Sexuality as a Prognostic Factor-Results of an Individual Patient Data NOGGO (North-Eastern German Society of Gynecological Oncology)-Meta-Analysis of 644 Recurrent Ovarian Cancer Patients Prior to Chemotherapy

BACKGROUND

The aim of this study was to analyze the associations between sexuality, quality of life, treatment discontinuation, and survival in recurrent ovarian cancer (OC).

METHODS

Raw data from various phase II/III studies, including the questionnaires EORTC-QLQ-C30 and QLQ-OV28, were included. Data from the meta-analysis were calculated using logistic and Cox regression.

RESULTS

Data on sexuality were available for 644 patients. A total of 162 patients had an interest in sex and were sexually active (Group A). A total of 45 patients had an interest in sex and were sexually not active (Group I) and 437 patients had no interest in sex and were not sexually active (Group N). Group A was younger in median age (age at randomization), at 57 years, than Group I, at 60 years, and Group N, at 65 years (p < 0.001). Group A had a better ECOG performance status and fewer recurrences (all p < 0.001). FIGO stage, grading, and BMI were not associated with interest in sex and sexual activity. Group A showed higher scores in role, body, and social function (all p < 0.001), emotional functionality (p < 0.002), and body image (p = 0.012). In addition, Group A reported less pain, less peripheral neuropathy, and less fatigue (all p < 0.001). There was no association with the premature discontinuation of chemotherapy. Group A showed better survival rates compared to group N (22.3 months vs. 17.4 months, p < 0.001).

CONCLUSIONS

Physicians should routinely address the topic of sexuality with ovarian cancer patients. Sexuality appears to be a marker for quality of life as well as overall survival.

Role of Creative Therapies in Gynecological Oncology: Results of a Multigenerational Survey in Patients and Caregivers

INTRODUCTION

Although creative therapies like painting, dancing, and writing are often used and encouraged to treat various diseases, including cancer, there are few systematic scientific studies on innovative therapies in medical care.

METHODS

An anonymous survey was developed for female patients, their relatives, and female medical staff on the impact of creative therapies on optimizing clinical therapy management in exclusively female trials.

RESULTS

Of 718 respondents, 358 were female patients, 69 were medical personnel, and 291 were in the control group. Overall, 91.2% of respondents had sought access to creative therapies, indicating strong self-motivated engagement in activities to improve health and well-being. This study also uncovered a significant preference for creative writing among patients. Furthermore, the data suggest that integrating innovative therapies into biopsychosocial anamnesis could offer valuable insights into patients' mobility, mood, and social behaviors. Despite a general hesitation to discuss leisure activities with medical professionals, many patients wanted to incorporate creative activities into their treatment plans. Moreover, group settings for innovative therapy were preferred, highlighting the need for more structured support in medical environments to facilitate these therapeutic interactions.

CONCLUSIONS

This study suggests creative therapies can be valuable in medical care.

Side Effects from Cancer Therapies and Perspective of 1044 Long-Term Ovarian Cancer Survivors-Results of Expression VI-Carolin Meets HANNA-Holistic Analysis of Long-Term Survival with Ovarian Cancer: The International NOGGO, ENGOT, and GCIG Survey

The aim of this survey was to increase the knowledge on the characteristics and health concerns of long-term survivors (LTS; survival > 5 years) after ovarian cancer in order to tailor follow-up care. This international survey was initiated by the NOGGO and was made available to members of ENGOT and GCIG. The survey is anonymous and consists of 68 questions regarding sociodemographic, medical (cancer) history, health concerns including distress, long-term side effects, and lifestyle. For this analysis, 1044 LTS from 14 countries were recruited. In total, 58% were diagnosed with FIGO stage III/IV ovarian cancer and 43.4% developed recurrent disease, while 26.0% were receiving cancer treatment at the time of filling in the survey. LTS who survived 5-10 years self-estimated their health status as being significantly worse than LTS who survived more than 10 years (p = 0.034), whereas distress also remained high 10 years after cancer diagnosis. Almost half of the cohort (46.1%) reported still having symptoms, which were mainly lymphedema (37.7%), fatigue (23.9%), pain (21.6%), polyneuropathy (16.9%), gastrointestinal problems (16.6%), and memory problems (15.5%). Almost all patients (94.2%) regularly received follow-up care. Specialized survivorship care with a focus on long-term side effects, lifestyle, and prevention should be offered beyond the typical five years of follow-up care.

Health concerns in long-term survivors with ovarian cancer: Results of Expression VI–Carolin meets HANNA–Holistic Analysis of Long-term survival with Ovarian Cancer—The international NOGGO, ENGOT and GCIG survey

12023

Background: So-called long-term survivors (LTS) may be cured from cancer but still experience a wide range of long-term side effects. Aim was to analyze the main concerns in long-term survival to improve follow-up care. Methods: Within the study “Carolin meets HANNA” (www.carolinmeetshanna.com) long-term survivors with ovarian cancer (LTS) were recruited since 11/2016. Long-term survival was defined as an ovarian cancer diagnosis more than five years ago. Results: Until 02/2021 1,044 long-term survivors with ovarian cancer could be recruited. Median survival time at recruitment was 11 years (range 5-43 years). More than half had been diagnosed with advanced stage ovarian cancer (58.6% FIGO III/IV). Almost half have developed recurrent disease (43.4%). 26.0% were under cancer treatment at recruitment. Health status was rated very good or good by 52.0% while 20.3% report a bad or very bad health status. Almost half of the LTS have current concerns/long-term side effects (46.1%). Main concerns are fatigue (23.9%), pain (21.6%), polyneuropathy (16.9%), gastrointestinal symptoms (16.6%) and memory problems (15.5%). 42.8% still regard themselves as cancer patients. Health status and distress did not differ between LTS 5-10 years after diagnosis and > 10 years after diagnosis (p = 0.59 and p = 0.0843 respectively). Patients with a history of recurrence and those under current treatment had a worse health status and more health concerns. LTS without recurrence reported fatigue in 18.4%, pain in 19.2%, polyneuropathy in 13.1%, gastrointestinal problems in 13.4% and memory problems in 14.4%. Fatigue, polyneuropathy, nausea and concentration problems improve with the time of survival. However, fatigue is still present in 21.1% after ten years survival time. There was no significant difference in pain between 5-10 (20.1%) and > 10 years (22.0%) survival time. In this cohort 94.2% receive regular follow-up care including CA125 testing in 77.0%, clinical examination in 54.3%, transvaginal ultrasound in 55.1%, abdominal ultrasound in 43.9%, mammogram in 50.5% and further radiological examinations such as CT scans in 53.4%. Conclusions: Follow-up care in ovarian cancer is usually delivered within the first five years after diagnosis. However, our analyses show the high frequency of health concerns in LTS despite the high frequency of follow-up care in this cohort. Therefore, specialized survivorship care should be offered beyond the typical five years of follow-up care with a focus on long-term side effects.

