of death compared to treatment at a low utilization hospital (HR 0.90 95% CI 0.83-0.97 and HR 0.85 95% CI 0.75-0.95). CONCLUSIONS Wide variation exists in the utilization of neoadjuvant chemotherapy to treat stage IIIC and IV epithelial ovarian cancer even among high volume hospitals. Patients treated at hospitals with low rates of neoadjuvant chemotherapy utilization experience decreased survival.
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Affiliation(s)
- Emma L Barber
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States.
| | - Stacie B Dusetzina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States; Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Karyn B Stitzenberg
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States; Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, NC, United States
| | - Emma C Rossi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Paola A Gehrig
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - John F Boggess
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Joanne M Garrett
- Division of Family Planning, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States
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Huelsmann E, Zighelboim I, Ahmed A, Dewdney S. The role of neoadjuvant chemotherapy in the management of patients with advanced stage ovarian cancer: Survey results from members of the society of gynecologic oncologists, a 5-year follow-up. Gynecol Oncol Rep 2017; 20:47-50. [PMID: 28317007 PMCID: PMC5344220 DOI: 10.1016/j.gore.2017.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 02/09/2017] [Accepted: 02/10/2017] [Indexed: 11/16/2022] Open
Abstract
NACT use among SGO members for ovarian cancer is explored given recent trials. Fewer SGO members feel they can't predict optimal cytoreduction pre-operatively. Laparoscopy use has increased both for diagnosis and treatment of ovarian cancer. Very high optimal cytoreduction rates are reported from SGO members. Despite recent studies, SGO members don't regularly treat patients with NACT/ID.
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Affiliation(s)
- Erica Huelsmann
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center/MedStar Georgetown University Hospital, United States
| | - Israel Zighelboim
- Department of Gynecologic Oncology, St. Luke's Cancer Care Associates, Temple University School of Medicine, United States
| | - Amina Ahmed
- Department of Obstetrics and Gynecology, Division of Gynecology Oncology, Rush University Medical Center, United States
| | - Summer Dewdney
- Department of Obstetrics and Gynecology, Division of Gynecology Oncology, Rush University Medical Center, United States
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Luo Y, Lee M, Kim HS, Chung HH, Song YS. Effect of neoadjuvant chemotherapy on platinum resistance in stage IIIC and IV epithelial ovarian cancer. Medicine (Baltimore) 2016; 95:e4797. [PMID: 27603388 PMCID: PMC5023911 DOI: 10.1097/md.0000000000004797] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
It remains controversial whether neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) induces chemoresistance in advanced epithelial ovarian cancer (EOC) compared with primary debulking surgery (PDS). The aim of this study was to compare platinum-resistant recurrence following treatment with NACT-IDS or PDS in patients with stage IIIC and IV EOC.We retrospectively reviewed the records of 341 patients who underwent PDS or NACT-IDS for Federation of Gynecology and Obstetrics stage IIIC or IV EOC between March 1990 and December 2010. Risk factors of platinum resistance, including NACT, postoperative residual tumor size, and various clinicopathological factors, were evaluated by univariate and multivariate logistic regression analyses. Survival analysis was performed by the Kaplan-Meier method and Cox regression modeling to measure overall survival (OS).Of 341 patients, 58 (17.0%) underwent NACT-IDS and 283 (83.0%) were treated with PDS. Twenty-nine (50.0%) patients developed platinum-resistant disease at first relapse after NACT-IDS and 99 (35.0%) patients recurred after PDS (P = 0.033). In the multivariate logistic regression analyses, NACT-IDS and postoperative residual tumor mass >1 cm were risk factors for platinum-resistant recurrence (adjusted odds ratios 2.950 and 2.915; 95% confidence intervals [CIs] 1.572-5.537 and 1.780-4.771, P = 0.001 and 0.000, respectively). Postoperative residual tumor mass >1 cm and platinum-resistant disease were significantly correlated with shorter OS (adjusted hazard ratios 1.579 and 4.078; 95% CI 1.193-2.089 and 3.074-5.412, P = 0.001 and 0.000, respectively), whereas NACT-IDS did not extend OS.NACT-IDS increases the risk of platinum-resistant recurrence in patients with stage IIIC and IV EOC.
