Sugery for Ovarian Cancer

[gdpawel]

It is recommended that patients with ovarian cancer undergo aggressive de-bulking surgery up front, prior to chemotherapy. It has long been observed that those patients whose tumors can be resected without any visible residual disease tend to live longer than those who are left with residual tumor after de-bulking surgery. Based upon this, up front, de-bulking surgery has become the standard of care.

Some researchers believe the reason for better survival for patients who could undergo complete resection without any tumor left behind is that these tumors are biologically less aggressive and would do better regardless of the type of treatment they receive, and that the removal of lymph nodes at the time of surgery may additionally contribute to a better outcome.

A study from Germany tested the role of surgery in patients with recurrent ovarian cancer and found that those patients who underwent resection without any residual tumor did better than those whose tumors could not be completely removed. The authors of this study identified four parameters that could predict the possibility of complete resection, which included:

--Good performance status

--No ascites (malignant fluid in the abdomen)

--No residual tumor after the first surgery

--No evidence of peritoneal spread of tumor on the preoperative tests

Patients who met all these criteria had an 80 percent chance of successful surgery with complete tumor removal.

Surgery is an integral part of the multimodality treatment of many cancers. In the case of ovarian cancer, proper patient selection will ensure the benefit of surgery for those who need it and avoid its morbidity and delay in the commencement of chemotherapy for those who are unlikely to benefit from it.

Full surgery superior to chemotherapy in recurrent cancer

Assessing the impact of secondary surgical cytoreduction on the survival of patients with recurrent ovarian cancer, compared with chemotherapy alone.

According to a recent article in Gynecologic Oncology, patients with recurrent ovarian cancer may have improved survival when treated with cytoreductive surgery compared to chemotherapy alone. However, patients who can have all of their visible cancer removed during surgery appear to gain the most benefit.

Complete surgical cytoreduction significantly lengthens survival of recurrent ovarian cancer patients, compared with salvage chemotherapy alone, reveal researchers who stress the need to assess tumor debulkability before surgery.

The possibility that secondary cytoreductive surgery may be beneficial to patients whose disease recurs with a disease-free interval of more than 6 months has been suggested by numerous authors, note Mete Gungor (Ankara University School of Medicine, Turkey) and colleagues.

To investigate, the team assigned 75 such patients to undergo salvage surgery (n = 44) or salvage chemotherapy alone (n = 31), and then followed them up for survival. A macroscopically complete surgical cytoreduction was achieved in 34 (77 percent) of the operated patients.

Survival was significantly longer in the women who were completely cytoreduced than in those who were incompletely cytoreduced and those who underwent chemotherapy (19 months vs 9 months and 12 months, respectively).

The researchers concluded that cytoreductive surgery may improve survival compared to chemotherapy alone in patients with recurrent ovarian cancer. Patients whose cancer is completely removed appear to achieve the greatest benefit from surgery. Future clinical trials are necessary to help determine specific patient and disease characteristics that are associated with optimal outcomes with cytoreductive surgery.

Surgery best option for ovarian cancer in diaphragm

In a retrospective study looking back at a decade of surgeries, Mayo Clinic Cancer Center researchers have determined that surgery to remove metastatic disease from the diaphragm, in conjunction with other procedures to remove the primary diseased tissue in ovarian cancer patients, significantly increases survival rates. Study results were published in Gynecologic Oncology online.

"Surgeons have long believed that removing as much diseased tissue as possible is important for survival of cancer patients," said William Cliby, M.D., associate professor of obstetrics and gynecology at Mayo Clinic. "The choice of many surgeons to not resect diaphragm disease in ovarian cancer patients seemed counterintuitive, but it was based on the feeling that it might not improve survival. We sought to address this issue."

Dr. Cliby's team cited lack of evidence of survival benefit, concerns over safety (related to complexity and length of the surgery) and lack of surgeon experience as justifications often given for not proceeding with diaphragmatic surgery in advanced ovarian cancer patients. Hoever, this study provided strong evidence of survival benefit. The five-year survival rates for patients with diaphragm disease who had optimal residual disease (less than 1 cm) was 55 percent for those undergoing diaphragm surgery versus 28 percent for those who did not.

The study group included 244 consecutive patients with primary ovarian cancer who were operated on at Mayo Clinic from 1994 through 1998 and from Aug. 1, 2002, through Aug. 31, 2004. Dr. Cliby and his colleagues found that at Mayo Clinic, the rate of diaphragm procedures for affected patients increased from 22.5 percent in the first period compared to 40 percent in the more recent period. They attribute this to increased surgeon experience, increased recognition of the importance of maximal effort for tumor resection and the cooperative working relationships with other surgical specialties at Mayo Clinic that provide the opportunity to train interdepartmentally and improve surgical techniques. "We hope to continue improving upon our ability to remove cancer disease from all affected areas," said Dr. Cliby. "With each operation, our surgeons become better equipped to handle the most difficult of surgeries, providing hope for more patients."

