The increased adoption of NACT for the treatment of advanced epithelial ovarian cancer decreased patient all-cause mortality within 3 years after diagnosis.

By Marielle Fares, Pharm. D

January 25, 2018- In patients with advanced epithelial ovarian cancer, the increased use of NACT led to higher declines in all-cause mortality within 3 years after diagnosis and improvement in surgical outcomes, a quasi-experimental study showed.

Alexander Melamed, MD, with the Division of Gynecologic Oncology and the Vincent Department of Obstetrics and Gynecology in the Massachusetts General Hospital in Boston, Massachusetts and colleagues reported the results in the January 3, 2018 issue of the British Medical Journal.

Ovarian cancer is a silent disease that is often diagnosed after it has metastasized. NACT is recommended only for patients who are not candidates for surgery, and it has been mostly used in advanced disease. Furthermore, large randomized trials failed to show a superior survival benefit of NACT followed by surgery in patients with advanced disease in comparison to initial primary cytoreductive surgery. This study looks at the effects of increasing NACT use on survival and outcomes in these patients.

A total of 6034 women with grade 3C or 4 epithelial ovarian cancer were selected from the US National Cancer Database. Enrolled patients belonged to either the rapidly adopting regions that increased NACT use between 2011 and 2012 (New England and south east central, n=1156) or to the control regions where NACT use remained unchanged during that time (south Atlantic, east north central and west north central regions, n=4878).

Women who received chemotherapy at diagnosis were included in the NACT or rapidly adopting group and patients treated with primary cytoreductive surgery at diagnosis formed the control group.

The primary endpoint was all-cause mortality within 3 years of diagnosis, defined as the time from diagnosis to death or last follow-up visit.

Starting in 2012, patients in the rapidly adopting regions had a significantly lower all-cause mortality hazard (hazard ratio 0.81) when compared with those treated in 2011. In contrast, the hazard ratio remained unchanged after 2012 in the control group when compared with previous years (1.02, 0.93 to 1.12).

In 2 of the control regions (south Atlantic and west north central) that started adopting NACT in 2013, results showed a significantly lower hazard of all-cause mortality in that year when compared with previous periods.

In addition, the authors “identified reductions in 30-day and 90-day postoperative mortality, and in the proportion of patients failing to receive both chemotherapy and surgery in high compared with low adopting regions as potential mechanisms underlying the lower mortality associated with NACT.”

Finally, the findings of the study indicated that “the survival benefit measure in this study is consequence of expanded adoption of NACT, which occurred selectively among older patients and those with stage 4 disease,” and may not benefit all patients with advanced stage ovarian. Since “the mechanism of benefit is reduction in postoperative morbidity and mortality” and that “regions which adopted NACT rapidly had higher perioperative mortality than control regions,” NACT use may also be less beneficial in expert centers with strong surgical outcomes, authors concluded.

This study was supported by the National Cancer Institute at the National Institute of Health and the Deborah Kelly Center for Outcome Research at Massachusetts General Hospital.

BMJ. Published on January 3, 2018.