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ASCO, Society of Gynecologic Oncology issue guideline for neoadjuvant chemotherapy use in ovarian cancer
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Neoadjuvant chemotherapy is the optimal first-line treatment for certain women with newly diagnosed advanced ovarian cancer, according to a joint clinical practice guideline from ASCO and the Society of Gynecologic Oncology.
Although treatment with primary cytoreductive surgery followed by chemotherapy has been the standard of care for women with advanced-stage disease, controversial evidence suggested some patients could benefit from neoadjuvant chemotherapy and interval cytoreduction.
Alexi A. Wright
Guideline panel members conducted a systematic review of four phase 3 clinical trials that included women with newly diagnosed or suspected stage IIIC or IV epithelial ovarian cancer, fallopian tube cancer or primary peritoneal cancer.
The panel members evaluated the use of neoadjuvant chemotherapy and interval cytoreduction compared with primary cytoreduction and chemotherapy.
The joint guideline recommended the following:
- All women with suspected stage IIIC or IV invasive epithelial ovarian cancer should be evaluated by a gynecologic oncologist prior to the initiation of therapy to determine candidacy for primary cytoreductive surgery;
- A primary clinical evaluation should include a CT scan of the abdomen and pelvis with oral and IV contrast and chest imaging to evaluate the extent of disease and the feasibility of surgical resection. Other assessment tools may include laparoscopic evaluation or additional radiographic imaging;
- Women who have a high perioperative risk profile or a low likelihood of achieving cytoreduction to less than 1 cm should receive neoadjuvant chemotherapy;
- Eligibility of medical or surgical cancer treatment should be decided upon after a consultation with a gynecologic oncologist or a medical oncologist with gynecologic expertise;
- Women who are fit for primary cytoreductive surgery, and with potentially resectable disease, may receive either neoadjuvant chemotherapy or primary cytoreductive surgery. However, primary cytoreductive surgery is preferred if there is a high likelihood of achieving cytoreduction to less than 1 cm — ideally to no visible disease — with acceptable morbidity;
- Before neoadjuvant chemotherapy is delivered, all patients should have confirmation of an invasive ovarian, fallopian tube or peritoneal cancer;
- A platinum/taxane doublet is recommended for neoadjuvant chemotherapy; however, alternate regimens, containing a platinum agent, may be selected based on individual patient factors;
- Interval cytoreductive surgery should be performed after four or fewer cycles of neoadjuvant chemotherapy for women with a response to chemotherapy or stable disease;
- Options for patients with progressive disease on neoadjuvant chemotherapy include alternative chemotherapy regimens, clinical trials or discontinuation of active cancer therapy and initiation of end-of-life care.
“For women with advanced ovarian cancer, decision-making regarding first-line treatment should be a process that is shared between clinicians and their patients,” guideline panel co-chair Alexi A. Wright, MD, MPH, medical oncologist at Dana-Farber Cancer Institute and assistant professor of medicine at Harvard Medical School, and colleagues wrote. “Clinicians must communicate evidence-based options for treatment, inclusive of their benefits and risks, and patients must be allowed to express their goals and preferences.”
The panel agreed future studies will focus on risk prediction models, risk-stratifying methods, the design of clinical trials in this population, weekly dosage and cycles of treatment, and the development of an ASCO Value in Cancer Care framework for neoadjuvant chemotherapy.
“For women in whom the choice is between neoadjuvant chemotherapy and primary cytoreductive surgery, sharing data about comparative morbidity, survival and quality-of-life outcomes in plain language can help to ensure understanding and help patients make more informed decisions,” Wright and colleagues wrote. – by Kristie L. Kahl
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