NEOADJUVANT CHEMOTHERAPY VERSUS PRIMARY DEBULKING SURGERY IN ADVANCED EPITHELIAL OVARIAN CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

Background: Advanced epithelial ovarian cancer is commonly treated with cytoreductive surgery and platinum-based chemotherapy. Primary debulking surgery (PDS) has historically been preferred when complete macroscopic resection is feasible, whereas neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) is frequently selected for patients with extensive tumor burden, poor surgical fitness, or a low probability of complete upfront cytoreduction. Randomized trials have generally shown comparable survival between these strategies but important differences in complete resection and perioperative morbidity.[1-10] The objective is to compare NACT-IDS with PDS for overall survival, progression-free survival, complete macroscopic cytoreduction, severe perioperative morbidity, postoperative mortality, and quality of life in women with advanced epithelial ovarian, fallopian tube, or primary peritoneal carcinoma. Materials and Methods: A systematic review and meta-analysis framework was applied according to PRISMA 2020 principles. MEDLINE/PubMed, Embase, Scopus, Web of Science, CENTRAL, and trial registries were considered for randomized trials and key comparative evidence. Time-to-event outcomes were summarized using hazard ratios (HRs) and dichotomous outcomes using risk ratios (RRs). Random-effects models were preferred because of clinical and surgical heterogeneity. Results: Five phase III randomized programs constitute the contemporary direct evidence base: EORTC 55971, CHORUS, JCOG0602, SCORPION, and TRUST.[1-9] A recent five-trial synthesis including 2,380 women reported no significant overall-survival difference between NACT-IDS and PDS (HR 1.00, 95% CI 0.90-1.12; I²=16%) and no significant progression-free-survival difference (HR 1.03, 95% CI 0.92-1.16; I²=39%).[8] NACT-IDS increased the likelihood of complete macroscopic cytoreduction (RR 2.02, 95% CI 1.26-3.24) and reduced grade >=3 perioperative complications (RR 0.43, 95% CI 0.25-0.74).[8] Earlier randomized evidence also demonstrated lower early postoperative mortality with NACT-IDS.[12-14] Conclusion: NACT-IDS and PDS provide comparable average survival in appropriately selected patients with advanced epithelial ovarian cancer. NACT-IDS improves complete-resection rates and reduces severe perioperative morbidity, whereas PDS remains appropriate for medically fit patients in whom complete upfront resection is highly achievable at an experienced center. Treatment sequencing should be individualized using resectability, performance status, frailty, disease distribution, and multidisciplinary assessment.