Emerging concerns when evidence-based medicine is translated into real life: the case of neoadjuvant chemotherapy in ovarian cancer.

Keywords Ovariancancer .Neoadjuvantchemotherapy .Optimalcytoreduction .SurgeryMore than 70 % of patients with epithelial ovarian cancerare diagnosed with an advance stage of disease. For deca-des, the therapeutic approach to these patients has consistedof cytoreductive surgery followed by a platinum-based che-motherapy regimen. Although there are no randomized clin-ical trials confirming that cytoreductive surgery improvessurvival, several retrospective studies as well as one meta-analysis have shown that the most important prognosticfactor for patients with advanced epithelial ovarian canceris the amount of residual disease after surgical cytoreduction[1, 2]. Constantly in the literature, the absence of macro-scopic residual disease after debulking surgery has beenassociated with better overall survival [3–5]. Recently, thefourth Ovarian Cancer Consensus Conference stated that theexpression “optimally debulked patients” should be re-served for those patients without residual macroscopic dis-ease after debulking surgery [6].However, the likelihood of achieving the objective of“optimal cytoreduction” is highly dependent on the skillsand experience of the surgical team operating on the patient.There are several data in the literature showing that that therate of optimal cytoreduction increases when the surgeonwho operates on an ovarian cancer patient is a well-trainedsubspecialist in gynecologic oncology [7, 8]. The mainreason for this is probably the necessity of sometimesperforming very complex procedures during the surgery inorder to obtain the goal of absence of residual disease. Suchprocedures might include, for instance, bowel resections,radical retroperitoneal lymphadenectomies, splenectomies,partial pancreatectomies, or resection of diaphragmaticimplants. Unfortunately, the training of the surgical teamsoperating on ovarian cancer patients around the world is nothomogeneous and, unlike in countries in which there is anofficial accreditation or specialization, we cannot expect thesame results from different teams in different parts of theworld or even in the same country. This heterogeneity canalso stimulate a further debate, beyond the scope of thisarticle, about the validity of performing clinical trials inwhich the main intervention is a complex surgical procedureas well as about the quality control in such as trials.Eisenkop and Spirtos [9], in an illustrative survey amongAmerican gynecologic oncologists, found that the main limi-tation for obtaining complete cytoreduction was the approachtotheupperabdomen,reinforcingtheneedforspecialtrainingfor the optimal surgery in this disease. Additionally, we havedatashowingthatthebetterthetrainingofthesurgicalteamincomplex procedures, including the approach to the upperabdomen, the higher is the rate of optimal cytoreductionamong these patients [10, 11].Neoadjuvant chemotherapy consists in the administrationof some courses of chemotherapy before surgery. This strat-egy has been used when the surgical team has considered itimpossible to achieve adequate cytoreduction in an individ-ual patient. Despite the absence of consensus on the criteriafor considering a patient to not be a candidate for upfrontsurgery, there are some patient circumstances that are uni-versally accepted, for instance, bad clinical condition of the