Giving neoadjuvant chemotherapy to patients with advanced ovarian cancer does not compromise median overall survival, according to an observational study published Sept. 30, 2021, in JAMA Oncology. What’s more, at cancer centers where patients were more likely to receive chemotherapy before surgery, more patients were alive shortly after surgery and one year later.
The findings complement the results of four randomized clinical trials, the first of which was published in 2010, that support the use of neoadjuvant chemotherapy for women with advanced ovarian cancer.
Even so, many academic gynecologic oncologists in the United States view upfront surgery as the default treatment for advanced ovarian cancer, said Alexander Melamed, MD, MPH, of Columbia University Vagelos College of Physicians and Surgeons in New York City, who led the new JAMA Oncology study.
“We should reset what we think of as the default,” said Dr. Melamed. “This idea that many patients could benefit from a primary surgery does not seem very consistent with the evidence that we have, neither the randomized evidence nor the observational evidence.”
The varied uptake of neoadjuvant chemotherapy allowed study researchers to compare cancer centers that increased their use of neoadjuvant chemotherapy after the first publication of trial results in 2010 with those that did not.
The researchers looked at the records of nearly 20,000 women from 332 cancer centers that approximately doubled their neoadjuvant chemotherapy use between 2004 to 2015, giving it to around one in five women at the start of the study period and two in five women by the end. They also looked at a second group of nearly 20,000 women who were treated at 332 cancer centers that did not up their use, continuing to administer neoadjuvant chemotherapy to approximately one in five women.
Both groups had a similar gain in median overall survival when the researchers compared outcomes between 2004 to 2009 and 2010 to 2015. According to Dr. Melamed, these gains can be attributed to a trend towards improved care of ovarian cancer patients.
“What we found was that there’s no evidence at all of any harm in the centers that enthusiastically embraced this treatment,” said Dr. Melamed. “In fact, there is evidence of benefit – that the short-term survival actually improves.”
In the near term, neoadjuvant chemotherapy appeared to decrease mortality. The group of cancer centers that upped their use of neoadjuvant chemotherapy saw a drop in mortality rate at 30 days after surgery from 3.3% to 1.6% and again at 90 days after surgery from 7.3% to 4.3%. The other group saw a smaller drop for both outcomes: 3.2% to 2.4% for 30-day mortality and 7.8% to 6.3% for 90-day mortality.
The mortality rate at one year dropped from 24.6% to 19.3% – a difference of 5.2 percentage points – for cancer centers that upped their use of neoadjuvant chemotherapy, while the other group saw a decline of 3.2 percentage points.
“This retrospective study is reassuring, that the increase in the use of neoadjuvant chemotherapy is safe, but it doesn’t specify what the differences were in how those programs chose who to give chemotherapy to,” commented Claire Hoppenot, MD, a gynecologic oncologist at the Dan L Duncan Comprehensive Cancer Center at Baylor College of Medicine in Houston.
Dr. Hoppenot, who was not involved in the study, said that the debate on neoadjuvant chemotherapy is not so much whether to use it at all, but which patients should receive it.
Dr. Melamed and Dr. Hoppenot reported no relevant financial relationships.
