The role of neoadjuvant chemotherapy in the management of patients with advanced stage ovarian cancer: Survey results from members of the society of gynecologic oncologists, a 5-year follow-up

Association of Chemotherapy Response Score with Multidrug Resistance 1 and CA125 ELIMination Rate Constant K in Patients with Advanced Ovarian Cancer Treated with Neoadjuvant Chemotherapy

AIM

The relationship between chemotherapy response score (CRS), a widely used response predictor of neoadjuvant chemotherapy-interval debulking surgery (NAC-IDS), and multidrug resistance 1 (MDR1) and CA125 ELIMination rate constant K (KELIM), is undetermined. We evaluated CRS in advanced ovarian cancer patients undergoing NAC and looked for associations between CRS and MDR1 and CA125 KELIM. Our aim was to predict the therapeutic effect of NAC before interval debulking surgery (IDS) by examining its association with CRS.

METHODS

This retrospective cohort study included patients who underwent NAC-IDS (first-line treatment) at Kurume University Hospital, Japan, between 2004 and 2017. CRS association with MDR1 and CA125 KELIM was examined using Cox proportional hazard regression analyses. Survival curves used Kaplan-Meier method, and survival differences between groups used log-rank test.

RESULTS

Overall, 55 patients were classified into CRS1 (n=22), CRS2 (n=19), and CRS3 (n=14). The CRS3 group had a significantly better prognosis than the CRS1 or CRS2 group. CRS, age, and IDS status were clinical prognostic factors for ovarian cancer. MDR1 positivity for excision repair cross-complementing group 1, β-tubulin, and Y-box binding protein-1 occurred in 15, 17, and 11 patients, respectively, but these were not associated with CRS. CA125 KELIM was <0.5 (n=8), 0.5-1.0 (n=30), and ≥ 1.0 (n=17) but not associated with CRS.

CONCLUSION

CRS is reconfirmed as a treatment response predictor for NAC-IDS, but its association with drug resistance factors remains unconfirmed.

Surgery in Advanced Ovary Cancer: Primary versus Interval Cytoreduction

Primary debulking surgery (PDS) has remained the only treatment of ovarian cancer with survival advantage since its development in the 1970s. However, survival advantage is only observed in patients who are optimally resected. Neoadjuvant chemotherapy (NACT) has emerged as an alternative for patients in whom optimal resection is unlikely and/or patients with comorbidities at high risk for perioperative complications. The purpose of this review is to summarize the evidence to date for PDS and NACT in the treatment of stage III/IV ovarian carcinoma. We systematically searched the PubMed database for relevant articles. Prior to 2010, NACT was reserved for non-surgical candidates. After publication of EORTC 55971, the first randomized trial demonstrating non-inferiority of NACT followed by interval debulking surgery, NACT was considered in a wider breadth of patients. Since EORTC 55971, 3 randomized trials-CHORUS, JCOG0602, and SCORPION-have studied NACT versus PDS. While CHORUS supported EORTC 55971, JCOG0602 failed to demonstrate non-inferiority and SCORPION failed to demonstrate superiority of NACT. Despite conflicting data, a subset of patients would benefit from NACT while preserving survival including poor surgical candidates and inoperable disease. Further randomized trials are needed to assess the role of NACT.

The prognostic effect of residual tumor for advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy or primary debulking surgery

PURPOSE

The role of neoadjuvant chemotherapy (NACT) and primary debulking surgery (PDS) in advanced epithelial ovarian cancer (EOC) remains controversial. This study aimed to investigate the prognosis between NACT and PDS in advanced EOC. We also investigated the prognostic effect of the residual tumor (RT) after NACT and PDS.

METHODS

Patients with stage III-IV EOC diagnosed between 2010 and 2017 were included from the Surveillance, Epidemiology, and End Results (SEER) database. Chi-square test, multivariate logistic regression analysis, Kaplan-Meier curves, and Cox proportional hazards model were used for statistical analyses.

