Corresponding author:
Robert Armbrust, Department of Gynecology with Center for Oncological
Surgery, Virchow Campus Clinic, Charité Medical University,
Augustenburger Platz, 10117 Berlin, Germany.
Robert.armbrust@charite.de
Despite all recent revolutionary systemic advances in the management of
AOC, the value of surgery remains unshaken as one the strongest
prognostic factors directly associated with survival (1). Intensive
debate persists whether a less radical approach facilitated through
neoadjuvant chemotherapy (NAC) followed by interval debulking surgery
(IDS) is less harmful. But are we talking about a matter of fact or
rather IDS being a “trojan horse”?
Jo Morrison (2) openly criticizes in her recent commentary (2) the
primary debulking surgical (PDS) approach strongly arguing in favour of
NAC/IDS. The quoted evidence is well known to be flawed through low
surgical quality, long recruitment periods and lack of selection
algorithms (1). The SCORPION-trial, designed as a superiority trial, is
negative, since the final results showed no survival- or QoL-benefit, .
As a direct consequence the TRUST-trial (AGO-OVAR-OP.7/NCT02828618) (3)
was developed. The name “Trust”, aimed to indicate that all
participating centres committed to screen and register all consecutive
eligible patients without selection bias. As crucial difference to the
other NAC-studies, only fit patients who were able to be operated
tumomorfree, as assessed by an expert team, were included. Most
importantly, also those patients who responded poorly to NAC proceeded
to IDS.
In her commentary Morrison states that the TRUST-centers were “very
small number of highly specialised, non-representative centres” (2).
With 20 participating centres from 8 countries across Europe, USA and UK
evaluating 800 patients, is the Trust study the largest RCT in the field
covering more countries and patients than any other study so far. The
centres eligibility criteria correspond with the quality-assurance and
accreditation criteria defined by the European Society of Gynaecological
Oncology (ESGO) (4), and so they definitively don’t represent unicorn
centres; on the contrary they reflect the reality and future of
AOC-surgery within centralised and specialised environments. Moreover,
all centers were actively involved in practice changing surgical trials
such as the LION- and the DESKTOP-III. The authors of the present letter
belong to the top recruiters and so it is difficult to accept such
unfounded criticism.
Morrison claims that the peer reviewed ESGO-Quality indicator of
>50% of AOC-patients undergoing PDS is likely to cause
unnecessary harm (2). While we know that NAC can bring fragile patients
and/or with inoperable disease to a state that they can receive
life-prolonging cytoreduction as compared to no surgery at all and
therefore is beneficial for the right patients ‘population; National
Cancer Data Base evidence including almost 23,000 patients shows that
PDS is associated with significantly improved survival compared to NAC
in fit AOC-patients who can be operated tumorfree (5). PARP-inhibitor
studies related to surgical outcome, reinforce this by demonstrating the
highest magnitude of benefit being derived from PARP-inhibitors in those
women operated tumorfree at PDS (6).
Lastly, Morrison states that it is openly implied that NAC is used
because someone is not a good surgeon, making an open, honest debate
uncomfortable. Since we as gynaecological oncology community indeed
support transparency and full disclosure, we also need to call the
elephant in the room and recognise that NAC is often being misused to
overbridge time for patients who can’t be operated timely due to limited
capacity and gaps in infrastructure and expertise.
So, before saying ‘just because you can, doesn’t mean you should’, we
should make sure we really can safely apply the right treatment to the
right patient.