Shift towards neoadjuvant chemotherapy found in ovarian cancer treatment

Shift towards neoadjuvant chemotherapy found in ovarian cancer treatment | Image Credit: © Queenmoonlite Studio - © Queenmoonlite Studio - stock.adobe.com.

A decrease in primary cytoreductive surgery (PCS) utilization has been observed following publication of the first randomized clinical trial reporting noninferiority from neoadjuvant chemotherapy (NACT) followed by interval cytoreductive surgery (ICS), according to a recent study published in JAMA Network Open.¹

While observational studies have reported a survival advantage from PCS in advanced epithelial ovarian cancer (EOC), similar progression-free and overall survival has been proven from NACT followed by ICS in 4 randomized clinical trials. These trials have also noted decreased postoperative morbidity when compared to PCS.¹

The studies included 1774 women with stage 3 or 4 ovarian cancer.² A hazard ratio (HR) of 0.96 was reported for overall survival when comparing NACT following by ICS with PCS. Similarly, the HR for progression-free survival was 0.98.

For adverse events, favorable outcomes were reported from NACT when compared to PCS. The rate of serious adverse events was 6% vs 29%, respectively. Additionally, reductions in the needs for stoma formation and bowel resection during surgery were found from NACT vs PCS, highlighting the advantages of NACT followed by ICS.²

Despite this data, national guidelines still recommend PCS to patients with a high risk of achieving an optimal resection.¹ However, an increase in NACT utilization among US patients has been observed over time.

To evaluate temporal and age trends in surgical treatments of patients with EOC, investigators conducted a retrospective cohort study. Participants included patients diagnosed with stage 3 to 4 EOC between 2010 and 2021 with available data in the National Cancer Database.¹

Patient categories included receiving PCS, NACT followed by ICS, and no cytoreductive surgery. Temporal and age trends for treatment methods were estimated using Poisson regression models. Stata statistical software, version 17.0 (StataCorp) was used in all analyses.¹

There were 87,449 patients aged a mean 63.7 years included in the analysis, 63.7% of whom had stage 3 disease. PCS was reported in 53.5% of participants, ICS in 29.6%, and no surgery in 16.9%.¹

A significant shift in ICS and PCS use was observed across the study period, leading to ICS being the most frequent method of care over PCS by 2021. The rate of PCS use decreased from 70.1% in 2010 to 37.2% in 2021, with a risk ratio (RR) of 0.54. In comparison, the ICS rate increased from 16.6% in 2010 to 40.8% in 2021, with an RR of 2.49.¹

There was also a rise in the prevalence of patients not undergoing surgery, from 13.3% in 2010 to 22% in 2021. This indicated an RR of 1.62. PCS rates significantly decreased over time in all age groups with high EOC prevalence.¹

PCS use in patients with stage 3 disease decreased from 79.3% in 2010 to 51.1% in 2021, with an RR of 0.65. In comparison, the drop among patients with stage 4 disease was from 50.2% in 2010 to 21% in 2021, with an RR of 0.42.¹

These results indicated a significant shift from PCS use to NACT followed by ICS following publication of randomized clinical trials reporting the noninferiority of the latter method. Investigators concluded the reduction in PCS use may be caused by recognition of excess operative morbidity and mortality.¹

References

1. Bercow A, Stewart T, Bregar AJ, et al. Utilization of primary cytoreductive surgery for advanced-stage ovarian cancer. JAMA Netw Open. 2024;7(10):e2439893. doi:10.1001/jamanetworkopen.2024.39893
2. Coleridge SL, Bryant A, Kehoe S, Morrison J. Neoadjuvant chemotherapy before surgery versus surgery followed by chemotherapy for initial treatment in advanced ovarian epithelial cancer. Cochrane Library. 2021. doi:10.1002/14651858.CD005343.pub6