The American Society of Clinical Oncology (ASCO) and the Society of Gynecologic Oncology (SGO) jointly issued new clinical practice guidelines for the treatment of patients with ovarian cancer.1

The guideline, Neoadjuvant Chemotherapy for Newly Diagnosed, Advanced Ovarian Cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline, was published in both the Journal of Clinical Oncology and Gynecologic Oncology.

The guideline provides evidence-based recommendations to clinicians on whether to use neoadjuvant chemotherapy or surgery as a first-line treatment for women with stage IIIC and IV epithelial ovarian cancers, which account for 70% to 80% of all ovarian cancers. The recommendations are based on 4 phase clinical trials: SCORPION, CHORUS, JCOG0602, and EORTC 55971.

“This guideline is a big step forward in 1 of the most contentious areas within gynecologic oncology,” said Alexi A. Wright, MD, MPH, co-chair and ASCO’s representative on the Expert Panel that developed the guideline. “It provides clear recommendations to help patients and physicians make more evidence-based and informed decisions when women are first diagnosed with ovarian cancer.”

Key recommendations of the new guideline include:

  • All women with suspected stage IIIC or IV invasive epithelial ovarian cancer should be assessed by a gynecologic oncologist before treatment initiation to determine whether they are candidates for primary cytoreductive surgery.
  • Neoadjuvant chemotherapy should be given to women who have a high perioperative risk profile or a low likelihood of achieving cytoreduction to less than 1 cm (ideally to no visible disease).
  • Women who are fit for primary cytoreductive surgery with potentially resectable disease may receive either primary cytoreductive surgery or neoadjuvant chemotherapy.
    • Primary cytoreductive surgery is preferred over neoadjuvant chemotherapy for women with a high likelihood of achieving cytoreduction to less than 1 cm (ideally to no visible disease).
    • Neoadjuvant chemotherapy is recommended for women who are fit for primary cytoreductive surgery but are deemed by a gynecologic oncologist as unlikely to have cytoreduction to less than 1 cm (ideally to no visible disease).

For neoadjuvant chemotherapy, clinicians are advised to treat patients with a doublet regimen consisting of a platinum agent and a taxane, though alternate platinum-containing regimens may be selected for subjective reasons. The Expert Panel notes that it is unclear how weekly dose-dense paclitaxel compares with every-3-week paclitaxel in the preoperative setting.

Prior to the delivery of chemotherapy, all patients should have histologic confirmation, preferentially by using core biopsy of an invasive ovarian, fallopian tube, or peritoneal cancer. When a core biopsy cannot be performed, cytologic evaluation with a serum CA-125 to carcinoembryonic antigen (CEA) ratio less than 25 can be used to confirm the primary diagnosis, and exclude a non-gynecologic malignancy.

“This guideline represents an important collaboration between the SGO and ASCO,” said Mitchell I. Edelson, MD, co-chair and SGO’s representative on the Expert Panel that developed the guideline. “These evidence-based recommendations will improve the quality of care provided to women with ovarian cancer.”

RELATED: Multi-gene Testing Increases Complexity of Counseling Women at Risk of Breast and Ovarian Cancer

Future clinical trials conducted in the United States should evaluate the impact of primary cytoreductive surgery versus neoadjuvant chemotherapy on median overall survival, average operative time, and rates of optimal cytoreduction.   

Reference

  1. Wright AA, Bohlke K, Armstrong DK, et al. Neoadjuvant chemotherapy for newly diagnosed, advanced ovarian cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical practice guideline. J Clin Oncol. 2016 Aug 8. doi: 10.1200/JCO.2016.68.69907 [Epub ahead of print]