Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: A meta-analysis
Graphical abstract
Introduction
Worldwide, approximately 225,000 women are diagnosed with ovarian cancer and 140,000 women die from this disease annually [1]. In the United States, ovarian cancer remains the leading cause of death from gynecological malignancy, with 21,990 new cases and 15,460 deaths in 2011 [1]. The majority of ovarian cancer patients are initially diagnosed with tumor metastases beyond the ovary, which results in diminished chances of long-term survival [2]. Surgical cytoreduction and adjuvant chemotherapy are the cornerstones of management for advanced ovarian cancer. Since the mid-1990s, primary cytoreductive surgery followed by platinum and taxane-based combination chemotherapy has been the standard treatment regimen for advanced-stage disease [3], [4], [5], [6].
Residual disease after cytoreductive surgery for advanced-stage ovarian cancer is estimated as the largest diameter of remaining tumor and is one of the most important prognostic factors [7], [8]. Paradoxically, universal consensus regarding the definition of “optimal” residual disease has been lacking. The Gynecologic Oncology Group (GOG) has defined optimal residual disease as residual tumor ≤ 1 cm in the largest diameter [9], [10]. However, optimal residual disease has been variously defined as ranging from no gross residual disease to remaining tumor nodules measuring ≤ 2 cm [11], [12], [13], [14]. More contemporary data suggest that the most favorable survival outcomes are associated with complete cytoreduction to no gross residual disease [15], [16], [17], [18], [19], [20], [21], [22]. Despite this observation the relative impact of complete cytoreduction, as opposed to “optimal but visible residual disease”, within the context of contemporary platinum–taxane-based adjuvant therapy has been difficult to determine. Therefore, the objective of the current study was to quantify the impact of complete cytoreduction to no gross residual disease on overall survival among patients with advanced-stage ovarian cancer treated during the platinum–taxane era using the technique of meta-analysis.
Section snippets
Study selection and data extraction
Potential articles for analysis were identified from a literature search of the National Library of Medicine (PubMed) and the Cochrane Library for all English-language publications between January 1, 1996 and July 31, 2011. The keywords used were “ovarian neoplasm,” “ovarian carcinoma,” “ovarian cancer,” and “surgery.” Two authors (S.J.C. and R.E.B.) independently reviewed the titles and abstracts of publications searched, and excluded the unrelated articles. A full-text audit of identified
Study characteristics
The initial electronic search yielded 1203 articles. The full-length published reports of 104 studies were formally reviewed, and 15 studies were identified as containing the minimum study inclusion criteria [5], [15], [16], [17], [18], [19], [20], [21], [23], [24], [25], [26], [27], [28], [29]. Of these 15 studies, 4 studies [18], [19], [20], [21] were ancillary data studies which retrospectively reanalyzed the data collected for 9 previous randomized prospective trials [5], [6], [23], [30],
Discussion
Meigs first described cytoreductive surgery for advanced ovarian cancer in 1934 [36]. Forty years later, Griffiths published a landmark study that conclusively demonstrated an inverse relationship between residual tumor diameter and patient survival [37]. Nearly every retrospective study and prospective study since then has demonstrated that the extent of residual disease and the use of platinum-based chemotherapy are key factors impacting survival in women with advanced staged ovarian cancer.
Conflict of interest statement
The authors do not have any potential conflicts of interest.
Acknowledgment
Dr. Robert E. Bristow was supported by the Queen of Hearts Foundation.
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