Interval debulking surgery for advanced epithelial ovarian cancer

Background Primary debulking surgery, a crucial step in the management of epithelial ovarian cancer, is not always an option in patients with advanced stage disease (stage III to IV). In some circumstances, surgery may not yield satisfactory results with residual tumour masses > 1 to 2 cm (so called suboptimal surgery). Induction or neoadjuvant chemotherapy followed by interval debulking surgery (IDS) may have an alternative role in this setting. However, the advantage of IDS compared to conventional methods is still a controversial issue. Objectives To assess the effectiveness and complications of IDS for patients with advanced stage epithelial ovarian cancer. Search strategy We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, Issue 2, 2008), MEDLINE (January 1966 to June 2008), EMBASE (January 1966 to June 2008), and reference lists of included studies. Selection criteria Randomised controlled trials (RCTs) comparing survival of women with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy). Data collection and analysis Two review authors independently assessed trial quality and extracted data. Searches for additional information from study authors were attempted. Meta-analysis of overall and progression free survival (PFS) was performed using fixed effects models. Main results Three RCTs, randomising 853 women of whom781 were evaluated, met the inclusion criteria. Overall survival (OS) showed substantial heterogeneity between trials (I-2 = 58%). Subgroup analysis for overall survival in two trials, wherein the primary surgery was not performed by gynecologic oncologists or was less extensive, showed a benefit of IDS: (relative risk) RR = 0.7 (95% confidence interval (CI): 0.5 to 0.9, I-2 = 0%). Likewise, substantial heterogeneity between two trials for PFS evaluating 702 women was also shown (I2 = 75%). Rates of toxic reactions to chemotherapy were similar in both arms (RR = 1.3, 95% CI: 0.4 to 3.6), but little information is available for other adverse events. Only one trial reported quality of life (QOL), which was generally similar in both treatment arms. Authors' conclusions No conclusive evidence was found to determine whether IDS between cycles of chemotherapy would improve or decrease the survival rates of women with advanced ovarian cancer, compared with conventional treatment of primary surgery followed by adjuvant chemotherapy. IDS appeared to yield benefit only in the patients whose primary surgery was not performed by gynecologic oncologists or was less extensive. Data on QOL and adverse events were inconclusive.