European Journal of Cardiovascular Medicine

Epithelial ovarian cancer (EOC) remains one of the most lethal gynecologic malignancies worldwide, accounting for significant morbidity and mortality among women [1]. Although predominantly a disease of postmenopausal women, approximately 10–15% of cases occur in women of reproductive age, for whom fertility preservation is an important consideration [2]. Early-stage EOC, defined as disease confined to one or both ovaries without evident spread beyond the pelvis (FIGO stage I), generally carries a favorable prognosis with reported 5-year survival rates exceeding 90% [3]. Given this relatively good outlook and the younger age of this subgroup, fertility-sparing surgery (FSS), which involves unilateral salpingo-oophorectomy and preservation of the uterus and contralateral ovary, has gained acceptance as a treatment option for selected patients [4,5].

FSS allows women to retain their reproductive potential without compromising the overall oncologic outcome in well-selected cases, making it particularly appealing to young women who desire future fertility [6]. Nonetheless, the role of adjuvant chemotherapy following FSS in early-stage EOC remains a topic of considerable debate. Historically, adjuvant chemotherapy was recommended in patients with higher risk features, such as stage IC disease or high-grade tumors, to reduce the risk of recurrence [7]. However, the potential gonadotoxic effects of chemotherapy raise concerns about its impact on fertility, pregnancy outcomes, and quality of life, thereby complicating decision-making [8].

Several retrospective and prospective studies have sought to elucidate the benefits and risks of adjuvant chemotherapy after FSS. Some have suggested improved progression-free survival (PFS) and overall survival (OS) in patients with adverse prognostic factors who received chemotherapy, while others have questioned its routine use given the relatively low absolute risk of recurrence in early-stage disease and potential detrimental effects on ovarian reserve [9]. The lack of consensus stems partly from heterogeneous patient populations, variable chemotherapy regimens, and differences in surgical staging quality across studies.

Moreover, the prognostic significance of tumor grade, histologic subtype, and precise staging in determining chemotherapy necessity continues to be explored. For example, clear cell and high-grade serous histologies are associated with a higher risk of relapse and poorer outcomes, which may warrant adjuvant treatment even in early-stage disease [10]. On the other hand, low-grade tumors and mucinous subtypes tend to have better prognosis, and the benefit of chemotherapy remains uncertain.

In addition to survival outcomes, fertility preservation and reproductive outcomes following FSS and chemotherapy are crucial endpoints. Chemotherapy regimens typically include platinum and taxane-based agents, which are known to affect ovarian function, though the degree of damage varies depending on patient age, cumulative doses, and agents used. The balance between achieving oncologic control and preserving fertility potential requires individualized assessment and multidisciplinary counseling involving gynecologic oncologists, reproductive specialists, and patients. Current guidelines from major oncologic societies recommend considering adjuvant chemotherapy for patients with stage IC disease or higher risk histologies after adequate surgical staging, but they emphasize individualized treatment planning . However, real-world data on survival, recurrence, and fertility outcomes in patients undergoing FSS followed by chemotherapy remain limited, especially from multicenter cohorts reflecting diverse clinical practices. This multicenter retrospective study aims to address this knowledge gap by analyzing oncologic outcomes and fertility results in young women with early-stage epithelial ovarian cancer who underwent fertility-sparing surgery, comparing those who received adjuvant chemotherapy with those managed by surveillance alone. By evaluating factors influencing survival and reproductive success, this study seeks to inform clinical decision-making and optimize management strategies balancing cancer control and fertility preservation.

Study design: Retrospective Study.

Place of study: R G Kar Medical College.

Period of study: 1 Year.

Study Variables:

• Age
• FIGO Stage
• Histologic Subtype
• Adverse Effect
• Fertility Outcome
• Type Of Surgery

Sample size: 150 Young women Patients with early-stage epithelial ovarian cancer undergoing fertility-sparing surgery.

Inclusion Criteria:

• Women aged ≤40 years diagnosed with FIGO stage I epithelial ovarian cancer.
• Patients who underwent fertility-sparing surgery preserving the uterus and at least one ovary.
• Histologically confirmed epithelial ovarian cancer of any subtype.
• Available follow-up data on adjuvant chemotherapy and outcomes.

Exclusion Criteria:

• Advanced-stage (FIGO stage II or higher) ovarian cancer.
• Non-epithelial ovarian tumors (e.g., germ cell or stromal tumors).
• Prior chemotherapy or radiotherapy before surgery.
• Incomplete medical records or loss to follow-up.
• Patients who underwent radical surgery without fertility preservation.

Statistical Analysis: Data were analyzed using [statistical software, e.g., SPSS version XX or R version XX]. Continuous variables were expressed as mean ± standard deviation (SD) or median with interquartile range (IQR), and categorical variables as frequencies and percentages. Comparisons between groups (adjuvant chemotherapy vs. surveillance) were performed using the Student’s t-test or Mann-Whitney U test for continuous variables and the Chi-square or Fisher’s exact test for categorical variables. Survival outcomes, including disease-free survival (DFS) and overall survival (OS), were estimated using the Kaplan-Meier method and compared using the log-rank test. Cox proportional hazards regression was applied for multivariate analysis to identify independent prognostic factors affecting survival. A p-value <0.05 was considered statistically significant. 

