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1Medical Oncology Unit, Oncology Center Mansoura University (OCMU), 33516 Mansoura, Egypt
2Surgical Oncology Department, Oncology Center Mansoura University (OCMU), 33516 Mansoura, Egypt
3Oncology Center Mansoura University (OCMU), 33516 Mansoura, Egypt
4Obstetrics and Gynecology Department, Faculty of Medicine, Beni-Suef University, 62511 Beni-Suef, Egypt
5Surgical Oncology Department, Elsalam Oncology Center, 42525 Cairo, Egypt
*Corresponding Author(s):Drislamhany@mans.edu.eg (Waleed Mohammed Elamin Khaled)
| History | Submitted: 20 December 2024 | Accepted: 18 April 2025 | Published: 15 August 2025 |
| Copyright: | ©2025 The Author(s). Published by MRE Press. |
Background: Epithelial ovarian cancer (EOC) is the leading cause of gynecologic cancer deaths and ranks as the seventh most common cancer among women worldwide. The conventional treatment for advanced EOC involves primary debulking surgery (PDS) followed by adjuvant chemotherapy (ACT), but high recurrence rates and chemoresistance hinder this approach. Recent research suggests that neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) may yield comparable survival rates with fewer postoperative complications, positioning NACT-IDS as a potential alternative for advanced EOC treatment. The optimal number of neoadjuvant chemotherapy cycles for ovarian cancer is still debatable, particularly regarding its effects on survival outcomes. Methods: This is a retrospective cohort study that included newly diagnosed ovarian cancer patients who received NACT and then underwent interval debulking surgery (IDS) at a tertiary cancer center between July 2011 and December 2021. Participants were categorized into two groups according to the number of NACT cycles: Group I (≤4 cycles) and Group II (≥5 cycles). Results: We analyzed 207 patients, Group I included 130 patients (62.8%) while Group II included 77 patients (37.2%). In Group I, 63.1% of patients presented with stage III disease, while stage IV disease was reported in 51.9% of patients. No statistically significant differences were observed between the two groups regarding pathological response to NACT (p = 0.9) or the rate of achieving optimal cytoreduction (p = 0.8). A higher total number of perioperative (pre & post-surgical) chemotherapy cycles was reported in Group II patients (median: 8 vs. 6; p < 0.001). However, overall survival (OS) (p = 0.5) or relapse-free survival (RFS) (p = 0.1) was not different among the two groups. Conclusions: Administering more than four cycles of NACT before cytoreductive surgery did not improve rates of optimal cytoreduction, nor did it affect surgical morbidity, mortality or overall or relapse-free survival.
Cite this article
Rehem Alghandour, Basel Refky, Hasan Alsalman, Waleed Mohammed Elamin Khaled, Sara Elbaz, Mohammad Zuhdy, et al.Evaluation of short versus long course chemotherapy in the neoadjuvant setting in ovarian cancer.European Journal of Gynaecological Oncology,2025,46(8):38-47 DOI:10.22514/ejgo.2025.107
1. Introduction
Ovarian cancer is the fifth leading cause of cancer-related deaths in women and is recognized as one of the most aggressive gynecological malignancies, with poor survival outcomes [1]. The standard treatment for advanced ovarian cancer involves a combination of cytoreductive surgery—also referred to as optimal debulking—and platinum-based chemotherapy [2]. Achieving no residual disease after surgery is critical for improving prognosis, which has led to the adoption of neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in cases where upfront surgery is not feasible due to extensive disease burden [3]. NACT aims to reduce tumor size, thereby enabling successful cytoreduction in patients with advanced or inoperable ovarian cancer. NACT has shown significant benefits for patients with stage IIIC or IV ovarian cancer. Furthermore, ongoing advancements in treatment strategies, including the incorporation of novel agents like anti-VEGF therapies, offer potential enhancements to NACT protocols [4]. Despite these developments, the optimal number of chemotherapy cycles before and after IDS remains debatable, as no definitive consensus has been established. Key studies, including three major randomized controlled trials (RCTs), have demonstrated the efficacy of NACT followed by IDS as an alternative to primary debulking surgery (PDS). For instance, Vergote et al. [5] (2010) showed that NACT resulted in a higher rate of complete cytoreduction compared to PDS, with fewer postoperative complications and similar survival outcomes [6]. Subsequent trials, such as those by Kehoe et al. [7] (2015) and others, further supported these findings, establishing NACT as a viable standard of care for advanced ovarian cancer. The current study evaluates the relationship between the number of NACT cycles and surgical and pathological outcomes. It also examines how varying the number of cycles impacts progression-free and overall survival in patients with advanced ovarian cancer, aiming to provide insights into optimizing treatment protocols.
