Ovarian cancer and malnutrition: a literature review

Introduction

Overview of ovarian cancer and malnutrition

Ovarian cancer remains a significant global health issue, being the eighth most common cancer among women and responsible for a considerable number of cancer-related deaths (1). Ovarian cancer accounts for approximately 23% of all gynecological cancer diagnoses but is responsible for 47% of all deaths from gynecological cancer (2). According to World Cancer Research Fund (https://www.wcrf.org/cancer-trends/ovarian-cancer-statistics/), in 2022, there were 324,603 new cases of ovarian cancer and 206,956 related deaths worldwide. Approximately 70% of newly diagnosed patients and 85% of those who experience relapse may have peritoneal metastasis, leading to symptoms such as abdominal pain, bloating, and decreased appetite, which can affect nutritional intake (3). The disease places the body in a high metabolic state, increasing the risk of malnutrition (4).

Malnutrition is a significant concern for patients with ovarian cancer, particularly those undergoing chemotherapy, due to its potential to exacerbate side effects, impair recovery, and worsen overall survival (OS) outcomes. Based on the Subjective Global Assessment (SGA) and Patient-Generated SGA (PG-SGA) scores, 24% of patients with gynecological cancer are classified as malnourished, with the highest prevalence among those with ovarian cancer (67%) (5). The incidence of malnutrition can be as high as 75% in patients with associated bowel obstruction. Furthermore, about 23% of patients are diagnosed with cachexia (6).

Although the relationship between malnutrition and poor clinical outcomes such as complications, prolonged hospital stays, and reduced quality of life (QoL) is well-documented, the mechanisms through which traditional treatments such as chemotherapy, tumor progression, and newer therapies such as PARP inhibitors contribute to nutritional decline have not been completely clarified. Despite the recognized importance of nutritional intervention, it remains under-addressed in clinical settings, and there is limited research on the multifaceted factors contributing to nutritional decline in patients with ovarian cancer.

This review was thus conducted to address the deficiencies in understanding regarding malnutrition in ovarian cancer via a focus on the nutritional challenges these patients face, particularly the underexplored impact of PARP inhibitors. We also evaluated the role of early nutritional assessment and intervention in addressing these challenges and improving patient outcomes. The ultimate goal is to identify more effective strategies for the prevention and management of malnutrition and to optimize the overall therapeutic strategy for patients with ovarian cancer. We present this article in accordance with the Narrative Review reporting checklist (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-758/rc).

Methods

The MEDLINE, Embase, Cochrane, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched from inception until November 2024. One author (Z.S.) screened the title and abstracts of the retrieved records for keywords and reviewed the full text of all relevant publications for eligibility. The search strategy was limited to English-language articles, and there were no restrictions on date of publication. The search strategy is described in Table 1.

Causes of malnutrition in ovarian cancer

Tumor progression-related factors

Patients with ovarian cancer often experience loss of appetite, which may be related to hormones such as leptin and ghrelin secreted by the tumor. The levels and mechanisms of action of these hormones are altered in those with cancer, leading to decreased appetite and reduced food intake (7,8). Moreover, advanced ovarian cancer can cause bowel obstruction and ascites (fluid accumulation in the abdomen), leading to nausea, vomiting, and early satiety, which reduce food intake (9).

Ovarian cancer can cause systemic inflammatory response in the body. Inflammatory factors [such as tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and interleukin-1 beta (IL-1β)] secreted by tumor cells and their microenvironment activate signaling pathways such as nuclear factor kappa beta (NF-κB) and signal transducer and activator of transcription 3 (STAT3) (10-12). Activation of these inflammatory factors and signaling pathways can lead to increased protein catabolism, fat decomposition, and decreased appetite, leading to malnutrition (13).

Ovarian cancer places the body in a hypercatabolic state and consumes a large amount of energy and nutrients (such as glucose and amino acids) to support the rapid growth of the tumor (14). This leads to an insufficient supply of energy and nutrients for normal cells. In addition, ovarian cancer can also cause enhanced gluconeogenesis in the liver, leading to an increased demand for glucose in the liver, leading to systemic malnutrition. The substantial consumption of energy by tumors leads to rapid depletion of fat and muscle reserves in patients. These may explain why about 23% of patients with ovarian cancer have cachexia at the time of diagnosis (6).

