New Guidelines for Treating Ovarian Cancer
New Guidelines for Treating Ovarian Cancer
By Mike Fillon
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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)