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Ovarian Cancer (Expert Forum)
Does surgery or second look laparoscopy improve prognosis?
Answered by
Annekathryn Goodman, M.D. - Gynecologic Cancers, Complex Gynecologic, Surgeries, Palliative Care, Acupuncture
Massachusetts General Hospital Cancer Center
Boston - MA
This forum is for questions and support regarding ovarian cancer issues, such as: Biopsy, Chemotherapy, Clinical Trials, Genetics, Hysterectomy,Immunotherapy, Ovarian Cancer Types, Radiation Therapy, Risk Factors, Screening, Staging, Surgery.
Does surgery or second look laparoscopy improve prognosis?
by Jatoo, Sep 21, 2006 12:00AM
Dear Dr. Goodman:
This is a follow up to my previous post re my wife's recurrence. She (52 yrs old) had a first complete surgery last June/05. We told our onc as to a possible surgery to remove a remaining small isolated mass of 1.3 X 0.8 cm in the abdomen ( a density adjacent to the posterior margin of the ascending colon) and she said: there is no study that shows surgery improves prognosis. This is after 6 cycles of doxil and her CA 125 has been normal since the 2nd treatment (9). It was 300 when it recurred.
Is there really no study that shows 2nd debulking or laparoscopy improves prognosis?
Thank you again for your answer.
Jatoo
This is a follow up to my previous post re my wife's recurrence. She (52 yrs old) had a first complete surgery last June/05. We told our onc as to a possible surgery to remove a remaining small isolated mass of 1.3 X 0.8 cm in the abdomen ( a density adjacent to the posterior margin of the ascending colon) and she said: there is no study that shows surgery improves prognosis. This is after 6 cycles of doxil and her CA 125 has been normal since the 2nd treatment (9). It was 300 when it recurred.
Is there really no study that shows 2nd debulking or laparoscopy improves prognosis?
Thank you again for your answer.
Jatoo
Doctor's Answer
by Annekathryn Goodman, M.D., Sep 23, 2006 12:00AM
, Sep 23, 2006 12:00AM
Dear Jatoo,
Thank you for your excellent question. First I would like to be philosophical. I feel that each person is unique. The challenge of giving excellent care and making appropriate treatment recommendations has to do with balancing data, studies, science, with the unique human being with their unique story. If we ignored data, that would be wrong. If we blindly treated people according to data but without looking at the individual, that would be wrong as well. Sometimes, there are no wrong answers. There are many possible approaches; none of them are perfect. And one just needs to decide with the help of the person who is going through the illness what is the best choice.
I need to stress, that without seeing your wife or the x-rays, I cannot comment on whether “secondary cytoreduction” is right for her. I would say that for the majority of women who have a recurrent ovarian cancer that I personally take care of who ask me if there is a role for surgery – I tell them that surgery is not the right thing for them.
Now for the data:
In 1996, Bristow, Lagasse, and Karlan published a paper “Secondary Surgical cytoreduction for advanced epithelial ovarian cancer.” (Cancer 1996; volume 78; pages 2049-2062). They reviewed all the published reports in the world’s literature on secondary cytoreduction. Secondary cytoreduction means that a first surgery has been performed, chemotherapy has been given, and now one is thinking about a second surgery to try to remove as much of the cancer as possible.
There are four very different clinical situations where the term “secondary cytoreduction” is used.
1.Recurrent disease Those patients who have enjoyed a prolonged disease free interval (>6 months) after completing primary therapy and then develop recurrent disease.
2.Second look laparotomy (SLL) Patients who are clinically and radiologically free of disease after primary surgery and first-line chemotherapy who are found to have visible cancer at second look surgery. In this setting, SLL is performed immediately after the course of chemotherapy has been completed.
3.Interval debulking Patients who have unresectable cancer at their first surgery who then receive chemotherapy. They then undergo “interval cytoreductive surgery” and then receive more chemotherapy. The whole packet of therapy (surgery, chemo, surgery, chemo) is together considered their primary therapy.
4.Progressive Disease Patients who have evidence of clinical disease progression while receiving first line therapy.
These four situations are very different and people experiencing these different situations have different prognoses. There are studies and commentary, and opinion on all four separate situations. Bristow’s group concluded that women with recurrent disease particularly after a prolonged disease free interval may derive a significant survival benefit if the disease could be surgically removed.