Effects of sarcopenia and malnutrition on morbidity and mortality in gynecologic cancer surgery: results of a prospective study

BACKGROUND

Malnutrition and sarcopenia often occur simultaneously in cancer patients and are thought to have harmful effects on both surgical and oncological outcomes. Therefore, we want to evaluate the effects of sarcopenia and malnutrition on severe postoperative complications and overall survival in gynecologic cancer patients.

METHODS

We assessed nutritional parameters and run a bioelectrical impedance analysis in 226 women. Extracellular mass to body cell mass index, phase angle alpha, muscle mass, and fat mass were evaluated. To determine if patients suffer from sarcopenia, we ran the Timed 'Up and Go' test, performed hand grip strength, and calculated a skeletal muscle index. Postoperative complications were categorized using Clavien-Dindo Classification. Utilizing ROC analysis and logistic regression, we determined predictive clinical factors for severe postoperative complications. Kaplan-Meier method and log-rank test were used for overall survival analysis.

RESULTS

Of the 226 female patients, 120 (53%) had a BMI ≥ 25 kg/m2 , 56 (26%) had a phase angle < 4.75°, and 68 (32%) were sarcopenic according to skeletal muscle index < 27%. Within 30 days after surgery, 40 (18%) patients developed severe postoperative complications, and 4% had died. According to multivariable regression analysis, ECOG status > 1 (OR 4.56, 95% CI: 1.46-14.28, P = 0.009), BMI ≥ 25 kg/m2 (OR 8.22, 95% CI: 3.01-22.48, P < 0.001), phase angle < 4.75° (OR 3.95, 95% CI: 1.71-9.10, P = 0.001), and tumour stage ≥ III A (OR 3.65, 95% CI: 1.36-9.76, P = 0.01) were predictors of severe postoperative complications. During 59 months of follow-up, 108 (48%) patients had died. According to multivariable Cox regression ECOG status > 1 (HR 2.51, 95% CI: 1.25-5.03, P = 0.01), hypoalbuminemia (HR 2.15, 95% CI: 1.28-3.59, P = 0.004), phase angle < 4.5° (HR 1.76, 95% CI 1.07-2.90, P = 0.03), tumour stage ≥ III A (HR 2.61, 95% CI: 1.53-4.45, P < 0.001), and severe postoperative complications (HR 2.82, 95% CI: 1.80-4.41, P < 0.001) were predictors of overall mortality.

CONCLUSIONS

We observed that preoperatively assessed ECOG status > 1, BMI > 25 kg, as well as phase angle alpha < 4.75° and FIGO stage ≥ III A are significantly associated with severe postoperative complications within the first month. Whereas ECOG status > 1, hypoalbuminemia, phase angle < 4.5° as well as FIGO stage ≥ III A and severe postoperative complications within 30 days correlate significantly with poor overall survival.

Impact of health-related quality of life (HRQoL) on short-term mortality in patients with recurrent ovarian, fallopian or peritoneal carcinoma (the NOGGO-AGO QoL Prognosis-Score-Study): results of a meta-analysis in 2209 patients

Objective

Recurrent ovarian cancer is an incurable disease with variable but poor prognosis. Health-related quality of life (HRQoL) is a patient-reported outcome measure generally applied to measure effects of therapies. Our aim was the development and validation of a risk score for the prediction of short-term mortality using the combination of sociodemographic and clinical factors and HRQoL.

Methods

For exploratory and validation analysis, the North-Eastern German Society of Gynecological Oncology (NOGGO) and Working Group Gynecological Oncology (AGO) study databases were screened for trials. Only trials which obtained defined HRQoL measurements were included in the final analysis. Multivariable logistic regression analyses were used to identify risk factors and their weighting for the risk score. Modulation with cubic regression analyses revealed median survival and short-term mortality defined as 1-year mortality for each value.

Results

For exploration, 974 patients from three clinical studies of the NOGGO and for validation, 1235 patients from several clinical studies of the AGO were eligible. The risk score included platinum-free interval, performance status, age, global QoL and nausea/vomiting. Receiver operating characteristic analysis showed a good predictive value with an area under the curve of 0.81 for model 1 in the exploration and 0.74 in the validation. Short-term mortality in model 1 was 8.2%, 23.5% and 58.4% in the exploration sample, and 19.7%, 38.1% and 63.4% in the validation sample for patients under low, medium and high risk, respectively.

Conclusions

This risk score discriminates well between recurrent ovarian cancer patients under low, medium and high risk of short-term mortality. It may help to identify a risk group under high risk for short-term mortality that can be used for randomization in clinical trials and may support decision making for palliative chemotherapy.

•

This newly developed NOGGO-AGO QoL prognosis score clearly discriminates recurrent ovarian cancer (rOC) patients under low, medium and high risk for short-term survival (<1 year).

•

The risk score included platinum-free interval, performance status, age, global QoL and nausea/vomiting.

