Neoadjuvant Chemo Preferable to Surgery in Certain Tubo-Ovarian Cancers
For patients with advanced tubo-ovarian cancers, neoadjuvant chemotherapy and upfront debulking surgery yield similar survival results, but in certain subgroups, neoadjuvant chemotherapy reigns supreme (Lancet Oncol. 2018 Nov 6. Epub ahead of print).
“[T]he selection of women with advanced ovarian cancer for neoadjuvant
chemotherapy or upfront debulking surgery remains controversial,” explained Ignace Vergote, MD, Professor, University Hospitals Leuven, Department of Obstetrics and Gynaecology, Belgium, and colleagues, who conducted a pooled analysis to compare the survival outcomes with neoadjuvant chemotherapy versus upfront debulking surgery.
The analysis was conducted using the reverse Kaplan-Meier method and patient data from 2 randomized clinical trials comparing these therapeutic approaches in patients with advanced tubo-ovarian cancer (N = 1220). These 2 trials were the European Organisation for Research and Treatment of Cancer (EORTC) 55971 trial and the Medical Research Council Chemotherapy Or Upfront Surgery (CHORUS) trial.
In addition, Dr Vergote and colleagues used Cochran’s Q heterogeneity statistic to test for heterogeneity.
Women eligible for inclusion in the EORTC (n = 670) and CHORUS (n = 550) trials had biopsy-proven International Federation of Gynecology and Obstetrics (FIGO) stage IIIC or stage IV invasive epithelial tubo-ovarian cancer; the CHORUS trial also included women with apparent FIGO stage IIIA and stage IIIB disease. Among all patients in both trials, the median age was 63 years and the median size of the largest metastatic tumor at diagnosis was 8 cm.
A total of 612 were randomized to undergo upfront debulking surgery and 608 were randomized to receive neoadjuvant chemotherapy. The median follow-up time frame was 7.6 years (EORTC, 9.2 years; CHORUS, 5.9 years). A total of 55 (5%) women had FIGO stage II to stage IIIB disease, 831 (68%) had stage IIIC disease, and 230 (19%) had stage IV disease; staging data were absent for 104 (9%) women.
Dr Vergote and colleagues observed no difference in median overall survival (OS) between patients who received neoadjuvant chemotherapy and underwent upfront debulking surgery (27.6 months vs 26.9 months, respectively; hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.86-1.09; P = .586). The median OS between EORTC and CHORUS cohorts was significantly different (30.2 months vs 23.6 months, respectively; HR, 1.20; 95% CI, 1.06-1.36; P = .004), but not heterogeneous (Cochran’s Q, P = .17).
Of note, women with stage IV disease had significantly better outcomes with neoadjuvant chemotherapy than with upfront debulking surgery (median OS, 24.3 months vs 21.2 months, respectively; HR, 0.76; 95% CI, 0.58-1.00; P = .048; median progression-free survival, 10.6 months vs 9.7 months, respectively; HR, 0.77; 95% CI, 0.59-1.00; P = .049).
“Long-term follow-up data substantiate previous results showing that neoadjuvant chemotherapy and upfront debulking surgery result in similar overall survival in advanced tubo-ovarian cancer, with better survival in women with stage IV disease with neoadjuvant chemotherapy,” the investigators reported.
According to Dr Vergote and colleagues, these long-term follow-up results show that neoadjuvant chemotherapy is a valuable therapy option for patients with stage IIIC to stage IV tubo-ovarian cancer (especially if they have high tumor burden at diagnosis or a poor performance status).
“Our data suggest that neoadjuvant chemotherapy should be the standard of care for most patients with FIGO stage IV tubo-ovarian cancer, and primary surgery should only be undertaken in these stage IV patients in exceptional circumstances with easily resectable disease,” they concluded.—Hina Khaliq
