New Guidelines for Treating Ovarian Cancer

JNCI: Journal of the National Cancer Institute, Oct 2016

Fillon, Mike

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New Guidelines for Treating Ovarian Cancer

New Guidelines for Treating Ovarian Cancer By Mike Fillon - The American Society of Clinical Oncology (ASCO) and the Society of Gynecologic Oncology (SGOhave together developed clinical practice guidelines for treating advanced-stage ovarian cancer. The guidelines help society members decide whether to use neoadjuvant chemotherapy (NACT) as a first step to chemically reduce tumor size, or primary cytoreductive surgery (PCS) to remove the bulk of a tumor before chemotherapy. “It was an important collaboration since it tackled a highly controversial area,” said Mitchell Edelson, M.D., cochair and SGO’s representative on the expert panel that developed the guidelines. “Bringing the two groups together to tackle this issue gets the word out to both memberships, which encompass a large number of physicians that take care of women with gynecologic cancers. The new recommendations could affect the treatment regimen that most women with ovarian cancer receive. According to the International Federation of Gynecology and Obstetrics, nearly 75% of women with epithelial ovarian cancer present with stages IIIC and IV disease. “I’ve been hoping for guidelines like these to come out for some time. I think they’re appropriate and hope that we’ll see more NACT in this country. Until now, it has been more of a European thing and hasn’t caught on in this country.” Whether to prescribe NACT or PCS has been controversial. Until now, treatment with primary PCS followed by chemotherapy has been the standard of care for advanced disease. “For years we believed that any woman diagnosed with advanced ovarian cancer should have surgery before chemotherapy,” said Alexi Wright, M.D., M.P.H., assistant professor of medicine at Harvard Medical School and a researcher at Dana–Farber Cancer Institute in Boston. “However, recent randomized clinical trials compared PCS and chemotherapy to NACT followed by interval cytoreductive surgery and adjuvant chemotherapy for women with advanced ovarian cancer,” and the researchers reported that, with respect to progression-free and overall survival, NACT was sometimes as effective as PCS—and caused less treatmentrelated morbidity and mortality. “Still, many American physicians doubted the findings and others ignored them,” Wright said. “With these guidelines we’ve clarified that women with stage IV ovarian cancer should receive chemotherapy before surgery, but women with stage III disease who have a high likelihood of having a complete cytoreduction— reducing the number of cancer cells to no visible disease—should have surgery first if it is safe.” Wright served as cochair and ASCO’s representative on the expert panel that developed the new standards. The guidelines appeared in the Aug. 8, 2016, issues of Gynecologic Oncology and the Journal of Clinical Oncology. A multidisciplinary panel with expertise in gynecologic oncology and medical oncology developed the list. The panel also included a patient advocacy representative. The panel reviewed literature published between March 20, 2005, and March 20, 2015, with the primary evidence forming the recommendations derived from four phase III clinical trials. The panel’s key recommendations include the following: • Evaluating all women with suspected stage IIIC or IV invasive epithelial ovarian cancer before starting chemotherapy to determine whether they are candidates for PCS • Giving NACT to all women at high risk or who are unlikely to achieve cytoreduction • Offering women likely to achieve cytoreduction to less than 1 cm PCS over NACT ASCO’s membership includes more than 40,000 oncology professionals. SGO has 2,000 members, including primarily gynecologic oncologists as well as allied health care professionals involved in treating and caring for women with cancer. “The collaboration is significant because if either group had done this alone, it would be easy to argue that the guidelines were biased,” Wright said. Many oncology professionals, including Gary Leiserowitz, M.D., belong to both organizations. Leiserowitz is professor and chair of the department of obstetrics and gynecology and chief of the division of gynecologic oncology at UC Davis Health System in Davis, Calif. He said he was impressed with the makeup of the committee: “It includes several people who have been strong proponents and champions of primary surgery for ovarian cancer. So it lends weight to the views that in the right setting, use of NACT is a completely reasonable alternative to primary debulking surgery.” William McGuire, M.D., professor of internal medicine at Massey Cancer Center at Virginia Commonwealth University School of Medicine in Richmond, said he is pleased overall with the committee’s recommendations. “I’ve been hoping for guidelines like these to come out for some time. I think they’re appropriate and hope that we’ll see more NACT in this country. Until now, it has been more of a European thing and hasn’t caught on in this country.” Edelson said (...truncated)


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Fillon, Mike. New Guidelines for Treating Ovarian Cancer, JNCI: Journal of the National Cancer Institute, 2016, Volume 108, Issue 10, DOI: 10.1093/jnci/djw242