Comparative efficacy and safety of different treatment strategies for primary advanced ovarian cancer: a systematic review and network meta-analysis of randomized control trials

Background: For patients with primary advanced ovarian cancer (OC), multiple treatment strategies based on cytoreductive surgery and adjuvant chemotherapy are available, but the optimal strategy remains undetermined. This network meta-analysis (NMA) aims to evaluate the efficacy and safety of primary debulking surgery (PDS), interval cytoreductive surgery (IDS) and IDS combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in treating primary advanced OC. Methods: We conducted a comprehensive search of PubMed, EMBASE, Web of Science, and the Cochrane Library databases, covering publications up to June 23, 2025. The surface under the cumulative ranking curve (SUCRA) was used to assess the probability that each treatment strategy would be the better choice for each outcome. Results: Seven RCTs involving 2,058 patients were included in this NMA. Based on the SUCRA values, the IDS plus intraoperative HIPEC strategy achieved the highest ranking for overall survival (OS; SUCRA = 0.99) and disease-free survival (DFS; SUCRA = 0.99). Meanwhile, the addition of intraoperative HIPEC did not increase major postoperative complications (SUCRA = 0.68) or prolong the duration of hospital stay (SUCRA = 0.47). IDS could enhance the complete resection rate (SUCRA = 0.81) and reduce major postoperative complications (SUCRA = 0.75). Conclusions: Until new evidence becomes available, IDS plus intraoperative HIPEC are associated with better OS and DFS for patients with primary advanced OC. Besides, IDS had advantages in increasing the complete resection rate and reducing major postoperative complications.