•

NOGGO-AGO QoL score can be used for stratification or randomization in clinical trials and for identification of a group under high risk for short-term mortality.

•

It may also help the decision making for chemotherapy and provide more precise information of further life expectation for rOC patients.

Secondary malignancies in long-term ovarian cancer survivors: results of the 'Carolin meets HANNA' study

OBJECTIVE

To evaluate the rate of secondary malignancies in long-term survivors with ovarian cancer.

METHODS

Long-term survivors with ovarian cancer (survival ≥8 years after initial diagnosis) with multiple malignancies were identified within the Tumorbank Ovarian Cancer and our study 'Carolin meets HANNA - Holistic Analyses of Long-term Survivors with Ovarian Cancer'.

RESULTS

Of a total of 225 long-term survivors with ovarian cancer, 36 patients (16%) had at least one more cancer diagnosis before, concomitant with, or after, ovarian cancer. Median age was 52.5 years (range 37-79). A total of 60% were diagnosed with stage III/IV and most tumors were high-grade (88.6%), as well as of serous histology (63.9%). Median overall survival was 10 years (range 8-19). Secondary cancer after ovarian cancer was found in 17 long-term survivors (7.6%). Breast cancer was the most frequent secondary malignancy. Median duration between diagnosis of primary ovarian cancer and secondary cancer diagnosis was 78.5 months (range 12-220). BRCA was tested in 11 patients with seven patients being BRCA1 and one patient BRCA2 positive. Secondary cancers were detected by screening in 35.3% and self-detected in 29.4% of patients (breast self-examination).

CONCLUSION

A secondary malignancy was diagnosed in 7.6% of long-term survivors. Routine follow-up and cancer screening should be performed in long-term ovarian cancer survivors.

Frailty Index for prediction of surgical outcome in ovarian cancer: Results of a prospective study

BACKGROUND

Complete macroscopic tumor resection is the strongest prognostic factor for patients with ovarian cancer, which requires complex surgery for achievement. Based on the mostly advanced tumor stage and high symptom burden many patients are classified as frail which may limit optimal surgical outcome. Aim of this study is to evaluate the predictive ability of Frailty Index for surgical outcomes in patients with ovarian cancer.

METHODS

This prospective study enrolled patients with ovarian cancer undergoing cytoreductive surgery. We classified frailty proposed by Mitnitski et al. regarding the cumulative deficit model of frailty. Utilizing Receiver Operator Characteristic (ROC) analysis and logistic regression, we determined predictive clinical factors for severe postoperative complications. The Kaplan-Meier method and log-rank test were used for overall survival analysis.

RESULTS

Out of f 144 enrolled patients, the overall prevalence of frailty based on a Frailty Index >0.26 and Frailty Index >0.15 was 33% and 74%, respectively. The logistic regression shows that frail patients with a Frailty Index >0.26 (Odds ratio (OR): 3.64, 95% CI: 1.34-9.85, p = 0.01), ECOG PS > 1 (OR 6.33, 95% CI:1.31-30.51, p = 0.02) and high surgical complexity score (OR 8.86, 95% CI:1.88-41.76, p = 0.006) had a significant higher risk for severe postoperative complications. According to multivariable cox regression Frailty Index >0.15 (hazard ratio (HR) (HR 1.87, 95% CI: 1.01-3.47, p = 0.048), residual tumor <1 cm (HR 2.75, 95%CI: 1.53-4.99, p = 0.001), residual tumor >1 cm (HR 5.00, 95% CI: 2.74-9.13, p < 0.001) and albumin<35.5 g/dl (HR 1.92, 95% CI: 1.08-3.43, p = 0.03) resulted as significant parameters for poor overall survival. Resulted as significant parameters for poor overall survival.

CONCLUSION

Next to surgical complexity score, ECOG PS > 1 and recurrent surgery, Frailty Index >0.26 is associated with severe postoperative complications in patients with ovarian cancer. Besides tumor residuals and low albumin levels a Frailty Index >0.15 predicts poor survival.

Impact of clinical factors and surgical outcome on long-term survival in high-grade serous ovarian cancer: a multicenter analysis

INTRODUCTION

Long-term survivors of ovarian cancer are a unique group of patients in whom prognostic factors for long-term survival have been poorly described. Such factors may provide information for a more personalized therapeutic approach. The objective of this study is to determine further characteristics of long-term survivors with high-grade serous ovarian cancer.

METHODS

Long-term survivors were defined as patients living longer than 8 years after first diagnosis and were recruited within seven high volume centers across Europe from November 1988 to November 2008. The control group included patients with high-grade serous ovarian cancer with less than 5 years' survival identified from the systematic 'Tumorbank ovarian cancer' database. A subanalysis of Charité patients only was performed separately for in-depth analysis of tumor dissemination. Propensity score matching with nearest-neighbor caliper width was used to match long-term survivors and the control group regarding age, FIGO stage, and residual tumor.

RESULTS

A total of 276 patients with high-grade serous ovarian cancer were included, divided into 131 long-term survivors and 145 control group patients. After propensity score matching and multivariable adjustment, platinum sensitivity (p=0.002) was an independent favorable prognostic factor whereas recurrence (p<0.001) and ascites (p=0.021) were independent detrimental predictors for long-term survival. Significantly more long-term survivors tested positive for mutation in the BRCA1 gene than the BRCA2 gene (p=0.016). Intraoperatively, these patients had less tumor involvement of the upper abdomen at initial surgery (p=0.024). Complexity of surgery and surgical techniques were similar in both cohorts.

CONCLUSION

Platinum sensitivity constitutes a favorable factor for long-term survival whereas tumor involvement of the upper abdomen, ascites, and recurrence have a negative impact. Based on clinical estimation, long-term survival is associated with combinations of clinical, surgical, and molecular factors.

