Wingo Weighs in on Surgical Approaches in Ovarian Cancer

Shana Wingo, MD

Although cytoreduction followed by a platinum-based compound and a taxane agent has been the preeminent method of treatment for patients with ovarian cancer, Shana Wingo, MD, explains that neoadjuvant therapy is becoming more openly adopted in the field.

“Neoadjuvant therapy has sustained a certain dogma in ovarian cancer for years, but there’s been more comfort in foregoing upfront debulking as the data come out in support of the approach,” says Wingo. She notes, that a patient’s comorbidities and cancer may preclude them from receiving surgery upfront.

Though neoadjuvant therapy is appropriate for some patients, it is unlikely to alter the role of surgery in the future, said Wingo, a gynecologic oncologist at Arizona Oncology.

OncLive: How have surgical options for patients with newly diagnosed ovarian cancer changed over the past year?

In an interview during the 2018 OncLive^® State of the Science Summit™ on Ovarian Cancer, Wingo discussed the surgical landscape in patients with newly diagnosed ovarian cancer.Wingo: There are no new data to support any exciting or cutting-edge surgical approaches. As time goes on, more papers are coming out that support what we are already doing. There has been a shift in the adoption of minimally invasive surgery in ovarian cancer. Some people are adopting that a little bit more.

How has the role of neoadjuvant therapy evolved?

Which patients are best suited for neoadjuvant therapy and what are the available, go-to regimens?

Can oligometastatic ovarian cancer be surgically removed?

Will surgery always play a part in the management of this disease?

There is also more adoption of neoadjuvant chemotherapy. Many patients may not end up seeing a gynecologic oncologist before they start their therapy. Most of us administer everything from chemotherapy to surgery and then follow-up. Every patient needs to be evaluated by a gynecologic oncologist to determine whether or not they are suitable for surgery.For all of us, it is a paradigm shift because we have been so used to upfront debulking. We feel less apprehensive about [bypassing] upfront debulking as the data come out in support of neoadjuvant therapy. It’s a nice shift that hopefully helps patients.We usually use carboplatin and paclitaxel in the neoadjuvant setting. The way we determine who is appropriate for upfront surgery versus upfront chemotherapy is by evaluating their disease burden and the location of their cancer. There are certain areas where you can’t safely operate, or you know you’re not going to be able to get all of the cancer removed. We will also look at a patient’s comorbidities. The goal is to get every patient to surgery, but some patients are too ill to have upfront surgery. It requires an approach from both directions.Sometimes it can, but removal of the disease is more likely in a recurrent-type setting. An upfront surgery [consists of] either debulking and removing widespread metastasis or a staging procedure. If the cancer is confined to the ovary, you’re doing a staging procedure. Even so, surgeons are still removing specific things, such as lymph nodes and omentum. It is not very typical that you would have a specific area with a metastatic implant. The way that ovarian cancer spreads, typically, is by exfoliating; cells are dropping and spreading with the peristaltic movement of the bowel. Usually, patients have advanced-stage disease at diagnosis, with the majority being stage III or IV.It will forever play a part. I say to all my patients, “Surgery and adjuvant therapy or chemotherapy are ‘married.’ They go hand in hand.” One does not do well without the other. Our goal is still to get patients to the operating room. I don’t know if there are any minimally invasive surgery—focused trials coming down the pike, but looking at whether or not it is reasonable to do a robotic or laparoscopic debulking was a topic at the 2018 Society of Gynecologic Oncology Annual Meeting. I would say the majority of us still tend to do open surgery for the bigger cases.

Are there any new surgical techniques you would like to see take hold in ovarian cancer?

It’s still too difficult to see well enough and get all of the cancer out [without an open approach]. There are too many historical data, and even [too many] current data, on upfront chemotherapy that support the use of surgery at some point in the [course of] treatment. I don’t think that will drop off anytime soon.The complexity of gynecologic oncology is a bunch of specialties melded into 1 specialty. As you get more advanced surgical training, surgeons are going to do more complex surgeries in the upper abdomen. One thing that has persisted over time [and remains true] is that the amount of residual disease affects survival. We have to continue to improve and modify our surgical skills so that we are continuing to get the best outcomes for the patients. We have to continue to learn more and keep our skillset up.

I wonder what people would have said about this [with regard to] endometrial cancer 20 years ago. Back then, all the surgeons were doing open cases for endometrial cancer. That has shifted to the point that now, 80% to 90% of surgeries are minimally invasive. It is possible that the technique in ovarian cancer will be developed and perfected so that we can give patients better recoveries. If patients have quicker recoveries, we can give the second part of their treatment sooner, as well.