Should Surgery Be Performed for Recurrent Ovarian Cancer?

Ovarian cancer is one of the cancer types that, by its nature, is diagnosed at a late stage. Almost three-quarters of patients are diagnosed at stages 3 and 4 . Standard treatment for ovarian cancer is comprehensive tumor-clearing surgery inside the abdomen (cytoreductive surgery) followed by adjuvant (protective and recurrence-preventing) chemotherapy. Unfortunately for our patients and their relatives, more than half of this patient group experience, within 5 years, recurrence , meaning that the disease comes back.

The site of disease recurrence is most often inside the abdomen, particularly the peritoneum(the lining of the abdomen). The most important factor in determining treatment strategies for these patients is the time until disease recurrence. For patients whose disease recurs in the first 1 year, particularly in the first 6 months after completion of chemotherapy, the disease is described as resistant and aggressive; different chemotherapy and targeted drugs (targeted therapy) are the main treatment options for these patients. This group of patients is described as having platinum-resistant ovarian cancer; conversely, those whose cancer recurs at least 6 months after completion of platinum-based chemotherapy are described as having platinum-sensitive ovarian cancer.

For platinum-sensitive ovarian cancers (patients experiencing recurrence at least 6 months after completion of chemotherapy), whether secondary surgery is appropriate has long been a topic of debate in oncology. Indeed, these operations are now performed in many cancer centers. Retrospective study results have provided data suggesting that secondary operations increase survival in this patient group. This gave rise to the need for a prospective and randomized clinical trial . The results of such a study were published in November 2019 in the respected medical journal NEJM.

The GOG-0213 study

In the phase III GOG-0213 study conducted by Dr. Robert L. Coleman and colleagues, data from 485 patients with recurrent platinum-sensitive ovarian cancer were presented. Of these patients, 240 received secondary surgery followed by chemotherapy, while 245 received chemotherapy alone.

Complete resection was achieved in 67% of patients undergoing secondary surgery, meaning all visible tumors inside the abdomen were surgically removed. At a median follow-up of 48.1 months, there was an overall survival advantage for patients who had not undergone secondary surgery:

• Median overall survival in patients who underwent surgery was 50.6 months , whereas in patients without surgery this period was 64.7 months(HR 1.72, P=0.08).
• Mean progression-free survival was longer in patients receiving surgery; however, this difference was not statistically significant (18.9 months versus 16.2 months).
• The rate of surgery-related problems (morbidity) in the surgery group was 9%, and one patient died from postoperative complications.
• Immediately after surgery, patients reported a quality of life decline that was marked, but it was temporary and did not result in a difference in quality of life between the two treatment groups.

Conclusion

According to the results of this most comprehensive clinical trial evaluating secondary surgery in recurrent ovarian cancer, secondary cytoreductive surgery does not improve outcomes in patients with recurrent ovarian cancer, and this treatment does not appear appropriate for this patient group. In light of these data, current guidelines recommending secondary cytoreductive surgery will need to be reviewed . However, additional studies are needed to define the characteristics of a suitable subgroup that might benefit from secondary surgery in ovarian cancer; several ongoing trials will address these questions. In addition, with treatments other than chemotherapy that were not taken into account in this study and have entered ovarian cancer treatment, namely new-generation systemic treatments (PARP inhibitors) , the difference between surgery and systemic treatment may widen further in the future. All these conditions and eligibility factors should be evaluated by a multidisciplinary oncology team, and the most appropriate treatment should be determined in patients with recurrent ovarian cancer, also taking the patient’s views into account.

Related Topic:

- Surgery Together with Heated Chemotherapy (Hyperthermic Chemotherapy) in Recurrent Ovarian Cancer