Role of predictive markers for severe postoperative complications in gynecological cancer surgery: a prospective study (RISC-Gyn Trial)

BACKGROUND

Surgery for gynecological cancer involves highly invasive and complex procedures potentially associated with various complications, which can cause extended hospital stays and delay of subsequent therapy, with a detrimental effect on the prognosis. The aim of this study was to explore and define the predictors of severe postoperative complications in patients undergoing surgery for gynecologic cancer.

METHODS

Patients undergoing surgery for gynecologic cancers were analyzed prospectively from October 2015 through January 2017. Using validated assessment tools preoperatively, we assessed comorbidities, performance status, quality of life, nutritional and body composition by bioelectrical impedance analysis, and the surgical data of each patient. Surgical complications were graded using the Clavien-Dindo criteria. Using stepwise logistic regression models, we identified predictive markers for postoperative complications.

RESULTS

Of the 226 enrolled patients, 40 (17.7%) experienced a grade ≥IIIb complication according to the Clavien-Dindo criteria. In the regression analysis, overweight/obesity (body mass index >25) (OR 6.41, 95% CI 2.38 to 17.24; p<0.001) and impaired physical functioning defined by a quality of life questionnaire (OR 4.19, 95% CI 1.84 to 9.50; p=0.001) emerged as significant predictors of postoperative complications. Moreover, postoperative complications were predicted by phase angle of bioelectrical impedance analysis <4.75° (OR 3.11, 95% CI 1.35 to 7.16; p=0.008) and Eastern Cooperative Oncology Group (ECOG) performance status >1 (OR 2.51, 95% CI 1.06 to 5.92; p=0.04). Intraoperative factors associated with higher risk of postoperative complications were increased use of norepinephrine (>11 µg/kg/min) (OR 5.59, 95% CI 2.16 to 14.44; p<0.001) and performance of large bowel resection (OR 4.28, 95% CI 1.67 to 10.97; p=0.002).

CONCLUSION

In patients undergoing surgery for gynecological cancer, preoperative evaluation of performance status according to ECOG, domains of quality of life and nutritional status, as well as intraoperative monitoring of risk factors, might help to identify patients at high risk for severe postoperative complications, and thus reduce surgical morbidity and mortality.

Can Fried Frailty Score predict postoperative morbidity and mortality in gynecologic cancer surgery? Results of a prospective study

BACKGROUND

Aim of this study is to evaluate the predictive ability of Fried Frailty Score for surgical outcomes in patients undergoing gynecologic cancer surgery.

METHODS

This is a prospective cohort study at an academic gynecological cancer center from Oct 2015 through Jan 2017. We applied systematically numerous screening tools, geriatric questionnaires and single measurements which may provide predictions for surgical outcomes. We classified frailty according to the Fried definition and surgical complications were graded according Clavien-Dindo criteria. Using logistic regression analysis, we identified predictive clinical variables for postoperative complications (POC).

RESULTS

Overall 226 patients were enrolled (median age 59 years, range 18-87 years). The prevalence of frailty based on the presence of three or more frailty criteria was 14.2%, the presence of one or two frailty criteria was classified as prefrail with 59.4% and without any presence as robust with 26.5%. Within 30 days of surgery, nine (3.8%) patients have died and 40 (18.3%) experienced a grade ≥ IIIb complication. In the regression analysis obesity (OR: 5.37, 95% CI 1.99-14.49, p = 0.001) as well as ECOG >1 (OR: 4.32, 95% CI 1.28-1.55, p = 0.018) and Albumin<3.6 g/dl (OR: 3.88, 95% CI 1.37-10.98, p = 0.011) emerged as significant predictors of postoperative complications (POC). Fried Frailty Score (OR: 2.41, 95% CI 0.91-6.41, p = 0.077) showed no significant additional predictive value.

CONCLUSION

Fried Frailty Score could help the surgeon to estimate the risk for POC among patients undergoing gynecologic cancer surgery. But preoperatively determined ECOG, BMI and Albumin can predict severe POC in patients undergoing gynecologic surgery more precisely and should be assessed routinely.

Fatigue in long-term survivors with ovarian cancer: Results of Expression VI – Carolin meets HANNA – Holistic analysis of Long-term survival with ovarian cancer—The international NOGGO, ENGOT and GCIG survey

12065

Background: Long-term survivors (LTS) with ovarian cancer may be cured from cancer but frequently experience long-term toxicities such as fatigue with a huge impact on quality of life. Aim of this study was to evaluate factors associated with fatigue in LTS. Methods: Within the study “Carolin meets HANNA” ( www.carolinmeetshanna.com ) long-term survivors with ovarian cancer (LTS) were recruited since 11/2016. Long-term survival was defined as an ovarian cancer diagnosis more than eight years ago. Results: Until 12/2019 473 LTS could be recruited. 211 LTS (44.5%) have experienced fatigue. At the time point of recruitment in 23.4% (111 LTS) fatigue was still present. LTS with fatigue were not more frequently under current treatment compared to LTS without fatigue (p = 0.348). LTS with fatigue were not younger at initial diagnosis (50.4 vs. 51.9 years, p = 0.228). 58.6% of LTS with fatigue compared to 41.5% without fatigue have developed recurrent disease (p = 0.002) and LTS had more frequently more than one recurrence (66.1% vs. 51.7%, p = 0.055). Fatigue was associated with worse health status (2.9 vs. 2.2 on a scale from 1-5, p < 0.001). Fatigue was associated with medical complaints in general (82.0% vs. 43.0%, p < 0.001). Symptoms such as nausea and vomiting (p < 0.001), loss of appetite (p < 0.001), constipation (p < 0.001), diarrhea (p < 0.001), weight loss (p = 0.001) and bloating (p < 0.001) were more frequent in LTS with fatigue. This also accounts for cognitive disorders (39.6% vs. 10.5%, p < 0.001), depression (23.4% vs. 7.4%, p < 0.001), polyneuropathy (39.6% vs. 13.2%, p < 0.001) and cardiovascular disease (11.7% vs. 3.6%, p = 0.002). LTS with fatigue regard themselves more frequently as cancer patient (73.9% vs. 40.8%), p < 0.001). Conclusions: Fatigue is still very common in LTS despite the long survival time. Fatigue is associated with worsened health status and other long-term side effects underlining the impact on LTS. There is a high need for survivorship clinics that should ask for and, if necessary, should address still existing side effects such as fatigue.