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Affiliation(s)
- Yanlin Luo
- Department of Gynecologic Oncology, Affiliated Cancer Hospital of Zhengzhou University (Henan Cancer Hospital), Zhengzhou, China
| | - Maria Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Hoon Chung
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Sang Song
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Major in Biomodulation, World Class University, Seoul National University, Seoul, Korea
- Correspondence: Yong Sang Song, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (e-mail: )
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Goh J, Mohan GR, Ladwa R, Ananda S, Cohen PA, Baron-Hay S. Frontline treatment of epithelial ovarian cancer. Asia Pac J Clin Oncol 2016; 11 Suppl 6:1-16. [PMID: 26669253 DOI: 10.1111/ajco.12449] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2015] [Indexed: 11/29/2022]
Abstract
This is a contemporaneous review of the frontline treatment of epithelial ovarian cancer (EOC), specifically on the importance of optimal surgical cytoreductive surgery, the pivotal role of platinum-based adjuvant chemotherapy (which encompasses intraperitoneal and dose-dense regimens) and the emergence of neo-adjuvant chemotherapy. Additionally, the benefit of concurrent and maintenance bevacizumab in the suboptimally debullked stage III and stage IV EOC setting is also reviewed. The article also discusses the increasing importance of prognostic and predictive molecular biomarkers in the future management of EOC.
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Affiliation(s)
- Jeffrey Goh
- Royal Brisbane and Women's Hospital (RBWH), Herston.,University of Queensland, St Lucia.,Greenslopes Private Hospital, Greenslopes, Queensland
| | - G Raj Mohan
- King Edward Memorial Hospital, Subiaco.,St John of God Hospital, Subiaco.,School of Women's and Infants' Health, University of Western Australia, Crawley, Western Australia
| | - Rahul Ladwa
- Royal Brisbane and Women's Hospital (RBWH), Herston
| | | | - Paul A Cohen
- St John of God Hospital, Subiaco.,School of Women's and Infants' Health, University of Western Australia, Crawley, Western Australia
| | - Sally Baron-Hay
- Royal North Shore Hospital, St Leonards, New South Wales, Australia
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FIGO stage IV epithelial ovarian, fallopian tube and peritoneal cancer revisited. Gynecol Oncol 2016; 142:597-607. [PMID: 27335253 DOI: 10.1016/j.ygyno.2016.06.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 12/14/2022]
Abstract
Epithelial ovarian, fallopian tube and peritoneal cancer (EOC) is the seventh most common cancer diagnosis among women worldwide and shows the highest mortality rate of all gynecologic tumors. Different histological and anatomic spread patterns as well as multiple gene-expression based studies have demonstrated that EOC is indeed a heterogeneous disease. The prognostic factors that best predict the survival in this disease include: age, performance status and patient's comorbidities at the time of diagnosis; tumor biology, histological type, amount of residual tumor after surgery and finally tumor stage as surrogate for pre-operative tumor burden and growth pattern. In the majority of patients, the disease is diagnosed in advanced stage, disseminated intra- and/or extra-abdominally. It is unclear whether this is a consequence of distinct tumor biology, absence of anatomic barriers between ovary and the abdominal cavity, delay of diagnosis and/or the lack of sufficient early detection methods. FIGO stage IV disease, defined as tumor spread outside the abdominal cavity (including malignant pleural effusion) and/or visceral metastases, will be present in 12-33% of the patients at initial diagnosis. Overall, median survival for patients with stage IV disease ranges from 15 to 29months, with an estimated 5-year survival of approximately 20%. Unfortunately, over the past decades the overall survival gain compared to stage III remains disappointing. The current review aims to summarize the current data published in the international literature concerning FIGO stage IV EOC and discusses the published evidence for the clinical management of these patients.
