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Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer

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Abstract

Background

Epithelial ovarian cancer presents at an advanced stage in the majority of patients. These women require chemotherapy and surgery for optimal treatment. Conventional treatment is to perform surgery first and then give chemotherapy. However, it is important to determine whether there is any advantage to using chemotherapy prior to surgery.

Objectives

To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy prior to debulking surgery (neoadjuvant chemotherapy) compared with conventional treatment where chemotherapy follows maximal debulking surgery.

Search methods

RCTs were identified by searching The Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2006), MEDLINE (Silver Platter, from 1966 to 1st Sept 2006), EMBASE via Ovid (from 1980 to 1st Sept 2006), CANCERLIT (from 1966 to 1st Sept 2006), PDQ (search for open and closed trials) and MetaRegister (most current search Sept 2006).

Selection criteria

Women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III‐IV); randomized allocation to treatment groups which compared platinum‐based chemotherapy before debulking surgery with platinum‐based chemotherapy following debulking surgery.

Data collection and analysis

Data were extracted by three independent authors, and the quality of included trials was assessed by three independent authors.

Main results

One RCT was identified as meeting the inclusion criteria. This trial randomized 85 women and compared standard debulking surgery followed by eight cycles of platinum‐based chemotherapy with pre‐operative intra‐arterial platinum‐based chemotherapy and ovarian artery embolization followed by debulking surgery and seven cycles of platinum‐based chemotherapy. There was no statistical difference in median overall survival (OS) between the two treatment groups. Three on‐going RCTs were identified and their results are awaited.

Authors' conclusions

There is as yet no good evidence that neoadjuvant chemotherapy prior to debulking surgery for women with advanced epithelial ovarian cancer is superior to conventional debulking surgery and platinum‐based chemotherapy.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

Does giving chemotherapy before surgery improve survival or quality of life for women with advanced ovarian epithelial cancer?

Epithelial ovarian cancer is the sixth commonest cancer world‐wide and is the commonest form of ovarian cancer (approximately 90% of ovarian cancers). Unfortunately most women with ovarian cancer (75%) present at a late stage when their disease has spread throughout the abdomen. This is because symptoms are vague, often occur only after the cancer has spread, and can be misdiagnosed as being caused by other benign conditions. The five‐year survival for women with ovarian cancer is poor (approximately 30%).

Conventional treatment for ovarian cancer is to have surgery (laparotomy) to remove the womb, ovaries, the omentum (a fatty apron that hangs down from the stomach in the upper abdomen) and to sample the lymph nodes (glands) in the pelvis and abdomen. The intention of surgery is to stage the disease (assess where the cancer has spread to) and remove as much of the cancer as possible (debulking). However, since most women will have widespread disease, surgery is not normally curative and further treatment is necessary, in the form of chemotherapy. Chemotherapy for ovarian cancer uses platinum‐based drugs (carboplatin and cisplatin) to treat any cancer cells that cannot be removed by surgery or are too small to be seen (microscopic disease).

Chemotherapy can be used before surgery (also called neoadjuvant chemotherapy) with the aim of shrinking the cancer and making it easier to remove all of the cancer. This approach has been used to treat other cancers (e.g. cancer of the cervix).

Currently there is no conclusive evidence from randomized control trials (RCTs) to suggest that neoadjuvant chemotherapy for ovarian cancer followed by surgery is better than conventional surgery then chemotherapy. Only one small RCT was found that compared platinum‐based chemotherapy before surgery with chemotherapy after surgery. No difference in terms of survival was found between the two groups. However, this is likely to be because the trial included too few women to detect any small improvement or decrease in survival. Also the women in the pre‐operative chemotherapy group received the chemotherapy directly into the arteries that supply the ovaries, after which the arteries were blocked off (embolized). This was not performed in the other group (primary surgery then chemotherapy), so it is not possible to say whether the reduced complications during surgery seen in the pre‐operative chemotherapy group were due to the embolization or the neoadjuvant chemotherapy.

Three on‐going trials were identified and it is hoped that these will answer the question in the future.