Robert F. Ozols, MD, PhD

There will be no further randomized phase III trials of cytotoxic IP chemotherapy; IP therapy in ovarian cancer will soon be an historical footnote along with other failed approaches in cancer care.

Over the past 2 decades, we have seen major progress in the management of women with ovarian cancer, with improvements in both overall survival and quality of life. To truly appreciate this progress, it is important to understand the state of affairs regarding the treatment of ovarian cancer in the early 1980s. This paper will discuss that historical background, describe the increasingly favorable impact of evolving treatment paradigms in ovarian cancer, and note future directions for clinical research in this complex disease process.

Neoadjuvant, or induction, chemotherapyhas been usedextensively in selected carcinomas,particularly head andneck cancer (recently reviewed inONCOLOGY)[1] and locally advancedbreast cancer. Despite beneficialeffects on morbidity, long-termsurvival has not been significantly improvedby neoadjuvant chemotherapy.

Ovarian cancer is the leading cause of death from a gynecologic malignancy in the United States. Most patients present with advanced disease and are treated with a combination of surgery and chemotherapy. Recently,

Fennelly and Schneider review a controversial area in ovarian cancer management in a comprehensive, objective, and thoughtful manner. This review is particularly timely in light of the ever-increasing number of ovarian cancer patients in whom high-dose chemotherapy, with either bone marrow transplantation or peripheral stem-cell transfusion, is being proposed as a treatment option. The authors support the contention that the majority of such patients are being offered a treatment that has little likelihood of providing a meaningful benefit. The take home message from this review is that outside of an appropriately designed clinical trial, there is no established role for high-dose chemotherapy with hematologic support in any subset of patients with advanced ovarian cancer. At the conclusion of this commentary, I will return to the issue of what constitutes an appropriate clinical trial design to evaluate the efficacy of high-dose chemotherapy in ovarian cancer.

Approximately one third of patients with epithelial ovarian cancer present with localized or early-stage disease. Prognostic features identify certain subsets of patients with good risk characteristics who do not require adjuvant