Primary Cytoreductive Surgery May Be Best For Advanced EOC In Under 70s With Good PS

Overall survival in advanced epithelial ovarian cancer patients aged less than 70 years without comorbidity is higher with primary cytoreductive surgery than neoadjuvant chemotherapy but may be affected by performance status

medwireNews: Primary cytoreductive surgery offers superior overall survival (OS) to neoadjuvant chemotherapy for select women with stage IIIC and IV epithelial ovarian cancer (EOC), but this may be dependent upon ECOG performance status, suggest findings from the US National Cancer Database.

The review included data for 22,962 women aged 70 years or less (mean, 56.1 years) who were treated between 2003 and 2011 at US hospitals. All of the patients had a Charlson comorbidity index of 0 and were therefore candidates for either treatment approach, the study authors explain in JAMA Oncology.

In all, 19,836 patients underwent primary cytoreductive surgery and were followed up for a median of 56.4 months, while 2935 women received neoadjuvant chemotherapy and were followed up for 56.3 months.

Propensity score matching analysis for the whole patient population gave significantly longer OS for the primary cytoreductive surgery group, at a median of 37.3 versus 32.1 months for the neoadjuvant chemotherapy group (hazard ratio [HR]=1.18).

And this was true for patients whether they were treated in 2003–2005, 2006–2009 or 2010–2011 (HR=1.19, 1.15 and 1.24, respectively), or whether they had stage IIIC or IV disease (HR=1.24 and 1.13, respectively).

“Remarkably, nearly 15% of women never initiated chemotherapy after [primary cytoreductive surgery] while approximately 26% of the women treated with [neoadjuvant chemotherapy] did not undergo surgery”, observe J Alejandro Rauh-Hain, from Massachusetts General Hospital in Boston, USA, and co-workers.

But OS remained superior with primary cytoreductive surgery when comparing only the patients in the neoadjuvant chemotherapy group who went on to receive surgery, they say.

The authors also report that sensitivity analysis showed that their “findings were robust” to the possibility of large differences in the prevalence of two unobserved confounding factors in the treatment groups – high disease burden and BRCA status.

However, the team admits that their results were “less robust” if “moderate-sized differences” in patient performance status had occurred between the two treatment groups.

For example, if 60% of patients given neoadjuvant chemotherapy had an ECOG performance status of 1–2, indicating a higher mortality risk, compared with 50% of primary cytoreductive surgery patients, first-line surgery would no longer offer significantly better OS, they explain.

The researchers therefore emphasise that “the results of the present study are limited to otherwise healthy women 70 years or younger and should not be extrapolated to other populations.”

They recommend that information on such confounding factors is important to collect during future studies, adding that such research “should focus on which patients benefit most from [primary cytoreductive surgery] or [neoadjuvant chemotherapy] to tailor the treatment of women with advanced-stage EOC.”


Rauh-Hain JA, Melamed A, Wright A, et al. Overall survival following neoadjuvant chemotherapy vs primary cytoreductive surgery in women with epithelial ovarian cancer. Analysis of the National Cancer Database. JAMA Oncol; Advance online publication 17 November 2016. doi:10.1001/jamaoncol.2016.4411

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