Neoadjuvant Chemo Optimal Choice for Some Women With Ovarian Cancer

Larissa A. Meyer, MD

Neoadjuvant chemotherapy (NACT) is likely the optimal treatment choice for some women with newly diagnosed advanced ovarian cancer, while other patients should receive primary cytoreductive surgery (PCS), according to a recently published report in the Journal of Clinical Oncology.¹

This observational study found that patients with stage IIIC disease who NACT had significantly decreased overall survival (OS) compared with those treated with PCS (median, 33 vs 43 months; HR, 1.40; 95% CI, 1.11-1.77). Among patients with stage IV disease, however, there was no significant difference in OS (median, 31 vs 36 months; HR, 1.16; 95% CI, 0.89-1.52).

“Our results suggest that primary cytoreductive surgery may improve survival for patients with stage IIIC ovarian cancer who are likely to achieve an optimal cytoreduction, while neoadjuvant chemotherapy may be the preferred option for many women with stage IV ovarian cancer,” Larissa A. Meyer, MD, assistant professor, Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, said in an interview with OncLive.

These results are consistent with a subset analysis in the EORTC study, which demonstrated improved survival in patients with stage IIIC disease and <45 mm of disease who received PCS versus NACT.

The current study examined the use of NACT, as well as outcomes associated with it, at 6 National Cancer Institute—designated cancer centers between 2003 and 2012. Patients were assigned to a treatment arm (NACT or PCS) on the basis of whether they initially received chemotherapy or surgery.

In the first cohort of patients, the authors examined NACT use over time among 1538 patients diagnosed between 2003 and 2012 and treated within 12 weeks of diagnosis. In the second cohort, the goal was to examine factors and outcomes associated with NACT versus PCS within a subset of 1158 patients from the first cohort. This subset excluded patients who had received intraperitoneal and intravenous (IP/IV) chemotherapy, as few patients treated with NACT receive IP/IV chemotherapy, and it is associated with its own independent survival benefit.

The results of the study showed that, between 2003 and 2011, the use of NACT increased steadily over time from 16% to 34% among patients with stage IIIC ovarian cancer, and from 41% to 62% among patients with stage IV disease.

The authors noted that the degree of variation in the use of NACT between such similar academic institutions suggests that uptake of NACT is influenced by local culture, clinical practice leaders within institutions, and maybe even patients’ preferences.

PCS was found to be associated with significantly improved survival in women with stage IIIC, but not stage IV disease, compared with NACT.

Patients with stage IIIC and IV disease treated with NACT were more likely to achieve <1 cm or microscopic residual disease after interval cytoreductive surgery (ICS) compared with PCS. However, few differences were found in complexity, aggressiveness, or complications of surgery.

The authors wrote that it was important to note that, although patients with stage IIIC disease who received NACT were significantly more likely to have <1 cm or R0 microscopic residual disease after ICS, this finding was not associated with a survival benefit.

In contrast, patients who achieved <1 cm of residual disease after PCS, rather than NACT and ICS, had significantly longer survival. Future research should prospectively compare the survival outcomes of patients treated with PCS versus NACT stratified by residual disease after surgery, according to the authors.

These results come shortly after the publication of ASCO’s new NACT ovarian cancer guideline, which recommends NACT as the optimal first-line treatment for some women with newly diagnosed, advanced ovarian cancer.²

“The findings in our study are aligned with the recently issued ASCO/SGO guideline for neoadjuvant chemotherapy,” said Meyer.

One of the guideline recommendations states that NACT is favored over PCS for women who are fit for PCS, but are also deemed unlikely to achieve cytoreduction to <1 cm (ideally to no visible disease) by a gynecologic oncologist. Meyer says the findings of the current study support that recommendation.

The choice between PCS and NACT remains highly controversial, as the optimal treatment of advanced ovarian cancer includes both surgical cytoreduction and platinum-based chemotherapy.

“The bottom line is a one-size-fits-all strategy no longer works for treatment of ovarian cancer,” said Meyer.

References

1. Meyer LA, Cronin AM, Sun CC, et al. Use and effectiveness of neoadjuvant chemotherapy for treatment of ovarian cancer (published online September 6, 2015). J Clin Oncol. doi:10.1200/JCO.2016.68.1239.
2. Wright AA, Bohlke K, Armstrong DK, et al. Neoadjuvant chemotherapy for newly diagnosed advanced ovarian cancer: Society of Gynecological Oncology and American Society of Clinical Oncology clinical practice guideline [published online August 8, 2016]. J Clin Oncol. doi:10.1200/JCO.2016.68.6907.