Your wife is experiencing the situation described in #1: recurrent disease. Here are some examples of studies that have looked at the question of whether “secondary cytoreduction” improves survival for women experiencing recurrent ovarian cancer after being in remission:
Eisenkop, Friedman, and Spirtos. (California)“The role of secondary cytoreductive surgery in the treatment of patients with recurrent epithelial ovarian cancer.” Cancer 200 volume 88 pages 144-153.
They looked at 106 women who recurred after 6 months. 87 women underwent complete removal of all visible tumor. The survival of these women was influenced by how long it was between primary therapy and recurrence. For 6 to 12 months after primary therapy, median survival with secondary surgery was 25 months. For 13 to 36 months, median survival was 44 months, and for greater than 36 months, the median survival was 57 months. In contrast, for women where it was not possible to remove the recurrent tumor, the median survival was 12 months.
Munkarah and colleagues(MD Anderson, Texas). “Secondary Cytoreductive Surgery for localized intra-abdominal recurrences in epithelial ovarian cancer.” Gynecologic Oncology 2001 volume 81 pages 237-241.
This group looked at 25 women who had a solitary recurrence of ovarian cancer that occurred on average 37.6 months after their primary diagnosis. For the 18 women who had optimal resection of their recurrent tumor, the median survival after “secondary cytoreduction” was 56.9 months. For the 7 women who did not have optimal resection of their recurrence, the median survival was 25.1 months.
Scarabelli, Gallo, Carbone. (Italy)“Secondary cytoreductive surgery for patients with recurrent epithelial ovarian carcinoma. ” Gynecologic Oncology 2001;volume 83 pages 504-512.
149 women underwent “secondary cytoreduction”. After surgery 69 women had a recurrence free interval (RFI) (which means being in remission) of 7-12 months, 59 women had a RFI of 13-24 months, and 21 women had a RFI of greater than 24 months. They concluded that there was a direct correlation with RFI and the ability to surgically remove the recurrent cancer.
Tay, Grant, Gebski, Hacker (Australia) “Secondary Cytoreductive Surgery for recurrent epithelial ovarian cancer.” Obstetrics & Gynecology 2002 volume 99 pages 1008-10013.
46 women underwent “secondary cytoreduction”. Women who had any residual cancer after this surgery had a median survival of 11 months. Women who had no residual cancer at the conclusion of surgery had a median survival of 38 months.
The important criticism of all studies on surgery in ovarian cancer is that these studies report on the experience of taking care of women and summarizing that experience. However there are no studies that randomize women with recurrent ovarian cancer to getting “secondary cytoreduction” versus just chemotherapy. That is probably what your oncologist means when saying there is no study to show that surgery improves prognosis. In medicine studies called “prospective randomized controlled studies” are thought to give the most rigorous and exact data about a particular therapy. That kind of study will probably never be done for surgery in ovarian cancer. We will continue to have to rely on our experience to make decisions about surgery.
In summary, there may be a role for “secondary cytoreduction” for women who have an isolated area of recurrence that has occurred more than 6 months after primary therapy.
Best wishes
Thank you for your excellent question. First I would like to be philosophical. I feel that each person is unique. The challenge of giving excellent care and making appropriate treatment recommendations has to do with balancing data, studies, science, with the unique human being with their unique story. If we ignored data, that would be wrong. If we blindly treated people according to data but without looking at the individual, that would be wrong as well. Sometimes, there are no wrong answers. There are many possible approaches; none of them are perfect. And one just needs to decide with the help of the person who is going through the illness what is the best choice.
I need to stress, that without seeing your wife or the x-rays, I cannot comment on whether “secondary cytoreduction” is right for her. I would say that for the majority of women who have a recurrent ovarian cancer that I personally take care of who ask me if there is a role for surgery – I tell them that surgery is not the right thing for them.
Now for the data:
In 1996, Bristow, Lagasse, and Karlan published a paper “Secondary Surgical cytoreduction for advanced epithelial ovarian cancer.” (Cancer 1996; volume 78; pages 2049-2062). They reviewed all the published reports in the world’s literature on secondary cytoreduction. Secondary cytoreduction means that a first surgery has been performed, chemotherapy has been given, and now one is thinking about a second surgery to try to remove as much of the cancer as possible.