RESULTS

A total of 5522 women patients were identified, 2017 (36.5%) and 3505 (63.5%) patients received NACT and PDS, respectively. There were 2971 (53.8%), 1637 (29.6%), and 914 (16.6%) patients who had no residual tumor, RT ≤1 cm, and RT >1 cm, respectively. There were 25.5% of patients receiving NACT in 2010 and 48.4% in 2017 (p < 0.001). Women treated with NACT were not related to a higher chance of complete resection than the PDS group (p = 0.098). Patients receiving PDS had significantly better cancer-specific survival (CSS) than those receiving NACT (p < 0.001). The 5-year CSS was 35.3% and 51.1% in those receiving NACT and PDS, respectively. In patients receiving NACT, those who had no residual tumor had significantly better CSS compared to those who had RT ≤1 cm (p < 0.001), while comparable CSS was found between those who had RT ≤1 cm and RT >1 cm (p = 0.442). In those receiving PDS, the CSS was decreased with a RT increase (p < 0.001).

CONCLUSIONS

Our study suggests that PDS may be the optimal procedure for the majority of advanced EOC patients. Complete resection of all residual diseases should be the goal with the increased utilization of NACT.

Primary treatment of advanced ovarian cancer: how does the 'real world' practice?

Aims: This study evaluated primary treatment modalities in advanced ovarian cancer according to sociodemographic characteristics and characterized chemotherapy regimens used. Methods: This was a retrospective study of newly diagnosed advanced ovarian, tubal or peritoneal cancer patients at two hospitals from 2011 to 2016. Results: Of 175 women, 41% received neoadjuvant chemotherapy and 59% received primary cytoreductive surgery. Within the neoadjuvant chemotherapy group, 23% did not have a surgical consultation prior to initiating treatment. Women receiving neoadjuvant chemotherapy lived closer to an academic center and more frequently received carboplatin/paclitaxel every 3 weeks. Cytoreductive surgery patients more frequently received intraperitoneal chemotherapy. Conclusion: The authors identified disparities in age, insurance, distance from treatment center and chemotherapy choice in the primary treatment for ovarian cancer.

A novel laparoscopy-based model for the prediction of optimal cytoreduction and prognosis of epithelial ovarian cancer in a Chinese population

OBJECTIVES

This study aimed to investigate the predictive value of laparoscopy for the prediction of optimal cytoreduction and prognosis of epithelial ovarian cancer (EOC) in a Chinese population.

STUDY DESIGN

This study enrolled 162 EOC patients in Obstetrics and Gynecology Hospital of Fudan University from January 2015 to December 2016. All patients underwent preoperative CT scans and laparoscopic assessments. Each patient was scored according to the CT-based predictive model by Bristow and laparoscopy-based predictive model by Fagotti. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) of each model were calculated. The predictive scores and clinicopathologic factors were all analyzed using the Kaplan-Meier method and multivariate Cox analysis. A prognostic predictive nomogram was formulated in R software.

RESULTS

The AUCs of the laparoscopy-based predictive model and CT-based predictive model was 0.955 and 0.755 respectively. At a laparoscopic score ≥ 10, the possibility of optimal cytoreduction was 0, and the risk of unnecessary explorative attempts was 6%. Additionally, laparoscopic score, independent of residual tumor size and FIGO stage, was an independent prognostic factor for both overall survival (OS) and recurrence-free survival (RFS) in EOC. Notably, the predictive nomogram that we established further confirmed the prognostic value of laparoscopy for prognostic predictions in EOC.

CONCLUSIONS

Laparoscopy has a better discriminating performance than CT in the prediction of optimal cytoreduction in EOC. Moreover, the laparoscopic score is directly correlated with the survival of EOC patients. The laparoscopic score-based nomogram we established showed good potential to predict the prognosis of EOC patients.

Clair CM, Hou JY, Collado FK, Hershman DL, Wright JD, Melamed A. Trends in Primary Treatment and Median Survival Among Women With Advanced-Stage Epithelial Ovarian Cancer in the US From 2004 to 2016

This cohort study compares time trends in the use of neoadjuvant chemotherapy and survival rates among women with advanced-stage epithelial ovarian cancer.

African American women with advanced-stage ovarian cancer have worse outcomes regardless of treatment type

OBJECTIVE

There has been an increase in the use of neoadjuvant chemotherapy in recent years. Our objective was to determine if African American women are more likely to receive neoadjuvant chemotherapy than primary debulking surgery, when compared to their Caucasian counterparts, and the impact of such an approach on oncologic outcomes.

