In 2021, neoadjuvant chemotherapy (NACT) followed by interval cytoreductive surgery (ICS) became the most frequently used initial treatment approach for patients diagnosed with advanced epithelial ovarian cancer (EOC), overtaking primary cytoreductive surgery (PCS). This shift reflects evolving treatment strategies and considerations of patient outcomes. A recent research letter published in JAMA Network Open analyzed trends in surgical treatment for advanced-stage ovarian cancer, highlighting this significant change in clinical practice.
Decline in Primary Cytoreductive Surgery
The study, utilizing data from the National Cancer Database (NCDB) from 2010 to 2021, identified 87,449 patients with stage III to IV EOC. The data showed a marked decrease in the utilization of PCS, from 70.1% in 2010 to 37.2% in 2021 (RR, 0.54; 95% CI, 0.52-0.55). This decline was observed across different stages of the disease, with stage III EOC experiencing a decrease from 79.3% to 51.1% (RR, 0.65; 95% CI, 0.63-0.67) and stage IV EOC dropping from 50.2% to 21.0% (RR, 0.42; 95% CI, 0.39-0.45).
Increase in Neoadjuvant Chemotherapy
Conversely, the use of NACT followed by ICS saw a substantial increase during the same period. Overall, the percentage of patients undergoing ICS rose from 16.6% to 40.8% (RR, 2.49; 95% CI, 2.36-2.61). While the increase was more pronounced in stage IV disease, the trend was significant across all stages and age groups.
Potential Drivers of Change
The researchers suggest several factors contributing to this shift. "The decline of PCS may be driven by recognition of the excess operative morbidity and mortality that results from this treatment approach," the authors noted. Prior randomized clinical trials have indicated that NACT followed by ICS achieves similar progression-free and overall survival rates as PCS but with reduced postoperative complications.
Impact of COVID-19 Pandemic
Additionally, the timing of NACT overtaking PCS coincided with the COVID-19 pandemic, which led to limitations in operating room availability nationwide. This may have further accelerated the adoption of NACT as an initial treatment strategy.
Implications for Clinical Practice
These findings underscore a significant change in the management of advanced epithelial ovarian cancer. While national guidelines continue to recommend PCS as the preferred approach for patients with a high likelihood of optimal resection, the increasing utilization of NACT followed by ICS suggests a growing recognition of its benefits in terms of reduced morbidity and comparable survival outcomes. Healthcare professionals should consider these trends when determining the most appropriate initial treatment strategy for patients with advanced EOC.