2. Patients and methods
This retrospective cohort study was conducted at the Oncology Center Mansoura University (OCMU) and included patients presenting to the tertiary cancer center between July 2011 and December 2021. The study aimed to evaluate the impact of the number of neoadjuvant chemotherapy (NACT) cycles on surgical and pathological outcomes in patients with advanced epithelial ovarian carcinoma. Patients were selected based on specific inclusion and exclusion criteria to ensure consistency and focus on the effectiveness of varying NACT cycles.
2.1 Inclusion criteria
1. Advanced newly diagnosed epithelial ovarian carcinoma patients (International Federation of Gynecology and Obstetrics (FIGO) stage III–IV) in whom optimal cytoreduction was not feasible (Marked ascites, Distant metastasis, Multivisceral resection required, Mesenteric retraction, Hilum of liver or pancreatic head involvement, high PCI score).
2. Patients deemed unsuitable for primary debulking surgery due to factors such as poor performance status or significant comorbidities.
3. Patients who underwent interval debulking surgery following NACT.
2.2 Exclusion criteria
Patients with recurrent ovarian carcinoma.
2.3 Patients’ assessment
All patients underwent Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) of the chest abdomen and pelvis, radiologic guided or laparoscopic biopsy taken and tumor markers (at least Cancer antigen 125 (CA125) done), finally upper & lower Gastrointestinal (GI) endoscopies were done selectively if the involvement of GI organs suspected radiologically or Ovarian secondary suspected.
2.4 Chemotherapy protocols used
All studied patients received neoadjuvant chemotherapy carboplatin, taxane doublet (paclitaxel or docetaxel) every 21 days unless severe complications occurred like prolonged myelosuppression. The used dose was for taxane (paclitaxel 175 mg/m2 and for docetaxel 75 mg/m2) and for carboplatin area under curve (AUC 5) with Granulocyte colony-stimulating factor for five days after finishing the chemotherapy cycle by 24 hours. Group I patients received ≤4 cycles of neoadjuvant chemotherapy, while Group II patients received ≥5 cycles. Some patients were managed by dose modification if persistent toxic adverse events occurred like more than grade 2 peripheral neuropathy or grade 3 myelosuppression.
2.5 Data collection
Demographic, preoperative, operative, postoperative, pathological and oncological follow-up data for all eligible patients were obtained from a prospectively maintained internet-based registry.
2.6 Study outcomes
The primary outcome of the study was to evaluate the surgical and pathological outcomes based on the number of NACT cycles received. Secondary outcomes included the evaluation of survival trends namely overall and relapse-free survival (OS&RFS).
2.7 Statistical analysis
We analyzed all data using SPSS software (Version 26; IBM Corp., Armonk, NY, USA). Mean ± standard deviation was used to express continuous variables if normally distributed data or median (range) if non-normally distributed data. We compared parametric data using the independent samples t-test, while non-parametric data were analyzed using the Mann-Whitney U test. Categorical variables were analyzed using Pearson’s Chi-square test or Fisher’s Exact test, as appropriate. OS and PFS were calculated from the date of surgery till the date of death or progression and estimated measured using Kaplan-Meier survival curves. The log-rank test was employed to compare OS and RFS. A p-value of < 0.05 was considered statistically significant.
