Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment

Ovarian cancer is the sixth most common cancer and seventh commonest cause of cancer death in women worldwide. Traditionally, many people who have been treated for cancer undergo long-term follow-up in a hospital outpatient setting. However, it has been suggested that the use of routine review (check-ups) may not result in women with ovarian cancer living longer. We set out to review the evidence for different types of follow-up for women who have completed treatment for the commonest type of ovarian cancer. Only one randomised study was found, and it did not find that immediate treatment with chemotherapy for relapse (identified by a tumour marker - CA125 - blood test) produced a benefit compared to delaying treatment until the women developed symptoms. The limited evidence suggests that there may be no benefit from early detection of recurrence of ovarian cancer and starting chemotherapy before symptoms develop. In addition, early treatment of recurrence with chemotherapy may reduce overall quality of life.

Randomised controlled trials are needed to compare different types of follow-up, looking at survival and quality of life outcomes. If new treatments become available for relapsed ovarian cancer, the methods of follow-up may need to be re-assessed to see if earlier intervention improves survival.

Authors' conclusions: 

Limited evidence from a single trial suggests that routine surveillance with CA125 in asymptomatic patients and treatment at CA125 relapse does not seem to offer survival advantage when compared to treatment at symptomatic relapse. RCTs are needed to compare different types of follow-up, looking at survival, QoL, cost and psychological effects as outcomes.

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Background: 

Ovarian cancer is the sixth most common cancer and seventh commonest cause of death in women worldwide. Traditionally, many people who have been treated for cancer undergo long-term follow-up in secondary care. However, it has been suggested that the use of routine review may not be effective in improving survival, quality of life (QoL), or relieving anxiety, or both. In addition, traditional follow-up may not be cost-effective.

Objectives: 

To compare the potential benefits of different strategies of follow-up in patients with epithelial ovarian cancer following completion of primary treatment.

Search strategy: 

For this update we searched the Cochrane Gynaecological Cancer Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 7, 2013, MEDLINE and EMBASE from November 2010 to July 2013. We also searched reference lists of review articles and contacted experts in the field.

Selection criteria: 

All relevant randomised controlled trials (RCTs) that evaluated follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment.

Data collection and analysis: 

Two review authors independently abstracted data and assessed risk of bias.

Main results: 

The authors did not identify any new studies that were eligible for inclusion in this update of the review. The search for the original review identified only one RCT that met the inclusion criteria, which included 529 women. This study reported data on immediate treatment of ovarian cancer relapse following rise of serum CA125 levels versus delaying treatment until symptoms developed. All the women participating had previous confirmation of remission, with normal CA125 concentration and no radiological evidence of disease, after surgery and first-line chemotherapy for ovarian cancer.

Overall survival between the immediate and delayed arms showed no difference after a median follow-up of 56.9 months (unadjusted hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.80 to 1.20; P value 0.85). Time from randomisation to first deterioration in global health score or death was shorter in the immediate treatment group than in the delayed treatment group (HR 0.71, 95% CI 0.58 to 0.88; P value < 0.01). The trial was at low risk of bias.

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