The use of neoadjuvant chemotherapy (NACT), or chemo administered before surgery, in patients with ovarian cancer has increased as an alternative to primary cytoreductive surgery (PCS), performed when a woman is diagnosed.

But in women with stage 3C disease, NACT correlates with shorter overall survival compared to surgery, according to a recent study published in the Journal of Clinical Oncology.

However, the study, “Use and Effectiveness of Neoadjuvant Chemotherapy for Treatment of Ovarian Cancer,” from the University of Texas MD Anderson Cancer Center, shows that women with stage IV disease have similar survival rates but lower hospital readmission rates when treated with NACT, suggesting that ovarian cancer patients should be carefully selected to receive either neoadjuvant chemotherapy or surgery.

In 2010, two clinical trials revealed that women with stages 3 and 4 ovarian cancer who receive NACT have similar progression-free survival and overall survival, and less treatment-related side effects and mortality compared to those who receive PCS.

However, few studies have examined the impact these trials had on the use of NACT in clinical practice, and those that did reported opposing findings.

In this study, the researchers examined the use of NACT in 1,538 women with stage 3C and 4 ovarian cancer diagnosed between 2003 and 2012 in six comprehensive cancer centers. The outcomes associated with NACT, including overall survival, morbidity, and postoperative residual disease, were also analyzed in a matched sample of 594 patients.

The researchers found that between 2003 and 2012, 206 of 1,066 women with stage 3C disease and 210 of 472 patients with stage 4 disease received NACT. The results showed that NACT use increased in 2011 and 2012 compared to the period between 2003 and 2010, suggesting that the clinical trials had an impact on the use of NACT.

In fact, in patients with stage 3C disease, NACT use increased from 16 to 34 percent, and in women with stage 4 disease, NACT use increased from 41 to 62 percent.

However, the adoption of NACT varied widely among institutions; stage 3C disease varied from 8 to 30 percent, and stage 4 disease varied from 27 to 61 percent during this time period.

The investigators also found that, although NACT reduced the likelihood of having postoperative residual disease, rehospitalizations, or admissions to intensive care units (ICU) compared to PCS, NACT correlated with shorter overall survival in stage 3C disease, with those receiving NACT having a 40 percent higher risk of death. This decrease in survival, however, was not seen in patients with stage 4 disease, suggesting that these patients may benefit more from NACT due to its reduced morbidity.

“Our results suggest that in carefully selected patients with stage IIIC disease, PCS is associated with a survival advantage, with overall low rates of surgical morbidity,” Larissa A. Meyer and her colleagues wrote.

“In contrast, for patients with stage IV disease, our results confirm that NACT is noninferior to PCS for survival, with fewer ICU admissions and rehospitalizations, which suggests that NACT may be preferable for patients with stage IV ovarian cancer,” they wrote.