3. Results
3.1 Epidemiology
The study included 207 patients, with a mean age of 55.9 ± 9.5 years and a median body mass index (BMI) of 33 (range: 16–62). A family history of breast or ovarian cancer was reported in only 15 patients (7.2%). Comorbidities were present in 101 patients (48.8%), with hypertension being the most prevalent, followed by diabetes mellitus. Most participants were postmenopausal (76.8%).
The most frequent presenting symptom was abdominal pain (63.8%), followed by abdominal enlargement (26.1%). Nearly all patients underwent CT of the chest, abdomen and pelvis (98.6%), while MRI of the pelvis was performed in 55.1%. Bilateral adnexal masses were observed in 57% of cases. Peritoneal and omental deposits were reported in 71% and 83.1% of patients, respectively. 90.3% of patients had ascites, while 20.3% of patients were diagnosed with pleural effusion. Additionally, regional lymphadenopathy was reported in 45.4% of patients.
Serous carcinoma was encountered in 94.7% of patients, while 97.6% of patients suffered from high-grade malignancies (Supplementary Table 1).
3.2 Neoadjuvant therapy
The primary indication for neoadjuvant chemotherapy (NACT) in 56% of patients was unresectable disease at diagnosis. The majority (95.7%) received Taxane (paclitaxel or docetaxel) combined with carboplatin. None of the patients received neoadjuvant bevacizumab. The number of NACT cycles varied: 35.3% received three cycles, 27.5% received six cycles, and 26.6% received four cycles.
Response to therapy was assessed by imaging (CT scan mainly) using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria [8]. However, staging laparoscopy was used in some cases according to surgeon discretion. In 83.1% of patients, partial radiological response was reported, while in 7.2% complete radiologic response was achieved.
3.3 Surgery and adjuvant treatment
All patients underwent surgery; with median 1 (0–7) months post neoadjuvant therapy. However, in 3.4% of cases, complete cytoreduction could not be achieved, resulting in closure without resection. Optimal cytoreduction (residual tumor <1 cm) was achieved in 70% of patients. Laparoscopic surgery was performed in 8.7% of cases. Lymphadenectomy was conducted in 49.3% of patients. Additionally, 7.3% underwent gastrointestinal resection, while 1.4% required partial liver or bladder resection.
The 30-day morbidity rate was 6.8%, the commonest was surgical site infection in 3 patients, bleeding, pulmonary embolism, and anemia in 2 patients each followed by burst abdomen, intestinal fistula, vesicovaginal fistula, wound gap, and seroma in 1 patient each. A single case of postoperative death secondary to pulmonary embolism encountered as such 30-day mortality rate of 0.5%.
Adjuvant chemotherapy was administered to 87.4% of patients (123 in Group I and 58 in Group II). The number of adjuvant cycles varied, with 30.9% receiving three cycles, 22.2% receiving two, and 22.2% receiving four cycles.
3.4 Relapse/progression
Relapse or disease progression was observed in 140 patients (67.6%), with 43.6% experiencing locoregional recurrence. Among these cases, 71.4% were platinum-sensitive, occurring more than six months after the completion of platinum-based adjuvant chemotherapy. Most relapses (88.6%) were managed with chemotherapy alone.
