As many of you know when I recurred on my liver and spleen, I chose to have surgery followed by chemo. I made that decision after being offered three options. Option 1 surgery first then chemo ( carbo /taxol). Option 2 chemo first then surgery. And a clinical trial (GOG 213 ). I chose surgery first followed by chemotherapy.
The question about the benefits of a second surgery on recurrence has been ongoing. Last year at the SGO meeting there was a excellent discussion of the pros and cons given by Dr Gardner and Dr Coleman during the Education Forum. See this blog post .
Two of the trials that were discussed during the Forum included SOC-1 and GOG-213 .
SOC 1
"Eligible
participants were randomly assigned (1:1)... to
undergo secondary cytoreductive surgery followed by intravenous chemotherapy (six
3-weekly cycles of intravenous paclitaxel [175 mg/m2] or docetaxel [75 mg/m2] combined with intravenous carboplatin [area under the curve of 5 mg/mL per min];
surgery group) or intravenous chemotherapy alone (no surgery group)."
The reported results showed a median progression-free survival (PFS) of 17.4 months in patients
who had surgery
and 11.9 months among those who did not have surgery. The trial has not yet reported Overall Survival (OS) numbers.
Conclusion: "Secondary cytoreduction followed by chemotherapy was associated with significantly
longer progression-free survival than was chemotherapy alone in patients with platinum-sensitive
relapsed ovarian cancer,..."
GOG 213
"The GOG-0213 trial is an open-label, phase 3, multicenter,
international, randomized clinical trial designed to assess two
clinically relevant hypotheses: that bevacizumab added to paclitaxel and
carboplatin chemotherapy followed by maintenance bevacizumab improves
overall survival (chemotherapy objective) and that secondary surgical
cytoreduction in platinum-sensitive, surgically amenable patients
improves overall survival (surgical objective)."
This study did not show any significant difference in PFS or OS in those who had secondary surgery and those who did not.
Conclusion:
"In this trial involving patients with platinum-sensitive, recurrent
ovarian cancer, secondary surgical cytoreduction followed by
chemotherapy did not result in longer overall survival than chemotherapy
alone."
DESKTOP
Earlier this month, the DESKTOP trial results was reported in the NEJM. https://www.nejm.org/doi/full/10.1056/NEJMoa2103294
This trial involved "first re-
lapse after a platinum-free interval ... of 6 months or more to undergo secondary cytoreductive
surgery and then receive platinum-based chemotherapy or to receive platinum-
based chemotherapy alone. Patients were eligible if they presented with a positive
Arbeitsgemeinschaft Gynäkologische Onkologie (AGO) score, defined as an Eastern Cooperative Oncology Group performance-status score of 0 (on a 5-point scale,
with higher scores indicating greater disability), ascites of less than 500 ml, and
complete resection at initial surgery."
In the study the median OS was 53.7 months for those who had surgery and 46.0
months in those that did not have surgery. Patients with a complete
resection (all visible disease removed) had a median overall survival
of 61.9 months.
Conclusion:
"In women with recurrent ovarian cancer, cytoreductive surgery followed
by chemotherapy resulted in longer overall survival than chemotherapy
alone. "
An editorial written by Drs Gardner and Chi ( also in the NEJM) regarding the DESKTOP trial and the SOC and GOG trials provides an excellent analysis of the differences in trial design, patient selection, quality of surgery and use of bevacizumab. https://www.nejm.org/doi/full/10.1056/NEJMe2116353
I may be biased, since my second surgery has kept me disease free for years, but I hope going forward secondary surgery, where appropriate, is included in all discussions between women with recurrent ovarian cancer and their gynecologic oncologists.
Thank you Drs Lars Henning (@mdlhenning) and Maria Kfoury (@kfoury) for the Twitter discussion on the DESKTOP results.
Dee
Every Day is a Blessing!