The researchers conclude that while health issues in some patients will complicate the success of surgery in general, and prevent the option of radical surgery, surgeons should work to increase the rate of tumor reduction, including diaphragm surgery, in appropriate cases.

Source: Gynecologic Oncology 2005; 97: 74-79

[gdpawel]

Mayo Clinic Cancer Center researchers report aggressive surgical removal of as much cancer as possible throughout the abdomen in ovarian cancer patients is the best option for most women. Results of the study are published in the January issue of Obstetrics & Gynecology.

"This study provides further evidence that surgery to remove as much tumor as possible at the initial operation is the best option for most patients," says William Cliby, M.D., Mayo Clinic gynecologic oncologist and lead investigator of the study. "It helps to define a topic that is often debated within our specialty -- the benefit of radical surgery for advanced ovarian cancer patients." Dr. Cliby says that data demonstrate many surgeons choose the more cautious route of less surgical intervention, and this results in shorter overall survival.

Dr. Cliby and his team of researchers found that aggressive surgery greatly improves survival rates for patients with the most severe disease spread. They also found similar five-year survival rates in most cases for patients undergoing radical and non-radical surgery, indicating to the researchers that aggressive surgery is not a significant risk factor, but instead aids in survival. In those patients with the highest volume of disease (carcinomatosis), the researchers found that radical surgery greatly improved the five-year survival rates (44 percent versus 17 percent).

The American Cancer Society predicts over 16,000 women in the United States will die from ovarian cancer this year, and Dr. Cliby's team hope their study will promote a trend toward more aggressive surgeries when warranted. "Our study showed a significant survival advantage when a more aggressive surgical approach is used," says Dr. Cliby. "Hopefully we'll see increased education and a movement towards a more uniform surgical management of ovarian cancer."

Dr. Cliby's team notes that while surgery is just one part of the treatment for advanced ovarian cancer, it is the one variable gynecologic oncologists treating this disease can most control. To improve the outcomes of this disease, they hope to see more research in resistance to chemotherapy, prevention of recurrent disease, and earlier detection.

This study's purpose was to estimate the effect of aggressive surgery on overall survival rates for ovarian cancer patients. The main outcome measures were residual disease after tumor reduction surgery, frequency of radical surgical procedures and five-year, disease-specific survival. Radical surgery procedures included diaphragmatic surgery, bowel resection, splenectomy or extensive abdominal peritoneal stripping or resection.

Because several other factors are part of the decision to perform surgery, especially more radical surgeries, Dr. Cliby's team also looked at risks related to age, preoperative medical condition and operative time. They found that residual disease and radical surgery were the only factors that consistently predicted survival.

The study cohort of 194 women was assembled from patients who underwent primary surgery for stage IIIC ovarian cancer at Mayo Clinic between 1994 and 1998.

January 2006 issue of Obstetrics & Gynecology

[gdpawel]

Gynecologic Oncologists Have Better Outcomes Than General Surgeons Treating Ovarian Cancer

Elderly women with ovarian cancer tend to survive longer when treated by gynecologic oncologists than by general surgeons, according to results of a meta-analysis published in the Journal of the National Cancer Institute for February 1.

Dr. Craig C. Earle, from Dana-Farber Cancer Center in Boston, and his colleagues analyzed data from the Surveillance, Epidemiology and End Results (SEER) program for 3067 women aged 65 or older who underwent surgery for pathologically confirmed invasive epithelial ovarian cancer between 1992 and 1999.

These data were linked to Medicare data and American Medical Association files to obtain information about medical care they received and specialty type of the surgeon who performed cancer-related procedures. Records showed that 33% were operated on by a gynecologic oncologist, 45% by a general gynecologist, and 22% by a general surgeon.

Patients with stage I or stage II disease treated by gynecologic oncologists were more likely to undergo lymph node dissection (60% versus 36% by general gynecologists and 16% by general surgeons).

Those treated by gynecologic oncologists and general gynecologists were more likely to undergo a debulking procedure at the time of their first surgery than those operated on by general surgeons (58%, 51% and 40%, respectively) and to receive postoperative chemotherapy (79%, 76%, 62%).

Even though patients operated on by gynecologic oncologists tended to have more advanced disease at diagnosis, their survival rates were similar to those operated on by general gynecologists and better than those operated on by general surgeons (median survival 32.5 months, 35.6 months, and 24.3 months, respectively).

"Our data support professional societies' recommendations that it is preferable for ovarian cancer patients to be operated on by gynecologic oncologists when possible," Dr. Earle's group concludes.

SOURCE: J Natl Cancer Inst 2006;98:163-180.

[Robinflamingo]

My doctor will have done four courses of chemo before surgery, which is scheduled to be sometime in October for me. His experience is that reducing the size of the tumor, and the fluid accompanying it makes for a better surgery as well as being less invasive and less traumatic for the patient. If I had had surgery at the very top, I would have had to have lung drains and abdomen drains. At this point, after draining, the residual fluid has all but dissapated, and my surgery should go off without a hitch.

I have full confidence in my doctor, who is a lecturer and staff member at all the well known Michigan cancer centers, including Detroit Medical Center and Karmanos.