3.5 Comparison of ≤4 cycles vs. ≥5 cycles
Patients were divided into two groups based on the number of NACT cycles: Group I (≤4 cycles; 130 patients) and Group II (≥5 cycles; 77 patients). No significant differences were found between the groups regarding age, comorbidities, menopausal status, presence of peritoneal or omental deposits, ascites, pleural effusion, lymphadenopathy, pathologic subtype, grade, response to neoadjuvant therapy, or cytoreduction outcomes (Table 1).
| Variable | ≤4 cycles (130 patients) | ≥5 cycles (77 patients) | Significance | |
| Age mean +/− Standard deviation | 55.9 +/− 9.2 | 55.9 +/− 10.2 | 0.970 | |
| Comorbidity | ||||
| No | 65 | 41 | 0.670 | |
| Yes | 65 | 36 | ||
| Menopausal status | ||||
| Pre-menopause | 31 | 17 | 0.860 | |
| Post-menopause | 99 | 60 | ||
| CA125/CEA ratio | ||||
| ≤25 | 6 | 3 | 1.000 | |
| >25 | 69 | 36 | ||
| Peritoneal deposits | ||||
| No | 39 | 21 | 0.750 | |
| Yes | 91 | 56 | ||
| Omental deposits | ||||
| No | 23 | 12 | 0.850 | |
| Yes | 107 | 65 | ||
| Pleural effusion | ||||
| No | 106 | 58 | 0.290 | |
| Yes | 24 | 19 | ||
| Regional nodes | ||||
| No | 72 | 41 | 0.770 | |
| Yes | 58 | 36 | ||
| Non-regional nodes | ||||
| No | 113 | 62 | 0.230 | |
| Yes | 16 | 15 | ||
| Visceral metastasis | ||||
| No | 111 | 62 | 0.440 | |
| Yes | 19 | 15 | ||
| Clinical FIGO stage | ||||
| I | 3 | 3 | 0.030 | |
| II | 3 | 1 | ||
| III | 82 | 33 | ||
| IV | 42 | 40 | ||
| Pathology | ||||
| Serous carcinoma | 121 | 75 | 0.340 | |
| Mucinous carcinoma | 1 | 0 | ||
| Clear cell carcinoma | 2 | 0 | ||
| Others | 6 | 1 | ||
| Grade | ||||
| Low | 3 | 1 | 1.000 | |
| High | 127 | 75 | ||
| Radiologic response to NACT | ||||
| CR | 10 | 5 | 0.980 | |
| PR | 107 | 65 | ||
| PD | 6 | 3 | ||
| SD | 7 | 4 | ||
| Type of surgery | ||||
| Optimal cytoreduction | 93 | 52 | 0.820 | |
| Suboptimal cytoreduction | 33 | 22 | ||
| Irresectable | 4 | 3 | ||
| Approach | ||||
| Laparotomy | 119 | 70 | 1.000 | |
| Laparoscopy | 11 | 7 | ||
| LN surgery | ||||
| No | 67 | 38 | 0.770 | |
| Yes | 63 | 39 | ||
| 30-day morbidity | ||||
| No | 124 | 69 | 0.150 | |
| Yes | 6 | 8 | ||
| Pathologic response | ||||
| No | 5 | 3 | 0.960 | |
| Partial | 113 | 67 | ||
| Complete | 8 | 4 | ||
| Adjuvant chemotherapy | ||||
| No | 7 | 19 | <0.001 | |
| Yes | 123 | 58 | ||
| Total number of perioperative chemotherapy median (min–maximum) | 6 (3–13) | 8 (5–12) | <0.001 | |
| NACT: neoadjuvant chemotherapy; CA125: Cancer Antigen 125; CEA: Carcinoembryonic Antigen; FIGO: International Federation of Gynecology and Obstetrics; CR: Complete Response; PR: Partial Response; PD: Progressive Disease; SD: Stationary disease. |
However, there was a significant difference in FIGO staging: stage III was reported in 63.1% of Group I patients, while stage IV was reported in 51.9% of Group II patients (p = 0.03). Additionally, 94.6% of Group I received adjuvant chemotherapy compared to 75% in Group II (p < 0.001). A higher total perioperative chemotherapy dose was administered to Group II patients (median 8 vs. 6 cycles, p < 0.001) (Fig. 1).
