Introduction/Background*The standard of treatment for advanced epithelial ovarian cancer (EOC) is primary debulking surgery (PDS) followed by platinum-based systemic chemotherapy. Due to the presence of extensive metastatic disease in most of the cases, primary debulking surgery can be an aggressive procedure associated with high peri-operative morbidity and mortality. In this study we aim to investigate whether neoadjuvant chemotherapy (NACT) offers superior survival rates, less peri-operative morbidity and mortality and better quality of life compared to primary debulking surgery in patients with advanced epithelial ovarian cancer.

Methodology We searched the electronic databases PubMed, Cochrane Central Register of Controlled trials, and Scopus from inception to March 2021. We considered randomised controlled trials (RCTs) comparing NACT with PDS for women with EOC stages III and IV. The primary outcomes were overall survival and progression-free survival. Secondary outcomes were optimal cytoreduction rates, peri-operative adverse events, and quality of life.

Result(s)*Six RCTs with a total of 1901 participants were included. Meta-analysis demonstrated similar overall survival (HR = 0.96, 95% CI [0.86 – 1.07]) and progression-free survival

(HR = 0.98, 95% CI [0.89 – 1.08]) between NACT and PDS. Subgroup analyses did not demonstrate higher survival for stage IV patients (HR = 0.88, 95% CI [0.71 – 1.09]) nor for patients with metastatic lesions >5 cm (HR = 0.86, 95% CI [0.69 – 1.08]) treated with NACT, albeit with some uncertainty due to imprecision. Similarly, no survival benefit was observed in the subgroup of patients with metastatic lesions >10 cm (HR = 0.94, 95% CI [0.78 – 1.12]). NACT was associated with significantly higher rates of complete cytoreduction (RR = 2.34, 95% CI [1.48 – 3.71]). Severe peri-operative adverse events were less frequent in the NACT arm (RR = 0.34, 95% CI [0.16 – 0.72]. NACT was also associated with a significantly lower risk of post-operative mortality within 28 days (RR = 0.16, 95% CI [0.06 – 0.46], I² = 0%).

Conclusion*Patients with stage III and IV epithelial ovarian cancer undergoing NACT or PDS have similar overall survival. NACT is likely associated with higher rates of complete cytoreduction and lower risk of severe adverse events and peri-operative death.