Primary Chemo Good Option in Advanced Ovarian Cancer

Results of the phase III CHORUS trial found that the use of primary chemotherapy resulted in similar and noninferior survival compared with primary surgery in women with newly diagnosed stage III/IV ovarian cancer.

Based on the results of this study, Sean Kehoe, of the University of Birmingham, United Kingdom, and colleagues wrote that “in this study population, giving primary chemotherapy before surgery is an acceptable standard of care for women with advanced ovarian cancer.”

The CHORUS trial enrolled 552 women with suspected stage III or IV ovarian cancer from 87 hospitals and randomly assigned them to undergo primary surgery followed by 6 cycles of chemotherapy, or to 3 cycles of chemotherapy, then surgery, followed by 3 more cycles of chemotherapy.

At follow-up, primary chemotherapy was found to be noninferior to primary surgery. The median overall survival was 22.6 months in the primary surgery groups compared with 24.1 months in the primary chemotherapy group, equating to a hazard ratio for death of 0.87 for the chemotherapy group.

Patients assigned to primary chemotherapy also had improved adverse events and quality of life. Specifically, 24% of women assigned primary surgery had grade 3 or 4 postoperative adverse events compared with 14% of patients assigned primary chemotherapy (P = .0007). In addition, more deaths occurred within 28 days of surgery in the primary surgery group (6% vs 1%; P = .001).

The researchers assessed quality of life using the EORTC quality of life questionnaire core-36 (QLQC-30) and the ovarian cancer-specific quality of life questionnaire (QLQ-Ov28). After adjusting for baseline scores, patients assigned primary chemotherapy had slightly higher quality of life scores than the primary surgery group at 6 months and 12 months.

“CHORUS shows that for patients with advanced ovarian cancer and a poor performance status profile, primary chemotherapy followed by delayed surgery are associated with similar overall survival as patients given primary surgery,” the researchers wrote in the Lancet. “The associated reduction in treatment associated morbidity and mortality, combined with a trend towards better quality of life suggests that primary chemotherapy is a valid option for treating these patients.”

In an comment that accompanied this research, Sokbom Kang, of the National Cancer Center, Goyang, South Korea, wrote that despite emerging evidence to suggest it, whether or not neoadjuvant chemotherapy before surgery should be a new standard of care in these patients is still not straightforward. Specifically, Kang points to the low quality of surgical care seen in the CHORUS trial.

“In the primary-surgery group in CHORUS, 27% of patients did not receive bilateral oophorectomy and 24% of patients did not receive a hysterectomy,” Kang wrote. “Additionally, more than 80% of patients did not receive upper abdominal surgeries. As a result, the median time for surgery was only 120 min and optimum cytoreduction was achieved only in 41% of the primary-surgery group.”

These results raise two questions, Kang wrote: whether the CHORUS findings apply to expert surgeons, and which patients would benefit most from this treatment strategy.

“Concerns are also increasing that neoadjuvant chemotherapy could be used as an excuse for neglecting maximum surgical efforts or improvement of competent surgical skills,” Kang wrote. “Despite these questions and concerns, Kehoe and colleagues are to be congratulated on their research showing that neoadjuvant chemotherapy lowers treatment-related morbidity without sacrificing treatment efficacy. However, efforts should now be directed towards identifying and resolving the remaining uncertainties.”