The TRUST study that I just presented here at ASCO is a study that examines the optimal timing of surgery in advanced ovarian cancer. There are basically two options – either upfront surgery followed by chemotherapy or three cycles of neoadjuvant chemotherapy, interval cytoreductive surgery, and subsequent chemotherapy. We analysed these two treatment strategies in a randomised fashion 1:1 and found that in the overall population regarding progression free survival we could find a significant benefit for primary interval cytoreductive surgery, however, in overall survival this benefit was so diluted that there was no statistical significance anymore.
When we analysed specific subgroups of the patients, however, we found that especially patients with FIGO stage 3 disease do benefit from upfront surgery, as well as those patients with complete gross tumour resection. This is, indeed, probably the most interesting finding because, in contrast to previous studies that addressed the question, in the TRUST study we put a lot of energy into surgical quality assurance. So participating centres had to qualify in order to participate in the study and had to have high resection rates, high surgical volume and they were actually audited in their OR by a group of experts to check on the surgical proficiency and also the infrastructure.
With this high selection for expert surgical centres we actually achieved a very high rate of complete tumour resections, which is the most important aspect of surgery in advanced ovarian cancer. Just to give you an example, in the primary surgery group the rate of complete gross resection was 70%; in the interval cytoreductive surgery it was 85%. So this was really cutting-edge, high-quality surgery that led to this excellent outcome of the patients.
What are the clinical implications of these findings?
This is something that everybody now needs to find in their specific centres. I can tell you how we, in my centre in the University of Munich, we interpret these results. This is that if we have a patient with advanced ovarian cancer sitting in front of us that we consider potentially resectable and consider fit enough to undergo surgery, we do a surgical exploration in these patients. If we find out that we can completely resect a tumour, even with ultra-radical surgical procedures, if we achieve complete gross resection then we do it because we know, based on the TRUST data, that this improves their progression free survival by six months and their overall survival by 12 months. However, if we cannot achieve complete gross resection then we end the exploratory surgery there, give neoadjuvant chemotherapy and then do an interval cytoreductive surgery and hopefully then completely resect the tumour. Based on the TRUST data, even if it’s best to have a complete resection up front, even in these patients that we cannot completely resect at the beginning, there is still a 50% chance that those patients can be completely resected at interval surgery. So it’s a two-step or three-step procedure we currently do.
Is there anything else you would like to add?
Personally, for me, the most relevant takeaway is that if you look at the excellent progression free and overall survival, together with low morbidity, mortality and no detrimental effect on quality of life, short as well as long term, that radical surgery in the hands of qualified centres really makes a big difference and that we should all try to get our patients operated in centres that really know what they do.