Fig. 1.Comparison of distribution of total number of perioperative chemotherapies between both groups.
3.6 Outcomes
There was no statistically significant difference between the two groups in terms of overall survival (OS) (p = 0.5) (Fig. 2A), with a three-year OS of 75% in Group I and 67% in Group II. Relapse rates were also comparable (63.1% vs. 71.5%, p = 0.57), as was relapse-free survival (RFS) (p = 0.13) (Fig. 2B), with a three-year RFS of 20% in Group I and 16% in Group II (Table 2).
Fig. 2.Kaplan-Meier curve. (A) Comparison of overall survival between short and long course neoadjuvant chemotherapy. (B) Comparison of relapse free survival between short and long course neoadjuvant chemotherapy.
| Variable | ≤4 cycles | ≥5 cycles | Significance | |
| Relapse | ||||
| No | 43 | 18 | 0.20 | |
| Yes | 82 | 55 | ||
| Relapse type | ||||
| Sensitive | 56 | 42 | 0.57 | |
| Resistant | 17 | 9 | ||
| Refractory | 9 | 4 | ||
| Site of relapse | ||||
| Locoregional | 37 | 24 | 0.98 | |
| Distant | 23 | 16 | ||
| Both | 22 | 15 | ||
| Estimated mean Overall survival (95% CI) | 95.4 (86.0–104.8) | 69.3 (60.1–78.6) | 0.50 | |
| 3-year OAS | 75% | 67% | ||
| Median Relapse free survival (95% CI) | 17 (11.9–22.1) | 15 (11.8–18.1) | 0.13 | |
| 3-year RFS | 20% | 16% | ||
| RFS: relapse-free survival; CI: Confidence interval; OAS: Overall survival. |
3.7 Subgroup analysis based on debulking
In patients who underwent optimal debulking, both OS and RFS were similar between the groups (p = 0.85 and p = 0.3, respectively). Similarly, no significant differences were observed in OS and RFS among patients with suboptimal debulking (p = 0.65 and p = 0.39, respectively) (Table 3).
| Variable | ≤4 cycles | ≥5 cycles | Significance | |
| Optimal debulking | ||||
| Estimated mean overall survival (95% CI) | 97.7 (87.1–108.3) | 74.5 (64.2–84.9) | 0.85 | |
| Estimated median relapse free survival (95% CI) | 19 (13.2–24.8) | 16 (12.4–19.6) | 0.30 | |
| Suboptimal debulking | ||||
| Estimated mean overall survival (95% CI) | 72.4 (59.3–85.6) | 60.5 (44.2–76.8) | 0.65 | |
| Estimated median relapse free survival (95% CI) | 16 (9.5–22.4) | 12 (7.0–17.0) | 0.39 | |
| CI: Confidence interval. |
3.8 Correlation between total perioperative chemotherapy and RFS
Notably, relapse-free survival was not affected by the total number of neoadjuvant and adjuvant chemotherapy cycles (p = 0.46).
4. Discussion
There is no doubt that neoadjuvant chemotherapy (NACT) followed by interval cytoreductive surgery (ICS) is a validated option for treating advanced ovarian cancer [9]. While this approach has demonstrated improved surgical outcomes with reduced residual disease, overall survival (OS) and progression-free survival (PFS) remain comparable to the standard approach of primary cytoreductive surgery (PCS) followed by adjuvant chemotherapy [10, 11, 12]. However, pooled data from the European Organisation for Research and Treatment of Cancer (EORTC) 55971 and Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS) trials suggest that administering three cycles of NACT before ICS offers a small rise in PFS and OS in patients with more advanced disease [13].
