Neoadjuvant Chemotherapy in Advanced Ovarian Cancer

Optimal Patient Selection and Response Evaluation

Jae Hyun Cho; Seik Kim; Yong Sang Song

Disclosures

Chin Clin Oncol. 2018;7(6) 

In This Article

Abstract and Introduction

Abstract

Epithelial ovarian cancer (EOC) is the leading cause of death from gynecologic malignancy and is the seventh most common cancer among women worldwide. The primary debulking surgery (PDS) followed by adjuvant chemotherapy (ACT) is a standard treatment of advanced EOC. However, there are still several limitations, such as high recurrence rate and subsequent chemoresistance. To date, many studies have reported that neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) shows non-inferior survival outcome and is associated with less postoperative morbidity compared with PDS. Therefore, NACT-IDS might be an alternative treatment strategy in advanced EOC. Nevertheless, the efficacy of NACT-IDS and selection of patients who would gain benefit from NACT-IDS are still on debate. To date, several studies have been conducted to predict the response of NACT using various methods, such as imaging studies and molecular biology techniques. In this article, the optimal indications for NACT using various methods will be discussed.

Introduction

Epithelial malignancies of ovarian, fallopian tube and peritoneal origin demonstrate similar clinical characteristics and behavior. So these malignancies have been categorized together as epithelial ovarian cancer (EOC) in clinical trials or clinical practice. According to the World Health Organization report, the annual incidence of EOC is estimated as 225,500 with 140,200 deaths worldwide, affecting 3.7% of all female cancers and 4.2% of cancer deaths.[1] Approximately 80% of EOC cases are diagnosed at advanced stage, the International Federation of Gynaecology and Obstetrics (FIGO) stage III and IV, resulting in poor survival outcome.[2] Most patients experience disease relapse within the first 5 years despite primary aggressive treatment, whereas only 20–25% of cases are cured. Furthermore, the 5-year survival rate of patients with advanced EOC has not been improved in the last decade.

Current standard therapy for patients with advanced EOC is primary debulking surgery (PDS), followed by adjuvant chemotherapy (ACT) with a combination of paclitaxel and carboplatin.[3] Complete or optimal cytoreductive surgery, defined as grossly no residual cancer or <10 mm of residual disease at the end of surgery, respectively, is known as the most important prognostic factor. Recently, interval debulking surgery (IDS) after a short course of neoadjuvant chemotherapy (NACT) has become an alternative treatment strategy for EOC patients expecting non-optimal cytoreduction during PDS. Several randomized controlled trials (RCTs) have reported that patients who underwent NACT-IDS had significantly lower adverse effect and surgical mortality rate after IDS than those who underwent PDS.[4] Survival outcomes, such as progression-free survival (PFS) and overall survival (OS), were similar between NACT-IDS and PDS.[5–7] The use of NACT gradually increased from 16% during 2003 to 2010 to 34% during 2011 to 2012 in stage IIIC disease, and from 41% to 62% in stage IV disease.[8]

In accordance with the increased use of NACT, the efficacy of NACT-IDS and selection of patients who would gain benefit from NACT-IDS are still on debate. In this review, we will describe the up to date evidence and indications of NACT, using various diagnostic attempts to improve treatment outcomes of NACT.

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