There are four very different clinical situations where the term “secondary cytoreduction” is used.
1.Recurrent disease Those patients who have enjoyed a prolonged disease free interval (>6 months) after completing primary therapy and then develop recurrent disease.
2.Second look laparotomy (SLL) Patients who are clinically and radiologically free of disease after primary surgery and first-line chemotherapy who are found to have visible cancer at second look surgery. In this setting, SLL is performed immediately after the course of chemotherapy has been completed.
3.Interval debulking Patients who have unresectable cancer at their first surgery who then receive chemotherapy. They then undergo “interval cytoreductive surgery” and then receive more chemotherapy. The whole packet of therapy (surgery, chemo, surgery, chemo) is together considered their primary therapy.
4.Progressive Disease Patients who have evidence of clinical disease progression while receiving first line therapy.
These four situations are very different and people experiencing these different situations have different prognoses. There are studies and commentary, and opinion on all four separate situations. Bristow’s group concluded that women with recurrent disease particularly after a prolonged disease free interval may derive a significant survival benefit if the disease could be surgically removed.
Your wife is experiencing the situation described in #1: recurrent disease. Here are some examples of studies that have looked at the question of whether “secondary cytoreduction” improves survival for women experiencing recurrent ovarian cancer after being in remission:
Eisenkop, Friedman, and Spirtos. (California)“The role of secondary cytoreductive surgery in the treatment of patients with recurrent epithelial ovarian cancer.” Cancer 200 volume 88 pages 144-153.
They looked at 106 women who recurred after 6 months. 87 women underwent complete removal of all visible tumor. The survival of these women was influenced by how long it was between primary therapy and recurrence. For 6 to 12 months after primary therapy, median survival with secondary surgery was 25 months. For 13 to 36 months, median survival was 44 months, and for greater than 36 months, the median survival was 57 months. In contrast, for women where it was not possible to remove the recurrent tumor, the median survival was 12 months.
Munkarah and colleagues(MD Anderson, Texas). “Secondary Cytoreductive Surgery for localized intra-abdominal recurrences in epithelial ovarian cancer.” Gynecologic Oncology 2001 volume 81 pages 237-241.
This group looked at 25 women who had a solitary recurrence of ovarian cancer that occurred on average 37.6 months after their primary diagnosis. For the 18 women who had optimal resection of their recurrent tumor, the median survival after “secondary cytoreduction” was 56.9 months. For the 7 women who did not have optimal resection of their recurrence, the median survival was 25.1 months.
Scarabelli, Gallo, Carbone. (Italy)“Secondary cytoreductive surgery for patients with recurrent epithelial ovarian carcinoma. ” Gynecologic Oncology 2001;volume 83 pages 504-512.
149 women underwent “secondary cytoreduction”. After surgery 69 women had a recurrence free interval (RFI) (which means being in remission) of 7-12 months, 59 women had a RFI of 13-24 months, and 21 women had a RFI of greater than 24 months. They concluded that there was a direct correlation with RFI and the ability to surgically remove the recurrent cancer.
Tay, Grant, Gebski, Hacker (Australia) “Secondary Cytoreductive Surgery for recurrent epithelial ovarian cancer.” Obstetrics & Gynecology 2002 volume 99 pages 1008-10013.
46 women underwent “secondary cytoreduction”. Women who had any residual cancer after this surgery had a median survival of 11 months. Women who had no residual cancer at the conclusion of surgery had a median survival of 38 months.
The important criticism of all studies on surgery in ovarian cancer is that these studies report on the experience of taking care of women and summarizing that experience. However there are no studies that randomize women with recurrent ovarian cancer to getting “secondary cytoreduction” versus just chemotherapy. That is probably what your oncologist means when saying there is no study to show that surgery improves prognosis. In medicine studies called “prospective randomized controlled studies” are thought to give the most rigorous and exact data about a particular therapy. That kind of study will probably never be done for surgery in ovarian cancer. We will continue to have to rely on our experience to make decisions about surgery.
In summary, there may be a role for “secondary cytoreduction” for women who have an isolated area of recurrence that has occurred more than 6 months after primary therapy.
Best wishes
Member Comments (5)
by Jatoo, Sep 21, 2006 12:00AM