Delaying the primary surgical effort for advanced ovarian cancer: A systematic review of neoadjuvant chemotherapy and interval cytoreduction

Objective.: To summarize the existing data on interval cytoreductive surgery and neoadjuvant chemotherapy as alternative treatment strategies for patients with advanced-stage ovarian cancer. Methods.: All investigational studies with evaluable survival data on interval cytoreductive surgery and neoadjuvant chemotherapy for ovarian cancer reported in the English language literature between 1989 and 2006 were systematically reviewed. Results.: Three randomized trials and six non-randomized studies of interval cytoreduction following suboptimal initial surgery were identified. Twenty-six studies, including a total of 1336 patients, reporting on neoadjuvant chemotherapy administered in lieu of primary cytoreductive surgery were analyzed according to the survival outcome achieved, the degree of surgical effort or success, and the particular selection criteria employed to justify deferring an attempt at primary cytoreductive surgery. Conclusions.: Interval surgery following a concerted but suboptimal attempt at up-front cytoreduction does not appear to have an appreciable impact on survival outcome. Maximal primary cytoreductive surgery remains the standard of care for the majority of women with suspected advanced ovarian cancer. Neoadjuvant chemotherapy represents a viable alternative management strategy for the limited number of patients felt to be optimally unresectable by an experienced ovarian cancer surgical team; however, currently available data suggest that the survival outcome achievable with initial chemotherapy is inferior to successful up-front cytoreductive surgery. Additional research is needed to devise universal selection criteria for neoadjuvant chemotherapy, determine the most efficacious treatment program, and characterize the appropriate proportion of patients in which an attempt at primary surgery should be abandoned in favor of initial chemotherapy.