The prognostic and predictive role of pain before systemic chemotherapy in recurrent ovarian cancer: an individual participant data meta-analysis of the North-Eastern German Society of Gynecological Oncology (NOGGO) of 1226 patients

BACKGROUND

Aim of this study was to analyze the impact of pain on quality of life and survival in recurrent OC patients.

METHODS

Raw data including the QLQ-C30 questionnaire from three phase II/III trials ("Topotecan phase III," "Hector," and "TRIAS") conducted by the North-Eastern German Society of Gynecological Oncology (NOGGO) were synthesized and analyzed using logistic and Cox regression analyses.

RESULTS

Data on pain was available for 952 patients out of 1226. Moderate to severe pain, which was defined as pain ≥ 50 in the QLQ-C30 symptom scale, was experienced by more than one-third of patients (36.6%). A total of 31% were taking non-opioid pain medication and 16% opioids. Median age at randomization was 61 years (range 25-84). Most patients (84.7%) were diagnosed in FIGO III/IV. Pain was independent from age, FIGO stage, grading, amount of recurrences, and chemotherapy-free interval. ECOG was significantly worse in patients with pain (p < 0.001). Fatigue, nausea/vomiting, sleeping disorders, and abdominal symptoms such as loss of appetite, diarrhea, and constipation were more frequently found in patients with pain (all p < 0.001). Quality of life was significantly diminished (p < 0.001). Pain was also an independent marker for overall survival (OS). Median OS was 18.2 months in patients with pain compared with 22.0 months in patients without pain (p = 0.013, HR 1.25, 95% confidence interval 1.05-1.48). OS was shorter in patients with pain and without pain medication compared with those on sufficient pain medication, whereas OS was mostly decreased in patients having pain despite pain medication (18.5, 19.6, and 15.0 months respectively; p = 0.026). Progression-free survival and prior treatment discontinuation were not associated with pain.

CONCLUSION

Best supportive care including sufficient pain medication should be delivered as early as possible because effective pain management is crucial for both quality of life and overall survival in patients with recurrent ovarian cancer.

Vascular endothelial growth factor receptor 2 (VEGFR2) correlates with long-term survival in patients with advanced high-grade serous ovarian cancer (HGSOC): a study from the Tumor Bank Ovarian Cancer (TOC) Consortium

OBJECTIVE

The impact of angiogenesis on long-term survival of high-grade serous ovarian cancer (HGSOC) patients remains unclear. This study investigated whether angiogenic markers correlated with 5-year progression-free survival (PFS) in a large cohort of matched advanced HGSOC tissue samples.

METHODS

Tumor samples from 124 primary HGSOC patients were retrospectively collected within the Tumor Bank Ovarian Cancer ( http://www.toc-network.de ). All patients were in advanced stages (FIGO stage III-IV). No patient had received anti-angiogenesis therapy. The cohort contains 62 long-term survivors and 62 controls matched by age and post-surgical tumor residuals. Long-term survivors were defined as patients with no relapse within 5 years after the end of first-line chemotherapy. Controls were patients who suffered from first relapse within 6-36 months after primary treatment. Samples were assessed for immunohistochemical expression of vascular endothelial growth factor (VEGF) A and VEGF receptor 2 (VEGFR2). Expression profiles of VEGFA and VEGFR2 were compared between the two groups.

RESULTS

Significant correlation between VEGFA and VEGFR2 expression was observed (p < 0.0001, Spearman coefficient 0.347). A high expression of VEGFR2 (VEGFR2^high) was found more frequently in long-term survivors (77.4%, 48/62) than in controls (51.6%, 30/62, p = 0.001), independent of FIGO stage and VEGFA expression in multivariate analysis (p = 0.005). Also, VEGFR2^high was found the most frequently in women with PFS ≥ 10 years (p = 0.001) among all 124 patients. However, no significant association was detected between VEGFA expression and 5-year PFS (p = 0.075).

CONCLUSIONS

VEGFR2 overexpression significantly correlated with long-term PFS in HGSOC patients, independent of age, FIGO stage, tumor residual and VEGFA expression.

Impact of Body Mass Index (BMI) on Chemotherapy-associated Toxicity in Ovarian Cancer Patients. A Pooled Analysis of the North-Eastern German Society of Gynecological Oncology (NOGGO) Databank on 1,213 Patients

BACKGROUND/AIM

Chemotherapy-associated toxicity is one of the limiting factors regarding treatment efficacy, patient outcome and quality of life in this collective. Underweight or obese patients represent a major group in which the therapy seems to be more challenging. The aim of this analysis was to evaluate the impact of BMI on the toxicity in patients undergoing chemotherapy.

PATIENTS AND METHODS

The data of three prospective phase II/III studies ('Tower', 'Topotecan phase III' and 'Hector') of the North-Eastern German Society of Gynecological Oncology including 1,213 patients with recurrent ovarian cancer were retrospectively analyzed. The study was performed using logistic regression and Cox regression analysis.

RESULTS

The median age at diagnosis was 59 years. Sixty-seven (5.5%) patients had BMI <20 and 272 (22.4%) patients had BMI >30. Preterm termination of the chemotherapy was associated with lower BMI (p=0.017). Moreover, non-hematological toxicity grade III/IV was mainly observed in underweighted women as well (p<0.001). Patients with higher BMI more often presented with grade III/IV anemia (p=0.019) and as a consequence required blood transfusions more frequently (p=0.005). The overweight group was also associated with a higher number of co-medications. However, no difference in survival regarding BMI was observed in our study.

