Let's talk about Secondary Cytoreductive Surgery DESKTOP results and more...

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)."

Source: https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(21)00006-1/fulltext

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)."

Source : https://www.nejm.org/doi/full/10.1056/nejmoa1902626

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!

 

ASCO from a Distance

I've attended the ASCO Annual meeting in person for the past two years. This year I observed from a distance checking on the latest ovarian Cancer news by following ASCO post on Facebook, Tweets by those I follow and the Daily news e-mail. I also checked the online listing of abstracts for ovarian cancer. I've put together a few abstracts I found most interesting.


Randomized, double-blind, phase III trial of pazopanib versus placebo in women who have not progressed after first-line chemotherapy for advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer (AEOC): Results of an international Intergroup trial (AGO-OVAR16).
Pazopanib is a multikinase inhibitor and an oral formulation. The 940 patients in the randomized trial were initially diagnosed Stage III or IV and had 5 or more cycles of platinum- taxane chemotherapy. Women who took the pazaponib had an average  Progression Free Survival (PFS) of 5.6 months longer than women give a placebo. Patients did experience some adverse reactions. The Study concluded"Conclusions: Pazopanib maintenance therapy provided a statistically significant and clinically meaningful PFS benefit in patients with AEOC; OS data are not mature. The safety profile of pazopanib in this setting was consistent with its established profile. Clinical trial information: NCT00866697. "

My thoughts: Will the overall survival (OS) for the women in the pazopanib arm correlate to the PFS time? Will OS be 5 months? longer? shorter?
note:After reading a Medpage article and comments, I learned that the 800 mg pill taken daily cost $54 each.

Chemotherapy or upfront surgery for newly diagnosed advanced ovarian cancer: Results from the MRC CHORUS trial 

The first treatment for Ovarian Cancer is normally Primary surgery( PS)  followed by adjuvant platinum-taxane chemotherapy(P-CT). This study compared survival rates for PS/ P-CT versus neoadjuvant chemotherapy (NACT) where chemo is given first and then surgery occurs after there is tumor shrinkage. There were 550 women in the study. The median OS was 22.8 months for PS vs 24.5 months for NACT. They study concluded " NACT was associated with increased optimal debulking, less early mortality and similar survival in this poor prognosis group. CHORUS results are consistent with EORTC55971 and strengthen evidence that NACT is a viable alternative to PS. Clinical trial information: ISRCTN74802813"

My thoughts: Knowing that there are no issues with NACT is important information for doctors to have when they are deciding what is best for their patients.

Comparative effectiveness of treatments for recurrent ovarian cancer.
In the past recurrent OC has been treated with chemotherapy but in some cases secondary cytoreductive surgery has been done (SCS). This study compared survival between chemotherapy vs SCS vs both or neither. There were 1623 women in the study. "Conclusions: Patients with recurrent ovarian cancer treated with both secondary surgery and chemotherapy survive longer than patients treated with either chemotherapy or surgery. Women who are Black, or older at time of recurrence have worse survival. "

My Thoughts:After reading this abstract I am happy I  chose SCS followed by chemotherapy when I recurred in 2008.

I with continue to read through the abstracts and will share more of my favorites in the future.

Dee
Every Day is a Blessing!