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Makar AP, Tropé CG, Tummers P, Denys H, Vandecasteele K. Advanced Ovarian Cancer: Primary or Interval Debulking? Five Categories of Patients in View of the Results of Randomized Trials and Tumor Biology: Primary Debulking Surgery and Interval Debulking Surgery for Advanced Ovarian Cancer. Oncologist 2016; 21:745-54. [PMID: 27009938 PMCID: PMC4912357 DOI: 10.1634/theoncologist.2015-0239] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/11/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Standard treatment of stage III and IV advanced ovarian cancer (AOC) consists of primary debulking surgery (PDS) followed by chemotherapy. Since the publication of the European Organisation for Research and Treatment of Cancer/National Cancer Institute of Canada trial, clinical practice has changed and many AOC patients are now treated with neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). The best option remains unclear. Ovarian cancer is a heterogenic disease. Should we use the diversity in biology of the tumor and patterns of tumor localization to better stratify patients between both approaches? METHODS This analysis was based on results of five phase III randomized controlled trials on PDS and IDS in AOC patients, three Cochrane reviews, and four meta-analyses. RESULTS There is still no evidence that NACT-IDS is superior to PDS. Clinical status, tumor biology, and chemosensitivity should be taken into account to individualize surgical approach. Nonserous (type 1) tumors with favorable prognosis are less chemosensitive, and omitting optimal PDS will lead to less favorable outcome. For patients with advanced serous ovarian cancer (type 2) associated with severe comorbidity or low performance status, NACT-IDS is the preferred option. CONCLUSION We propose stratifying AOC patients into five categories according to patterns of tumor spread (reflecting the biologic behavior), response to chemotherapy, and prognosis to make a more rational decision between PDS and NACT-IDS. IMPLICATIONS FOR PRACTICE Trial results regarding effect and timing of debulking surgery on survival of patients with advanced ovarian cancer have been inconsistent and hence difficult to interpret. This review examines all randomized trials on primary and interval debulking surgery in advanced ovarian cancer, including the results of the newly published CHORUS (chemotherapy or upfront surgery for newly diagnosed advanced ovarian cancer) trial. On the basis of findings presented in this review and in view of recent molecular data on the heterogeneity of ovarian tumors, we propose prognostic categorization for patients with advanced ovarian cancer to better distinguish those who would optimally benefit from primary debulking from those who would better benefit from interval debulking following neoadjuvant chemotherapy.
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Affiliation(s)
- Amin P Makar
- Department of Gynecologic Oncology, the Middelheim Hospital, Antwerpen, Belgium Department of Gynecologic Oncology, University Hospital of Ghent, Ghent, Belgium
| | - Claes G Tropé
- Department of Gynecologic Oncology, The Norwegian Radium Hospital, Oslo, Norway
| | - Philippe Tummers
- Department of Gynecologic Oncology, University Hospital of Ghent, Ghent, Belgium
| | - Hannelore Denys
- Department of Medical Oncology, University Hospital of Ghent, Ghent, Belgium
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Ørskov M, Iachina M, Guldberg R, Mogensen O, Mertz Nørgård B. Predictors of mortality within 1 year after primary ovarian cancer surgery: a nationwide cohort study. BMJ Open 2016; 6:e010123. [PMID: 27103625 PMCID: PMC4853993 DOI: 10.1136/bmjopen-2015-010123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To identify predictors of mortality within 1 year after primary surgery for ovarian cancer. DESIGN Prospective nationwide cohort study from 1 January 2005 to 31 December 2012. SETTING Evaluation of data from the Danish Gynaecology Cancer Database and the Danish Civil Registration System. PARTICIPANTS 2654 women who underwent surgery due to a diagnosis of primary ovarian cancer. OUTCOME MEASURES Overall survival and predictors of mortality within 0-180 and 181-360 days after the primary surgery. Examined predictors were age, preoperative American Society of Anesthesiologists (ASA) score, body mass index (BMI), International Federation of Gynaecology and Obstetrics (FIGO) stage, residual tumour tissue after surgery, perioperative blood transfusion and calendar year of surgery. RESULTS The overall 1-year survival was 84%. Within 0-180 days after surgery, the 3 most important predictors of mortality from the multivariable model were residual tumour tissue >2 cm versus no residual tumour (HR=4.58 (95% CI 3.20 to 6.59)), residual tumour tissue ≤2 cm versus no residual tumour (HR=2.50 (95% CI 1.63 to 3.82)) and age >64 years versus age ≤64 years (HR=2.33 (95% CI 1.69 to 3.21)). Within 181-360 days after surgery, FIGO stages III-IV versus I-II (HR=2.81 (95% CI 1.75 to 4.50)), BMI<18.5 vs 18.5-25 kg/m(2) (HR=2.08 (95% CI 1.18 to 3.66)) and residual tumour tissue >2 cm versus no residual tumour (HR=1.84 (95% CI 1.25 to 2.70)) were the 3 most important predictors. CONCLUSIONS The most important predictors of mortality within 1 year after surgery were residual tumour tissue (0-180 days after surgery) and advanced FIGO stage (181-360 days after surgery). However, our results suggest that the surgeon should not just aim at radical surgery, but also pay special attention to comorbidity, nutritional state, age >64 years and the need for perioperative blood transfusion.
