Abstract
ObjectiveTo assess whether neoadjuvant chemotherapy (NACT) is superior to primary debulking surgery (PDS) with regard to optimal cytoreduction, peri-operative morbidity, mortality, and quality of life (QOL) in advanced epithelial ovarian cancer (EOC).MethodsWe searched the PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Registers of Clinical Trials for randomized controlled trials (RCTs) comparing NACT to PDS in women with Federation of International Gynaecologists and Obstetricians stage Ⅲ-Ⅳ EOC. RevMan 5.3 software was utilized for statistical analysis.ResultsFour RCTs involving 1,607 women with advanced EOC were included. Compared with PDS, NACT provided a higher rate of complete cytoreduction (risk ratio [RR], 1.95; 95% confidence interval [CI], 1.33 to 2.87), optimal cytoreduction (RR: 1.61 [95%CI: 1.05 to 2.47]), but there was no significant difference in residual disease 0–1 cm (p = 0.49). NACT was associated with lower peri-operative morbidity with respect to infection (RR: 0.30 [95% CI: 0.16 to 0.56]), gastrointestinal fistula (RR: 0.24 [95% CI: 0.06 to 0.95]), any grade 3 or 4 adverse event (RR: 0.29 [95% CI: 0.11 to 0.78]), and less post-surgical death within 28 days (RR: 0.14 [95% CI: 0.04 to 0.49]). NACT provided better QOL in terms of fatigue (weight mean difference [WMD], -3.28; [95% CI: -3.99 to -2.57]), role functioning (WMD: 5.29 [95% CI: 4.44 to 6.14]), emotional functioning (WMD: 6.19 [95% CI: 5.57 to 6.82]), and cognitive functioning (WMD: 1.02 [95% CI: 0.43 to 1.61]) at 6-month follow-up compared with PDS.ConclusionsNACT is associated with superior optimal cytoreduction, lower peri-operative morbidity as well as post-surgical mortality, and better QOL compared to initial surgery in patients with advanced EOC. Future research should focus on improving the efficacy of NACT.
Highlights
Epithelial ovarian cancer (EOC) is the leading cause of death from gynecologic malignancy and is the seventh most common cancer among women worldwide [1]
Compared with Primary debulking surgery (PDS), neoadjuvant chemotherapy (NACT) provided a higher rate of complete cytoreduction, optimal cytoreduction (RR: 1.61 [95%confidence intervals (CIs): 1.05 to 2.47]), but there was no significant difference in residual disease 0–1 cm (p = 0.49)
NACT was associated with lower peri-operative morbidity with respect to infection (RR: 0.30 [95% CI: 0.16 to 0.56]), gastrointestinal fistula (RR: 0.24 [95% CI: 0.06 to 0.95]), any grade 3 or 4 adverse event (RR: 0.29 [95% CI: 0.11 to 0.78]), and less post-surgical death within 28 days (RR: 0.14 [95% CI: 0.04 to 0.49])
Summary
Epithelial ovarian cancer (EOC) is the leading cause of death from gynecologic malignancy and is the seventh most common cancer among women worldwide [1]. The 5-year survival rate for women with advanced EOC is approximately 30% [3]. Primary debulking surgery (PDS) followed by platinum-based adjuvant chemotherapy is considered standard of care. PDS is conducted to achieve optimal cytoreduction (residual disease 1 cm [4], ideally to achieve no visible disease) as the extent of tumour cytoreduction is considered the most important prognostic factors for survival of advanced EOC [5]. PDS is not the first-line treatment for women with unresectable disease, and PDS is associated with increased peri-operative morbidity, mortality, and diminished quality of life (QOL) as an extensive debulking procedure [6, 7]. Given the disadvantages of PDS, alternative treatment strategies may be beneficial
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