Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer

Ovarian cancer tends to be chemosensitive and confine itself to the surface of the peritoneal cavity for much of its natural history. These features have made it an obvious target for intraperitoneal chemotherapy. Chemotherapy for ovarian cancer is usually given as an intravenous infusion repeatedly over 5 to 8 cycles. Intraperitoneal chemotherapy (IP) is given by infusion of the chemotherapeutic agent directly into the peritoneal cavity. This may increase the anticancer effect with fewer systemic adverse effects in comparison to intravenous therapy.

To determine if adding a component of the chemotherapy regime into the peritoneal cavity affects overall survival, progression free survival, quality of life (QOL) and toxicity for women receiving primary treatment of epithelial ovarian cancer.

The reviewers searched the UK Cochrane trials register, Gynaecological Cancer Group Specialised Register, computer databases and handsearched and cascade searched the major gynaecological oncology journals.

The analysis was restricted to randomised controlled trials assessing women with a new diagnosis of primary epithelial ovarian cancer, of any FIGO stage, following primary cytoreductive surgery. Standard intravenous chemotherapy was compared with chemotherapy that included a component of intraperitoneal administration.

Two reviewers conducted data extraction independently. The reviewers retrieved data on overall and disease free survival as well as adverse events and QOL and then performed a meta-analysis of outcomes, using hazard ratios for time-to-event variables and relative risks for dichotomous outcomes.

Eight randomised trials studied 1819 women receiving primary treatment for ovarian cancer. Women were less likely to die if they received an intraperitoneal (IP) component to the chemotherapy (hazard ratio (HR) =0.79; 95% confidence interval (CI): 0.70 to 0.90)and the disease free interval (HR =0.79; 95%CI: 0.69 to 0.90) was also significantly prolonged. There may be greater serious toxicity with regard to gastrointestinal effects, pain and fever but less ototoxicity with the intraperitoneal than the intravenous route.

This analysis establishes the benefit of IP chemotherapy. It increases overall survival and progression free survival from advanced ovarian cancer. The results of this meta-analysis provide the most reliable estimates of the relative survival benefits of IP over IV therapy and should be used as part of this decision making process. However, the potential for catheter related complications and toxicity needs to be considered when deciding on the most appropriate treatment for each individual woman. The optimal dose, timing and mechanism of administration cannot be addressed from this meta-analysis. This needs to be addressed in the next phase of clinical trials.