Trends for Cytoreductive Surgery Use in Ovarian Cancer
Hello. I'm Dr Maurie Markman, from City of Hope. I'd like to discuss what I consider to be a very interesting paper. It's one that actually falls along the lines of my own clinical interests in gynecologic malignancies, ovarian cancer in particular.
The paper is titled, 'Utilization of Primary Cytoreductive Surgery for Advanced-Stage Ovarian Cancer,' published in JAMA Network Open . It's a very interesting question. The more general question, I would say, is that there are a number of high-quality, peer-reviewed publications of randomized trials published, but how does that transfer over a period of time into what is done in the academic centers and in the community centers in the United States?
There are really interesting papers. What impact might they have had? This particular question is one that is relevant to address in that way. In fact, there have been four phase 3, high-quality, large, randomized trials looking at primary cytoreductive surgery for advanced ovarian cancer — stage III and stage IV— vs a neoadjuvant approach (chemotherapy first once you have a diagnosis, then interval cytoreductive surgery), and then potentially additional chemotherapy.
Of those two strategies — in other words, start with chemotherapy and then go on to surgery or surgery first — the neoadjuvant approach is associated with equivalent survival but reduced morbidity. In fact, [it] significantly reduced morbidity to the point where there are reduced postoperative deaths associated with this on the basis of the trial data.
There are four randomized trials showing the value of the chemotherapy-first approach, but even today, several national guidelines in the United States make it very clear that, certainly for stage III advanced ovarian cancer, surgery should be done as the primary treatment strategy. The guidelines say this, but I mentioned data from four randomized, controlled trials.
What is actually happening in the United States? We have data, and then we might have some guidelines that may fall behind or expert opinion may not agree with the studies.
This was a very interesting retrospective cohort study involving patients with stage III and stage IV epithelial ovarian cancer from 2010 to 2021 using the National Cancer Database. There were 87,449 patients included. The overall use of primary cytoreductive surgery was 53.5%. The neoadjuvant or interval cytoreductive surgery approach was 29.6%. Interestingly, 16.9% of patients had no surgery.
That's a category where we don't know exactly why they didn't have surgery at all. They were maybe too old or had excessive morbidity, or they may have had the neoadjuvant approach, they had a greater response, and they didn't have surgery. It's not clear. It's important to note, but we don't know exactly why they didn't have surgery.
Here are the results. I mentioned what the results were overall, but from 2010 to 2021, primary cytoreductive surgery decreased in this whole population from 70.1% to 37.2%. The neoadjuvant approach with subsequent surgery increased from 16.6% to 40.8%, so now actually almost being equal to the primary surgery.
The no-surgery group, again, an interesting group that we don't know much about, increased from 13.3% to 22%. That may be because we're doing a more neoadjuvant approach and that there's no disease and surgery isn't done, but it's not clear.
Overall, what we see here is an increase in the neoadjuvant approach — a very meaningful increase — supported by data from four randomized, controlled trials.
Not surprisingly, and I would argue quite appropriately, the greatest decline in the use of the primary cytoreductive surgery has been in fact in the stage IV disease, as shown in this analysis, and much less in the stage III disease where it is more possible to essentially remove all gross cancer.
The data and the analysis make sense. It's very interesting to see that the community has, over time, embraced the data from phase 3 randomized trials of high quality. This is really, I think, quite refreshing information. It also demonstrates many values, but one particular value of looking at population-based data through the National Cancer Database and other registries.
Thank you for your attention.
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