A retrospective review showed that primary cytoreductive surgery (PCS) was associated with longer survival than neoadjuvant chemotherapy (NACT) in women with advanced-stage epithelial ovarian cancer. This could be explained by poorer performance status among those undergoing NACT, however.
“The role of NACT in the treatment of epithelial ovarian cancer remains controversial,” wrote study authors led by J. Alejandro Rauh-Hain Fernandez, MD, of Massachusetts General Hospital in Boston. Several retrospective studies have favored PCS over NACT, while two phase III randomized trials demonstrated noninferiority of NACT in women with high disease burden. All the studies have had some methodologic issues, though.
The new analysis included 22,962 women under the age of 70 included in the National Cancer Database who were treated for stage IIIC and IV epithelial ovarian cancer who were diagnosed between 2003 and 2011. Of those, 19,836 (86.4%) were treated with PCS, and 3,126 (13.6%) received NACT; a propensity-matched analysis included 2,935 patients from each treatment group. The results were published online ahead of print in JAMA Oncology.
The median overall survival duration in the propensity-matched analysis was 37.3 months with PCS, and 32.1 months with NACT, for a hazard ratio (HR) of 1.18 (95% CI, 1.11–1.26). Both groups saw improved survival in later years of the study period compared to earlier years of diagnosis, but the association of improved survival with PCS remained as both groups’ survival lengthened.
The difference was slightly more pronounced in stage IIIC patients, with an HR of 1.24 (95% CI, 1.11–1.37) in favor of PCS. In stage IV patients, the HR was 1.13 (95% CI, 1.04–1.23).
Sensitivity analyses of unobserved variables found that the results would be robust to large differences in prevalence of high disease burden and to BRCA mutation status. However, the improvement in survival could be explained by differences in performance status; if 60% of women receiving NACT had an ECOG performance status of 1 to 2 compared with 50% in the PCS group, that would negate the difference in survival.
“Such information will be important to collect for future observational studies,” the authors wrote. “Future research should focus on which patients benefit most from PCS or NACT to tailor the treatment of women with advanced-stage epithelial ovarian cancer.”