Introduction
Epithelial ovarian cancer (EOC) is the leading cause of death among
gynaecological cancers in many countries.1−3 Most
patients with chemotherapy-sensitive disease develop
chemotherapy-resistant relapse after undergoing several lines of
therapy. Maintenance therapy with targeted agents following primary
cytoreductive surgery and chemotherapy to extend the progression-free
interval (PFI) is promising for improving EOC
prognosis.4,5 Bevacizumab (BEV) can improve overall
response rates in front-line or relapse therapy
settings.5,6 Front-line chemotherapy with BEV
throughout improved progression-free survival (PFS) in the
GOG-2187 and ICON7trials8 and
prolonged overall survival (OS) in GOG-218 stage IV and ICON7-defined
high-risk patients.9,10 The reductions in the risk of
progression or death by adding BEV to chemotherapy were observed in
platinum-sensitive recurrent EOC in the OCEANS11 and
GOG-213 trials,12 respectively. A 52% reduction in
the risk of progression or death was seen in platinum-resistant
recurrent EOC in AURELIA.13 However, OS was not
significantly extended.9,11−13
BEV-related adverse effects (AEs) are well
understood.7,8,11−14 Patients treated with BEV
experienced a higher incidence of hypertension, proteinuria,
gastro-intestinal (GI) and non-central nervous system (non-CNS) bleeding
events, and thromboembolism (TE) than those not treated with BEV.
Based on these large clinical trials, BEV is used as the standard of
care in EOC patients in many countries. However, the medical cost of
adding BEV to chemotherapy may make this treatment unaffordable for EOC
patients if it is not covered by the national health insurance (NHI).
Moreover, the disease status in real-world patients is much more complex
than that in clinical trials. Some real-world investigations have
focused on the impact on PFS and AEs when BEV is added to front-line
treatment.15−17 More real-world data to compare BEV
effects on prognosis in recurrent EOCs or AEs between patients with or
without prior BEV treatment are needed to assess
cost-effectiveness.18−20
Therefore, our study focused on EOC/tubal cancer (TC)/primary peritoneal
cancer (PPC) patients who underwent front-line paclitaxel-carboplatin
chemotherapy ± BEV or those with recurrent/persistent disease who
underwent BEV ± chemotherapy. Our primary aim was to describe the
correlation between clinico-pathological factors and physician-patient
shared-decision making (SDM), as well as the survival benefits of adding
BEV to front-line chemotherapy. Secondarily, we aimed to determine the
safety of combination regimens of BEV plus chemotherapy, with or without
prior BEV use. We aimed to identify advanced-stage or ICON7-defined
high-risk patients who may have a more favourable outcome in the
front-line setting and predict which subgroup has a better prognosis
after adding BEV.