CONCLUSION

Fewer chemotherapy cycles and preterm discontinuation were more frequent in patients with lower BMI. Hematological toxicity and higher medication intake appeared more often in patients with higher BMI.

Morphology and tumour-infiltrating lymphocytes in high-stage, high-grade serous ovarian carcinoma correlated with long-term survival

AIMS

Advanced-stage ovarian high-grade serous carcinoma (HGSC) is a poor-prognosis cancer; however, a small and poorly characterised subset of patients shows long-term survival. We aimed to establish a cohort of HGSC long-term survivors for histopathological and molecular analysis.

METHODS AND RESULTS

Paraffin blocks from 151 patients with primary FIGO III/IV HGSC and progression-free survival (PFS) >5 years were collected within the Tumorbank Ovarian Cancer (TOC) Network; 77 HGSC with a PFS <3 years were used as a control group. A standardised analysis of histological type and morphological features was performed. Ki67 index, tumour-infiltrating lymphocytes (TILs) and major histocompatibility complex expression (MHC1/2) were determined by immunohistochemistry. A total of 117 of 151 tumours (77.5%) in the long-term survivor group fulfilled the World Health Organisation (WHO) criteria of HGSC after review, and of these, 83 patients (70.9%) fulfilled all clinical criteria for inclusion into our cohort. Tumours of long-term survivors had significantly higher CD3⁺ and CD8⁺ TILs and were more frequently positive for MHC2 than controls (P = 0.004, P = 0.025, P = 0.048). However, there were also long-term survivors (up to 20%) with low TILs or low MHC expression. TILs and MHC had no impact on survival in long-term survivors. Morphological and Ki67 analysis revealed no differences between long-term survivors and controls.

CONCLUSIONS

HGSC from long-term survivors have higher-level T cell infiltration and antigen-presentation capacity; however, this is not a prerequisite for an excellent prognosis. Histopathological criteria are not capable to identify these patients. Further extensive clinical and molecular characterisation of this enigmatic subgroup is ongoing to understand the reasons of long-term survival in HGSC.

Morphology and tumour-infiltrating lymphocytes in high-stage, high-grade serous ovarian carcinoma correlated with long-term survival

AIMS

Advanced-stage ovarian high-grade serous carcinoma (HGSC) is a poor-prognosis cancer; however, a small and poorly characterised subset of patients shows long-term survival. We aimed to establish a cohort of HGSC long-term survivors for histopathological and molecular analysis.

METHODS AND RESULTS

Paraffin blocks from 151 patients with primary FIGO III/IV HGSC and progression-free survival (PFS) >5 years were collected within the Tumorbank Ovarian Cancer (TOC) Network; 77 HGSC with a PFS <3 years were used as a control group. A standardised analysis of histological type and morphological features was performed. Ki67 index, tumour-infiltrating lymphocytes (TILs) and major histocompatibility complex expression (MHC1/2) were determined by immunohistochemistry. A total of 117 of 151 tumours (77.5%) in the long-term survivor group fulfilled the World Health Organisation (WHO) criteria of HGSC after review, and of these, 83 patients (70.9%) fulfilled all clinical criteria for inclusion into our cohort. Tumours of long-term survivors had significantly higher CD3⁺ and CD8⁺ TILs and were more frequently positive for MHC2 than controls (P = 0.004, P = 0.025, P = 0.048). However, there were also long-term survivors (up to 20%) with low TILs or low MHC expression. TILs and MHC had no impact on survival in long-term survivors. Morphological and Ki67 analysis revealed no differences between long-term survivors and controls.

CONCLUSIONS

HGSC from long-term survivors have higher-level T cell infiltration and antigen-presentation capacity; however, this is not a prerequisite for an excellent prognosis. Histopathological criteria are not capable to identify these patients. Further extensive clinical and molecular characterisation of this enigmatic subgroup is ongoing to understand the reasons of long-term survival in HGSC.

The impact of polypharmacy and comorbidities on surgical morbidity and mortality in patients with gynecological malignancies: Results of a prospective study in 237 patients

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Background: Physicians need to risk-stratify their patients preoperatively to adjust the radicality and the indication of surgery. So far, there are only retrospective and limiting data available. Aim of this study is to evaluate the predictive clinical characteristics such as polypharmacy and Charlson-Comorbidity Index (CCI) for postoperative complications in patients undergoing gynecologic cancer surgery. Methods: This is a prospective cohort study of patients undergoing gynecologic cancer surgery at a tertiary care academic center from October 2015 through January 2017. Surgical complications were graded using validated Clavien-Dindo criteria. Using logistic regression, we identified demographic and predictive clinical characteristics for postoperative complications. Results: Out of the 237 enrolled patients 41(17.3%) experienced a grade≥3b complication. Within 30 days of surgery, 9 (3.8%) patients has died. Charlson Comorbidity index (CCI)> 2(p<0.015, OR 2.33, 95% CI 1.18-4.61), polypharmacy (p<0.001, OR 3.40, 95% CI 1.63-7.10), ASA (p<0.0001, OR 2.98, 95% CI 1.65-5.38), BMI>25kg/m2 (p<0.001, OR 4.25, 95% CI 1.86-9.69), preoperative albumin<3.5 g/dl (p<0.009, OR 3.22, 95% CI 1.33-7.79) and potassium < 3.6 mmol/L (p=0.007, OR 5.11, 95% CI 1.55-16.81) were predictive for complications grade≥3b. A multivariable model included duration of surgery (p=0.012, OR 1.26, 95% CI 1.05-1.52), ASA (p=0.01, OR 2.60, 95% CI 1.20-5.60), preoperative albumin<3.5 g/dl (p=0.028, OR 3.37, 95% CI 1.14-10.00), BMI >25kg/m2 (p=0.009, OR 3.81, 95% CI 1.40-10.35) and potassium < 3.6 mmol/L (p=0.02, OR 3.69, 95% CI 1.20-11.38) was predictive of 30-day Morbidity and Mortality. Age (p=0.49, OR 0.89, 95% CI 0.95-1.02), CCI > 2(p=0.88, OR 1.06, 95% CI 0.42-2.69) and polypharmacy (p=0.65, OR 1.26, 95% CI 0.41-3.98) showed no association for postoperative complications. Conclusions: Only ASA, BMI, preoperative albumin and potassium are associated with severe postoperative complications in patients undergoing gynecologic cancer surgery. Subsequent studies should confirm this result to identify better frail cancer patients.

