The principle of surgical cytoreduction, as applied in epithelial ovarian cancer (EOC),
has been an inspiring example of how the evolution of a treatment, enwrapped with
the refinement of surgical skills and expertise, optimization of infrastructural support
and collective team effort can contribute to the overall improvement of patients'
outcome, potentially even overcoming adverse aspects of a presumed less favorable
tumor biology in extensive tumor dissemination [1
2]. In a disease where cure rates remain dismal, the gynecological oncological community,
in its different facets, has largely managed to change its course towards a rather
chronic condition, where patients may live longer, even if in need of repeated sequence
of therapies [3].
Nevertheless, this increased “radicality” in both surgical but also systemic therapeutic
approaches, has brought in novel aspects of an iatrogenic morbidity profile, which
renders the implementation of any innovative techniques in special subpopulations
highly challenging and with even questionable benefit. This labile balance between
the hoped survival benefit and the actually generated side effects, represents one
of the most common and major caveats of our therapeutic attempts, so that adequate
patient selection and allocation of the right patient to the optimal treatment pathway
is the key for overall success [4
5
6
7].
In this issue by Liu et al. [8], the team from Memorial Sloan Kettering Cancer Center
has demonstrated that more than a quarter of women with advanced EOC who are treated
with neoadjuvant chemotherapy (NACT) do not ever reach the point of being able to
undergo cytoreductive surgery at an interval setting (IDS). Advanced age, lower albumin
levels, frailty scores and extensive disease of predominantly high-grade serous histology,
were identified as the most significant risk factors for inability to undergo surgery.
The reasons of that were mainly quoted as 1) extent of disease not amenable to surgery
or lack of response to NACT; 2) patient comorbidities preventing surgery; 3) both
extent of disease and patient comorbidity [8]. The findings of this study confirmed
the intuitive expectation that these, never operated, patients will have a >3-fold
increase in all-cause mortality compared to those who underwent surgery at some point
in their journey, even after risk adjustment for age, tumor dissemination patterns
and dose reductions. These findings demonstrate the unmet need for systematic studies
and algorithms to identify optimal treatment strategies in this high-risk, elderly
and/or frail population, in an attempt to maximize outcomes without detrimental increase
of iatrogenic toxicity. The numbers quoted in the present study (28%) are higher than
the ones reported in the European Organisation for Research and Treatment of Cancer
(12%)- and CHemotherapy OR Upfront Surgery (14.2%)- NACT-studies [4
5], most probably due to the known selection bias of prospective randomized studies,
where more fragile or older patients are a priori not considered for trial participation.
In times of significant and continuous increase of the elderly population worldwide
and hence the increased average age of the patients that we, as gynecological oncology
community, are called to treat, it is high time we developed and established validated
geriatric scores for the adequate stratification of our patients. In the paper by
Liu et al. [8] 74% of the patients in the non-surgical group was ≥70 years of age
compared with only 36% in the surgical group. The non-surgical group was also on average
8.8 years older compared to the surgical group; data correlating with similar experiences
in numerous other studies, where the aging population represents a considerate challenge
in the implementation of traditional treatment strategies [8].
One the most important attempts to identify fragility scores in gynecological cancer
surgery, is the AGO-OVAR OP.7/AGO-OVAR19-Fragile study, which is part of the phase-III,
prospective randomized TRUST-study (NCT02828618) [9]. Aim of the study is to identify
the cohort of patients who may not benefit from standard surgery and chemotherapy,
defined as progression within 10 months after registration/randomization. The fragility
evaluation has been composed of following parameters: age adjusted Charlson-Comorbidity-Index,
timed ‘up and go’ test, Hospital Anxiety and Depression Scale-Score, serum albumin
levels, full blood count and urea and electrolytes, CA125, American Society of Anesthesiologists
and Eastern Cooperative Oncology Group scores, presence of tumor related symptoms
requiring intervention such as abdominal pain & bloating, shortness of breath, suspected
stage-IV disease, age and biometric data, volume of ascites and or pleural effusion.
The results of that study will provide important guidance of how to identify patients
who are less likely to benefit from our standard and traditional treatment strategies
already at the initial presentation of the disease and not after failure of our therapeutic
efforts.
Another study towards the same direction is the National Cancer Research Institute
currently under development FAIR-O-study (REC-reference:19/LO/1741/IRAS:263916) which
will address the feasibility of frailty assessment and implementation of protocol-led
geriatric interventions during oncologic treatment in women with EOC over the age
of 70. Evaluation of further risk factors such as sarcopenia, loss of muscle mass
and reduced muscle attenuation at baseline will aim to establish additional predictive
factors for reduced tolerance to oncologic treatment, functional decline and ultimately
poorer survival outcomes.
A further point of interest in the paper by Liu et al. [8], is that one of the reasons
for patients not undergoing IDS was stable/mixed response at NACT. There are indeed
very few large-scale prospective studies to assess value of debulking surgery in patients
with stable disease after NACT. However, the recently presented ICON-8 data demonstrated
interestingly, that both progression free survival and complete/optimal debulking
rates were similar in patients with stable disease and those with complete- or partial
response after NACT, suggesting that also patients with stable disease after NACT
are worth being offered IDS [10].
In conclusion, there is a strong rationale towards a personalization of surgical treatment
in patients with advanced EOC and to implement predictive and prognostic scores that
will already at the onset of the disease predict failure of treatment and patients'
inability to cope with our traditional strategies. All that within the restrains of
national health systems with the known infrastructural limitations. Liu et al. [8]
address marginally the practice modifications necessary to facilitate surgery in designated
cancer centers, as they are reflected for example in higher IDS rates. Our ultimate
goal will be to adequately and wisely allocate the right treatment to the right patient
to avoid unnecessary iatrogenic toxicity but also unopposed exhaustion of infrastructural
and healthcare resources.