Future directions in the surgical management of ovarian cancer

The surgical management of ovarian cancer is surrounded by controversy. This review summarizes our current understanding of these issues with the goal of improving survival, enhancing quality of life, and containing costs.

Six currently unresolved issues are addressed through a review of the existing literature: (1) the extent of surgery indicated in the primary surgical management of advanced-stage disease, (2) the prognostic features of ovarian cancer, (3) the role of interval debulking following neoadjuvant chemotherapy, (4) the role of fertility-sparing surgery, (5) the role of "second-look" surgery, and (6) the role of secondary tumor debulking.

The criteria for justifying extraordinary measures to reduce the tumor burden in patients with advanced disease to an "optimal" state have not been established. Likewise, the factors that influence prognosis and treatment are not well defined or understood. Interval debulking following neoadjuvant chemotherapy is a promising approach to the management of advanced-stage disease, but no clinical trials have been conducted comparing it to primary surgery followed by chemotherapy. Fertility-sparing surgery may be appropriate even for women with frankly malignant epithelial cancers when disease is confined to one ovary. No convincing data are available showing that second-look surgery improves the chances for cure or prolongs survival. Finally, few data show a benefit from secondary tumor resection in patients who progress while undergoing first-line chemotherapy or have a recurrence soon afterward.

Controlled clinical trials are needed to guide clinicians in making appropriate management decisions for their patients.