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Affiliation(s)
- Mette Ørskov
- Research Unit of Gynecology, Department of Gynecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Maria Iachina
- Research Unit of Clinical Epidemiology, Centre for Clinical Epidemiology Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rikke Guldberg
- Research Unit of Clinical Epidemiology, Centre for Clinical Epidemiology Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ole Mogensen
- Research Unit of Gynecology, Department of Gynecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Mertz Nørgård
- Research Unit of Clinical Epidemiology, Centre for Clinical Epidemiology Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Outcome of Epithelial Ovarian Cancer: Time for Strategy Trials to Resolve the Problem of Optimal Timing of Surgery. Int J Gynecol Cancer 2016; 25:993-9. [PMID: 25914962 DOI: 10.1097/igc.0000000000000461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The standard treatment of ovarian cancer is the combination of debulking surgery and chemotherapy. There is an ongoing discussion on which treatment is best: primary debulking surgery (PDS) or neoadjuvant chemotherapy with interval debulking (NACT-IDS). Even a large randomized trial has not settled this issue. We examined whether comparing a specified treatment protocol would not be a more logical approach to answer this type of discussions. METHODS A retrospective study of 142 consecutively treated patients according to a fixed protocol between 2000 and 2012 was conducted. Disease-free survival and overall survival were calculated by univariate and multivariate analyses for the whole group and for advanced stages separately. Specific differences between PDS and NACT-IDS were studied. Comparison of results from large databases was made. RESULTS Disease-free survival and overall 5-year survival for the whole group were 35% and 50%. For the advanced stages, disease-free survival and overall 5-year survival were 14% and 36%, with a median disease-free and overall survival of 16 and 44 months. Of the 98 women with advanced ovarian carcinoma, 54% of operable patients underwent PDS and 44% underwent NACT-IDS. More patients in the PDS group were optimally (<1 cm) debulked: 80% vs 71%. There was no significant difference in survival between PDS or NACT-IDS. Optimally debulked patients had a significant better overall survival in multivariate analysis with a hazard ratio of 2.1. DISCUSSION Outcome of treatment according to a fixed protocol with a mixture of PDS and NACT-IDS was similar to results from large databases. We hypothesize that comparison of a specific strategy may yield more useful results than awaiting the perfect randomized trial.
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Kehoe S, Fares R, Phillips A. Ovarian cancer: is chemotherapy before surgery the way forward? INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2016. [DOI: 10.2217/ije.15.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The treatment of advanced ovarian cancer is a combination of surgery and platin-based chemotherapy, with surgery traditionally the first intervention. Neoadjuvant therapy was only used in women who were deemed unfit for an operation. However, in recent years, two prospective randomized studies have evaluated the concept of neoadjuvant chemotherapy, and in both studies the results revealed that neoadjuvant chemotherapy with delayed surgery afforded similar survival rates compared with primary surgery but with reduced treatment-related morbidity. Thus, a novel evidence-based alternative approach to advanced ovarian cancer is now available.
