Better Survival With Surgery in Stage IIIC Ovarian Cancer

Over a 10-year period, the use of neoadjuvant chemotherapy increased significantly in women with advanced ovarian cancer, according to a new observational study. The use of neoadjuvant chemotherapy was associated with poorer overall survival compared with primary cytoreductive surgery in those with stage IIIC disease, but not stage IV.

A 2010 study showed that neoadjuvant chemotherapy was noninferior with regard to overall and progression-free survival compared with primary cytoreductive surgery in advanced ovarian cancer, and another more recent trial found similar results. “Both trials have been criticized because the median overall survival, mean operative times, and rates of optimal cytoreduction were significantly lower than expected,” wrote study authors led by Larissa A. Meyer, MD, of the University of Texas MD Anderson Cancer Center in Houston.

The new study was designed to see whether those other trials have had an effect on the use of neoadjuvant chemotherapy in these women, and what effect it might have on survival. It included 1,538 women with stages IIIC to IV ovarian cancer treated at six National Cancer Institute–designated cancer centers between 2003 and 2012. The patients were compared with a propensity score-matched cohort of 594 women; the results were published online ahead of print in the Journal of Clinical Oncology.

The use of neoadjuvant chemotherapy increased over time, from 16% in the 2003–2010 period to 34% in the 2011–2012 period specifically in women with stage IIIC disease (P for trend < .001); in those with stage IV disease, use of neoadjuvant chemotherapy rose from 41% to 62% (P for trend < .001).

Based on the propensity score–matched analysis, stage IIIC patients who received neoadjuvant chemotherapy had shorter overall survival than those treated with primary cytoreductive surgery, with a median of 33 months vs 43 months (hazard ratio [HR], 1.40 [95% CI, 1.11–1.77]). The difference was not significant, however among stage IV patients, with a median overall survival of 31 months with neoadjuvant chemotherapy and 36 months with primary cytoreductive surgery (HR, 1.16 [95% CI, 0.89–1.52)]. The authors noted that these survival results were “robust to sensitivity analyses.”

They wrote that the study is limited by its observational design and all the possible biases associated with such studies. Also, these results may not be generalizable beyond major academic centers, where survival tends to be better than elsewhere.

“Our results suggest that in carefully selected patients with stage IIIC disease, primary cytoreductive surgery is associated with a survival advantage, with overall low rates of surgical morbidity,” the authors concluded. “In contrast, for patients with stage IV disease, our results confirm that neoadjuvant chemotherapy is noninferior to primary cytoreductive surgery for survival.”