Clinical characterization of long term survivors (LTS) in ovarian cancer (OC): Results of a propensity score matched (PSM) analysis of the international prospective tumor bank for ovarian cancer (TOC Network)

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Background: OC has the highest mortality rate amongst gynecological malignancies. Nevertheless a small fraction of OC patients will survive longer than 8 years. Aim of our study was to analyze differences in the clinical appearance and management of LTS versus “classical” OC patients. Methods: OC patients living longer than 8 years were identified within the TOC Network between 1998 and 2008, representing the LTS subgroup. PSM analysis was used to select comparable groups of LTS and OC patients who died within first 5 years (control group - CG). PSM was conducted using nearest neighbor caliper matching without replacement to match LTS and CG for age, FIGO and residual tumor mass. All calculations were performed with the R project for Statistical Computing (R-packages used: “MatchIt”). Results: A total of 347 OC patients with different histological subtypes were included in the current analysis, i.e. 173 LTS and 174 in the CG. After PSM 114 patients remained in each group. Patients had similar age, FIGO stage and residual mass (p = 0.99, p = 0.35 and p = 0.88, respectively). Tumor spread in middle and upper abdomen (p = 0.002 and 0.013, respectively) was higher and diaphragm, mesentery and peritoneum (p = 0.009, 0.037 and 0.002, respectively) were significantly more often involved in CG than in the LTS. When only considering the HGSOC patients, 95 patients remained in each group. All patients received surgery and platinum based chemotherapy. The PSM analysis showed significant higher involvement of upper abdomen (p = 0.028), higher peritoneal spread (p = 0.002), higher ascites volume (p = 0.0007) and higher bowel resection rates (p = 0.002) in the CG compared to LTS. Neoadjuvant chemotherapy rate was similar in the LTS and CG (p = 0.5). Conclusions: Based on this PSM analysis, HGSOC-LTS seem to have mainly similar clinical pattern as the control group, however with lower rates of ascites and involvement of upper abdomen. Molecular characterization including analysis of clonal diversity might help elucidate mechanisms of tumor spread and good prognosis.

The influence of chemotherapy induced nausea and vomiting (CINV) on survival: An individual participant data meta-analysis of the North-Eastern German Society of Gynecological Oncology (NOGGO) of 1213 recurrent ovarian cancer patients

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Background: Nausea and vomiting are frequent side effects of chemotherapy and are the most feared toxicities of our patients. Aim of this study is to evaluate the potential influence of chemotherapy induced nausea and vomiting (CINV) on survival. Methods: Synthesized raw data of three phase II/III studies (“Tower”, “Topotecan phase III” and “Hector”) of the North-Eastern German Society of Gynecological Oncology (NOGGO) including 1213 patients were analyzed using logistic regression and cox regression analyses. Results: In this analysis 661 patients (54.5%) developed grade I/II and 44 patients (3.6%) grade III/IV nausea. 343 patients (28.3%) had grade I/II vomiting and 33 patients (2.7%) grade III/IV. There were no differences between severity of CINV regarding FIGO, grading, histology and amount of recurrences. Patients <65 years developed more frequently grade III/IV nausea than patients ≥ 65 years (p<0.001, OR 1.29, 95% CI 0.68-2.46). Polypharmacy was also associated with grade III/IV CINV (p<0.001 and p=0.002 respectively). Progression free survival was worse in patients with grade III/IV nausea (p=0.023, HR 1.58, 95% CI 1.14-2.20). Median overall survival (OAS) in patients without nausea was 19.0 months compared to patients with grade III/IV nausea with 11.0 months (p<0.001, HR for grade III/IV 2.35, 95% CI 1.64-3.37). Grade III/IV vomiting was also highly associated with worse OAS (median of 22.0 months in patients without vs. 5.9 months in patients with grade III/IV vomiting, p<0.001, HR for grade III/IV vomiting 3.4, 95% CI 2.32-5.00). However, dose reductions and prior discontinuation of chemotherapy were not more frequent in patients with nausea and vomiting. Conclusions: Patients with nausea and vomiting had a decreased progression and overall survival. This study underlines once again the importance of early best supportive care on survival.

Neuroendocrine Neoplasms of the Ovary: A Retrospective Study of the North Eastern German Society of Gynecologic Oncology (NOGGO)

BACKGROUND/AIM

Neuroendocrine neoplasms (NEN) of the female genital tract account for 2% of gynecological cancers. The aim of this study was to share our experience of 11 primary neuroendocrine neoplasms of the ovary.

PATIENTS AND METHODS

All patients who presented and/or were treated at our Institution with histologically-confirmed NEN of the ovary were included. Clinical data including tumor stage, diagnostic and therapeutic management and survival were assessed. Pathological specimens were critically reviewed.

RESULTS

We identified 11 patients with NEN of the ovary consisting of nine neuroendocrine cancers and two carcinoids. Median age was 55.9 years. NEN were mostly poorly differentiated (72.4%). Primary surgery was performed in all patients. Adjuvant chemotherapy was administered in five patients consisting of platinum-based regimens. Median overall survival was 20 months.

CONCLUSION

We propose a diagnostic algorithm for NEN of the ovary and discuss possible treatments according to FIGO stages. Patients should be included in multicenter studies whenever possible.

