Conservative Surgery for Ovarian Cancer Preserves Fertility

SAN DIEGO—Conservative surgery can preserve fertility in young women with epithelial ovarian cancer and achieve survival rates comparable to standard surgery (total abdominal hysterectomy and removal of the fallopian tubes and ovaries), researchers from Memorial Sloan-Kettering Cancer Center reported at the 31^st annual meeting of the Society of Gynecologic Oncologists (SGO).

These conclusions were based on a retrospective review of 127 patients treated for stage I epithelial ovarian cancer between 1982 and 1999, said lead investigator Carol L. Brown, MD, assistant attending surgeon, Memorial Sloan-Kettering, and assistant professor of obstetrics and gynecology, Cornell University Weill Medical College. All patients had complete surgical staging that included multiple biopsies of the peritoneum, removal of the omentum, and lymph node biopsies.

Sixteen patients, all of whom were under age 40 at diagnosis, had conservative surgery, defined as preservation of the uterus and at least a portion of one ovary.

Five of the 16 patients (32%) were also treated with adjuvant platinum-based chemotherapy. The decision to treat with adjuvant therapy in the conservative-surgery group was based on the presence of perceived high-risk factors, including grade 2 disease or higher, adherence to pelvic structures requiring sharp dissection, and prestaging rupture or drainage of a malignant cyst, Dr. Brown said.

Ninety-two patients, aged 28 to 87, had standard surgery. The choice of conservative surgery in the study was made by the individual surgeon based on criteria that included patient age, parity, stage, grade, and the patient’s wish to preserve childbearing capability.

“The standard management of early ovarian cancer abruptly causes menopause and leaves no options for future childbearing. Our current practice is to offer conservative surgery to patients who are of childbearing age (40 or younger) and who have stage I cancer and a desire to have children in the future,” she said.

Study Results

Dr. Brown reported that 14 (88%) of the conservative-surgery patients vs 71 (77%) of the standard-surgery patients were alive with no signs of disease at median follow-up of 79 months. Two of the conservative-surgery patients had cancer recurrence in the retained ovary at 11 and 20 months, and both died of their disease. Fourteen (15%) patients in the standard-surgery group had a recurrence, and 8 have died of their disease.

In the conservative-surgery group, five patients had a total of eight successful pregnancies, Dr. Brown said. This included two pregnancies in women who had received adjuvant chemotherapy. One patient was treated unsuccessfully for infertility, one was on oral contraceptives, and the remaining seven patients had regular menstrual cycles.

“The Memorial Sloan-Kettering group would not undertake conservative surgery in any patient who had ovarian cancer in both ovaries (stage IB), who had a grade 3 tumor, or who had the histologic subtype of clear cell cancer,” Dr. Brown told ONI in an interview.

This study did not include patients who had stage II-IV ovarian cancer, and Dr. Brown said she would not offer this approach to these patients at present.

She also feels strongly that staging surgery for ovarian cancer should be performed only by an appropriately trained gynecologic oncologist.

“These findings expand our understanding of ovarian cancer in two ways,” Dr. Brown said. “First, the data suggest that although ovarian cancer is not common in young women, when it does occur, an option exists to treat the cancer adequately and yet preserve the woman’s reproductive ability and hormonal function.” Second, she continued, “young women who have undergone conservative treatment will likely have normal hormonal function afterwards and can successfully become pregnant and bear children, even after chemotherapy.”