Identifying patients who would benefit most from NACT requires a comprehensive evaluation using scoring models based on either clinical, radiological, molecular or laparoscopic retrieved data [9]. The topic of ongoing debate is the optimal number of NACT cycles. Current guidelines from the American Society of Clinical Oncology (ASCO) and the Society of Gynecologic Oncology (SGO) recommend 3–4 cycles of platinum-based chemotherapy for patients unlikely to achieve complete cytoreduction through primary surgery [14]. Meanwhile, the National Comprehensive Cancer Network (NCCN) suggested 3–6 cycles of NACT followed by interval debulking surgery for similar patients [10]. This study was conducted to explore the optimal number of NACT cycles in terms of response and survival outcomes for patients with advanced ovarian cancer who are not candidates for primary cytoreductive surgery.
In this study, 56% of the 207 patients recruited were considered irresectable at diagnosis. These patients were categorized into two groups: Group I (130 patients) received four or fewer NACT cycles, while Group II (77 patients) received 5–6 cycles. This was justified that extending treatment beyond four cycles in Group II could improve the possibility of optimal cytoreduction, based on multidisciplinary team discussions. Most of these patients had stage IV disease and stable conditions following 3–4 cycles of NACT.
Previous studies by Marchetti et al. [15] and Phillips et al. [16] have highlighted that achieving optimal cytoreduction is a critical independent prognostic factor, irrespective of the number of NACT cycles. In this study, optimal cytoreduction was achieved in 70% of patients, consistent with rates reported in the literature [16, 17]. However, no significant difference in optimal cytoreduction, pathological response, or radiological response (complete or partial) was observed between the groups receiving fewer or more than four NACT cycles. This finding contrasts with Marchetti et al. [15], who reported a significant increase in response rates with prolonged NACT [18].
Additionally, no significant differences were reported in terms of surgical approach (laparotomy vs. laparoscopy), surgical morbidity, or mortality between the two groups. This discrepancy may be attributed to heterogeneity among the included patients and the lack of baseline homogeneity in surgical scores. Conversely, higher rates of optimal cytoreduction and reduced surgical morbidity were reported in some studies in which patients received six NACT cycles [18].
While Bell et al. [19] reported reduced recurrence risk by 24% in patients with serous histology who received six NACT cycles, this was not replicated in the present study. Here, the recurrence risk or type (platinum-sensitive or resistant) was not impacted by the number of NACT cycles.
Regarding survival outcomes, no significant differences in OS or relapse-free survival (RFS) were observed between short and long NACT courses. This aligns with previous studies reporting no survival advantage with extended NACT [15, 20]. However, other research, including a retrospective analysis from Memorial Sloan Kettering Cancer Center, indicated worse PFS and OS with five or more NACT cycles, even after accounting for factors like Breast cancer gene (BRCA) mutation status and complete resection [21]. Marchetti et al. [15] also found no difference in overall survival patterns based on NACT duration, though BRCA mutations were associated with improved survival in univariate analyses. These findings are supported by a recent large meta-analysis that included more than 7000 advanced ovarian cancer patients from 22 studies. The authors reported that more neoadjuvant cycles (>3–4 NACT) were associated with worse overall survival, and that patients who received 5 or more NACT experienced worse PFS. Although they did not find enough evidence to determine the optimal number of NACT cycles before surgery, they reported that patients who received less NACT cycles were associated with better prognosis [22].
Residual disease remains the most important prognostic factor for OS, irrespective of the number of NACT cycles. Betrian et al. [23]. also found no difference in OS or RFS concerning the number of NACT cycles. However, their study suggested that poor response to NACT, regardless of cycle count, is a surrogate marker for higher recurrence risk, as these patients suffer from high peritoneal cancer index which makes it more difficult to achieve complete cytoreduction [23].
Interestingly, this study noted a significant difference in the total perioperative chemotherapy dose, with patients receiving five or more NACT cycles having a higher median dose (eight vs. six cycles, p < 0.001). This aligns with NCCN guidelines, which recommend at least three cycles of adjuvant chemotherapy following ICS, regardless of NACT cycles [10].
