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Guest column

De-bulking good for less advanced ovarian cancer cases

By V. UPENDER RAO
Published October 10, 2005

Patients with ovarian cancer usually undergo aggressive de-bulking surgery up front, prior to chemotherapy. It has long been observed that those patients whose tumors can be resected without any visible residual disease tend to live longer than those who are left with residual tumor after de-bulking surgery. Based upon this, up front, de-bulking surgery has become the standard of care, although there are no recently conducted, randomized clinical trials within the context of the varying biological behavior of cancers to substantiate this assertion.

Some researchers believe the reason for better survival for patients who could undergo complete resection without any tumor left behind is that these tumors are biologically less aggressive and would do better regardless of the type of treatment they receive.

To test this hypothesis, researchers from the Royal Marsden Hospital in London conducted a prospective randomized observational trial. Patients were accrued onto this trial from the United Kingdom and various centers in Europe, the United States and Australia.

The results of this study, presented at the 41st annual meeting of the American Society of Clinical Oncology, indicate that de-bulking surgery is beneficial for only those patients who have less advanced disease, and that the removal of lymph nodes at the time of surgery may additionally contribute to a better outcome.

The authors of this study suggest that the better prognosis for surgically resectable disease depends on the favorable biological profile of the tumor rather than on the surgery itself. It was also mentioned that, for those patients who met the criteria for upfront surgery, removal of lymph nodes conferred additional benefit.

Another study from Germany tested the role of surgery in patients with recurrent ovarian cancer and found that those patients who underwent resection without any residual tumor did better than those whose tumors could not be completely removed. The authors of this study identified four parameters that could predict the possibility of complete resection, which included:

--Good performance status

--No ascites (malignant fluid in the abdomen)

--No residual tumor after the first surgery

--No evidence of peritoneal spread of tumor on the preoperative tests

Patients who met all these criteria had an 80 percent chance of successful surgery with complete tumor removal.

Surgery is an integral part of the multimodality treatment of many cancers. However, with the advent of new knowledge about the biology of individual tumors, its role is changing but not necessarily diminishing.

In the case of ovarian cancer, proper patient selection will ensure the benefit of surgery for those who need it and avoid its morbidity and delay in the commencement of chemotherapy for those who are unlikely to benefit from it.

--V. Upender Rao, MD, FACP, practices at the Cancer and Blood Disease Center in Lecanto.

[Last modified October 10, 2005, 01:18:12]