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Affiliation(s)
- Sean Kehoe
- Institute of Cancer & Genomics, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- St Peter's College, New Inn Hall St, Oxford OX1 2DL, UK
| | - Rami Fares
- Institute of Cancer & Genomics, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Pan Birmingham Gynecological Cancer Center, City Hospital, Birmingham, West Midlands B18 7QH, UK
| | - Andrew Phillips
- Pan Birmingham Gynecological Cancer Center, City Hospital, Birmingham, West Midlands B18 7QH, UK
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Chiva L, Lapuente F, Castellanos T, Alonso S, Gonzalez-Martin A. What Should We Expect After a Complete Cytoreduction at the Time of Interval or Primary Debulking Surgery in Advanced Ovarian Cancer? Ann Surg Oncol 2015; 23:1666-73. [DOI: 10.1245/s10434-015-5051-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Indexed: 11/18/2022]
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Vidal F, Al Thani H, Haddad P, Luyckx M, Stoeckle E, Morice P, Leblanc E, Lecuru F, Daraï E, Classe JM, Pomel C, Mahfoud Z, Ferron G, Querleu D, Rafii A. Which Surgical Attitude to Choose in the Context of Non-Resectability of Ovarian Carcinomatosis: Beyond Gross Residual Disease Considerations. Ann Surg Oncol 2015; 23:434-42. [PMID: 26542592 DOI: 10.1245/s10434-015-4890-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND In ovarian cancer, the increased rate of radical surgery comprising upper abdominal procedures has participated to improve overall survival (OS) in advanced stages by increasing the rate of complete cytoreductions. However, in the context of non-resectability, it is unclear whether radical surgery should be considered when it would lead to microscopic but visible disease (≤1 cm). We aimed to compare the survival outcomes among patients with incomplete cytoreduction according to the extent of surgery. METHODS Overall, 148 patients presenting with advanced stage ovarian carcinomas were included in this retrospective study, regardless of treatment schedule. These patients were stratified according to the extent of surgery (standard or radical). Complete cytoreduction at the time of debulking surgery could not be carried out in all cases. RESULTS Among our study population (n = 148), 96 patients underwent standard procedures (SPs) and 52 underwent radical surgeries (RP). Patients in the SP group had a lower Peritoneal Index Cancer (PCI) at baseline (12.6 vs. 14.9; p = 0.049). After PCI normalization, we observed similar OS in the SP and RP groups (39.7 vs. 43.1 months; p = 0.737), while patients in the SP group had a higher rate of residual disease >10 mm (p < 10(-3)). Patients in the RP group had an increased rate of relapse (p = 0.005) but no difference in disease-free survival compared with the SP group (22.2 for SP vs. 16.3 months; p = 0.333). Residual disease status did not impact survival outcomes. CONCLUSIONS In the context of non-resectable, advanced stage ovarian cancer, standard surgery seems as beneficial as radical surgery regarding survival outcomes and should be considered to reduce surgery-associated morbidity.
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Affiliation(s)
- Fabien Vidal
- Stem Cell and Microenvironment Laboratory, Weill Cornell Medical College in Qatar, Education City, Qatar Foundation, Doha, Qatar.,Department of Genetic Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Haya Al Thani
- Stem Cell and Microenvironment Laboratory, Weill Cornell Medical College in Qatar, Education City, Qatar Foundation, Doha, Qatar
| | - Pascale Haddad
- Biostatistics Core, Weill Cornell Medical College in Qatar, Education City, Qatar Foundation, Doha, Qatar
| | - Mathieu Luyckx
- Department of Gynecologic Surgery, Saint Luc Academic Hospital, Catholic University of Louvain, Bruxelles, Belgium
| | - Eberhard Stoeckle
- Comprehensive Cancer Center, Department of Surgery, Institut Bergonie, Bordeaux, France
| | - Philippe Morice
- Department of Gynecologic Surgery, Institut Gustave Roussy, Cancer Campus, Grand Paris, Villejuif, France
| | - Eric Leblanc
- Department of Gynecologic Oncology, Centre Oscar Lambret, Lille, France
| | - Fabrice Lecuru
- Department of Gynecologic Oncology, Georges Pompidou European Hospital, Paris, France
| | - Emile Daraï
- Department of Gynecologic Surgery, Tenon Hospital, Paris, France
| | - Jean-Marc Classe
- Department of Surgical Oncology, Centre Gauducheau, Comprehensive Cancer Center, Saint Herblain, France
| | - Christophe Pomel
- Department of Surgical Oncology, Jean Perrin Cancer Center, Clermont-Ferrand, France
| | - Ziyad Mahfoud
- Biostatistics Core, Weill Cornell Medical College in Qatar, Education City, Qatar Foundation, Doha, Qatar
| | - Gwenael Ferron
- Comprehensive Cancer Center, Department of Surgical Oncology, Institut Claudius Regaud, Toulouse, France
| | - Denis Querleu
- Comprehensive Cancer Center, Department of Surgical Oncology, Institut Claudius Regaud, Toulouse, France
| | - Arash Rafii
- Stem Cell and Microenvironment Laboratory, Weill Cornell Medical College in Qatar, Education City, Qatar Foundation, Doha, Qatar. .,Department of Genetic Medicine, Weill Cornell Medical College, New York, NY, USA. .,Department of Genetic Medicine and Obstetrics and Gynecology, Weill Cornell Medical College in Qatar, Education City, Doha, Qatar.
