Do all patients that undergo a 'complete' secondary cytoreductive surgery for platinum-sensitive recurrent ovarian cancer, benefit from it?

Following the results of three randomized trials (GOG-213, DESKTOP-III, and SOC-1), secondary cytoreductive surgery (sCRS) is recommended as a therapeutic option for all patients with platinum-sensitive recurrence by the NCCN guidelines and for oligometastatic recurrence by the ESMO-ESGO guidelines. Criteria for predicting a complete gross resection (CGR) were used to select patients for sCRS in all three trials. No trial used surgical prognostic factors like disease sites or disease extent for stratification. The outcomes of sCRS varied in preplanned/post-hoc subgroup analyses. The survival following an incomplete CRS was worse than with systemic chemotherapy alone. Not all patients will benefit similarly from sCRS, even if a CGR is obtained. No trial evaluated the benefit of sCRS in patients receiving poly-ADP ribose polymerase (PARP) inhibitors. While GOG-213 showed no benefit of sCRS when bevacizumab was used, the role of bevacizumab in patients having a CGR was not evaluated. The use of targeted therapies during first-line therapy is increasing, affecting treatment decisions and future clinical trial designs. New trials on sCRS should stratify patients according to surgical prognostic factors; sub-group analyses should be performed only in patients with CGR. - Selection criteria used in all three randomized trials are predictive of a complete cytoreduction and not the benefit of surgery - Post-hoc & prespecified subgroup analyses indicate that not all patients undergoing secondary cytoreduction benefit from it - Post-hoc and sub-group analysis should be performed separately for patients undergoing a complete gross resection - Impact of incomplete cytoreduction on quality of life and subsequent therapy needs further evaluation - Future randomized trials should use surgical prognostic factors like disease sites and extent as stratification factors