Interval Cytoreductive Surgery Following Neoadjuvant Chemotherapy Improves Advanced Ovarian Cancer Outcomes

Patients with advanced ovarian cancer treated with neoadjuvant chemotherapy (NACT) followed by interval cytoreductive surgery (ICS) had significantly better 3-year progression-free survival (PFS) and overall survival (OS) than those who received chemotherapy alone, according to a study published in Gynecologic Oncology.¹

Traditionally, ovarian cancer treatment involves primary cytoreductive surgery followed by adjuvant chemotherapy. However, over the last decade, there has been a shift toward NACT followed by ICS.

NACT is preferred for patients unfit for primary surgery or unlikely to achieve complete cytoreduction.² The researchers explained that while avoiding surgery may be appealing, especially in elderly patients, the outcomes of this approach remain largely undescribed.¹

Neoadjuvant chemotherapy followed by interval cytoreductive surgery significantly improves survival rates in patients with advanced ovarian cancer compared with chemotherapy alone. | Image Credit: MohammedElAmine - stock.adobe.com

To address this knowledge gap, the researchers conducted a retrospective cohort study comparing patients treated with chemotherapy only vs chemotherapy followed by ICS. Eligible patients were adults with stage IIIC/IV, high-grade epithelial ovarian cancer at a single tertiary referral center who began treatment with at least 3 cycles of chemotherapy between 2017 and 2022. The primary analysis compared 3-year PFS and OS.

Two secondary analyses were also performed. One compared patients who underwent standard vs delayed ICS, and the other stratified patients for optimal surgical candidacy, defined as being younger than 80, having an Eastern Cooperative Oncology Group performance status of 0 or 1, having albumin of 3.5 g/dL or less, and the absence of disease progression during chemotherapy.

Of 232 patients initially triaged to NACT, 176 were included in the final cohort. Of these, 138 (78.4%) underwent ICS, and 38 (21.6%) never had surgery.

Patients treated only with chemotherapy were older (median age, 72.5 vs 65.0 years; P < .01), had higher body mass index (BMI; median BMI, 31.0 vs 26.8 kg/m²; P < .01), and had more comorbidities (median Charlson Comorbidity Index, 10 vs 7; P < .01) than those who underwent ICS. Both groups were otherwise similar in race, pretreatment stage, histology, and NACT indication.

In the primary analysis, recurrence within 3 years occurred in 106 patients. Three-year PFS was 7.2% for patients who only received chemotherapy vs 22.0% for those who received NACT and ICS. Additionally, 52 patients experienced death within 3 years, with a 3-year OS of 14.0% for patients who received chemotherapy alone and 61.1% for those who received NACT and ICS. Multivariable analysis showed that chemotherapy alone was independently associated with recurrence (adjusted [aHR], 2.58; 95% CI, 1.63-4.10) and death (aHR, 4.60; 95% CI, 2.43-8.71).

Among patients who underwent ICS, 105 experienced standard ICS and 33 had delayed ICS. Three-year PFS was 23.7% for standard ICS vs 16.2% for delayed ICS. Similarly, 3-year OS was 59.9% for standard ICS and 62.6% for delayed ICS. Kaplan-Meier curves showed no statistically significant differences in PFS or OS between standard and delayed ICS.

Of 118 patients meeting the criteria for optimal surgical candidacy, 108 underwent NACT and ICS, while 10 received only chemotherapy. PFS was not significantly different between the 2 groups (log-rank P = .19), as 3-year PFS was 12.5% for chemotherapy only vs 18.7% for ICS. In contrast, OS was significantly different between groups (log-rank P = .02), with 3-year OS being 25.7% for chemotherapy only and 62.4% for NACT/ICS.

The researchers acknowledged their limitations, including the small, homogeneous patient population from a single institution. Consequently, they advised cautious interpretation of their results. Still, the researchers expressed confidence in their findings.

“Interval surgery appears beneficial in most instances, and thus, we recommend that gynecologic oncologists continue to recommend surgery for patients who demonstrate a response to chemotherapy, are fit surgical candidates, and have a reasonable likelihood of a successful operation,” the authors concluded.

References

1. Bruce KH, Xu C, Shah RP, et al. Real-world outcomes of neoadjuvant chemotherapy for advanced ovarian cancer: what happens to patients who never undergo surgery? Gynecol Oncol. Published online August 26, 2025. doi:10.1016/j.ygyno.2025.08.020
2. Gaillard S, Lacchetti C, Armstrong DK, et al. Neoadjuvant chemotherapy for newly diagnosed, advanced ovarian cancer: ASCO guideline update. J Clin Oncol. 2025;43(7):868-891. doi:10.1200/JCO-24-02589