medwireNews: The early adoption of neoadjuvant chemotherapy (NACT) for patients with stage IIIC or IV epithelial ovarian cancer has led to an improvement in mortality rates, US study findings confirm.
“These findings should reassure clinicians and policy makers who have greeted increasing acceptance of NACT with some concern”, say Alexander Melamed, from Massachusetts General Hospital in Boston, USA, and co-workers.
The analysis follows two clinical trials demonstrating noninferior but not superior overall survival with NACT versus surgery alone, they explain in The BMJ.
The analysis shows that the New England and east south central regions of the USA had a corresponding 27.3% and 23.3% increase in the use of NACT from 2011 to 2012. This change of practice for patients who underwent interval debulking surgery led to a significant improvement in survival, giving a mortality hazard ratio (HR) of 0.81 compared with 2011.
No such survival gain was detected in control regions of the USA without a recorded increase in the use of NACT over this period, namely the south Atlantic, west north central and east north central areas, the researchers report.
Cross-sectional analysis confirmed that NACT use reduced the risk of all-cause mortality significantly after adjusting for confounding factors, such as year of diagnosis, age, comorbidity, and disease stage, grade and histology.
Early adoption of NACT was also associated with a greater decrease in 90-day surgical mortality between 2011 and 2012 than in control regions, from 7.0% to 4.0% versus 5.0% to 4.3%, as well as a greater decline in the number of women who did not receive surgery and chemotherapy, from 20.0% to 17.4% versus 19.0% to 19.5%.
“Importantly, our findings do not indicate that all patients with advanced epithelial ovarian cancer will benefit from NACT”, the authors write, noting that the increasing NACT use was restricted to older patients and those with stage IV disease.
Alexander Melamed et al also caution that “if the mechanism of benefit for NACT observed in this study is reduction in postoperative morbidity and mortality, NACT may be less beneficial in the context of expert centers that achieve better than average surgical outcomes.”
They write: “Indeed, in this study we observed that regions which adopted NACT rapidly had higher baseline perioperative mortality than control regions”.
The team concludes: “Future research may elucidate how patients who may benefit most can be identified and selected to receive NACT.”
Melamed A, Fink G, Wright AA, et al. Effect of adoption of neoadjuvant chemotherapy for advanced ovarian cancer on all cause mortality: quasi-experimental study. BMJ; 360: j5463. Advance online publication 3 January 2018. doi: https://doi.org/10.1136/bmj.j5463
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