Very helpful Cochrane Review: Interventions for the treatment of borderline ovarian tumours

VERY helpful Cochrane review re. treatment of BOTs.

Why is it helpful?

While clear guidelines are often available for the management of ovarian cancer, less clear guidelines exist for the management of the rarer, less lethal and less researched borderline ovarian tumours (FIGO 2006). Consequently, our aim is to review the available evidence from studies on the effectiveness of treatment in improving survival and quality of life (QoL) in women with borderline ovarian tumours, which could assist in formulating guidelines for their management.

Specifically, it is vital to review previous studies to compare the risks of recurrence and survival for patients who have had different extents of surgery for borderline ovarian tumours of similar stages and co-morbidity. Furthermore, it is important to review previous studies that attempted to determine the benefits from additional treatments in the form of chemotherapy, hormonal therapy, radiotherapy or experimental therapy. It is possible that there has not been adequate research comparing the different forms of surgical treatment or evaluating the benefits of additional treatment after surgery. This review could reveal such gaps in knowledge and prompt further research on such issues in order to guide future patient management.

Author’s conclusions:

Implications for practice

From the trials reviewed here, we did not find evidence to support the use of any specific treatment modality for borderline ovarian tumours. Furthermore, the high rate of tumour recurrence in the only trial in which patients had conservative surgery by laparoscopy would question the safety of this approach in women who have completed childbearing. However, patients with bilateral borderline ovarian tumours who are wishing to preserve fertility may be offered bilateral cystectomy by an experienced surgeon with an explanation of a significant risk of early recurrence within 16 months. Such patients need to be made aware that it is inadvisable to delay pregnancy as salvage radical surgery for recurrence may become necessary. Furthermore, long-term follow up with surveillance for recurrence for at least eight years is essential for patients who have undergone conservative surgery (Palomba 2007).

Implications for research

The observation of only four pre-planned RCTs, reported more than 15 years ago from a single centre, on adjuvant therapy for borderline ovarian tumours (Trope 1993 (Study 1)) suggests that the effectiveness of interventions for this tumour type is an under-studied area. The rarity of this tumour type and its otherwise excellent prognosis may partly explain this. Nevertheless, given the suggestion of a higher recurrence rate for serous borderline ovarian tumours of Stage III or above, it would appear that patients with advanced tumours should be the immediate focus for subsequent trials of adjuvant therapy. The excellent survival from Stage I tumours suggests that any trials on women with these tumours should use disease progression as a primary end point and should consider progression to invasive ovarian carcinoma and death as secondary endpoints. This would be a valid and clinically relevant early end point, provided it is precisely defined (Altman 1995). Furthermore, pre-planned analysis of the benefit of interventions for different histological variants, bilateral, micro-papillary and aneuploid tumours which may have a worse prognosis, should be incorporated. Optimally dosed platinum-based chemotherapy regimens and hormonal therapy with inhibitors of estrogen synthesis, in particular, merit further evaluation. Careful evaluation of any toxicity is essential in early stage disease where severe side effects may outweigh the benefits.

The decision on radical or conservative surgery for borderline ovarian tumour is often a choice dictated by women’s wishes on preservation of fertility. However, conservative surgery could also improve the quality of life of pre-menopausal women who do not necessarily wish to preserve their fertility. Therefore, RCTs comparing outcomes after either type of surgery are probably warranted, at least in this subgroup, to quantify the level of extra risk of recurrence from conservative surgery. Furthermore, other RCTs comparing outcomes after laparoscopy and laparotomy will also be important. Stratification by tumour histology and stage, as well as radical or conservative surgical treatment, will probably be necessary in such trials.  

In order to minimise the risk of bias, future studies should ensure satisfactory randomisation, concealment of the allocation sequence from participants and healthcare providers, blinding of outcome assessors to the treatment status of participants, adequate follow-up and histological diagnosis of disease recurrence.  They should be reported according to the CONSORT guidelines and all outcomes specified in the trial protocol should be reported (CONSORT2010).https://www.dropbox.com/s/wlup86kgqtpaciz/2010Cochrane%20Review_InterventionsBOTs.pdf?dl=0

Very helpful Cochrane Review: Interventions for the treatment of borderline ovarian tumours