Journal List > J Gynecol Oncol > v.31(2) > 1142869

Lv, Cui, Zhang, and Ren: Efficacy and safety of neoadjuvant chemotherapy versus primary debulking surgery in patients with ovarian cancer: a meta-analysis

Abstract

Objective

Neoadjuvant chemotherapy (NACT) for the treatment of epithelial ovarian cancer (EOC) has remained controversial. This meta-analysis was performed to systematically assess the efficacy and safety of NACT versus primary debulking surgery (PDS) in patients with EOC.

Methods

PubMed, Embase, ClinicalTrials.gov, and Cochrane Library were queried to assess the therapeutic value of NACT versus PDS in EOC. Electronic databases were queried by using the keywords “ovarian cancer/neoplasms”, “primary debulking surgery”, and “neoadjuvant chemotherapy”.

Results

The available trials were pooled, and hazard ratios (HRs), relative risk ratios (RRs) and associated 95% confidence intervals (95% CIs) were determined. Sixteen trials involving 57,450 participants with EOC (NACT, 9,475; PDS, 47,975) were evaluated. We found that NACT resulted in markedly decreased overall survival than PDS in patients with EOC (HR=1.30; 95% CI=1.13–1.49; heterogeneity: p<0.001, I2=82.7%). Furthermore, our results demonstrated that the NACT group displayed increased completeness of debulking removal (RR=1.69, 95% CI=1.32–2.17; heterogeneity: p<0.001, I2=81.9%), and reduced risk of postsurgical death (RR=0.18, 95% CI=0.06–0.51; heterogeneity: p=0.698, I2=0%) and major infection (RR=0.29, 95% CI=0.17–0.51; heterogeneity: p=0.777, I2=0%) compared with patients administered PDS.

Conclusions

This meta-analysis indicated that NACT results in increased completeness of debulking removal, and reduced risk of postsurgical death and major infection compared with PDS, while PDS is associated with improved survival in comparison with NACT in EOC patients.

References

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Fig. 1.
Flow diagram of study inclusion.
jgo-31-e12f1.tif
Fig. 3.
Post-operative complications and mortality. (A) Postsurgical death, (B) Major infections, and (C) Wound complications. CI, confidence interval; NACT, neoadjuvant chemotherapy; PDS, primary debulking surgery; RR, risk ratio.
jgo-31-e12f2.tif
Fig. 2.
Forest plots for survival and extent of surgical debulking. (A) OS, (B) PFS, (C) Completeness of debulking removal, and (D) Residual disease ≤1 cm. CI, confidence interval; HR, hazard ratio; NACT, neoadjuvant chemotherapy; PDS, primary debulking surgery; RR, risk ratio.
jgo-31-e12f3.tif
Table 1.
Characteristics of the studies included in this meta-analysis
First authors/ year of publication Country Mean age (yr) Study design No. of patients in intervention Stage Period of study (yr) Outcomes assessed
NACT PDS
Loizzi/2005 [18] Italy NACT: 64±11.35 PDS: 58±10.57 A case-control study 30 30 IIIC, IV 1994–2003 OS, PFS, and residual disease ≤1 cm
Vergote/2010 [7] Belgium NACT: 63±12 PDS: 62±15.25 RCT 334 336 IIIC, IV 1998–2006 OS, PFS, completeness of debulking removal, residual disease ≤1 cm, postsurgical death, and major infection
Milam/2011 [19] USA NACT: 61±13.5 PDS: 57±17 Cohort study 46 217 IIIC, IV 1993–2005 OS, PFS
Glasgow/2012 [20] USA NACT: 76.9±4.75 PDS: 75.9±4.75 Cohort study 42 62 IIIC, IV 1996–2009 OS, PFS, completeness of debulking removal, residual disease ≤1 cm, postsurgical death, major infection, and wound complication
Zheng/2012 [21] China NACT: 55.8 PDS: 54.5 Cohort study 30 37 IIIC, IV 2006–2009 OS, PFS
Taskin/2013 [31] Turkey NACT: 60.5±11.3 PDS: 56.4±12.6 Cohort study 74 23 IIIC, IV 2001–2010 OS
Worley/2013 [22] USA NACT: 74±3.5 PDS: 75±6.25 Cohort study 40 125 IIIC, IV 2000–2010 OS, PFS, postsurgical death, major infection, and wound complication
Colombo/2014 [23] France NA Cohort study 147 220 IIIC, IV 1995–2010 OS
Fagö-Olsen/2014 [24] Denmark NACT: 66±3.25 PDS: 65±4.25 Cohort study 515 990 IIIC, IV 2005–2011 OS, completeness of debulking removal, and residual disease ≤1 cm
Kehoe/2015 [8] UK NACT: 65±13.5 PDS: 66±15.25 RCT 274 276 III, IV 2004–2010 OS, PFS, completeness of debulking removal, residual disease ≤1 cm, postsurgical death, and major infection
Bian/2016 [25] China NACT: 53±10.25 PDS: 50.7±15.75 Cohort study 114 225 IIIC, IV 2005–2010 OS, PFS, completeness of debulking removal, and residual disease ≤1 cm
Kessous/2016 [26] Canada NACT: 64.8±12.5 PDS: 58±11.5 Cohort study 127 136 IIIC 2003–2015 OS, PFS
Lim/2017 [27] Korea NACT: 57 PDS: 53 Cohort study 136 143 III, IV 2000–2009 OS, PFS
May/2017 [28] USA NACT: 62.2±12.25 PDS: 59.3±11 Cohort study 161 142 IIIC, IV 2004–2011 OS, completeness of debulking removal, and residual disease ≤1 cm
Seagle/2017 [29] USA NACT: 65±4 PDS: 61±4.5 Cohort study 7,348 44,970 III, IV 1998–2011 OS
Siesto/2018 [30] Italy NACT: 63.2±10.1 PDS: 60.8±10.7 Cohort study 50 50 IIIC, IV 2009– OS, PFS, completeness of debulking removal, residual disease ≤1 cm, major infection, and wound complication

NACT, neoadjuvant chemotherapy; OS, overall survival; PDS, primary debulking surgery; PFS, progression-free survival; RCT, randomized controlled trial.

Table 2.
Methodological quality of observational studies included in the meta-analysis*
First author/ year of publication Representativeness of the exposed cohort Selection of the unexposed cohort Ascertainment of exposure Outcome of interest not present at start of study Control for important factor or additional factor Outcome assessment Follow-up long enough for outcomes to occur Adequacy of follow-up of cohorts Total quality scores
Loizzi/2005 [18] 8
Milam/2011 [19] 7
Glasgow/2012 [20] 8
Zheng/2012 [21] 7
Taskin/2013 [31] 8
Worley/2013 [22] 8
Fagö-Olsen/2014 [24] 8
Colombo/2014 [23] 7
Bian/2016 [25] 8
Kessous/2016 [26] 8
May/2017 [28] 8
Lim/2017 [27] 8
Seagle/2017 [29] 8
Siesto/2018 [30] 7

* A study could be awarded a maximum of one star for each item except for the item control for important factor or additional factor.

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