The carcinoma of ovaries is ranked as the 7^th most common cause of mortality among other malignancies and is 6^th most commonly occurring carcinoma among other cancers. However, it is more prevalent in Asian nation. In India, it is third leading cause of malignancy among women and 4^th commonest carcinoma in Pakistan. Pakistan comprises of around eighteen million populations with an immense weight of the illness. The age-related occurrences of ovarian malignant growth fluctuate somewhere in the range between 5.4 and 8.0 per hundred thousand individuals in various areas of the nation. Cancer of ovaries has the most noticeably poor outcomes among all gynecological malignancies. The general five-year survival is roughly forty five percent, fundamentally because of the late diagnosis [1-5]. Researches have shown that a combination of surgery along with post-chemotherapy has enhanced survival rates in women having advance stage carcinoma of ovaries than those who did not receive proper treatment [6].

The treatment and management of ovarian cancer has been upgraded in past few years. In the USA, cisplatin was used as chemotherapeutic agent. With the advances in the treatment options, the ideal treatment rates have been enhanced remarkably since past decade with an increase in survival rate as confirmed by the study conducted in Netherlands [7]. A recent investigation regarding ovarian cancer in the US has found that almost 50% of older-aged women had surgery followed by six cycles of chemotherapy [8]. In the early 70s, the idea of carrying out a cellular reduction surgery in order to remove cancer in ovaries followed my utilization of paclitaxel-containing chemotherapy in early 90s. A systemic review have shown great survival rates following debulking surgery [9]. The preliminaries inspected the advantages of chemotherapy for ovarian disease. They reasoned that platinum-based chemotherapy with blend of taxane can decrease the danger of ovarian malignant growth by 55% out of which, the 30% of the advantage may likewise be accomplished with a standard platinum-based blend. Surveys that condensed later clinical researches indicated likewise results [10, 11]. In light of evidences, the chemotherapy has been suggested in all women with ovarian malignancy following surgical reduction [12]. In the course of recent years, various investigations have archived that numerous chemotherapy specialists for ovarian carcinomas are financially practical in the preliminary setting [13-15].

The vast majority of the cancers of ovaries are treated by gynecologists due to shortage of gynecological oncologists. A large number of the patients receive way below treatment than standard treatment protocol due to financial and economical requirements. Numerous patients of Pakistan belong to rural areas with the lack of sources and poor access to particular human services. The restrictive expense of antineoplastic medications is a significant impediment for a significant number of the patients to proceed with the treatment. Late diagnosis, improper administration, and lack of interest to consistent treatment are all together accountable for lowering survival in the patients. There is a need to unbiasedly evaluate these components regarding ovarian carcinoma. Therefore, the current study determines the treatment pattern and their outcomes among ovarian cancer patients.

It was a longitudinal study conducted at the department of medical oncology, Jinnah postgraduate medical center (JPMC), Karachi Pakistan from June 2019 to March 2021. Sample size was estimated using open epi sample size calculator by taking statistic of mortality as 65% [16] for women with ovarian cancer who underwent neoadjuvant chemotherapy, margin of error as 8.5% and 95% confidence interval, the estimated sample size was 121≈125 patients. All women 0f 20-80 years with confirmed diagnosis of ovarian carcinoma (stage 1-4) from JPMC and who were referred from different medical institutes of Karachi were included in the study. Patient with history of platinum based agents and pregnant women were excluded from the study.

The ethical approval was sought out before initiation of study (NO.F.2-81-IRB/2019-GENL/7552/ JPMC). The written informed consent was taken from all the eligible patients before data collection from patient or guardian. The details regarding socio-demographics, medical history, histological features, family history of breast cancer, family history of other cancer and clinicopathological characteristics were reported on predesigned proforma.

Surgery and systematic chemotherapy were the primary treatment at the time of ovarian cancer diagnosis. Until death or last follow-up, treatment results were measured. Based on the treatments received from recurrence, systematic chemotherapy was further classified as 2^nd line and 3^rd line. All females who underwent 1^st line chemotherapy based on platinum were assessed in terms of platinum free interval (PFI) for treatment response. PFI was defined as the number of months from the last platinum dose to recurrence. Females with PFI of 6 months or more were considered to be platinum-sensitive, females with PFI of less than 6 months were considered to be platinum-resistant disease and platinum-refractory disease if patients did not respond at least partially to 1^st line platinum therapy. Platinum-based chemotherapy includes carbonplatin and paclitaxel in combination or separately. Females who relapse after 6 months of 1^st line with platinum based treatment were underwent for re-treatment with carboplatin and cisplatin in combination or alone. Retreatment were not considered for the females who had history of adverse event, hypersensitivity reaction or persistent toxicities from 1^st line chemotherapy.

