ASCO, SGO Update Guidelines On Role Of Chemo For Advanced Ovarian Cancer
- FLASCO
- September 16, 2016
- News
All patients with stage IIIC or IV epithelial ovarian cancer associated with high clinical risk or a low likelihood of optimal surgical resection should receive neoadjuvant chemotherapy, according to a new clinical practice guideline.
The recommendation pertains to women who have high-risk features such as older age or a high comorbidity burden or who are unlikely to achieve optimal cytoreduction (<1 cm residual disease). Lower-risk patients with potentially resectable disease may receive neoadjuvant chemotherapy or undergo cytoreductive surgery.
Primary cytoreductive surgery is preferable for patients who have a high likelihood of achieving cytoreduction to <1 cm residual disease (ideally, no visible disease), concluded an expert panel representing the American Society of Clinical Oncology (ASCO) and the Society of Gynecologic Oncology (SGO). The recommendations were published online simultaneously in the Journal of Clinical Oncology and Gynecologic Oncology and posted on the ASCO and SGO websites.
“This guideline is a big step forward in one of the most contentious areas within gynecologic oncology,” panel co-chair Alexi A. Wright, MD, of Dana-Farber Cancer Institute in Boston, said in a statement. “It provides clear recommendations to help patients and physicians make more evidence-based and informed decisions when women are first diagnosed with ovarian cancer.”
In arriving at its recommendations, the panel relied primarily on the results of four published phase III clinical trials. The collective evidence from the trials showed neoadjuvant chemotherapy and interval cytoreduction to be noninferior to primary cytoreductive surgery followed by adjuvant chemotherapy. The two strategies led to similar progression-free and overall survival, but neoadjuvant chemotherapy and interval cytoreduction resulted in less perioperative morbidity and lower mortality.
“These evidence-based recommendations will improve the quality of care provided to women with ovarian cancer,” said the panel’s other co-chair, Mitchell I. Edelson, MD, of Abington Jefferson Health in Abington, Pa.
Three fourths of patients with ovarian cancer have advanced disease (stage IIIC/IV) at diagnosis. Until recently, primary cytoreductive surgery followed by adjuvant chemotherapy constituted standard of care for all patients with stage IIIC/IV epithelial ovarian cancer. However, many gynecologic oncologists have reconsidered the standard in light of clinical trial studies showing that neoadjuvant chemotherapy and interval cytoreduction resulted in similar outcomes with less morbidity.
To minimize uncertainty and provide guidance, ASCO and SGO convened a panel of ovarian cancer specialists representing the two organizations’ membership. Specifically, the panel was asked “to provide guidance to clinicians and patients regarding the use of neoadjuvant chemotherapy (NACT) and interval cytoreduction among women with advanced epithelial ovarian cancer.”
After reviewing the evidence, the panel recommended that all women with suspected stages IIIC or IV epithelial ovarian cancer undergo evaluation by a gynecologic oncologist before initiating treatment to determine the patients’ suitability for primary cytoreductive surgery. The evaluation should include contrast-enhanced computed tomography imaging of the abdomen and pelvis to determine the extent of disease and feasibility of surgical resection.
With regard to the choice of primary surgery or neoadjuvant chemotherapy, the panel made the following five recommendations:
Women should receive NACT if they have a high perioperative risk profile or a low likelihood of achieving cytoreduction to <1 cm residual disease (optimally, no visible residual disease);
NACT or primary cytoreductive surgery is appropriate for physically fit patients who have “potentially resectable disease”;
Primary surgery is favored over NACT for women who have a high likelihood of achieving cytoreduction to <1 cm residual disease with acceptable morbidity;
NACT is preferred for women who are physically fit but have a low likelihood of achieving cytoreduction to <1 cm residual disease; and
The determination that a patient is not a candidate for NACT or primary surgery should be made after consultation with a gynecologic oncologist or medical oncologist.
Prior to administration of NACT, patients should have a biopsy to confirm the presence of invasive ovarian, fallopian tube, or primary peritoneal cancer. In exceptional cases when biopsy is not feasible, cytologic evaluation plus a serum CA-125:carcinoembryonic antigen ratio >25 is acceptable for confirmation of the diagnosis and exclusion of other potential diagnoses.
The panel recommended a platinum/taxane doublet as the preferred regimen for NACT but allowed for other choices as determined by individual patient factors. Interval cytoreduction should be performed after no more than four cycles of NACT in women who achieve stable disease or objective response.
“Patients with progressive disease on NACT have a poor prognosis,” the panel noted. “Options include alternative chemotherapy regimens, clinical trials, and/or discontinuation of active cancer therapy and initiation of end-of-life care. In general, there is little role for surgery, and it is not typically advised, unless for palliation.”
