Neoadjuvant chemotherapy (NACT) is a treatment for advanced ovarian cancer – cancer at stage III or IV. It uses chemo drugs to shrink tumors before any surgery is done to remove them. NACT uses a reverse approach to the standard treatment of having primary debulking surgery (PDS) before chemo.
What’s the Difference?
With primary debulking surgery, the surgeon seeks to remove all visible cancer and tumors larger than 1 centimeter, which is about half an inch. (Some oncology journals report the goal having been set higher, with no visible tumor left at all.) Doctors deem this “optimal debulking,” or optimal cytoreduction. It typically leads to a better outcome. Chemo is then used to boost surgery results and further shrink tumors. This is called adjuvant treatment.
Sometimes it isn’t possible for people with advanced ovarian cancer to have primary debulking surgery (PDS). Neoadjuvant chemotherapy has become more popular since 2010, and after several trials has shown good results. Some researchers consider neoadjuvant chemotherapy no better or worse than primary debulking surgery and adjuvant therapy, but NACT is now accepted as an alternative way to treat advanced ovarian cancer.
When Neoadjuvant Chemotherapy Might Be Needed
Reasons your surgeon might opt for NACT include:
- Your health is considered too fragile to have PDS, or you have other health issues that might lead you to have a poor outcome.
- Older age can play a role. PDS has a higher survival rate for healthy women 70 and under than NACT. But your age can affect your health and also bring in other conditions that make surgery more risky.
- Your doctor might decide optimal debulking in a primary surgery isn’t likely or possible, or would require measures that might be life threatening.
- Resources in your area might not be ideal for major surgery. For example, a gynecologic oncologist might not be available. Highly skilled and trained, these specialists are five times more likely to completely remove tumors during surgery than other surgeons. Or you might not live near a hospital large enough to offer this type of surgery.
Benefits of Neoadjuvant Chemotherapy
NACT can improve the condition of your ovarian cancer by first shrinking the tumor. This ups your chances of having the entire tumor removed when you do have surgery afterward. Surgery in this order is called interval debulking (IDS).
NACT can offer other advantages, too. They include:
- It increases your chances of having optimal debulking afterward.
- Your hospital stay will be shorter.
- It improves your quality of life during your treatment.
- Your success and survival rate is about the same as with PDS.
- It gives your doctor a chance to see how well chemo has worked for you.
How Many Chemo Cycles Are Needed?
Your chemo will likely have a combo of a platinum compound, such as cisplatin or carboplatin, and another drug called a taxane, such as paclitaxel (Taxol) or docetaxel (Taxotere). The mix will be injected into your vein by IV according to your treatment plan. It’s usually about once every 3 or 4 weeks. A rest period afterward is part of the cycle.
Three cycles of chemo are thought of as ideal for neoadjuvant chemotherapy. It’s possible to have four to six if your doctor decides it’s needed. It’s a complex call that would have to be made very carefully. However, some studies have shown that having five or more cycles of NACT may have been linked with worse outcomes than three to four cycles. This has held even in cases when tumors were optimally reduced.
Although IDS after chemo is deemed a part of NACT, your surgeon will assess your response to the chemo before moving ahead with surgery. They’ll likely use special computer imaging after two or three chemo cycles to decide whether they think they’ll be able to remove the whole tumor. They’ll also weigh other factors such as your age and other conditions you might have before going forward with surgery.
Disadvantages of Neoadjuvant Chemotherapy
As with all procedures, there are downsides to NACT you and your surgeon will talk over and take into account before you proceed. These include:
- It’s possible to lose the opportunity for surgery should NACT have negative effects.
- If chemo is successful, shrinkage can make it harder for the surgeon to see and assess tumor spread at the time of surgery. This can lead to incomplete removal of the tumor.
- If all the tissue isn’t taken out, there’s a chance you can have platinum resistance to future treatments. This means that while chemo drugs that have metal platinum – like cisplatin and carboplatin – can be effective at first, they might not work if the cancer returns.