In a new practice guideline, the American Society of Clinical Oncology offered recommendations on the use of neoadjuvant chemotherapy and interval cytoreduction for women with stage IIIC or IV epithelial ovarian cancer.
In a new practice guideline, the American Society of Clinical Oncology (ASCO) offered recommendations on the use of neoadjuvant chemotherapy and interval cytoreduction for women with stage IIIC or IV epithelial ovarian cancer. Neoadjuvant treatment has been found to be noninferior to primary cytoreduction in certain women.
“The choice between primary cytoreductive surgery and neoadjuvant chemotherapy remains controversial,” wrote authors led by Mitchell Edelson, MD, of the Hanjani Institute for Gynecologic Oncology in Abington, Pennsylvania. ASCO and the Society of Gynecologic Oncology (SGO) convened an expert panel and conducted a literature review to help resolve that controversy.
The panel reviewed four phase III clinical trials that form the primary evidence base for the new guideline. The guideline was published online ahead of print in the Journal of Clinical Oncology.
The first recommendation is simply that all women with suspected stage IIIC or IV invasive epithelial ovarian cancer should undergo an evaluation along with a CT scan of the abdomen and pelvis prior to therapy initiation. Based on that evaluation, women with a high perioperative risk profile or who have a low likelihood of achieving cytoreduction to < 1 cm (ideally with no visible disease) should undergo neoadjuvant chemotherapy.
Among women who are candidates for primary cytoreductive surgery, either that or neoadjuvant chemotherapy can be offered, as the randomized trials found chemotherapy to be noninferior to the surgical option. Neoadjuvant chemotherapy is clearly associated with less perioperative and postoperative morbidity and mortality along with shorter hospitalizations, but primary cytoreductive surgery may “offer superior survival in select patients,” the authors wrote.
If the evaluation finds a high likelihood that cytoreduction to < 1 cm along with an acceptable morbidity risk, primary cytoreduction is preferred over neoadjuvant chemotherapy.
For women who do receive neoadjuvant chemotherapy, a platinum/taxane doublet regimen is preferred, according to the guideline. After at least 4 cycles of that therapy, interval cytoreduction should be performed with stable disease or who responded to the therapy. The guideline also notes that for patients with progressive disease on neoadjuvant chemotherapy, the prognosis is poor; other chemotherapy regimens can be offered in these patients, as can participation in a clinical trial or initiation of end-of-life care.
“For patients faced with a decision between primary cytoreductive surgery and neoadjuvant chemotherapy, it is essential that providers first explain the diagnosis,” wrote the authors. “Only by ensuring a common starting point can each discuss and ultimately decide on a treatment plan.”