Significant advances in medical treatment options and surgical techniques over recent years have resulted in improved outcomes for patients with recurrent, platinum-sensitive ovarian cancer. The management of ovarian cancer now extends beyond the traditional combination of surgery and chemotherapy to include numerous targeted therapies.

Expanded surgical techniques and their application in the management of patients with recurrent, platinum-sensitive ovarian cancer have been studied in three randomized controlled trials—the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO) Desktop III trial, the SOC-1 trial, and the GOG-0213 trial [[1], [2], [3]]. In Desktop III, the median overall survival (OS) for patients who underwent secondary cytoreductive surgery (SCS) followed by chemotherapy was 53.7 months compared with 46 months for patients who received chemotherapy alone [1]. Similarly, SOC-1 trial interim OS data showed a median OS of 58.1 months in the SCS arm compared with 53.9 months in the no surgery arm [2]. While GOG-0213 trial data did not show an OS benefit for secondary surgical resection, key study differences included the application of surgical case selection criteria and the high rate of bevacizumab maintenance use in both study arms [3]. The Food and Drug Administration (FDA) approved bevacizumab maintenance for recurrent, platinum-sensitive ovarian cancer in 2016 [4].

In parallel, the findings of several key studies of targeted therapies, such as Poly(ADP-ribose) polymerase (PARP) inhibitors, have expanded the treatment armamentarium of recurrent, platinum-sensitive ovarian cancer. PARP inhibitors prevent repair of single-strand DNA breaks, resulting in double-strand breaks, which leads to DNA damage and tumor cell death [5]. Data from three phase 3 trials demonstrated improvement in progression-free survival (PFS) with PARP inhibitor maintenance therapy for recurrent, platinum-sensitive ovarian cancer [[6], [7], [8]]. The ENGOT-OV16/NOVA trial showed niraparib maintenance significantly improved PFS following response to platinum-based chemotherapy for recurrent, platinum-sensitive ovarian cancer, regardless of BRCA status [6]. Study 19 (NCT00753545) showed improvement in PFS with the PARP inhibitor olaparib as maintenance versus placebo (8.4 vs 4.8 months, respectively; HR: 0.35; 95% CI: 0.25–0.49; p < 0.0001) [9]. The SOLO2 trial showed improvement in PFS with olaparib over placebo (19.1 vs 5.5 months, respectively) among BRCA1/2 mutation carriers, and included both high-grade serous and high-grade endometrioid histologic subtypes [7]. The results of the SOLO2 and Study 19 trials led to FDA approval of olaparib maintenance therapy in the recurrent setting in 2017. Furthermore, the PARP inhibitor rucaparib, which significantly improved PFS in patients with recurrent, platinum-sensitive ovarian cancer, was approved in 2018. In patients with a BRCA mutation, median PFS was 16.6 months compared with 5.4 months in the placebo arm [8].

In 2020, the American Society of Clinical Oncology (ASCO) guidelines were updated to state that PARP inhibitor maintenance with olaparib, rucaparib, or niraparib should be considered in patients with response to platinum-based chemotherapy for recurrent, platinum-sensitive ovarian cancer who have not received prior treatment with a PARP inhibitor. Although the greatest benefit with PARP inhibitors had been seen in patients with a deleterious BRCA alteration, the initial approvals did not consider BRCA mutation status [10]. However, the FDA subsequently restricted the use of niraparib and rucaparib to patients with BRCA mutations based on emerging OS data [11].

With the above data to support bevacizumab and PARP inhibitor maintenance for recurrent, platinum-sensitive ovarian cancer, there is now a growing dataset of patients from which to evaluate oncologic outcomes when SCS is included as a component of management. As suggested by the high rate of bevacizumab use in GOG-0213, with no reported OS benefit with SCS in that trial, we sought to determine whether expanding the use of targeted therapies for recurrent, platinum-sensitive ovarian cancer abrogates the benefit of SCS. Of note, the impact of PARP inhibitor maintenance was not investigated in the three randomized controlled trials evaluating SCS given the time of study accrual. We therefore sought to evaluate SCS outcomes with the expanding use of targeted maintenance therapies. We used a comparative study design to evaluate SCS outcomes pre and post FDA approval of PARP inhibitor and bevacizumab maintenance for recurrent, platinum-sensitive ovarian cancer.