5. Conclusions
Administering more than four cycles of neoadjuvant chemotherapy in patients with advanced epithelial ovarian cancer is not associated with improvement in either response rates, chance for optimal cytoreduction, or survival outcomes. Furthermore, extended NACT did not reduce recurrence risk or alter its type. Future randomized controlled trials are needed to clarify the optimal number of NACT cycles, assess the role of baseline surgical scores, and incorporate molecular markers to refine treatment strategies.
6. Strengths and limitations
6.1 Strengths
1. Comprehensive Data Collection: The study provides detailed epidemiological, clinical, radiological and surgical data, offering a thorough analysis of patients with advanced ovarian cancer.
2. Subgroup Analysis: Dividing patients based on the number of neoadjuvant chemotherapy (NACT) cycles and comparing their outcomes enhances the study’s ability to draw nuanced conclusions.
3. Real-World Relevance: The inclusion of a broad patient population with diverse clinical presentations (e.g., varying stages, comorbidities and surgical outcomes) reflects real-world clinical scenarios.
4. Focus on Survival and Recurrence Outcomes: The study evaluates key clinical endpoints, including overall survival (OS), relapse-free survival (RFS) and recurrence, which are critical for clinical decision-making.
5. Alignment with Guidelines: The discussion places findings in the context of established guidelines (ASCO, SGO, NCCN), ensuring relevance to clinical practice.
6.2 Limitations
1. Retrospective Design: The retrospective nature of the study may introduce biases, such as selection bias and unmeasured confounders, which could affect the reliability of the results.
2. Small Sample Size in Subgroups: The division of patients into subgroups (≤4 cycles vs. ≥5 cycles) may limit the statistical power to detect significant differences, especially in survival outcomes.
3. Lack of Molecular Data: The absence of molecular markers, such as BRCA mutations, limits the ability to explore personalized treatment approaches.
4. Heterogeneity in Treatment: Variations in the number of adjuvant chemotherapy cycles and surgical approaches (e.g., laparotomy vs. laparoscopy) may have confounded the outcomes.
5. Limited External Validity: Findings may not be generalizable to all populations due to potential differences in patient demographics, healthcare systems or clinical practices.
6. No Randomization: The non-randomized allocation of patients to different NACT cycles weakens the ability to infer causality between the number of cycles and outcomes.
7. Implications for practice and research
Further randomized controlled trials are required to resolve the debate about the ideal number of NACT cycles in advanced ovarian cancer and to explore the impact of molecular profiles and surgical scoring on treatment outcomes.
Availability of data and materials
All data generated or analyzed during this study are available in supplementary tables.
Author contributions
RA—contributed to the conceptualization, methodology, data collection and drafting of the original manuscript. BR—supervised the study, validated the results and reviewed and edited the manuscript. HA—was involved in investigation, data analysis and visualization. WMEK—handled data curation, resources and project administration. DHS—conducted a formal analysis, contributed to the result interpretation, and participated in reviewing and editing the manuscript. MZ—supported data analysis, software utilization and visualization. SE—conducted the investigation, performed a literature review, and contributed to draft preparation. IHM—provided supervision, conceptualization, validation, funding acquisition, study design and reviewing and editing the manuscript. All authors actively participated in the preparation of this manuscript, including the cases they performed. They reviewed the completed manuscript and gave their approval for publication.
Ethics approval and consent to participate
Mansoura Faculty of Medicine Institutional Review Board (MFM-IRB) https://irb.mans.edu.eg/ approved the study and waived informed consent (Approval No: R.22.01.1601). All procedures performed in the study were per the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments.
Acknowledgment
Not applicable.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.
Conflict of interest
The authors declare no conflict of interest. Basel Refky is serving as one of the Guest editors of this journal. We declare that Basel Refky had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to SC.
Supplementary material
Supplementary material associated with this article can be found, in the online version, at https://oss.ejgo.net/files/article/1956173559716823040/attachment/Supplementary%20material.docx.
