A meta-analysis: neoadjuvant chemotherapy versus primary surgery in ovarian carcinoma FIGO stageIII and IV
Ma Dai-yuan
0
Tan Bang-xian
0
Li Xian-fu
0
Zhou Ye-qin
0
Cai Hong-Wei
0
0
Department of Oncology, the First Affiliated Hospital of North Sichuan Medical College
,
Nanchong 637000
,
People's Republic of China
Background: The purpose of the current study is to analyze the existing data comparing neoadjuvant chemotherapy with primary debulking surgery (PDS) in patients with advanced ovarian carcinoma. Methods: Patients with stage IIIC and IV ovarian cancer were identified from articles in Medline, PubMed, Cochrane Library, and EMBASE database (1989 to February 2013). Two authors independently extracted the data. To assess the risk of bias of included literatures, Cochrane Collaboration's risk of bias tool was used. Meta-analysis on literatures was conducted by using RevMan 5.2 software. Results: Two high-quality randomized controlled trials (RCTs) met the inclusion criteria. These multicenter trials randomized 1,220 women with stage IIIc/IV ovarian cancer to NACT or PDS followed by chemotherapy. There were no significant differences between the study groups with regard to overall survival (OS) (1,120 women; HR 0.98; 95% CI 0.85 to 1.14) or progression-free survival (PFS) (1,120 women; HR 1.03; 95% CI 0.91 to 1.16). Conclusion: There was no statistical difference in median OS and PFS between the two treatment groups. With regard to selecting who will benefit from NACT, treatment should be tailored to the patient and should take into account respectability, age, histology, stage, and performance status.
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Review
Introduction
An estimated 22,280 new cases of ovarian cancer are
expected in the US in 2012 [1]. Ovarian cancer causes
more deaths than any other cancer of the female
reproductive system [1]. In most patients with ovarian
carcinoma, the disease is diagnosed at an advanced stage and
they usually have a very poor prognosis [2].
Primary surgical treatment of ovarian cancer has
advantages in terms of diagnosis, staging, and tumor
debulking [3,4]. The value of debulking surgery is well
established in FIGO stage III epithelial ovarian cancer
[5]. Most women will have widespread disease, therefore
surgery alone does not cure the disease. Neoadjuvant
chemotherapy (NACT) prior to surgical debulking
proposes to increase the proportion of patients who may be
optimally cytoreduced, while decreasing surgical
morbidity and mortality [6].
Several retrospective studies have shown that there was
no difference in overall survival (OS) or progression-free
survival (PFS) for patients with advanced ovarian cancer
treated with neoadjuvant chemotherapy compared with
primary debulking surgery (PDS) [7-11]. However, the
result of a meta-analysis of Bristow and Chi [12] involving
835 patients suggested that NACT, compared with PDS,
was associated with a worse OS and it was suggested that
the definitive operative intervention should be undertaken
as early in the treatment program as possible. But a more
recent meta-analysis [13] of multiply central randomized
trials concluded that survival was similar in patients
treated with NACT followed by interval debulking surgery
compared to primary debulking followed by chemotherapy
and criticized the meta-analysis of Bristow and Chi [12].
Since randomized controlled trials (RCTs) are the gold
standard of evidence-based medical research, we hope
that a review of randomized evidence may clarify what
the benefits and risks are of using NACT for women
with advanced ovarian cancer, compared with the
standard treatment of PDS [13,14]. The purpose of the
current study is to analyze the existing data comparing
NACT with PDS in patients with advanced ovarian
carcinoma which included more RCTs.
Methods
Literature research
We undertook computerized literature searches of
MEDLINE, PubMed, Cochrane Library, and EMBASE
databases, from their inception to February 2013.
Search terms were ovarian carcinoma, ovarian cancer,
neoadjuvant chemotherapy, and primary surgery.
These terms were used in different combinations with
each other. Appropriate references cited by the
retrieved studies were also identified.
Study selection
Publications were selected for initial review if the
research subjects were patients with International
Federation of Gynecology and Obstetrics (FIGO) stage III and
IV ovarian cancer who underwent NACT and PDS. In
order to fully exclude the possibility of selection bias,
only RCTs of NACT versus PDS were permitted.
Duplicate publications or data were carefully reviewed by two
of the authors and the larger (primary decision) or the
most recent publication was included.
Data on trial size, patient characteristics (age, sex, AF
duration, left ventricular size, left ventricular ejection
fraction, and so on), procedure duration, and patient number
of sinus rhythm maintenance without anti-arrhythmic
drugs were extracted. Included studies were reviewed based
on randomization, allocation concealment, blinding, loss of
follow-ups, and ITT. The truths of the studies were divided
into thre (...truncated)