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A new joint clinical practice guideline from the American Society of Clinical Oncology (ASCO) and the Society of Gynecologic Oncology (SGO) states that neoadjuvant chemotherapy (NACT) is the optimal first-line treatment for some women who have newly diagnosed advanced ovarian cancer.

While the standard of care in this setting is primary cytoreductive surgery (PCS) followed by chemotherapy, the new guideline which was published in the Journal of Clinical Oncology suggests that some patients may benefit more from chemotherapy administered before surgery.

The evidence supporting these recommendations comes from four comparative clinical trials, which found that for women with stage 3C or 4 epithelial ovarian cancer, NACT and interval cytoreduction were preferable to adjuvant chemotherapy and primary cytoreduction with respect to overall and progression-free survival.

For women who are assessed by a gynecologic oncologist and are determined to be a fit for surgery, either adjuvant or NACT can be offered as treatment. With respect to progression-free and overall survival, as well as perioperative morbidity and mortality, NACT has been found to be generally non-inferior and is associated with less peri- and postoperative morbidity and mortality and shorter hospitalizations. Primary cytoreductive surgery, on the other hand, may offer superior survival results in patients with newly diagnosed stage 3C or 4 epithelial ovarian cancer.

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The recommendations are based on the results of four clinical trials comparing NACT and interval cytoreduction with primary PCS and adjuvant chemotherapy among women with advanced ovarian cancer.

Though many of these findings seem to favor neoadjuvant chemotherapy, it may not be the ideal choice of therapy for every woman with advanced ovarian cancer. According to the new guideline, patients with a high likelihood of achieving cytoreduction to less than 1 cm (ideally to no visible disease) with acceptable morbidity are recommended to receive primary cytoreductive surgery. However, for women with a high preoperative risk profile or a low likelihood of achieving cytoreduction to less than 1 cm of residual disease (ideally to no visible disease), NACT is preferred instead. Ideally, interval cytoreductive surgery should be performed after four or less cycles of NACT for those with a response to chemotherapy or stable disease.

Future studies will also explore novel agents in the neoadjuvant setting, such as targeted therapies, immunotherapy, vaccines, and cancer stem-cell-directed treatments.

Reference: Wright A, Bohlke K, Armstrong D, et al. Neoadjuvant Chemotherapy for Newly Diagnosed, Advanced Ovarian Cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline. *Gynecologic Oncology.*DOI: Neoadjuvant chemotherapy for newly diagnosed, advanced ovarian cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline.