Impact of increased utilization of neoadjuvant chemotherapy on survival in patients with advanced ovarian cancer: experience from a comprehensive cancer center

Yong Jae Lee; Young Shin Chung; Jung-Yun Lee; Eun Ji Nam; Sang Wun Kim; Sunghoon Kim; Young Tae Kim

doi:10.3802/jgo.2018.29.e63

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Lee, Chung, Lee, Nam, Kim, Kim, and Kim: Impact of increased utilization of neoadjuvant chemotherapy on survival in patients with advanced ovarian cancer: experience from a comprehensive cancer center

Original Article

J Gynecol Oncol 2018;29(4):e63.

Published online: 4 July 2018

DOI: https://doi.org/10.3802/jgo.2018.29.e63

Impact of increased utilization of neoadjuvant chemotherapy on survival in patients with advanced ovarian cancer: experience from a comprehensive cancer center

Yong Jae Lee, Young Shin Chung, Jung-Yun Lee, Eun Ji Nam, Sang Wun Kim, Sunghoon Kim, Young Tae Kim

Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea

Correspondence to Sunghoon Kim Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea. E-mail: SHKIM70@yuhs.ac

Received 25 January 2018 Revised 1 April 2018 Accepted 6 April 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

The choice between primary debulking surgery (PDS) and neoadjuvant chemotherapy (NAC) in advanced ovarian cancer remains controversial. We evaluated NAC use in our center before and after results from a randomized trial were published, with the aim to determine the impact of changes in the neoadjuvant strategy on survival in advanced-stage ovarian cancer.

Methods

We retrospectively investigated the clinical course of 435 patients with ovarian, tubal, or peritoneal carcinoma (International Federation of Gynecology and Obstetrics [FIGO] stage III or IV). According to the period of treatment, we stratified patients into a control group (n=216; diagnosed between 2006 and 2010; 83.8% underwent PDS) and a study group (n=219; diagnosed between 2011 and 2014; 48.9% received NAC followed by interval debulking surgery [IDS]).

Results

There were no between-group differences in age, body mass index, histology findings, or tumor grade. Compared to patients in the control group, those in the study group were more likely to receive NAC followed by IDS as first-line treatment (48.9% vs. 16.2%; p<0.001), cytoreductive surgery to no-residual disease (21.5% vs. 10.2%; p<0.001), or radical surgery (57.5% vs. 35.6%; p<0.001). However, there was no between-group difference in postoperative morbidity. Kaplan-Meier analysis showed no between-group differences in progression-free or overall survival (p=0.449 and 0.952, respectively).

Conclusion

NAC incorporation resulted in increased optimal cytoreduction rates although no significant differences in survival outcomes were noted. NAC is advantageous for patients with high perioperative morbidity or unresectable disease.

Keywords: Ovarian Neoplasms, Neoadjuvant Therapy, Debulking Surgical Procedure, Chemotherapy, Adjuvant

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Fig. 1.

Change in NAC use between 2006 and 2014. NAC, neoadjuvant chemotherapy; PDS, primary debulking surgery.

Fig. 2.

Kaplan-Meier curves of PFS (A) and OS (B) according to time period (2006–2010 vs. 2011–2014). OS, overall survival; PFS, progression-free survival.

Table 1.

Patient and clinical characteristics

Characteristics	Group 1 (n=216)	Group 2 (n=219)	p
Age (yr)	56 (22–83)	55 (26–79)	0.779
BMI (kg/m²)	22.9 (16.0–40.3)	22.5 (16.4–34.4)	0.530
FIGO stage			<0.001
III	152 (70.4)	93 (42.5)
IV	64 (29.6)	126 (57.5)
Tumor grade			0.214
1	16 (7.4)	11 (5.0)
2	72 (33.4)	62 (28.3)
3	107 (49.5)	113 (51.6)
Not available	21 (9.7)	33 (15.1)
Histologic type			0.696
Serous	174 (80.6)	179 (82.1)
Endometrioid	10 (4.6)	5 (2.3)
Mucinous	14 (6.5)	14 (6.4)
Clear cell	9 (4.2)	12 (5.5)
Other	9 (4.2)	9 (3.7)
ASA score			<0.001
1	128 (59.3)	60 (27.4)
2	77 (35.6)	110 (50.2)
3	5 (2.3)	42 (19.2)
4	0 (0)	1 (0.5)
Not available	6 (2.8)	6 (2.7)
Median CA-125 level (U/mL)	897.1 (8.7–30,008.8)	1,474.1 (12.9–30,000.0)	0.003
NAC			<0.001
Yes	35 (16.2)	107 (48.9)
No	181 (83.8)	112 (51.1)
Chemotherapy regimen			0.006
Paclitaxel+carboplatin	156 (72.2)	171 (78.1)
Docetaxel+carboplatin	25 (11.6)	36 (16.4)
Paclitaxel+carboplatin+bevacizumab	1 (0.5)	3 (1.4)
Paclitaxel+cisplatin	2 (0.9)	3 (1.4)
IP chemotherapy	28 (13.0)	0 (0)
Others	2 (0.9)	2 (0.9)
Not available	2 (0.9)	4 (1.8)
Not available Cycles of total chemotherapy	2 (0.9)	4 (1.8)	0.005
≤6	158 (73.1)	132 (60.3)
>6	58 (26.9)	87 (39.7)

Values are presented as median (range) or number (%).

ASA, American Society of Anesthesiologists; BMI, body mass index; CA-125, cancer antigen 125; FIGO, International Federation of Gynecology and Obstetrics; IP, intraperitoneal; NAC, neoadjuvant chemotherapy.

Table 2.

Classification of postoperative outcomes according to the Memorial Sloan-Kettering Cancer Center's surgical secondary events grading system

Variables	Group 1 (n=216)	Group 2 (n=219)	p
Complication grade^*			0.068
0	102 (47.2)	130 (59.4)
1	15 (6.9)	9 (4.1)
2	79 (36.6)	62 (28.4)
3	10 (4.7)	10 (4.6)
4	0 (0)	3 (1.4)
5	2 (3.7)	1 (0.5)
Not available	8 (3.7)	4 (1.8)
Major complications			0.465
0–2	196 (90.7)	201 (91.8)
3–5	12 (5.6)	14 (6.4)
Not available	8 (3.7)	4 (1.8)
Residual disease			<0.001
No gross	22 (10.2)	47 (21.5)
≤1.0 cm	94 (43.5)	111 (50.7)
>1.0 cm	52 (24.1)	13 (5.9)
Not available	48 (22.2)	48 (21.9)
PDS			<0.001
No gross	16 (8.8)	17 (15.2)
≤1.0 cm	77 (42.5)	60 (53.6)
>1.0 cm	49 (27.1)	8 (7.1)
Not available	39 (21.5)	27 (24.1)
NAC			0.466
No gross	6 (17.1)	30 (28.0)
≤1.0 cm	17 (48.6)	51 (47.7)
>1.0 cm	3 (8.6)	5 (4.7)
Not available	9 (25.7)	21 (19.6)
Radical surgery^†			<0.001
None	139 (64.4)	93 (42.5)
Any radical surgery	77 (35.6)	126 (57.5)
Surgical complexity score groups^‡			0.002
1	1 (0.5)	0 (0)
2	207 (95.8)	191 (87.2)
3	8 (3.7)	28 (12.8)

Values are presented as number (%). NAC, neoadjuvant chemotherapy; PDS, primary debulking surgery.

^* According to the Memorial Sloan-Kettering Cancer Center's surgical secondary events grading system [16];

^† Radical surgery included any of following: bowel surgery, cholecystectomy, diaphragm peritonectomy/resection, distal pancreatectomy video-assisted thoracoscopic surgery, splenectomy, liver resection, supraclavicular fossa resection, ureter resection, and others;

^‡ According to Aletti et al [17].

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