Treatment of ovarian cancers: the main drivers of progress
Press release from the French Academy of Medicine
June 28, 2024
In France, ovarian cancer affects nearly 5,900 women/year, 3500 of them dying each year. However, significant progress has been made over the last three decades, particularly in Europe [1]. Significant advance in the treatment of ovarian cancer results from three progress factors:
– Molecular dismemberment which made it possible to identify different types of ovarian cancer, guiding therapeutic strategies. Thus, the search for abnormalities in the repair of DNA double-strand breaks (Homologous Recombination Defect (HRD)), whether or not associated with deleterious mutations of the BRCA1 or 2 genes (germline or tumor), constitutes a “theranostic” test, which has become an essential prerequisite for the prescription of targeted therapies. This approach has notably made it possible to prescribe Poly-ADP-Ribose-Polymerase (PARP) inhibitors, which have revolutionized the treatment of some aggressive cancers [2];
– Quality of surgical management. Exploratory laparoscopy makes it possible to assess the state of the abdominal cavity and to carry out protected biopsies for histological and molecular analyses. The surgical procedure then aims for complete excision, either immediately or after chemotherapy. The challenge is to avoid leaving tumor residues in place, that will determine long-term survival; it is also important to prevent post-operative complications. The experience of the surgical team is therefore crucial [3];
– Recognition of expert centers based on minimum thresholds of activity and their number of surgeons. This underlines the organizational and public health dimension of care for advanced ovarian cancers. Following initial findings in Scandinavian countries and Germany, and then the recommendations from the European Society of Gynecologic Oncology (ESGO), the certification of expert centers [3] imposes a minimum activity of 20 cases of ovarian cancer treated per year and per surgeon, and a staff of at least two surgeons per establishment; the target to achieve after 5 years is at least 50 cases/year/practitioner [5].
In France, analysis of data from the Program for Medicalization of Information Systems (PMSI) revealed that around 3,700 surgical interventions for advanced ovarian cancers were carried out in 2016, and showed that only 11 establishments had treated more than 50 cases of ovarian cancer, with many of them fewer than 10 cases [6]. Faced with this observation, the regulatory conditions for authorizing cancer care activities have evolved, in particular to ensure that more than 20 cases of surgery for advanced ovarian cancer are performed each year [7].
Faced to these three factors of progress observed in the treatment of ovarian cancer, the French Academy of Medicine emphasizes that:
– a very important part of this progress has been the development of molecular and pathological diagnosis, which allows the therapeutic approach to be optimized, still requiring the inclusion of patients in large-scale clinical trials;
– the surgical component of the treatment requires, to be effective and safe, to be carried out by surgical teams that are very experienced in this field;
– the skills from several disciplines of great expertise need to be brought together; they are, at best, gathered in referral health establishments;
– the organization of care in the territory must be adjusted, so that patients with suspected, or confirmed, ovarian cancer can access to these referral establishments as quickly as possible.
Références
[1] Wojtyla C., Bertuccio P., Giermaziak P., et al., European trends in ovarian cancer mortality, 1990-2020 and predictions to 2025, Eur. J Cancer, 2023, 194, 113350
[2] Ray-Coquard I., Pautier P., Pignata S., et al., Olaparib plus Bevacizumab as First-Line Maintenance in Ovarian Cancer, N Engl J Med. 2019, Dec 19;381(25):2416-2428.
[3] Harter P., Muallem Z.M., Buhrmann C., et al., Impact of a structured quality management program on surgical outcome in primary advanced ovarian cancer. Gynecol Oncol. 2011 Jun 1;121(3):615-9.
[4] Querleu D., Planchamp F., Chiva L., et al., European Society of Gynaecologic Oncology Quality Indicators for Advanced Ovarian Cancer Surgery, International Journal of Gynecologic Cancer, 2016; 26:1354-1363.
[5] Fagö-Olsen C.L., Høgdall C., Kehlet H., et al., Centralized treatment of advanced stages of ovarian cancer improves survival: a nationwide Danish survey. Acta Obstet Gynecol Scand. 2011 Mar;90(3):273-9. doi: 10.1111/j.1600-0412.2010.01043.x. Epub 2010 Dec 14. PMID: 21306310.
[6] Meurette J, Daraï E, Tajahmady A, et al., Arguments for centralization of surgical treatment of ovarian cancer in France based on morbidity and mortality data. Bull Cancer. 2024 Mar;111(3):239-247. doi: 10.1016/j.bulcan.2022.12.016.
[7] Decree 2022-689 of April 26, 2022, relating to the conditions for establishing the cancer treatment care activity.
