2016 ASCO Ovarian Cancer Guidelines for Neo-Adjuvant Chemotherapy

In women with stage IIIC or IV ovarian cancer, primary cytoreductive surgery (PCS) may be preferred when there is a high chance to achieve cytoreduction to <1 cm with acceptable morbidity. This was concluded by an expert panel who published clinical guidelines in the Journal of Clinical Oncology (JCO) this week. Furthermore, the guidelines made recommendations on which patients may benefit from neoadjuvant chemotherapy (NACT).

“Nearly 75% of women with ovarian cancer are diagnosed with advanced-stage disease (IIIC or IV) at presentation.”

Background

In the recent past years, two randomised controlled clinical trials (RCTs), comparing treatment options for women with advanced and metastatic ovarian cancer, had led to debate among physicians.

“These trials demonstrated that NACT was not inferior to PCS for progression-free and overall survival and resulted in a lower incidence of treatment-related morbidity and mortality.” according to the authors, indicating the need for a systemic review and guidelines for practitioners.

“However, both trials have been criticised because of the median overall survival, mean operative time and rates of optimal cytoreduction were lower than expected” explained the expert panel of the American Society of Clinical Oncology (ASCO) and Society of Gynecologic Oncology (SGO).

The guidelines in JCO apply to patients, either newly diagnosed or suspected to have stage IIIC or IV epithelial ovarian cancer, fallopian tube cancer, or primary peritoneal cancer.

Methods

A multi-disciplinary expert panel conducted a systemic review of published studies in women with newly diagnosed stage III/IV epithelial ovarian cancer, fallopian tube cancer, or primary peritoneal cancer, published between March 20, 2005, and March 20, 2015.

Key Recommendations

The expert panel made the following key recommendations:

Upon suspicion or diagnosis of stage IIIC or IV invasive ovarian, fallopian tube, or peritoneal cancer, all patients should first be evaluated by a gynecologic oncologist before initiation of therapy. Primary clinical evaluation should include:
- Computed Tomography (CT) of the abdomen and pelvis with oral and intravenous contrast;
- Chest imaging, preferably by CT.
Patients unlikely to achieve a cytoreduction of < 1 cm of residual disease, or with a high risk of surgery-related co-morbidities should receive NACT.
For patients who are fit to undergo primary cytoreductive surgery, and with potentially resectable disease, a benefit may be derived from either NACT followed by surgery, or from PCS. Physicians should carefully weigh risks and benefits of the different treatments.
- Studies indicate progression-free survival and overall survival are equal for both NACT and PCS;
- NACT is associated lesser morbidity and mortality and shorter hospitalisations;
- PCS is associated with greater survival benefit in some patients.

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If there is a high possibility of achieving a near complete (< 1 cm, ideally no visible disease) cytoreduction with acceptable perioperative risk-benefit balance, PCS may be most beneficial.
To exclude non-gynecologic cancer, NACT should only be delivered to patients with histological confirmation of invasive ovarian, fallopian tube, or peritoneal cancer;
- In the unlikely event patients cannot undergo biopsy, cytologic evaluation plus biomarker status may confirm the diagnosis.
Platinum/taxane doublet is recommended;
- Other platinum-based regimens may be considered based on patient status.
- In patients achieving stable disease, or better, after four cycles of NACT, cytoreductive surgery should be performed.
  - Different timing has been insufficiently evaluated and should only be considered in individual patients.
- Progressive disease on NACT equals poor prognosis and patients may be candidates for another chemotherapy regimen, a clinical study, or best supportive care. Surgery in this patient population should only be considered for palliation.

Reference

Wright, A. A., Bohlke, K., Armstrong, D. K., Bookman, M. A., Cliby, W. A., Coleman, R. L., . . . Edelson, M. I. (2016). Neoadjuvant chemotherapy for newly diagnosed, advanced ovarian cancer: Society of gynecologic oncology and american society of clinical oncology clinical practice guideline. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 34(28), 3460-73. doi:10.1200/JCO.2016.68.690

Disclaimer

This article is not medical advice. Patients should seek personal assessment by a licenced specialist. Physicians are recommended to read the full publication(s) as cited in the article before making medical decisions. This article does not supersede nor replace the published article(s).

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