Treatment-related factors

The conventional treatment for advanced epithelial ovarian cancer is primary debulking surgery (PDS) and postoperative platinum-based adjuvant chemotherapy. If there is tumor involvement or invasion, multiple organs need to be removed to achieve satisfactory cytoreduction, usually including the intestines, which can directly affect nutritional intake and absorption. Epithelial ovarian cancer accounts for 90% of all cases (4).

Nausea and vomiting are common side effects of chemotherapy. A meta-analysis of 1,213 patients with recurrent ovarian cancer found that 58.1% of patients experienced nausea and 31.0% experienced vomiting, which can greatly reduce appetite and food intake. Mucositis and altered taste can make eating uncomfortable or unpalatable (15). Studies have shown that platinum-based chemotherapy regimens, commonly used for ovarian cancer, produce significant gastrointestinal reactions, which can lead to a significant reduction in dietary intake and consequently affect nutritional status (16,17).

Poly (ADP ribose) polymerase (PARP) inhibitors are a newer form of treatment for ovarian cancer, and several large clinical studies have shown the potential to cause decreased appetite, dysgeusia, nausea, and vomiting (18); these are summarized in Table 2 (19-28).

Although several large clinical studies have reported gastrointestinal side effects of PARP inhibitors, there is still a lack of high-quality, prospective studies directly linking PARP inhibitor use to malnutrition in ovarian cancer patients (19-28). Existing evidence primarily focuses on individual symptoms such as nausea, vomiting, or dysgeusia, rather than comprehensive nutritional outcomes. Furthermore, most clinical trials of PARP inhibitors were conducted in relatively homogenous populations, limiting their generalizability to patients from diverse ethnic and socioeconomic backgrounds.

To address this gap, future research should include nutritional endpoints in trials of PARP inhibitors, such as weight change, nutritional risk screening scores, and quality-of-life (QoL) measures. Subgroup analyses by age, comorbidities, and ethnicity would also help clarify how different populations may be disproportionately affected. Multicenter observational studies or randomized trials incorporating nutritional assessments could provide much-needed insight into the long-term nutritional impact of PARP inhibitors.

Psychological and economic factors

The psychological stress and emotional problems caused by cancer and its treatment may also affect patients’ eating behavior and nutritional status. For example, anxiety and depression may lead to a loss of appetite, thereby affecting nutrient intake (29).

Financial difficulties may limit patients’ ability to obtain high-quality food, especially when long-term treatment is required. In addition, economic pressure may also reduce patients’ overall QoL and indirectly impair their nutritional status (30).

Adverse effects of malnutrition in ovarian cancer

Malnutrition, cachexia, and sarcopenia in ovarian cancer

Malnutrition, cachexia, and sarcopenia have highly similar symptoms and often overlap. Malnutrition is a state of energy or nutrient deficiency caused by insufficient intake or utilization disorders, which in turn leads to changes in body composition, decreased physiological and mental functions, and adverse clinical outcomes. Cachexia, characterized by severe weight loss, muscle wasting, and fatigue, is common in patients with cancer. It is driven by a combination of metabolic changes induced by the tumor and inflammatory responses. Sarcopenia is a syndrome caused by progressive, widespread reduction in skeletal muscle mass, decreased muscle strength, and decreased human function, which is associated with an increased risk of adverse outcomes such as decreased motor ability, decreased QoL, and increased mortality.

Clinically, these three phenotypes often coexist and cannot be easily or completely differentiated (31-33). A study has found that 80% of older adult patients with cancer have at least one of these conditions, and 30% have all three (34). Indeed, malnutrition, cachexia, and sarcopenia have both similarities and differences.

