Expert Discusses Surgery's Evolving Role in Ovarian Cancer

Surgical resection continues to be useful in treating patients with advanced ovarian cancer, according to Shana Wingo, M.D.

Whether a treatment plan includes cytoreduction upfront or neoadjuvant chemotherapy, patients with advanced disease are likely to benefit from surgical approaches that reduce the volume of the tumor.

What did you discuss at this meeting in your overview of surgery in ovarian cancer?

Wingo, who specializes in gynecologic oncology at Arizona Oncology, discussed this in an interview with CURE.We covered what we do for ovarian cancer and how we manage patients, mainly focusing on advanced stage ovarian cancer and what we do for patients when they initially present. Generally, what happens is that for the majority of patients, we consider upfront cytoreduction, which is for bulky disease that has metastasized and we remove the bulk of the tumor. We also call it debulking surgery.

Now, when we do upfront surgery, there is a possibility where we might consider chemotherapy, depending on how involved a patient’s cancer is. If a patient has stage 4 disease that might not be resectable or they have other medical comorbidities, they might be a good candidate for neoadjuvant chemotherapy.

What evolution have we seen with surgery in ovarian cancer, and what can we expect going forward?

One of the things that is getting traction and is more adopted now is doing laparoscopy as an initial assessment to determine if a laparotomy to a much larger incision is appropriate. If patients aren’t felt to be appropriate surgical candidates at the time of laparoscopy for debulking, then we stop the procedure, give them chemotherapy, and then do an interval cytoreduction where you’re doing debulking after they have had some chemotherapy. That shrinks the size of the tumor, leading to better success with cytoreduction. We now have a real solid understanding that the less tumor that is left behind, the better patients do. Really, we are talking about the amount of time they survive. The surgeries that we do can be very labor intensive from a general perspective. Most of us are probably doing a lot more pelvic surgery — involving the uterus, cervix, fallopian tubes and ovaries — but then there are bowel resections that might involve the colon and pancreas, as well as lymph node removal. The omentum is always involved in the surgery, which is the upper abdomen.

Are there ongoing clinical trials focused on surgery in ovarian cancer?

As time goes on, you find that the more aggressive you are with surgery, perhaps the better patients do based on survival data. So, some of the high-volume centers are doing resection of liver metastases, the gallbladder and pancreas, and splenectomies. The goal is the same: no residual disease. That is a huge difference. The Gynecologic Oncology Group, over time, used to define optimal as less than 2 cm, then became less than 1 cm, and now the goal for all of us is a complete resection of disease. There are none to my knowledge. Some single institutions might be doing that. The clinical trials are not necessarily involving the actually surgery itself, but whether patients get chemotherapy or surgery upfront and then looking at the data to see if there is a difference.

The big thing with our surgeries, especially when you are doing large debulking surgeries, is that there tends to be a lot of morbidity, meaning patients can have complications that are pretty significant. The mortality rate is not high, but it is certainly higher if you do surgery upfront versus after initiating chemotherapy.

Are certain neoadjuvant chemotherapy regimens better than others?

With the explosion of PARP inhibitors and the possibility of immunotherapy, what role do you think surgery will eventuall have in ovarian cancer treatment?

What novel approaches could make their way through the field?

What are the major points from your lecture that you hope community oncologists took away?

There is more data looking into which one is the better approach. It has not been well adopted in the United States, truthfully, because it is a backbone of our training in gynecologic oncology to do cytoreduction. Until someone shows survival data that neoadjuvant chemotherapy might be a little more in line with upfront debulking, it is not probably going to gain major traction here. It is pretty standard across the board. The standard chemotherapy in ovarian cancer is really a platinum and a taxane. Nobody is really going off that path; it’s really the foundation of chemotherapy upfront.It is evolving. I don’t know that any of us would have predicted the evolution that is occurring, but the number of therapeutic agents that are coming out certainly have the potential to affect what we consider the backbone of our therapy. If we start to see better survival with an addition to the backbone, then it may make sense to alter how we do the surgery. Therefore, it’s subject to change but I don’t know if it’s going to happen anytime soon. More of us are doing minimally invasive surgery. But, with ovarian cancer, it is a little bit more difficult to adopt a minimally invasive approach, so we use robotic surgery because ovarian cancer tends to be a bulkier malignancy.I presented a slide where I talked about the guidelines that were recently published in the Journal of Clinical Oncology in October 2016. Essentially, the recommendation across the board is that all patients should be referred to a gynecologic oncologist.

It is very typical, depending on if you’re in a rural place or somewhere out of a big city, for a patient to end up with a medical oncologist who is certainly capable of delivering chemotherapy. However, patients need an upfront consultation with a gynecologic oncologist.

Neoadjuvant chemotherapy with interval cytoreduction is not — at this point — felt to be inferior to upfront cytoreduction. However, it is recommended that if a patient is suitable for surgery, to have surgery upfront because there is a substantial amount of data that still supports doing that approach first. The recommendation might evolve, but that is the take-home at this point.