SPSS version 23 was used to analyze data. Mean and SD were reported for normally distributed numeric variables whereas median and interquartile range were calculated for non-normally distributed numeric variables. Frequency and percentage were computed for categorical or nominal variables. P-value<=0.05 was considered as statistically significant. Kaplan Meier and time to event plot were used to investigate all patients who achieved complete remission after systematic chemotherapy with respect to duration of therapy. Log rank test was applied to compare the factor i.e. platinum based chemotherapy with probability of survival. P-value less and equal to 0.05 will be taken as statistically significant.

The mean age of the study sample was reported as 46.23 years. Majority of the females belonged from rural area (63.2%), illiterate (54.4%), had monthly income 15,000-30,000 (51.2%), married (76%) and unemployed (97.6%). The females who were ever married, majority of them had more than 2 parity (74.4%). About 74.4% had vaginal delivery and only one female had menopause therapy. One hundred and fourteen patient had no excess obesity, 8.8% had positive family history of breast cancer whereas 6.4% had positive family history of other cancers and only 5 patients had use oral contraceptives (Table 1).

This study delivers an exceptional viewpoint of treatment outcomes among ovarian cancer patients. The study suggests that ovarian cancer could occur in younger as well as older. The patients were also found to have positive family history of cancer and obesity was also linked to some extent. Few patients also used oral contraceptives and majority had more than three pregnancies along with more number of vaginal deliveries. The data also suggest that most of the patients belong to rural area and hence majority were not educated [17]. Carcinoma of ovaries usually occurs as progressive and extensive disease which appears to be significant reason of deaths [18]. This refutes with the findings of an Egyptian study where majority of the patients were diagnosed at early stage and 8% were having stage 3 cancer [19]. Considering the fact, present study results showed that about 53.6% and 56% patients had pathological and clinical stage 3 respectively similar to the study conducted in Asian region and western region also shows higher stage 3 involvement [20-22]. Voluminous studies had been conducted worldwide regarding the outcomes of platinum based therapy in ovarian cancer patients. The current study reveals that 13.5% patients had standard surgery whereas 54% patients had sub-optimal surgical staging (without lymph node dissection). The results are validated by Thrall et al. and Sehouli et al., where surgery was carried out in 58.8% and 89% respectively [23, 24].

A systemic review concluded that platinum based chemotherapy is beneficial in prolonging survival of the patients when used as adjuvant chemotherapy [25]. In a study, first line platinum based therapy was given in 63% patients. The survival from start of treatment until at the end of the treatment was 47 months [26]. Similarly, in the present study, 7.4% patients underwent for first line chemotherapy without surgery and survival rates were quite impressive. However, one study suggested that stage 1 and stage 2 ovarian cancers are not deemed to be chemotherapy treated as mortality rate was found 0.7 within 5 years [27]. The platinum based chemotherapy is also associated with no recurrence and increasing survival rates among patients of early stage ovarian cancer [28]. Similar results have been found out in another study [29]. The chemotherapy is associated with less risk of ovarian disease recurrence. In this way, chemotherapy in early stages ought to be considered in all patients. Another 5 years systemic review suggested that the platinum-based chemotherapy had better survivals by 7.1 times and survival was found increased without progression by 6.7 times [30].

Presently, chemotherapy as an adjuvant is suggested for patients at higher risk and patients with early stage incomplete staging. Though optimum regime is vacillating, majority of the specialists carry out combined treatment having paclitaxel and carboplatin as the efficiency has been found higher in previous studies and survival seems better in advance cases of ovarian cancer [31]. The present study results are in concurrence with few studies where platinum sensitive patients responded to platinum based chemotherapy in around 90% patients [32]. Another study also favors the use of platinum based chemotherapy. However, the drug regimen was different and main aim was to alleviate symptoms and improve quality of life in ovarian cancer patients [33].

In conclusion, the chemotherapy based on platinum showed complete remission in most of the patients. After second line therapy, few patients showed disease progression and they underwent for third line therapy. The median time from 2^nd line therapy to 3^rd line therapy was reported as 123 days. In third line therapy, majority patients received non-platinum based chemotherapy where majority showed disease progression. The median survival time of 2 patients who died during third line therapy was reported as 8.75 months. The median survival time after 1^st line therapy was 150 days. The median survival time after 2^nd line therapy was 156 days.

Funding Statement

Non-funded research

Approval

The ethical approval was sought out before initiation of study (NO.F.2-81-IRB/2019-GENL/7552/JPMC)

Conflict of Interest

Non to declare

Ethical Declaration

The ethical issue was handled by institutional review board of JPMC.

Authors Contribution

All authors contributed equally.

Data Availability

Data is available from corresponding author on reasonable request.