According to a new clinical guideline jointly created by the American Society of Clinical Oncology (ASCO) and the Society of Gynecologic Oncology, some women with advanced ovarian cancer should receive neoadjuvant chemotherapy as first-line treatment instead of the standard of care, primary cytoreduction surgery.

The guideline was recently published in the Journal of Clinical Oncology, under the title “Neoadjuvant Chemotherapy for Newly Diagnosed, Advanced Ovarian Cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline“.

Nearly 75 percent of women with ovarian cancer are diagnosed with advanced stage disease (stage IIIC or IV) at presentation. For them, standard of care treatment means primary cytoreductive surgery to reduce the tumor volume as much as possible, followed by chemotherapy.

But two recent clinical trials compared the standard care approach with neoadjuvant chemotherapy (NACT) as the first step to shrink the tumor, then followed by interval cytoreductive surgery. The NACT first approach showed lower treatment-related morbidity and mortality, though both were similar in progression-free survival and overall survival.

Still, the choice between one treatment or the other remains controversial. The new guidelines provide clinicians with information regarding the use of primary cytoreduction and chemotherapy versus NACT followed by interval cytoreduction for women with stage IIIC or IV epithelial ovarian cancer.

The clinical practice guidelines recommend the following:

• A gynecologic oncologist should evaluate all women with suspected stage IIIC or IV invasive epithelial ovarian cancer prior to initiation of therapy to determine if they are candidates for primary cytoreductive surgery.

• Patients should be primarily evaluated with computed tomography (CT) scans of the abdomen and pelvis with oral and IV contrast , as well as chest imaging, to evaluate the extent of the disease and the feasibility of surgical resection. Other tools that could refine the assessment include additional radiographic imaging; positron-emission tomography (PET) scans, magnetic resonance imaging (MRI), and laparoscopic evaluation.

• Women who have  a low likelihood of achieving cytoreduction to less than 1 cm or a high perioperative risk should receive NACT.

• Deciding whether women are eligible for medical or surgical cancer treatment should be made only after a consultation with a gynecologic oncologist or a medical oncologist with gynecologic expertise.

• Women who are for primary cytoreductive surgery, with potentially removable disease, may be offered either NACT or primary cytoreductive surgery. But if the women have high likelihood of achieving cytoreduction to less than 1 cm with accepted morbidity, primary cytoreductive surgery is recommended over NACT. The opposite is recommended for women who are not likely to achieve cytoreduction to less than 1 cm.

• Before NACT is delivered, patients should have confirmation of any invasive ovarian, fallopian tube, or peritoneal cancer.

• A platinum/taxane-based chemotherapy is recommended for NACT. However,  based on individual patient factors, alternative regimens containing a platinum agent can be selected.

• Interval cytoreductive surgery should be performed after four or fewer cycles of NACT for women who respond to the therapy or experience stable disease.

• For patients who do not improve or whose disease worsens on NACT, prognosis is poor.  Alternative options such as other chemotherapy regimens, clinical trials, or discontinuation of active cancer therapy and initiation of end-of-life care, should be considered.

The guideline review panel suggests that the decision of first-line treatment should be shared between clinicians and patients. Physicians should explain the diagnosis, extent of the disease, cancer stage, prognostic implications, and current evidence-based options for treatment in order to help patients make more informed choices.