Surgical outcomes

Malnutrition in women with ovarian cancer has been related to outcomes from surgery. Multiple studies have consistently shown that R0 resection is the most important factor related to the prognosis of patients with ovarian cancer (12,35). A prospective study enrolling 152 patients with ovarian cancer found that patients with age >65 years, ascites >500 mL, or platinum-resistant ovarian cancer had a significantly increased risk of a Nutritional Risk Score 2002 (NRS-2002) ≥3 (P=0.014, 0.001, and 0.007, respectively). In addition, NRS-2002 <3 was an independent predictor of complete tumor resection (P=0.009) (36).

Skeletal muscle mass reflects nutritional status. In a study that included 75 consecutive patients with advanced-stage ovarian cancer who underwent elective surgery, 26% of patients had sarcopenia. The results indicated that compared with patients without sarcopenia, patients with sarcopenia had a higher incidence of postoperative complications, especially nonsurgical complications (such as pneumonia, urinary tract infection, and cardiac complications). In addition, length of stay and mortality were significantly higher in patients with sarcopenia (37).

When surgery is required to treat intestinal obstruction, a common complication of ovarian cancer, malnutrition (as manifest by weight loss, low serum albumin, or low lymphocyte count) is a factor significantly associated with poor surgical outcomes, lower postoperative survival, and increased rates of postoperative infectious complications (38-40).

Length of hospital stay

Malnutrition is associated with the incidence and length of hospital stay of patients with ovarian cancer. A cohort study enrolled 157 patients with suspected or confirmed gynecologic neoplasms. Malnutrition (PG-SGA score group B or C), low health-related QoL (functional assessment of cancer therapy-general score) and diagnosis of advanced ovarian cancer were found to be the main factors contributing to prolonged hospitalization (41). Another study analyzed the National Surgical Quality Improvement Program database and included 290 patients who underwent surgery for ovarian, uterine, or cervical cancer. The study found that for patients with ovarian cancer, malnutrition [body mass index (BMI) <18.5 kg/m²], as defined by the European Society for Clinical Nutrition (ESPEN), was associated with higher rates of postoperative complications (risk ratio 1.36), reoperation (risk ratio 2.53), and rehospitalization (risk ratio 1.69). In addition, a serum albumin level <3.5 g/dL was also associated with poor postoperative outcomes in patients with ovarian cancer. The malnourished patients with ovarian cancer had higher rates of readmissions, reoperations, and complications (42).

Progression-free survival (PFS) and OS

Malnutrition may promote tumor metastasis and recurrence. Studies have shown that there is an interaction between malnutrition and tumor metastasis, with the greater the degree of malnutrition, the greater the degree of tumor infiltration and metastasis (43-45).

One study investigated the relationship between protein intake after primary treatment and disease recurrence and survival in patients with ovarian cancer. A higher level of protein intake was associated with better PFS [>1–1.5 g/kg body weight: adjusted hazard ratio (HR) =0.69, 95% confidence interval (CI): 0.48–1.00; >1.5 g/kg: adjusted HR =0.61, 95% CI: 0.41–0.90; >20% total energy intake: adjusted HR =0.77, 95% CI: 0.61–0.96]. A higher level of protein intake was associated with better PFS. The study concluded that protein intake should be encouraged after primary treatment in patients with ovarian cancer (45).

Multiple studies have consistently shown that malnutrition is a common complication in patients with ovarian cancer and is associated with shorter OS and PFS. A prospective study enrolling 152 patients with ovarian cancer found that the median OS for patients with NRS-2002 ≥3 was 7 months (95% CI: 0–24 months), while the median OS for patients with NRS-2002 <3 was 46 months (P=0.001) (36). A retrospective study included 213 patients with advanced ovarian cancer and used the Nutritional Risk Index (NRI) to assess nutritional status. The results showed that the 5-year OS rate of patients with moderate-to-severe malnutrition (45.3%) was significantly lower than that of patients with normal-to-mild malnutrition (64.0%) (44). After adjustments were made for known prognostic factors, the relative risk of death in patients with moderate-to-severe malnutrition was 5.8 times that of those with normal malnutrition, and the PFS was shorter in this group than in the normal-to-mild group (median PFS: 15 vs. 28 months; P=0.011).

