Ovarian Cancer Disease Burden Affects Survival Despite R0 Resection

Despite achieving complete surgical resection, women who underwent resection of advanced epithelial ovarian cancer or primary peritoneal cancer with a high preoperative disease burden had worse progression-free and overall survival than those with lower disease burden, results of a large multi-institutional study showed.

“We showed that both higher disease score and increased residual disease resulted in worse outcome compared with patients with less disease distribution before and after surgery,” wrote researchers led by Neil S. Horowitz, MD, of Brigham and Women’s Hospital, Boston, in the Journal of Clinical Oncology.

Looking at 2,655 patients with advanced epithelial ovarian cancer or primary peritoneal cancer from the Gynecologic Oncology Group 182 study, the researchers collected demographic, pathologic, surgical, and outcome data. Included women had achieved complete resection or residual disease of < 1 cm (MR). The researchers goal was to determine the effects of preoperative disease burden and complex surgery on residual disease and survival outcomes in this patient population.

As expected, Horowitz and colleagues found that patients with MR had a worse prognosis than did those patients who achieved complete resection, having worse progression-free survival (15 months vs 29 months; P < .01) and overall survival (41 months vs 77 months; P < .01).

In addition, those patients with the highest disease burden prior to surgery had significantly worse progression-free survival (15 months vs 23 or 34 months; P < .01) and overall survival (40 months vs 71 or 86 months; P < .01) compared with patients with either a moderate or low disease score. This worse prognosis remained even when the researchers looked at only those patients able to achieve complete resection.

“Although we were investigating a subset of patients from GOG-182 (< 1 cm of residual disease), we found that when we restricted our multivariable analysis to only those institutions that achieved complete resection in > 40% of patients with < 1 cm residual disease, our conclusions were not changed,” the researchers noted.

According to the study, there has been an increased trend toward aggressive primary debulking surgery for women with advanced epithelial ovarian cancer or primary peritoneal cancer, and based on these results, this approach makes sense for those women with low or moderate preoperative disease burden.

“We suggest the consideration of (and additional studies should explore) a potential paradigm shift, in which, if R0 is difficult to attain at primary cytoreduction, use of neoadjuvant chemotherapy with interval debulking to allow for R0 may be superior to primary surgery after which the patient is left with gross residual disease,” the researchers wrote.