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Survival outcomes after delayed cytoreduction surgery following neoadjuvant chemotherapy in advanced epithelial ovarian cancer
  1. Shih-Ern Yao1,
  2. Lee Tripcony2,
  3. Karen Sanday1,
  4. Jessica Robertson3,
  5. Lewis Perrin1,4,
  6. Naven Chetty1,4,
  7. Russell Land1,5,
  8. Andrea Garrett1,
  9. Andreas Obermair1,6,
  10. Marcelo Nascimento1,7,
  11. Amy Tang1,
  12. Nisha Jagasia1,4,
  13. Piksi Singh1 and
  14. Jim Nicklin1
  1. 1 Queensland Centre for Gynaecological Cancer, Royal Brisbane & Women's Hospital, Herston, Queensland, Australia
  2. 2 Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
  3. 3 Department of Obstetrics and Gynaecology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
  4. 4 Department of Gynaeoncology, Mater Adult Hospital, Brisbane, Queensland, Australia
  5. 5 Obstetrics and Gynaecology, The University of Queensland School of Medicine, Herston, Queensland, Australia
  6. 6 Centre for Clinical Research, The University of Queensland School of Medicine, Herston, Queensland, Australia
  7. 7 Department of Gynaecological Oncology, Gold Coast University Hospital, Southport, Queensland, Australia
  1. Correspondence to Dr Jim Nicklin, Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia; jimnicklin{at}me.com

Abstract

Objective Interval cytoreduction following neoadjuvant chemotherapy is a well-recognized treatment alternative to primary debulking surgery in the treatment of advanced epithelial ovarian cancer where patient and/or disease factors prevent complete macroscopic disease resection to be achieved. More recently, the strain of the global COVID-19 pandemic on hospital resources has forced many units to alter the timing of interval surgery and extend the number of neoadjuvant chemotherapy cycles. In order to support this paradigm shift and provide more accurate counseling during these unprecedented times, we investigated the survival outcomes in advanced epithelial ovarian cancer patients with the intent of maximal cytoreduction following neoadjuvant chemotherapy with respect to timing of surgery and degree of cytoreduction.

Methods A retrospective review of all patients aged 18 years and above with FIGO (2014) stage III/IV epithelial ovarian cancer treated with neoadjuvant chemotherapy and the intention of interval cytoreduction surgery between January 2008 and December 2017 was conducted. Overall and progression-free survival outcomes were analyzed and compared with patients who only received chemotherapy. Outcome measures were correlated with the number of neoadjuvant chemotherapy cycles and amount of residual disease following surgery.

Results Six hundred and seventy-one patients (median age 67 (range 20–91) years) were included in the study with 572 patients treated with neoadjuvant chemotherapy and surgery and 99 patients with chemotherapy only. There was no difference in the proportion of patients in whom complete cytoreduction was achieved based on number of cycles of neoadjuvant chemotherapy (2–4 cycles: 67.7%, n=337/498); ≥5 cycles: 62.2%, n=46/74). Patients undergoing cytoreduction surgery after neoadjuvant chemotherapy had a median 5-year progression-free and overall survival of 24 and 38 months, respectively. No significant difference in overall survival between surgical groups was observed (interval cytoreduction: 41 months vs delayed cytoreduction: 43 months, p=0.52). Those who achieved complete cytoreduction to R0 (no macroscopic disease) had a significant median overall survival advantage compared with those with any macroscopic residual disease (R0: 49–51 months vs R<1: 22–39 months, p<0.001 vs R≥1: 23–26 months, p<0.001).

Conclusions Survival outcomes do not appear to be worse for patients treated with neoadjuvant chemotherapy if cytoreduction surgery is delayed beyond three cycles. In advanced epithelial ovarian cancer patients the imperative to achieve complete surgical cytoreduction remains gold standard, irrespective of surgical timing, for best survival benefit.

  • ovarian cancer
  • neoplasm
  • residual
  • fallopian tube neoplasms
  • medical oncology
  • peritoneal neoplasms

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Footnotes

  • Contributors All authors provided substantial contributions to the final manuscript and had the opportunity to review and approve the planned submission. SE-Y: methodology, investigation, data curation, writing – original draft, writing – review & editing, visualisation, project administration. JR: methodology, investigation, data curation, writing – review & editing. JN: conceptualisation, methodology, investigation, writing – review & editing, supervision, project administration, funding acquisition. LT, KS: software, validation, formal analysis, visualisation. LP, NC, RL, AG, AO, MN, AT, NJ, PS: writing – review & editing.

  • Funding This study was funded by the Gynaecological Cancer Research Education and Development Society.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Please direct any requests for data to the corresponding author (Dr Jim Nicklin).

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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