Survival outcomes after delayed cytoreduction surgery following neoadjuvant chemotherapy in advanced epithelial ovarian cancer

Abstract

ObjectiveInterval cytoreduction following neoadjuvant chemotherapy is a well-recognized treatment alternative to primary debulking surgery in the treatment of advanced epithelial ovarian cancer where patient and/or disease factors prevent complete macroscopic disease resection to be achieved. More recently, the strain of the global COVID-19 pandemic on hospital resources has forced many units to alter the timing of interval surgery and extend the number of neoadjuvant chemotherapy cycles. In order to support this paradigm shift and provide more accurate counseling during these unprecedented times, we investigated the survival outcomes in advanced epithelial ovarian cancer patients with the intent of maximal cytoreduction following neoadjuvant chemotherapy with respect to timing of surgery and degree of cytoreduction.MethodsA retrospective review of all patients aged 18 years and above with FIGO (2014) stage III/IV epithelial ovarian cancer treated with neoadjuvant chemotherapy and the intention of interval cytoreduction surgery between January 2008 and December 2017 was conducted. Overall and progression-free survival outcomes were analyzed and compared with patients who only received chemotherapy. Outcome measures were correlated with the number of neoadjuvant chemotherapy cycles and amount of residual disease following surgery.ResultsSix hundred and seventy-one patients (median age 67 (range 20–91) years) were included in the study with 572 patients treated with neoadjuvant chemotherapy and surgery and 99 patients with chemotherapy only. There was no difference in the proportion of patients in whom complete cytoreduction was achieved based on number of cycles of neoadjuvant chemotherapy (2–4 cycles: 67.7%, n=337/498); ≥5 cycles: 62.2%, n=46/74). Patients undergoing cytoreduction surgery after neoadjuvant chemotherapy had a median 5-year progression-free and overall survival of 24 and 38 months, respectively. No significant difference in overall survival between surgical groups was observed (interval cytoreduction: 41 months vs delayed cytoreduction: 43 months, p=0.52). Those who achieved complete cytoreduction to R0 (no macroscopic disease) had a significant median overall survival advantage compared with those with any macroscopic residual disease (R0: 49–51 months vs R<1: 22–39 months, p<0.001 vs R≥1: 23–26 months, p<0.001).ConclusionsSurvival outcomes do not appear to be worse for patients treated with neoadjuvant chemotherapy if cytoreduction surgery is delayed beyond three cycles. In advanced epithelial ovarian cancer patients the imperative to achieve complete surgical cytoreduction remains gold standard, irrespective of surgical timing, for best survival benefit.

A New Paradigm in Managing Advanced Ovarian Cancer: Differentiating Patients Requiring Neoadjuvant Treatment from Primary Cytoreduction

“…In the NACT group, the median OS in our study was 52.8 months, in line with the findings of Luyckx (54 months), and is one of the highest reported values [20,[31][32][33]35,[37][38][39][40]. Despite our low PDS rate (38%), our median OS and PFS were 65.5 months and 21.9 months, respectively, for the whole cohort, which is concordant with data in literature [40,41].…”

Prediction for 2-year mortality of metastatic ovarian cancer patients based on surveillance, epidemiology, and end results database

“…As a practice recommended by the National Comprehensive Cancer Center (NCCN), complete cytoreduction to no gross residual disease is a vital factor affecting the progression-free and overall survival of ovarian cancer patients at stage IV ( 32 , 33 ). Another study also indicated that complete surgical cytoreduction had the best survival benefit in advanced epithelial ovarian cancer patients ( 34 ). Balkhy et al indicated that surgery was the cornerstone of treatment for most stages of non-epithelial ovarian cancers, which might correlate with the prognosis of those patients ( 35 ).…”

Insights into ovarian cancer care: report from the ANZGOG Ovarian Cancer Webinar Series 2020

“…Recent studies of survival outcomes and delayed debulking surgery following NACT concluded that delays between NACT and IDS were not associated with worse OS after adjusting for known confounders. However, debulking surgery was necessary in order to maintain improved survival with the caveat that it was undertaken after at least three cycles of NACT [ 41 42 ].…”