Amer Karam, MD, gynecologic oncologist, medical oncologist, obstetrician, and gynecologist (OB-GYN), clinical professor, Obstetrics & Gynecology, Gynecologic Oncology, Stanford Health Care, discusses determining whether to use debulking surgery after recurrence in ovarian cancer.

When patients with ovarian cancer recur, the question of whether another procedure to debulk the cancer would be helpful led to the development several clinical trials, Karam says. Moreover, retrospective examination indicated an advantage for interval or secondary cytoreductive surgery in this patient population, Karam explains. This led to 5 groups developing randomized clinical trials to examine this topic, Karam adds. However, 2 of the earlier clinical trials failed to accrue enough patients, so 3 trials studied the topic, Karam says. These 3 trials include the United States–based GOG-0123 study (NCT00565851), the German-based DESKTOPIII study (NCT01166737), and the Shanghai-based SOC-1 study (NCT01611766), Karem says. 

The 3 trials  were multi-institutional, Karam continues. The trials randomized patients with recurrent platinum-sensitive ovarian cancer to a secondary cytoreductive surgery followed by chemotherapy or salvage chemotherapy without surgery, Karem concludes.

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Amer Karam, MD, discusses determining whether to use debulking surgery after recurrence in ovarian cancer. 


Dr. Karam on the Role of Debulking Surgery in Recurrent Ovarian Cancer 

Amer Karam, MD, associate clinical professor of Gynecologic Oncology at Stanford Hospital and director of Robotic Surgery and Outreach in the Division of Gynecologic Oncology at Stanford Medicine, discusses the use of laparoscopy in advanced ovarian cancer.

Any patient who comes to the clinic with advanced-stage ovarian cancer should be offered laparoscopy as a way to triage them for primary debulking surgery, says Karam. It is something that is universally applied to all of Karam’s patients prior to undergoing primary debulking surgery.

Physicians may approach borderline tumors differently, explains Karam, as the rate of advanced-stage borderline tumors is lower than is expected in high-grade ovarian cancer, as such, physicians have a higher likelihood of finding early-stage disease with these tumors.

If a patient presents with a borderline tumor, diagnostic laparoscopy can still be useful, he adds, as there are situations in which borderline tumors are spread so far inside the abdomen that surgery would not be able to resect all of the disease. For these patients, there may be a role for surgical debulking, even if they’re not left with minimal residual disease, concludes Karam.

Dr. Karam on the Use of Laparoscopy in Advanced Ovarian Cancer

Amer Karam, MD, associate clinical professor, Gynecologic Oncology, Stanford Hospital, director, Robotic Surgery and Outreach, Division of Gynecologic Oncology, Stanford Medicine, discusses primary debulking surgery versus neoadjuvant chemotherapy in the treatment of patients with ovarian cancer.

In the United States and specifically at Stanford Medicine, physicians believe that primary debulking surgery should be the standard of care for eligible patients with advanced ovarian cancer. The goal of the surgery, says Karam, is to achieve microscopic residual disease.

Patients who are too ill, frail, or have extensive disease that prevents them from being eligible to undergo surgery, should be offered neoadjuvant chemotherapy, states Karam. Though there is some debate over the superiority of these approaches, Karam states that every patient who is eligible to undergo primary debulking surgery should be offered the procedure. The ongoing TRUST trial will compare the use of primary debulking surgery to neoadjuvant chemotherapy and help settle the debate of whether primary debulking surgery should be the standard of care for these patients.

Amer Karam, MD

Articles

Dr. Karam on the Role of Debulking Surgery in Recurrent Ovarian Cancer

Dr. Karam on the Use of Laparoscopy in Advanced Ovarian Cancer

Dr. Karam on Primary Debulking Surgery Versus Neoadjuvant Chemotherapy in Ovarian Cancer