Consider Chemotherapy First for Advanced Ovarian Cancer

Neoadjuvant chemotherapy is a reasonable alternative to primary debulking surgery in women with stage IIIc/IV ovarian cancer, according to new intervention review.¹

In most women, epithelial ovarian cancer, the most common form of ovarian cancer, is at an advanced stage when diagnosed. Both surgery and chemotherapy are standard therapies for advanced ovarian epithelial cancer, but cytoreductive surgery typically is performed first, followed by neoadjuvant chemotherapy. However, it is unknown whether using chemotherapy first can offer any benefit.

To determine whether the order of treatment affects outcomes, specifically whether treating women who have advanced epithelial ovarian cancer with chemotherapy before cytoreductive surgery has any advantages over conventional treatment, in which chemotherapy follows maximal cytoreductive surgery, researchers sought randomized controlled trials of women with advanced epithelial ovarian cancer (stage III/IV) who were randomly allocated to either platinum-based chemotherapy before surgery or surgery followed by chemotherapy. Only one randomized controlled trial met pre-specified inclusion criteria, and the trial involved 718 women with stage IIIc/IV ovarian cancer. In that trial, women received either neoadjuvant chemotherapy followed by interval debulking surgery or primary debulking surgery followed by chemotherapy.

The rates of overall survival and progression-free survival were similar between treatment groups, according to the review findings.1 However, significantly more women in the group that had primary debulking surgery as initial treatment, compared with the group who had interval debulking surgery after chemotherapy, experienced serious adverse events (grade 3/4) that were related to surgery. These adverse events included hemorrhage (23 in the primary group vs 12 in the interval group), venous thromboembolism (8 in the primary group vs 0 in the interval group), and infection (25 in the primary group vs 5 in the interval group). Quality of life measurements were similar for the treatment groups.

Women who had bulky tumors seemed to respond best to initial treatment with neoadjuvant chemotherapy, according to the researchers. As always, treatment should be tailored to each patient, and whether the patient will benefit from neoadjuvant chemotherapy first depends on numerous factors, including tumor resectability, patient age, histology, stage, and performance status. Primary debulking surgery remains the standard of care for women with stage IIIa and IIIb ovarian cancer, and the researchers emphasized that these findings should not be generalized to women with these stages of ovarian cancer. Currently, three other randomized controlled trials are ongoing, and their results may alter these conclusions, stated the researchers.

Pertinent Points:
- For women with stage IIIc/IV ovarian cancer, treatment with neoadjuvant chemotherapy before surgery is associated with fewer serious adverse events related to surgery and is a reasonable treatment option, especially for women with bulky tumors.
- Regardless of treatment order (chemotherapy first then surgery or surgery first then chemotherapy), the rates of overall survival and disease-free survival are similar for women with stage IIIc/IV ovarian epithelial cancer.

References:

1. Morrison J, Halder K, Kehoe S, Lawrie TA. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database System Rev. 2012;8:CD005343. DOI: 10.1002/14651858.CD005343.pub3.