Natural History of Untreated Early Ovarian Carcinoma

Knowing the natural history of untreated early ovarian cancer should identify the need for adjuvant chemotherapy. Assessing an observation arm in randomized controlled trials (RCTs) should be an accurate means of determining the true rate of recurrent cancer after surgical resection. Table 8-1 lists five prominent randomized controlled trials comparing observation with a treatment arm. The rate of cancer recurrence in the observation arm varies from 9% to 35% owing to differences in substages and grades among the trials. Once again, these trials point out the

Table 8-1. Recurrence Rate of Early Stage Ovarian Cancer in the No-Treatment Control Arms of Randomized Controlled Trials

Trial Stage and Grade N 5-Year Recurrence Rate

Hreshchyshyn et al (1980)5*

Stages IA, B, C Grades 1, 2, 3

86

17%

Young et al (1990)6t

Stages IA, B Grades 1, 2

81

9%

Bolis et al (GICOG, 1995)7t

Stages IA, B Grades 1, 2, 3

83

35%

Trope et al (2000)8*

Stages IA, B, C Grade 1 aneu Grades 2, 3

162

29%

Trimbos et al (ACTION, 2003)9*

Stages IA, B, Grade 2-3 Stage IC, all grades Stage IIA, all grades

448

32%

ACTION, Adjuvant Chemotherapy In Ovarian Neoplasm; aneu, aneuploldy; GICOG, Gruppo Itallano Collaboratlvo In Oncologla Glnecologlca.

* Incomplete surglcal staglng ln the majorlty of patlents, or extent of staglng unreported. fComplete surglcal staglng.

ACTION, Adjuvant Chemotherapy In Ovarian Neoplasm; aneu, aneuploldy; GICOG, Gruppo Itallano Collaboratlvo In Oncologla Glnecologlca.

* Incomplete surglcal staglng ln the majorlty of patlents, or extent of staglng unreported. fComplete surglcal staglng.

Ovarian Cancer Patient Mayowa Ahmed

Time since diagnosis (years)

Figure 8-1. Relapse-free survival by grade for Incompletely staged patients without adjuvant chemotherapy. (From Ahmed FY, Wiltshaw E, A'Hern RP, et al: Natural history and prognosis of untreated stage I epithelial ovarian carcinoma. J Clin Oncol 14[11]:2968-2975, 1996.)

Time since diagnosis (years)

Figure 8-1. Relapse-free survival by grade for Incompletely staged patients without adjuvant chemotherapy. (From Ahmed FY, Wiltshaw E, A'Hern RP, et al: Natural history and prognosis of untreated stage I epithelial ovarian carcinoma. J Clin Oncol 14[11]:2968-2975, 1996.)

importance of grade in the prognosis of early ovarian cancers. The randomized controlled trials indicate that well-differentiated tumors have less than a 10% chance of recurring after surgery only, whereas the more poorly differentiated cancers may recur in 30% to 35% of patients treated by surgery only. Figure 8-1 also demonstrates the impact of grade on survival in patients treated by surgery only.10

Evidence that dividing stage I disease into substages reflects differences in prognosis is seen in Table 8-2. Figures 8-2 and 8-3 show patients with stages IA and IB ovarian cancer, respectively.

Table 8-2. Five-Year Recurrence Rates for Stage I Cancer with Incomplete Surgical Staging and Without Adjuvant Chemotherapy

Stage 5-Year Recurrence Rate

IA IB IC

13% (95% CI 7.24) 35% (95% CI 16.65) 38% (95% CI 28.51)

Data from Ahmed FY, Wiltshaw E, AHern RP, et al: Natural history and prognosis of untreated stage I epithelial ovarian carcinoma. J Clin Oncol 14(11):2968-2975,1996.

Data from Ahmed FY, Wiltshaw E, AHern RP, et al: Natural history and prognosis of untreated stage I epithelial ovarian carcinoma. J Clin Oncol 14(11):2968-2975,1996.

Pictures Stages Ovarian Cancer
Figure 8-2. Photograph of gross stage IA ovarian cancer. The right ovarian mass is free of adhesions and visible adjacent to a normal fallopian tube and uterine corpus.
Abraham Lieberman
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