Ovarian cancer in 2010

Abstract

Ovarian cancer remains responsible for the most gynecologic cancer-related deaths in women worldwide, and is the fifth leading cause of death overall [1]. The careful development of a series of randomized trials involving numerous patients, investigators and clinical trial groups encompassing many countries have led to an improvement in median overall survival from 1 year in 1975 to approximately 5 years in 2009 for optimally debulked patients with stage III disease [2–4]. This issue of Therapy reviews ongoing studies on numerous fronts that have the potential to further improve outcomes related to the prevention, diagnosis and treatment of patients with ovarian cancer. Improved cancer outcomes are associated with the need to further improve fertility preservation techniques for women with ovarian cancer. However, a recent study suggested that only 47% of oncologists refer cancer patients of childbearing age to a reproductive endo crinologist [5]. This important issue is reviewed by Herzog and colleagues [6]. They review data supporting the appropriate setting to consider fertility preservation for patients with low malignant potential, germ cell tumors and early-stage epithelial ovarian cancer. The lack of large random ized studies to direct choices in an evidence-based fashion is acknowledged, but the careful interpretation of smaller studies has allowed the development of consensus-based recommendations. In addition to the technical aspects of fertility-sparing surgery, the lack of an apparent negative effect of modern adjuvant therapy on subsequent fertility is also discussed [7]. The second part of the review addresses the emerging technology with regard to fertility preservation options. Embryo, oocyte and ovarian tissue cryo preservation allow for a wide variety of options not heretofore possible. The retrieval of oocytes also no longer requires surges in estrogen, which is important in patients with potentially estrogensensitive malignancies [8]. In addition, in vitro maturation techniques are further improving the viability of oocyte and embryo cryopreservation specimens [9]. The challenges presented here are how to integrate these technologies in a way that does not compromise cancer outcome, and this requires a careful collaboration of medical and gynecologic oncology with reproductive endocrinologists and maternal–fetal specialists. The association with improved survival and optimal primary surgical cytoreduction remains well established and recent data support the goal of complete surgical cytoreduction as having the best outcome [10]. As with many important questions in oncology, the role of secondary surgical cytoreduction is not as well defined due to a variety of factors, including patient hetero geneity, physician and patient biases, and the lack of multiple random ized prospective trials. Chi and colleagues summarize the available data supporting this approach [11]. Theoretical support is derived from older mathematical models suggesting that there is an increased rate of growth (hence chemo therapy sensitivity) in small-volume tumors, and decreasing the number of tumor cells lessens the chance for resistance-inducing mutations. The case is made that the goal of secondary surgical cyto reduction must be a complete resection if a benefit is to be achieved. The article goes on to examine selection criteria proposed to predict a successful surgical outcome (utilizing the DESKTOP I and II trials), estimates the frequency with which this can be accomplished and, finally, identifies the prognostic factors to predict prolonged survival after secondary surgical cytoreduction [12]. Most importantly, both the AGO and GOG are conducting large random ized trials addressing the value of secondary cyto reduction followed by chemo therapy versus chemo therapy only, and participation in these trials is essential to define the role of this potentially important approach for patients.