title: Optimizing the treatment of ovarian cancer: Neoadjuvant chemotherapy and interval debulking versus primary debulking surgery for epithelial ovarian cancers likely to have suboptimal resection.
abstract: OBJECTIVE
  To: a) identify prognostic factors in patients with epithelial ovarian cancer treated with neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS), and b) compare post-surgical survival between patients treated with NACT/IDS for presumed unresectable disease and stage IIIC/IV patients who underwent suboptimal primary debulking surgery (PDS).
  
  
  METHODS
  This was a retrospective study of consecutive stage IIIC or IV patients undergoing IDS after NACT at Mayo Clinic from January 2007 to December 2013. A subset of patients receiving NACT/IDS for the indication of unresectable disease were matched 1:1 on age and stage to a cohort of patients who underwent suboptimal PDS between 2003 and 2011. Hazard ratios and corresponding 95% confidence intervals were estimated from Cox proportional hazards models.
  
  
  RESULTS
  We identified 87 patients treated with NACT/IDS: the median OS and PFS following surgery was 2.4 and 1.0years, respectively. Factors associated with significantly worse OS were older age (adjusted HR 1.60 per 10-year increase in age, 95% CI 1.18, 2.16) and elevated CA-125 before IDS (adjusted HR 2.30 for CA-125 >35U/mL, 95% CI 1.25, 4.23). Number of adjuvant chemotherapy cycles administered did not have a significant effect on survival. In the matched cohort analysis of presumed unresectable cases undergoing NACT/IDS vs suboptimal PDS cases (n=45 each), the NACT/IDS group had a significant OS advantage (HR 0.53; 95% CI 0.32, 0.88), and fewer patients experienced a 30-day postoperative Accordion grade 3/4 complication (11% vs 36%, P=0.01).
  
  
  CONCLUSIONS
  Younger age and normalization of CA-125 prior to IDS are associated with improved survival with NACT/IDS. For primary EOC where resection to residual disease of 1cm or less is unlikely, NACT/IDS is associated with improved survival and reduced perioperative morbidity compared to PDS. As these patients are likely best served by NACT/IDS, more reliable predictors of resectability would be valuable.
authors.affiliation: Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Gill
authors.affiliation: Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA.
authors.forename: Michaela E
authors.initials: ME
authors.lastname: McGree
authors.affiliation: Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA.
authors.forename: Amy L
authors.initials: AL
authors.lastname: Weaver
authors.affiliation: Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: William A
authors.initials: WA
authors.lastname: Cliby
authors.affiliation: Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address: langstraat.carrie@mayo.edu.
authors.forename: Carrie L
authors.initials: CL
authors.lastname: Langstraat
mesh_terms: D000368:Aged; D000077216:Carcinoma, Ovarian Epithelial; D017024:Chemotherapy, Adjuvant; D065426:Cytoreduction Surgical Procedures; D005260:Female; D006801:Humans; D008875:Middle Aged; D009367:Neoplasm Staging; D009375:Neoplasms, Glandular and Epithelial / Q000188:drug therapy / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D010051:Ovarian Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies
keywords: Interval debulking surgery; Neoadjuvant chemotherapy; Ovarian cancer; Unresectable