A critique of surgical cytoreduction in advanced ovarian cancer

Due in most part to the abundant retrospective evidence suggesting that surgical cytoreduction is essential to the management of advanced ovarian cancer, most clinicians do not question its application. Irrespective, there are many who still doubt its value, given its unique role in ovarian cancer, in comparison to other solid tumors. While many papers have extolled the virtues of debulking surgery, few have taken the opposing view. This paper attempts to expose the weaknesses in the current available data regarding surgical cytoreduction in advanced ovarian cancer. By reviewing the retrospective data, the theoretical benefits of surgery, cellular kinetics, the fallacies of residual disease, interval debulking surgery, and neoadjuvant chemotherapy, a critique of debulking surgery is made. Issues surrounding perioperative morbidity and its impact on quality of life have not been adequately addressed. Despite the need for randomized trials of surgery in advanced ovarian cancer, they are unlikely to occur. The window of opportunity with respect to studying the questions on the optimal timing, degree of aggressiveness, and patient selection for surgery has likely passed. Biases and ethical issues based upon the data cited in this paper have and will continue to hamper our ability to fully elaborate the benefits of surgery with respect to survival and quality of life.