Secondary Cytoreduction for Ovarian Cancer
Secondary cytoreduction for ovarian cancer has been hotly debated in the last year. Two large clinical trials, published only two years apart, came to contradicting conclusions. Here, I offer an explanation of the results and how those results can be reconciled so that they lead to beneficial patient outcomes.
Unfortunately, the majority of patients with advanced ovarian cancer will experience recurrence sooner or later. Whether surgery to remove the recurrence followed by chemotherapy or chemotherapy alone yields a survival benefit, has been a strongly debated issue.
Recently, two large RCTs were published and both examined if surgical removal of recurrence improves a patient's ovarian cancer survival chances. The trial from the USA enrolled 485 patients and found no survival advantage for surgery. The other trial, from Europe, enrolled 407 patients and found a distinct survival advantage for patients randomised to the surgery followed by chemotherapy arm compared to chemotherapy alone.
How can two trials examining the same research question come to contrary outcomes and conclusions?
In the European trial, the researchers were very strict in who was offered trial participation and who was offered a chance of surgery.
Only patients with a long disease-free interval and patients who were in excellent general medical health with no residual tumour at the initial surgery were considered. In 75% of those patients, no residual disease was left at the second surgical procedure. The median survival was 54 months, compared to 46 months if patients only had chemotherapy without surgery.
In both trials, where all tumour could not be removed, patients were actually harmed by surgery due to the post-operative delay in commencing chemotherapy, which was the beneficial treatment that those patients required.
In summary, we need to be aware that only a select group of patients will benefit from secondary cytoreduction for ovarian cancer recurrence. If there is a strong possibility that patients don’t qualify for secondary cytoreductive surgery because they do not meet one or more of the above criteria, there is a high probability that they will not benefit from a surgical intervention and should have systemic chemotherapy instead.
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