Abstract

There is a multitude of evidence from retrospective analyses and meta-analyses showing that the amount of residual tumor after debulking surgery and before chemotherapy is one of the most powerful prognostic determinants in advanced ovarian cancer. This supports the important role of maximum cytoreductive surgery as one of the cornerstones in the treatment of this disease. These same analyses, however, do not suggest that patients whose tumors cannot be debulked optimally derive a significant survival benefit from upfront surgery. For these patients and those who have a poor performance status or other morbidity, making comprehensive upfront surgery contraindicated, different therapeutic approaches have to be explored. One possible way to go is to change the timing of the different therapeutic modalities: upfront chemical cytoreduction, followed by a maximal surgical effort, in turn followed by the remainder of the first-line chemotherapy or neoadjuvant chemotherapy and interval or delayed debulking surgery. The potential role of this approach and the experience with it thus far are discussed.