METHODS

A retrospective cohort study was performed using the National Cancer Database (NCDB). Women aged 18-90 years, diagnosed with stage IIIC or IV epithelial ovarian cancer between January 2010 through December 2014 were included. Women with unknown treatment or treatments outside of neoadjuvant chemotherapy or primary debulking surgery were excluded. Only women of Caucasian, African American, or Hispanic origin who received either neoadjuvant chemotherapy or primary debulking surgery were included; all other races were excluded. Descriptive statistics were computed, and continuous variables were assessed for normality. Groups were compared using ANOVA or non-parametric medians tests for continuous variables, and chi-squared tests were used for dichotomous or categorical variables. Logistic regression was used to identify predictors of treatment. A p value of 0.05 was considered statistically significant.

RESULTS

A total of 19 838 women with stage IIIC and IV epithelial ovarian cancer met the inclusion criteria. A total of 14 988 (75.6%) were treated with primary debulking surgery, while 4850 women (24.4%) were treated with neoadjuvant chemotherapy. Of those treated with neoadjuvant chemotherapy, 24.5% were white, 27.0% were African American, and 22.1% were Hispanic (p=0.005), and when adjusted for confounders, being African American was a predictor of receiving neoadjuvant chemotherapy (adjusted odds ratio (aOR) 1.29, 95% CI 1.10 to 1.51). Ninety-day mortality rates were higher in African American women compared with Caucasian and Hispanic women (2.9% vs 2.0% vs 1.6%, p=0.013). There were no differences in 30-day mortality, 90-day mortality, or status at last contact in African American women, when comparing neoadjuvant chemotherapy and primary debulking surgery. In Caucasian women, outcomes were worse in women receiving neoadjuvant chemotherapy.

CONCLUSIONS

Compared to other races, African American women with advanced ovarian cancer are more likely to receive neoadjuvant chemotherapy than primary debulking surgery and had a higher 90-day mortality rate. In African American women there was no difference in outcomes based on treatment type.

In silico detection of potential prognostic circRNAs through a re-annotation strategy in ovarian cancer

Ovarian cancer (OC) is the most common and lethal gynecologic malignancy. The pathophysiology of OC tumor development is complex and involves numerous biological pathways. Previous studies suggest that circular (circ)RNAs serve important roles in OC tumor pathology. In the present study, a re-annotation strategy was performed to evaluate the expression level of circRNAs based on a microarray dataset obtained from the Gene Expression Omnibus database. Univariate and multivariate Cox regression analyses were performed to evaluate the association between survival and expression of circRNAs in each OC cohort. An expression-based risk score model was constructed to extrapolate the prognostic efficacy of this signature. In the GSE9891 dataset, the 278 OC patients were randomly divided into training and validating groups. A six-circRNA signature was significantly associated with overall survival in the training and validating datasets. The risk score model was further validated in GSE63885 and GSE26193 datasets. The six-circRNA signature was also significantly associated with patient progression-free survival and disease-free survival. Further investigation revealed that the signature had higher area under the curve values than the existing clinical and other molecular signatures in predicting survival. In conclusion, the present study revealed that the six-circRNA signature may serve as a potential prognostic biomarker of OC.

Meigs to modern times: The evolution of debulking surgery in advanced ovarian cancer

Joe V. Meigs was a visionary clinician and an early adopter of radical techniques in the surgical treatment of ovarian cancer. His 1934 textbook "Tumors of the Female Pelvic Organs", consolidated his approach to this "hopeless" disease, with pearls on diagnosis, outcomes, and even speculations about the benefits of minimally invasive surgery. Decades before adjuvant chemotherapy would prove of value, and in an era when sophisticated statistics were unheard of, he nonetheless tried to eke out what benefits he could using the methods available in his time. We transition his original findings and observations through the advent of platinum-based chemotherapy, retrospective cohort studies supporting the benefits of primary debulking, and finally the long-awaited randomized controlled trial. We aim to provide historical context for the underpinnings of how cytoreductive surgery has evolved into its current role in the treatment of advanced ovarian cancer.