The impacts of neoadjuvant chemotherapy and of debulking surgery on survival from advanced ovarian cancer
Introduction
The standard treatment of advanced ovarian cancer is a combination of debulking surgery and chemotherapy. The goal of surgery is to reduce the intra-abdominal tumor burden as much as possible; the survival of patients with no residual disease at the completion of surgery is superior to that of patients with visible residual lesions [1]. To maximize the likelihood that a patient is left with no residual disease, several aggressive surgical techniques have been proposed, including the removal of all visible disease on the diaphragm, the colon, spleen, pelvis and elsewhere in the abdomen [2]. These techniques include diaphragm resection, splenectomy, colon resection and extensive peritoniectomy. Conventional treatment also includes chemotherapy, typically a combination of a platinum-based drug and a taxane [3]. Chemotherapy may be given intravenously or by the intraperitoneal route. In several studies, intraperitoneal chemotherapy has been associated with improved survival [4], [5]. For some patients, chemotherapy is given prior to surgery (neoadjuvant chemotherapy). Neoadjuvant chemotherapy is used to treat patients if it is predicted that adequate debulking surgery is unlikely to be successful or if they are too ill to undergo an extensive and lengthy operation, but in some cases is used to reduce the tumor burden. Patients who are treated with neoadjuvant chemotherapy followed by surgery are more likely to achieve the status of no residual disease than are patients treated with surgery alone [6]. Consequently, it has been proposed that neoadjuvant chemotherapy is justified in order to achieve a status of no residual disease [6], [7]; however, treatment with neoadjuvant chemotherapy has not yet been shown to result in better survival than treatment with primary debulking surgery [6], [8].
The survival of patients with stage III or IV ovarian cancer who have no residual disease after primary debulking surgery is approximately 50% at 10 years [9]. It has not been established if patients who achieve a status of no residual disease through the combination of neoadjuvant chemotherapy and surgery have an equally good prognosis. In one randomized trial, the survival of women who were treated with neoadjuvant chemotherapy was similar to that of women who had primary debulking surgery, but this study is notable for the poor survival rates observed in both groups [6]. We compared seven-year survival rates for women treated for advanced stage serous ovarian cancer (stage IIIc or IV) with and without visible residual disease, who did and who did not receive neoadjuvant chemotherapy. We evaluated the impact of aggressive surgery on survival and we compared survival rates for women who received intraperitoneal chemotherapy or conventional chemotherapy.
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Patients
We reviewed the patient records in the electronic hospital database (synoptic operating reports) and identified 414 women who were treated for invasive ovarian cancer under age 80 at the University Health Network, Toronto, between 2001 and 2011. Of these, 64 patients were stages 1 to 3b and were excluded. The remaining 350 patients were stage 3c and 4 and were eligible. Of these information was missing on 14 and ten patients progressed under neoadjuvant chemotherapy; these were excluded leaving
Results
We studied 326 patients with stage IIIc or IV high grade serous ovarian cancer. These represent all patients below age 80 treated at the University Health Network between 2001 and 2011. Patients were followed from 0.1 to 9 years (median follow-up 3.2 years). The seven-year survival rate was 27.4% for patients with stage IIIc disease and was 18.7% for patients with stage IV disease (Fig. 1). The difference was not statistically significant and the two groups were combined.
Overall, 143 of the
Discussion
We found that the probability of being a seven-year survivor of advanced stage serous ovarian cancer was much higher for women who had no residual disease after surgery than for women who had visible residual disease, in particular for women who achieved this status through primary debulking surgery. We agree with Aletti et al. [1] that the most significant predictor of survival is the absence of residual disease. After primary debulking surgery, the probability of being a seven-year survivor
Conflict of interest statement
The authors declare no conflict of interest.
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