We are grateful to Martinelli et al1 for their interest in our study of laparoscopic debulking surgery after neoadjuvant chemotherapy in advanced ovarian cancer. Our study used data from the National Cancer Database, a registry that aggregates data from more than 1,500 cancer program networks in the United States. Using these data, we were able to identify women who underwent neoadjuvant chemotherapy and investigate associations between surgical approach and overall survival. However, the National Cancer Database lacks detailed information about chemotherapy regimens, including drug, route, cadence, and number of cycles completed, precluding any description or analysis of these important factors.
As Martinelli et al suggest, the observation that women who underwent laparoscopic interval debulking surgery had less extensive surgery than those who underwent laparotomy may reflect selection of surgical approach based on patients' response to neoadjuvant chemotherapy and resulting disease burden. However, patients selected for laparoscopy also had more comorbidities and were frequently diagnosed with stage IV disease, and it is possible that surgeons were less willing to perform extensive procedures in these patients because of their poor prognoses. Unfortunately, radiologic and biochemical measures of chemotherapy response are unavailable in the National Cancer Database.
At this time, available evidence suggests equipoise between laparoscopic and laparotomic interval debulking surgery for women with advanced ovarian cancer who have had a complete, or near complete, response to neoadjuvant chemotherapy.1–3 A randomized trial comparing these approaches is warranted. Only such a trial can answer the important questions raised by Martinelli et al.