[Advanced ovarian cancer: primary debulking (PDS) or neoadjuvant chemotherapy (NACT) - still a debate]

Up to 70% of women with ovarian cancer are diagnosed in the advanced stage. The standard treatment for advanced ovarian cancer is a combination of debulking surgery and chemotherapy. The goal of surgery is to reduce the intra-abdominal tumor burden as much as possible. The survival of patients with no residual disease post-surgery is superior to that of patients with visible residual lesions. In order to minimize the probability that a patient has residual disease, several aggressive surgical techniques have been proposed, including the removal of all visible disease on the diaphragm, the colon and elsewhere in the abdomen. These techniques include diaphragm resection, splenectomy and peritonectomy. Neoadjuvant chemotherapy is used to treat patients if it is expected that adequate debulking surgery is unlikely to be successful or if they are evaluated to be too ill to undergo an extensive and lengthy operation. Several multi-center prospective randomized studies have shown that patients who are treated with neoadjuvant chemotherapy followed by surgery are more likely to achieve the status of no residual disease than are patients treated with surgery alone. Consequently, it has been proposed that neoadjuvant chemotherapy is justified in order to achieve a status of no residual disease; however, treatment with neoadjuvant chemotherapy has not yet been shown to result in better survival than treatment with primary debulking surgery. On the other hand, large retrospective single institute studies have shown clear survival benefit to patients undergoing primary surgery with no residual disease at the end of surgery. Although it is hard to compare prospective randomized studies to retrospective studies, they could not be ignored. The goal of treatment should be no residual disease at the end of primary surgery. To achieve this goal, patients with advanced stage ovarian cancer should undergo a thorough evaluation prior to the decision on the right treatment. This evaluation should include imaging studies to assess the sites and size of metastasis, age and performance status. Furthermore, the surgical competence of each center should be evaluated periodically and a decision should be made individually for each patient and center. The aim of this review is to analyze the updated relevant data on the approach to advanced ovarian cancer, primary debulking (PDS) versus neoadjuvant chemotherapy (NACT).