Amer Karam, MD
Neoadjuvant chemotherapy has emerged as a potential treatment approach for patients with advanced-stage ovarian cancer, though primary debulking surgery remains the standard of care for those who are eligible, said Amer Karam, MD.
“In our division at Stanford Medicine, we believe that primary debulking surgery or upfront surgery should be the standard of care for those patients who can undergo surgery [with the goal of achieving] minimal residual disease (MRD),” he said.
Although neoadjuvant chemotherapy is believed to reduce the burden of disease in patients who are too ill or frail to undergo upfront surgery, there are no robust data to prove the superiority of the regimen.
Therefore, physicians are awaiting the results of the ongoing TRUST trial, which is investigating the use of radical upfront surgery versus neoadjuvant chemotherapy in patients with advanced-stage disease (NCT02828618). Patients in the comparator arm will receive primary debulking surgery followed by 6 cycles of standard chemotherapy, whereas those in the experimental arm will receive 3 cycles of standard neoadjuvant chemotherapy followed by interval debulking surgery and another 3 cycles of standard chemotherapy. The study has an estimated completion date of April 2023.
In an interview during the 2018 OncLive®
State of the Science Summit™ on Ovarian Cancer, Karam, associate clinical professor of Gynecologic Oncology at Stanford Hospital and director of Robotic Surgery and Outreach in the Division of Gynecologic Oncology at Stanford Medicine, discussed surgical options for patients with advanced-stage ovarian cancer and the emergence of neoadjuvant chemotherapy.
OncLive: Could you discuss the current surgical approaches used for the treatment of patients with ovarian cancer?
For almost a century now, the concept of surgery for advanced-stage ovarian cancer focused on surgical debulking or cytoreduction; moreover, the concept of leaving as little as possible in terms of residual disease. Our goal was to be able to remove as much as possible of the cancer. Over the years, more radical techniques, particularly ultra-radical surgery in the upper abdomen, have been used to do that.
The other concept that has started to come forward is neoadjuvant chemotherapy. Patients who are too ill or have an overwhelming burden of disease are given neoadjuvant chemotherapy in order to reduce their disease burden; [this] allows them to heal and get stronger before they undergo surgery to remove the cancer from their abdomen.
Is MRD commonly achieved after surgery?
We would like to leave our patients with optimal results, which would be less than 1 cm of residual disease. We leave over 75% of our patients with less than 1 cm of disease. For those patients who did not go through primary debulking surgery, our goal of no residual disease or MRD is over 50%.
Is neoadjuvant chemotherapy widely accepted?
Patients who cannot go through upfront debulking surgery, those who are too ill or frail, or those who have disease that is too overwhelming, should be offered neoadjuvant chemotherapy. However, we strive to offer upfront surgery to all of our patients, if possible.
How many patients receive neoadjuvant chemotherapy?
About one-third of our patients get neoadjuvant chemotherapy because of their disease status. At the time of diagnostic laparoscopy, these patients had a disease burden that [indicated] that they would not be good candidates for primary debulking surgery.
Where does interval cytoreduction fit into the paradigm?
Interval debulking surgery is part of the treatment paradigm for the majority of patients who undergo neoadjuvant chemotherapy. Not every single patient who gets neoadjuvant chemotherapy will get to interval debulking surgery. Unfortunately, some patients progress, and some patients have disease burden that's still very significant at the time of interval debulking surgery, [rendering them ineligible for] an optimal interval debulking surgery.