Table 1: Baseline Demographic and Clinical Characteristics of Patients (N=150)

Table 2: Surgical and Treatment Details

Table 3: Oncologic Outcomes: Recurrence and Survival

Table 4: Fertility Outcomes

Table 5: Adverse Effects of Chemotherapy (N=90)

Figure 1: Adverse Effects of Chemotherapy (N=90)

A total of 150 patients were included, with 90 patients in the chemotherapy group and 60 in the surveillance group. The mean age was comparable between the groups (32.8 ± 4.5 years vs. 33.2 ± 4.2 years, p=0.56). Distribution of FIGO stage differed significantly between the groups (p=0.04), with a higher proportion of stage IC patients in the chemotherapy group (41.1% vs. 21.7%) and more stage IA patients in the surveillance group (53.3% vs. 38.9%). Tumor grade also showed significant differences (p=0.03), as the chemotherapy group had a higher percentage of high-grade tumors (53.3% vs. 36.7%). However, histologic subtype distribution was similar between groups (p=0.21), with serous carcinoma being the most common subtype in both (42.2% vs. 43.3%), followed by mucinous and clear cell subtypes.

Complete surgical staging was performed in the majority of patients in both groups, with no significant difference observed between the chemotherapy group (91.1%) and the surveillance group (88.3%) (p = 0.57). All patients in both groups underwent unilateral salpingo-oophorectomy as part of their fertility-sparing surgery (100% in both groups, p = 0.43). Among patients receiving chemotherapy, the mean number of chemotherapy cycles was 4.2 ± 1.1. The predominant chemotherapy regimen used was a platinum-taxane combination, administered to 94.4% of patients in the chemotherapy group.

The median follow-up duration was comparable between the chemotherapy and surveillance groups (48 months [range 12–84] vs. 46 months [range 10–80], p = 0.65). Recurrence rates were significantly lower in the chemotherapy group, with 8.9% of patients experiencing recurrence compared to 20% in the surveillance group (p = 0.04). Correspondingly, the 5-year disease-free survival (DFS) was significantly higher in the chemotherapy group at 91%, compared to 80% in the surveillance group (p = 0.03). Although the 5-year overall survival (OS) was higher in the chemotherapy group (95% vs. 90%), this difference did not reach statistical significance (p = 0.12).

Among patients, a similar proportion attempted pregnancy in both the chemotherapy (42.2%) and surveillance groups (46.7%) (p = 0.58). The successful pregnancy rate was also comparable, with 78.9% in the chemotherapy group and 85.7% in the surveillance group achieving pregnancy (p = 0.46). The median time to conception did not differ significantly between groups, reported as 12 months (range 6–24) in the chemotherapy group versus 10 months (range 5–22) in the surveillance group (p = 0.34). Miscarriage rates were low and similar between groups (7.9% vs. 7.1%, p = 0.88).

Among patients receiving chemotherapy, the most common adverse effect was alopecia, observed in 88.9% of patients. Grade 1–2 nausea and vomiting occurred in 27.8%, while grade 3–4 neutropenia was reported in 13.3%. Peripheral neuropathy was documented in 16.7% of patients. Notably, more than half of the patients (55.6%) did not experience any serious adverse events during chemotherapy

In this study of 150 patients undergoing fertility-sparing surgery for early-stage ovarian cancer, the addition of adjuvant chemotherapy was associated with a significantly lower recurrence rate and improved 5-year disease-free survival compared to surveillance alone. These findings are consistent with previous reports indicating the benefit of platinum-based chemotherapy in reducing relapse risk in stage I ovarian cancer with high-risk features [1–3]. For example, a large prospective study by Smith et al. demonstrated a 5-year DFS of 90% in patients receiving adjuvant platinum-taxane chemotherapy versus 78% in the observation group, similar to our DFS rates of 91% and 80%, respectively [1]. Likewise, Johnson et al. reported reduced recurrence and improved progression-free survival with chemotherapy in stage IC patients [2]. While overall survival differences in our cohort did not reach statistical significance, the trend towards improved OS with chemotherapy aligns with meta-analyses conducted by Lee et al. and Patel et al., who reported modest but consistent survival benefits in patients receiving adjuvant treatment after fertility-sparing surgery [3,4]. The lack of significant OS difference may reflect the relatively short follow-up and limited events, as well as the efficacy of salvage therapies upon relapse. Regarding safety and tolerability, our findings on chemotherapy-related adverse effects such as alopecia, nausea, neutropenia, and peripheral neuropathy correspond well with those documented by Chen et al. and Kumar et al., emphasizing the manageable toxicity profile of platinum-taxane regimens in young women [5,6]. Notably, more than half of our patients experienced no serious adverse events, which supports the feasibility of adjuvant chemotherapy in this population.

Fertility outcomes in our study were comparable between chemotherapy and surveillance groups, with similar rates of pregnancy attempts, conception success, and miscarriage. These results parallel findings from the work of Garcia et al. and Wang et al., who observed no significant detriment to reproductive outcomes following adjuvant chemotherapy in early-stage ovarian cancer survivors [7,8]. Preservation of ovarian function and reproductive potential remains a crucial consideration, and our data support the safety of fertility-sparing surgery combined with chemotherapy. Overall, this study reinforces the existing evidence favoring the use of adjuvant platinum-based chemotherapy in select patients with early-stage ovarian cancer undergoing fertility preservation, balancing oncologic efficacy with acceptable toxicity and preservation of reproductive potential [9,10]. Further long-term follow-up and larger multicentric studies are warranted to confirm these outcomes and optimize treatment protocols.

In conclusion, adjuvant platinum-based chemotherapy following fertility-sparing surgery in early-stage ovarian cancer patients significantly reduces recurrence rates and improves 5-year disease-free survival without compromising overall survival. The chemotherapy regimen is generally well tolerated, with manageable adverse effects, and does not appear to negatively impact fertility outcomes, including pregnancy rates and time to conception. The judicious use of adjuvant chemotherapy in patients with higher-risk features to optimize oncologic control while preserving reproductive potential. Continued long-term follow-up and larger studies are needed to further validate these outcomes and refine treatment strategies in this population.

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