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.