Timing of cytoreductive surgery does not impact OS in ovarian cancer

Primary cytoreductive surgery (PCS) in patients with advanced, resectable ovarian cancer offers no significant improvement in overall survival (OS) compared with interval cytoreductive surgery (ICS). However, in selected participants from the phase 3 TRUST study, PCS was associated with improved progression-free survival (PFS).

The goal of surgery in advanced ovarian cancer is to prolong remission, improve OS, and maintain quality-of-life. Complete gross tumour resection is consistently associated with a favourable prognosis [1]. PCS followed by systemic therapy has been considered the standard-of-care for decades. However, neoadjuvant chemotherapy followed by ICS and then systemic therapy has emerged as an alternative strategy [2,3]. The optimal timing of surgery in resectable advanced ovarian cancer remains uncertain.

“The phase 3 TRUST study (NCT02828618) evaluated the optimal timing of maximal effort cytoreductive surgery in patients with advanced ovarian cancer,” explained Dr Sven Mahner (LMU University Hospital Munich, Germany) [4]. In total, 796 participants were randomised 1:1 to receive PCS or ICS. The primary endpoint was OS; key secondary endpoints included PFS, complete resection rate, and quality-of-life.

TRUST did not meet its primary endpoint: median OS was 54.3 months in the PCS arm versus 48.3 months in the ICS arm (HR 0.89; 95% CI 0.74–1.08; P=0.24). However, PCS resulted in a statistically significant improvement in median PFS: 22.1 months versus 19.7 months in the ICS arm (HR 0.80; 95% CI 0.66–0.96; P=0.018). “The PFS benefit of PCS was most evident in participants with FIGO stage III disease and those who achieved complete gross resection,” said Dr Mahner.

Surgical morbidity was low in both groups, with complications reported in 18% and 12% of participants in the PCS and ICS arms, respectively. No significant differences in quality-of-life scores were observed at any timepoint.

“TRUST is the first randomised phase 3 trial to demonstrate a PFS benefit of primary over interval cytoreductive surgery, without compromising short- or long-term quality-of-life,” concluded Dr Mahner.

1. Bristow RE, et al. J Clin Oncol. 2023;41:4065-4076.
2. Fagotti A, et al. Int J Gynecol Cancer. 2020;30:1657-1664.
3. Onda T, et al. Eur J Cancer. 2020;130:114-125.
4. Mahner S, et al. TRUST: Trial of radical upfront surgical therapy in advanced ovarian cancer. LBA5500, ASCO Annual Meeting 2025, 30 May–3 June, Chicago, IL, USA.

Medical writing support was provided by Dr Marten Dooper.
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Posted on 5 June 202530 July 2025