In a study reported in a research letter in JAMA Network Open, Bercow et al found reduced use of primary cytoreductive surgery (PCS) and increased use of neoadjuvant chemotherapy (NACT) followed by interval cytoreductive surgery (ICS) in patients with advanced epithelial ovarian cancer during recent years in the United States.
As stated by the investigators: “Despite single-institution observational studies demonstrating a survival advantage with…PCS in advanced … epithelial ovarian cancer epithelial ovarian cancer, … randomized clinical trials have found that … NACT followed by … ICS achieves similar progression-free and overall survival, with decreased postoperative morbidity.”
Study Details and Results
The study involved data from the National Cancer Database on patients with stage III or IV disease receiving upfront surgical treatment or no surgical treatment between 2010 and 2021. A total of 87,449 patients were included in the analysis (mean age = 63.7 years), with 55,717 (63.7%) having stage III disease. Over the entre study period, 46,754 patients (53.5%) underwent PCS, 25,893 (29.6%) underwent ICS, and 14,802 (16.9%) received no surgery.
ICS replaced PCS as the most frequently used treatment approach by 2021. Between 2010 and 2021, the proportion of patients receiving PCS declined from 70.1% to 37.2% (rate ratio [RR] = 0.54, 95% confidence interval [CI] = 0.52–0.55), and the proportion of patients receiving ICS increased from 16.6% to 40.8% (RR = 2.49, 95% CI = 2.36–2.61). The proportion of patients receiving no surgery increased from 13.3% to 22.0% (RR = 1.62, 95% CI = 1.52–1.73).
Over the study period, the proportion of patients who received PCS declined from 79.3% to 51.1% (RR = 0.65, 95% CI = 0.63–0.67) among those with stage III disease and from 50.2% to 21.0% (RR= 0.42, 95% CI = 0.39–0.45) among those with stage IV disease.
As stated by the investigators: “In the decade following the publication of the first randomized clinical trial that found NACT followed by ICS was noninferior to PCS for advanced-stage epithelial ovarian cancer, there has been a paradigm shift in the upfront treatment of patients with this disease in the United States. A substantial decline in the use of PCS occurred in conjunction with a large rise in the use of NACT and ICS and a modest increase in the proportion of patients who did not undergo any surgery….”
Alexander Melamed, MD, MPH, of Massachusetts General Hospital, is the corresponding author of the JAMA Network Open article.
Disclosure: For full disclosures of the study authors, visit jamanetwork.com.
