Diseasefree Interval

In many series, an important prognostic and therefore selection factor is the disease-free interval (DFI), defined as the interval from the completion of chemotherapy to the diagnosis of recurrence. The platinum-free interval is the interval of time between the last dose of platinum-based chemotherapy and the diagnosis of recurrence. Generally, the DFI and the platinum-free interval are the same, since almost all patients receive primary platinum-based chemotherapy.

The importance of the DFI in patient selection for secondary cytoreduction was demonstrated by Morris and colleagues24 in a retrospective series of 33 patients with advanced ovarian cancer who did not respond to first-line chemotherapy. In this cohort of patients with essentially no DFI, secondary cytoreduction was found to be of no benefit. However, numerous studies have demonstrated a survival benefit for patients whose DFI was longer than 12 months.

In 2006, the AGO (Arbeitsgemeinschaft Gynaekologische Onkologie) published a multicenter study on secondary cytoreductive surgery.21 This was a large trial evaluating 267 patients with recurrent ovarian cancer. The Descriptive Evaluation of

Preoperative Selection Kriteria for Operability in Recurrent Ovarian Cancer (DESKTOP) trial was an exploratory study based on data from a retrospective analysis of hospital records. Regarding DFI, the authors of DESKTOP could not detect any impact of DFI on outcome in patients with DFIs when comparing 6 to 12 months with more than 12 months. Other series have reported a significant survival impact for DFIs exceeding 12 months and up to 36 months,14,25-27 whereas other series did not detect any impact.28-31

In the same year as the AGO study, Chi and associates20 applied a statistical analysis called smoothing techniques to analyze survival as a function of DFI in a large cohort of patients who underwent secondary cytoreduction for recurrent ovarian cancer (Fig. 10-1). The analysis identified optimal DFI cut-points of 6 to 12 months,13 to 30 months, and more than 30 months. Survival after secondary cytoreduction was significantly improved in the longer DFI groups (Fig. 10-2).

Although DFI is one of the most frequently reported prognostic factors, it should not be the sole factor in deciding whether to offer secondary cytoreduction to women with recurrent ovarian cancer. Other factors, discussed in the following text, also carry weight in decision making. Moreover, some patients should not be offered surgery. For instance, women whose disease is persistent or progressive while they

Figure 10-1. Survival as a function of disease-free interval. (From Chi DS, McCaughty K, Diaz JP, et al: Guidelines and selection criteria for secondary cytoreductive surgery in patients with recurrent, platinum-sensitive epithelial ovarian carcinoma. Cancer 106:1933-1939, 2006, Figure 4.)

Disease-free interval (months)

Disease-free interval (months)

Figure 10-1. Survival as a function of disease-free interval. (From Chi DS, McCaughty K, Diaz JP, et al: Guidelines and selection criteria for secondary cytoreductive surgery in patients with recurrent, platinum-sensitive epithelial ovarian carcinoma. Cancer 106:1933-1939, 2006, Figure 4.)

6-12

13-30

Disease-free interval (months)

Figure 10-2. Disease-free interval and survival after secondary cytoreduction.

are receiving primary chemotherapy should not be offered surgical cytoreduction. Women with recurrent disease within 6 months of completing chemotherapy have a poor prognosis and generally gain little but morbidity from attempts at surgical cytoreduction. Women with a recurrence 6 to 12 months after completing chemotherapy can sometimes be offered surgical cytoreduction based on other variables. Patients with later recurrences and DFIs of 12 months to 30 months may be considered for secondary cytoreduction based on other factors, whereas patients with DFIs of 30 months or more should be assessed for surgical cytoreduction.

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