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Multiple Cycles of Neoadjuvant Chemotherapy Associated With Poor Survival in Bulky Stage IIIC and IV Ovarian Cancer. Int J Gynecol Cancer 2015. [DOI: 10.1097/igc.0000000000000517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Impact of Age on 30-Day Mortality and Morbidity in Patients Undergoing Surgery for Ovarian Cancer. Int J Gynecol Cancer 2015; 25:1216-23. [DOI: 10.1097/igc.0000000000000486] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
ObjectiveTo examine the effect of age on postoperative 30-day morbidity and mortality after surgery for ovarian cancer.MethodsThe American College of Surgeons National Surgical Quality Improvement Program files were used to identify patients with ovarian cancer who underwent surgery in 2005 to 2011. Women were divided into 4 age groups: <60, 60 to 69, 70 to 79, and ≥80 years. Multivariable logistic regression models were performed.ResultsOf 2087 patients included, 47% were younger than 60 years, 28% were 60 to 69 years old, 18% were 70 to 79 years old, and 7% were 80 years or older. Overall 30-day mortality and morbidity rates were 2% and 30%. Elderly patients 80 years or older were more likely to die within 30 days compared with patients younger than 60 years, 60 to 69 years old, and 70 to 79 years old (9.2% vs. 0.6% vs .2.8% vs 2.5%, P < 0.001). Elderly patient aged 80 years or older were more likely to develop pulmonary (9% vs 2% vs 5% vs 3%, P < 0.001) and septic (9% vs 3% vs 5% vs 4%, P = 0.01) complications compared with patients younger than 60 years, 60 to 69 years old, and 70 to 79 years old, respectively. No difference in the risk of renal (0.2% vs 1% vs 1% vs 1%, P = 0.20) complications and surgical reexploration (4% vs 4% vs 3% vs 5%, P = 0.80) between the 4 age groups. In multivariable analyses after adjusting for other confounders, age was a significant predictor of 30-day postoperative mortality and morbidity. Compared with younger patients, octogenarians were 9-times more likely to die and 70% more likely to develop complications within 30 days after surgery. Other significant predictors of 30-day mortality were higher American Society of Anesthesiologists class and hypoalbuminemia (serum albumin ≤ 3 g/dL), whereas, surgical complexity, higher American Society of Anesthesiologists class, longer operative time, and hypoalbuminemia were other significant predictors of 30-day morbidity.ConclusionsElderly patients have a higher risk of perioperative mortality and morbidity within 30 days. Therefore, those patients should be counseled thoroughly about the risk of primary debulking surgery vs neoadjuvant chemotherapy.
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Bian C, Yao K, Li L, Yi T, Zhao X. Primary debulking surgery vs. neoadjuvant chemotherapy followed by interval debulking surgery for patients with advanced ovarian cancer. Arch Gynecol Obstet 2015. [DOI: 10.1007/s00404-015-3813-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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