Phase III SCORPION trial (ID number: NCT01461850) in epithelial ovarian cancer patients with high tumor load receiving PDS versus NACT: An interim analysis on peri-operative outcome

Propensity score matching confirms that primary surgery or neoadjuvant chemotherapy result in equivalent survival within a comprehensive cohort of patients with high-grade serous ovarian cancer

OBJECTIVE

Our objective was to investigate whether trial evidence showing that neoadjuvant chemotherapy is non inferior to primary surgery for the primary treatment of advanced ovarian cancer could be extrapolated to groups of patients that were not included in the trials.

METHODS

Using a detailed retrospective cohort of all patients managed through a single tertiary hospital we carried out a propensity score analysis, principal component analysis, and cox proportional hazard analysis to compare survival in matched cohorts.

RESULTS

A propensity score analysis showed that for at least 41% of all patients with advanced high-grade serous cancer neoadjuvant chemotherapy is non inferior to primary surgery (median survival primary surgery: 38 months, neoadjuvant chemotherapy: 35 months. P = 0.39). However, principal component analysis, supported by cox modelling, suggests that for some subgroups, including patients with subdiaphragmatic nodal disease, primary surgery may be associated with improved survival (HR 0.11, CI 0.026-0.48).

CONCLUSIONS

We have shown that the findings of previous trials can be extrapolated to a wider population and that statistical modelling can be used to identify groups or patients who benefit from specific modalities of treatment.

Neoadjuvant Chemotherapy for Newly Diagnosed, Advanced Ovarian Cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline

PURPOSE

To provide guidance to clinicians regarding the use of neoadjuvant chemotherapy and interval cytoreduction among women with stage IIIC or IV epithelial ovarian cancer.

METHODS

The Society of Gynecologic Oncology and the American Society of Clinical Oncology convened an Expert Panel and conducted a systematic review of the literature.

RESULTS

Four phase III clinical trials form the primary evidence base for the recommendations. The published studies suggest that for selected women with stage IIIC or IV epithelial ovarian cancer, neoadjuvant chemotherapy and interval cytoreduction are noninferior to primary cytoreduction and adjuvant chemotherapy with respect to overall and progression-free survival and are associated with less perioperative morbidity and mortality.

RECOMMENDATIONS

All women with suspected stage IIIC or IV invasive epithelial ovarian cancer should be evaluated by a gynecologic oncologist prior to initiation of therapy. The primary clinical evaluation should include a CT of the abdomen and pelvis, and chest imaging (CT preferred). Women with a high perioperative risk profile or a low likelihood of achieving cytoreduction to < 1 cm of residual disease (ideally to no visible disease) should receive neoadjuvant chemotherapy. Women who are fit for primary cytoreductive surgery, and with potentially resectable disease, may receive either neoadjuvant chemotherapy or primary cytoreductive surgery. However, primary cytoreductive surgery is preferred if there is a high likelihood of achieving cytoreduction to < 1 cm (ideally to no visible disease) with acceptable morbidity. Before neoadjuvant chemotherapy is delivered, all patients should have confirmation of an invasive ovarian, fallopian tube, or peritoneal cancer. Additional information is available at www.asco.org/NACT-ovarian-guideline and www.asco.org/guidelineswiki.

Can advanced-stage ovarian cancer be cured?

Approximately 20% of women with advanced-stage ovarian cancer survive beyond 12 years after treatment and are effectively cured. Initial therapy for ovarian cancer comprises surgery and chemotherapy, and is given with the goal of eradicating as many cancer cells as possible. Indeed, the three phases of therapy are as follows: debulking surgery to remove as much of the cancer as possible, preferably to a state of no visible residual disease; chemotherapy to eradicate any microscopic disease that remains present after surgery; and second-line or maintenance therapy, which is given to delay disease progression among patients with tumour recurrence. If no cancer cells remain after initial therapy is completed, a cure is expected. By contrast, if residual cancer cells are present after initial treatment, then disease recurrence is likely. Thus, the probability of cure is contingent on the combination of surgery and chemotherapy effectively eliminating all cancer cells. In this Perspectives article, I present the case that the probability of achieving a cancer-free state is maximized through a combination of maximal debulking surgery and intraperitoneal chemotherapy. I discuss the evidence indicating that by taking this approach, cures could be achieved in up to 50% of women with advanced-stage ovarian cancer.