Does giving chemotherapy before surgery improve survival and quality of life in women with advanced epithelial ovarian cancer?

Key messages

• There is little difference in how long women with advanced (stage IIIC/IV) epithelial ovarian cancer (EOC) survive, whether they have chemotherapy or surgery first. There is probably little difference in how long it takes for EOC to return after treatment.

• Giving chemotherapy prior to surgery probably reduces serious risks of surgery; probably halves the risk of needing bowel removal during surgery; and probably results in a large reduction in needing a stoma (where the bowel is diverted through the abdominal wall into a bag to collect the contents).

• Giving chemotherapy prior to surgery is an alternative to surgery followed by chemotherapy in women with advanced EOC. Decisions about which treatment to have first depend on patient preference, how well the woman is at time of diagnosis, the risks of surgery, and the amount and spread of disease.

What is epithelial ovarian cancer, and how is it treated?

Ovarian cancer is the eighth most common cancer worldwide in women. Around 90% of ovarian cancers are epithelial ovarian cancer (EOC), arising from the surface of the ovary or lining of fallopian tubes. Most women with EOC are diagnosed when their cancer is at a late stage, and their disease has spread throughout the abdominal cavity (stage IIIC/IV). Although survival rates have improved over the last 30 years, only four in every 10 women with EOC are alive 10 years after diagnosis.

Treatment for ovarian cancer involves a combination of surgery and chemotherapy. Surgery aims to remove as much visible cancer as possible. However, surgery alone is unlikely to cure EOC, and most women will also need chemotherapy. Chemotherapy uses platinum-based medications to treat cells that cannot be removed by surgery or cannot be seen.

Traditionally, chemotherapy is given after surgery. However, chemotherapy can be given before surgery and then followed by the remaining cycles of chemotherapy, as usual.

Why is this important?

Women with advanced EOC may be too unwell at diagnosis to have surgery, or may require extensive surgery to remove all visible disease. Giving chemotherapy before surgery may shrink the cancer prior to surgery, so that women become well enough to undergo surgery or need less extensive surgery.

What did we want to find out?

We wanted to find out if giving chemotherapy before surgery was better than doing surgery first and then giving chemotherapy. We were interested in how many women with EOC:

• were alive 48 months after diagnosis;

• had no EOC 24 months after treatment;

• died following surgery;

• had unwanted effects due to surgery;

• needed to have their bowel diverted through the abdominal wall into a bag to collect bowel contents (a 'stoma'), or to have part of the bowel removed (a 'bowel resection'); and

• saw an improvement in their quality of life.

What did we do?

We searched for studies that investigated chemotherapy followed by surgery compared with surgery followed by chemotherapy in women diagnosed with advanced EOC. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.

What did we find?

We found seven studies with 2650 women with stage III/IV EOC that compared the effects of giving an initial chemotherapy treatment followed by surgery then chemotherapy as normal, with surgery followed by chemotherapy. Studies took place worldwide, in 20, mainly high-income countries.

Giving chemotherapy before surgery:

• makes little or no difference to the number of women still alive after 48 months (5 studies, 2380 women);

• probably makes little or no difference to the number of women who remained disease-free after 24 months (5 studies, 2380 women);

• reduces deaths due to surgery (5 studies, 2201 women);

• probably reduces the risk of severe unwanted effects of surgery (3 studies, 1094 women);

• probably results in a large reduction in the risk of needing a stoma (3 studies, 1291 women), or a bowel resection (5 studies, 2237 women);

• may slightly improve quality of life 6 months after treatment, but the results are uncertain (3 studies, 559 women).

What are the limitations of the evidence?

We are confident that chemotherapy before surgery makes no difference to overall survival and reduces deaths due to surgery. We are less confident in the rest of the evidence for several reasons. It was clear which treatment women received, which might change the results. Although the studies only enrolled women with advanced EOC (stage IIIC/IV), and many had extensive disease, later studies only enrolled women when the surgeons thought they could remove all of the visible disease with surgery. We could only analyse results from five of the seven studies. We will add results from further studies when they are available.

How up-to-date is the evidence?

The evidence is current to 9 October 2025.