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Neoadjuvant chemo noninferior to surgery in advanced tubo-ovarian cancer

Dr. Joseph Delano Fule Robles
08 Jan 2019

A pooled analysis of the European Organisation for Research and Treatment of Cancer (EORTC) 55971 trial and the Medical Research Council Chemotherapy Or Upfront Surgery (CHORUS) trial demonstrated that neoadjuvant chemotherapy and upfront debulking surgery result in similar overall survival (OS) in advanced tubo-ovarian cancer. 

Among 1,220 patients with advanced tubo-ovarian cancer (International Federation of Gynecology and Obstetrics [FIGO] stage IIIC and IV) who received neoadjuvant chemotherapy vs those who underwent upfront debulking surgery, median OS was 27.6 months (interquartile range [IQR], 14.1–51.3) vs 26.9 months (IQR, 12.7–50.1) (hazard ratio [HR], 0.97; 95 percent confidence interval [CI], 0.86 to 1.09; p=0.586). [Lancet Oncol 2018, doi: 10.1016/S1470-2045(18)30566-7] 

Median progression-free survival (PFS) was also similar with neoadjuvant chemotherapy vs upfront debulking surgery in patients with stage IIIC disease (median, 12.2 months [IQR, 8.4–18.3] vs 11.7 months [IQR, 7.5–19.9]; HR, 1.06; 95 percent CI, 0.92 to 1.22; p=0.429). 

“This pooled analysis with long-term follow-up substantiated previous findings showing that both upfront debulking surgery and neoadjuvant chemotherapy are potential treatment options for patients with FIGO stage IIIC or IV tubo-ovarian cancer,” the investigators of the study commented. 

Patients with stage IV disease who received chemotherapy were noted to have better median OS (24.3 months [IQR, 14.1–47.6] vs 21.2 months [IQR, 10–36.4]; HR, 0.76; 95 percent CI, 0.58 to 1.00; p=0.048) and PFS (10.6 months [IQR, 7.9–15.0] vs 9.7 months [IQR, 5.2–13.2]; HR, 0.77; 95 percent CI, 0.59 to 1.00; p=0.049) as compared with those who received debulking surgery.

“These findings indicate that when deciding on a treatment strategy, one should account not only for the risk of perioperative morbidity and the possibility of debulking the patient’s disease to zero residual tumour, but also for FIGO stage and the extent of metastatic disease at presentation,” the authors said. 

The recruitment of patients (median age, 63 years) lasted for almost 12 years (EORTC, n=670; CHORUS, n=550) and the patients were followed up for a median of 7.6 years. More than half of the recruited patients in the analysis had FIGO stage IIIC disease (68 percent), 19 percent had metastatic disease, and 5 percent had FIGO stage II–IIIB disease. 

“Both the EORTC and CHORUS trials permitted cytological diagnosis of malignant disease, which means that histology can reliably distinguish between high-grade and low-grade carcinomas. This is important because low-grade carcinomas are much less sensitive to chemotherapeutic regimens than high-grade carcinomas and primary surgery is an important intervention in this group. To facilitate decision making, tissue should therefore be obtained for histological diagnosis in all cases of tubo-ovarian cancer and assessed in combination with extensive radiological imaging,” the authors of the study commented.

More than 70 percent of women with tubo-ovarian cancer present with advanced disease and have very poor prognosis. [Eur J Cancer 2013;49:1347-1403] Since the 1970s, debulking surgery has remained a therapeutic strategy for advanced tubo-ovarian cancer. [Ann Oncol 1999;10:3-7] The EORTC and CHORUS trials then showed that both treatment strategies provided similar survival outcomes. [N Engl J Med 2010;363:943-953; Lancet 2015; 386:249-257]

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