The influence of polypharmacy on grade III/IV toxicity, prior discontinuation of chemotherapy and overall survival in ovarian cancer

BACKGROUND

Ovarian cancer is mostly diagnosed in the elderly woman who is likely to have comorbid disease and to take several comedications on a regular basis. Aim of this study was to evaluate the influence of polypharmacy on grade III/IV toxicity, prior discontinuation of chemotherapy and survival.

PATIENTS AND METHODS

In this individual participant data meta-analysis the original data of three phase II/III studies of the North-Eastern German Society of Gynecological Oncology (NOGGO) were analyzed using multivariate logistic and Cox regression.

RESULTS

Overall, 1213 patients with recurrent ovarian cancer were included in these analyses. An increasing amount of medication was associated with overall grade III/IV toxicity (p<0.001; OR 1.120), and hematological (p<0.001; OR 1.056) and non-hematological (p<0.001; OR 1.134) toxicities. Prior discontinuation of chemotherapy was not influenced by an increasing amount of medication (p=0.196). There was no association of polypharmacy with overall survival (p=0.068).

CONCLUSION

As polypharmacy does not influence survival ovarian cancer patients taking several comedications may be included in clinical trials and should not be deprived of adequate cancer treatment. However, a thorough monitoring is mandatory due to the increased risk of toxicities.

Overexpression of the epithelial cell adhesion molecule is associated with a more favorable prognosis and response to platinum-based chemotherapy in ovarian cancer

OBJECTIVE

Epithelial cell adhesion molecule (EpCAM) has experienced a renaissance lately as a binding site for targeted therapy as well as a prognostic marker in epithelial malignancies. Aim of this study was to study EpCAM as a potential prognostic marker in epithelial ovarian cancer (EOC).

METHODS

EpCAM expression was assessed by immunohistochemistry on paraffin-embedded primary EOC-tissue samples. EpCAM overexpression was defined as an expression of EpCAM of 76% to 100%. Tissue samples and clinical data were systematically collected within the international and multicenter "Tumorbank Ovarian Cancer" network.

RESULTS

Seventy-four patients, diagnosed with EOC between 1994 and 2009, were included in the study (median age, 56 years; range, 31 to 86 years). The majority of the patients (81.1%) presented with an advanced stage International Federation of Gynecology and Obstetrics (FIGO) III/IV disease. Histology was of the serous type in 41 patients (55.4%), endometrioid in 19 (25.6%), and mucinous in 14 (19%). EpCAM was overexpressed in 87.7%. Serous tumors overexpressed EpCAM significantly more often than mucinous tumors (87.8% vs. 78.6%, p=0.045); while no significant difference was noted between the other histological subgroups. EpCAM overexpression was significantly associated with a better progression free survival and higher response rates to platinum based chemotherapy (p=0.040 and p=0.048, respectively). EpCAM was identified as an independent prognostic marker for overall survival (p=0.022).

CONCLUSION

Our data indicate a significant association of EpCAM overexpression with a more favorable survival in EOC-patients. Serous cancers showed a significant EpCAM overexpression compared to mucinous types. Larger multicenter analyses are warranted to confirm these findings.

Prognostic value of epithelial cell adhesion molecule (EpCAM) in patients with primary epithelial ovarian cancer

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Background: EpCAM, a well known cancer antigene is currently experiencing a renaissance in its use as a binding site for targeted oncologic therapy and prognostic marker in various epithelial carcinomas such as breast cancer or carcinomas of the oral cavity. Goal of this retrospective study was to identify EpCAM as a potential prognostic marker for patients with primary epithelial ovarian cancer (EOC). Methods: EpCAM expression was assessed in tumor tissue by immunohistochemistry using the Avidin-Biotin-Complex method on paraffin-embedded ovarian cancer tissue samples. EpCAM overexpression was defined as an expression of EpCAM as high as 76-100%. Clinical data as well as tumor tissue samples were collected within the validated “Tumor bank Ovarian Cancer Network (TOC)”. Results: Seventy-four patients with the primary diagnosis of EOC between 01/1994 and 12/2009 were included in this study. Median age at diagnosis was 56 years. The vast majority of the patients (75.4%) presented an advanced stage disease (FIGO III/IV). Forty-one (55.4%) patients were diagnosed with a serous, 19 (25.6%) a endometrioid and 14 (19%) a mucinous histology. EpCAM was overexpressed in 87.7% of the patients. Serous tumors expressed EpCAM in significantly higher rates than mucinous tumors ( p=0.045). EpCAM overexpression correlated in univariate analysis with a significantly better overall survival. Multivariate analysis including histological subtype identified EpCAM expression of 76-100% to be independently associated with a significantly better overall survival compared to a lower EpCAM expression of ≤50% (p=0.008). Conclusions: EpCAM overexpression in EOC appears to be associated with significantly higher overall survival rates. Larger, prospectively assessed multicenter studies are warranted to further evaluate and confirm these novel findings and possibly establish EpCAM as a potent therapeutic target in EOC.

Current and future options in the treatment of malignant ascites in ovarian cancer

BACKGROUND

Malignant ascites is a frequent problem for ovarian carcinoma patients. Typical symptoms such as abdominal pain, nausea and dyspnea reduce quality of life. In this study, different treatment options for malignant ascites due to ovarian carcinoma were sought.

MATERIALS AND METHODS

Articles and reviews found in PubMed and reference books were evaluated and compared to each other.

RESULTS

Many treatment options exist. Current treatment options include paracentesis, intraperitoneal chemotherapy and therapy using intraperitoneal tumor necrosis factor alpha for example. Compared to other reviews, catumaxomab, a new antibody, was presented and the treatment options were focused on ovarian carcinoma patients. All these methods are palliative.

CONCLUSION

The treatment of malignant ascites keeps a demanding difficulty and requires further study especially on progressive free survival and overall survival. Paracentesis and systemic therapy with a later effect are recommended at the moment. Catumaxomab is the only medication that could achieve an improvement.