There is also a complex link between malnutrition and economic factors which deeply affects the medical and public health fields. One study examined 2,873 cases of ovarian cancer, and after adjustment for comorbid conditions, cancer stage, tumor histology, operation status, and lifestyle factors, it was found that in women with early-stage cancer, the HR for death among less educated women was 1.56 (95% CI: 1.11–2.68), which was higher than that for more educated women; moreover, they had a shorter survival time, thus suggesting socioeconomic differences associated with survival (46).

Although current evidence highlights the association between malnutrition and short-term clinical outcomes such as surgical complications, hospital length of stay, and postoperative readmissions, there is a notable paucity of studies focusing on long-term endpoints. These include OS, PFS, and patient-reported QoL measures. Most existing data are derived from retrospective analyses or cross-sectional studies, which may not fully capture the dynamic changes in nutritional status over the disease trajectory.

Therefore, future studies should prioritize long-term, prospective cohort designs or randomized controlled trials (RCTs) to evaluate the sustained impact of nutritional status and interventions. Incorporating validated QoL instruments and objective nutritional biomarkers could offer a more comprehensive understanding of how malnutrition affects survivorship in ovarian cancer. Longitudinal evidence will also support the development of targeted, stage-specific nutritional strategies and health policies.

Economic implications

Malnutrition increases the cost of treatment and thus increases the burden on the health system. Malnourished patients may require additional health care resources, such as additional nutritional support, management of complications, and specialized care. In one study, 39% of patients with ovarian cancer had a high level of financial burden, and 19% reported that ovarian cancer caused financial difficulties for their families (30). Another study examined the association between financial status, based upon family income and expenses, and QoL in Chinese women with recurrent ovarian cancer. The results indicated that low financial status was associated with poorer QoL scores, and patients with low financial status had a higher risk of a worsening QoL (47). Additionally, frequent hospitalizations and treatments result in an overuse of public healthcare resources, which places additional economic pressure on the healthcare system. One study assessed the burden of malnutrition among 70,855,014 patients receiving care in US hospitals and found that the mean length of hospital stay for malnourished patients was about 9–10 days, which equated to a mean total expenditure of USD 105,925–110,389. These findings demonstrate that malnutrition poses significant clinical and economic burden on patients and the healthcare system (48).

Malnutrition may also lead to reduced work capacity, lower earnings, and decreased productivity. Specifically, patients who are undernourished experience a decline in physical and cognitive functions, which in turn affects their ability to work. For low-income patients in particular, the loss of the ability to work means greater financial stress. In one study that included 6,925 patients with ovarian cancer, unemployed patients were more likely to have a high financial burden (P<0.001). The financial burden on patients included indirect costs of care (e.g., lost work), out-of-pocket costs, housing and heating costs, and transportation (49). When a large number of patients have reduced productivity due to malnutrition, this reduces the available workforce in society, adversely affecting the overall economy.

Socioeconomic factors such as education level, income, insurance coverage, and access to cancer centers significantly affect nutritional support and treatment adherence in ovarian cancer patients. While much of the available institutional data stems from China—owing to the country’s large patient population and centralized healthcare reporting systems—similar patterns have been observed globally. For example, a study from Europe also reports disparities in nutritional intervention access based on socioeconomic status, especially among uninsured, rural, or minority populations. A European guideline also emphasize early screening and support in socioeconomically disadvantaged groups (50). These international findings suggest that despite regional differences, socioeconomic inequality remains a common barrier to optimal nutritional care for ovarian cancer patients worldwide.

The impact of nutritional intervention

Many studies and guidelines emphasize that regular nutritional risk screening, timely nutritional assessment, and nutritional therapy are critical components in the comprehensive treatment of ovarian cancer (51,52). The OS of patients with improved nutritional status is significantly better than that of patients with deteriorated nutritional status and is independent of other prognostic factors (44). Therefore, it is important to assess the status of malnutrition in patients with ovarian cancer to provide effective nutritional intervention, reduce nutritional decline during treatment, prevent or control malnutrition, and reduce muscle loss, thereby improving survival.

Methods and tools for nutritional screening of patients with ovarian cancer

To address the challenges of malnutrition in ovarian cancer, a personalized, multidisciplinary, comprehensive, and proactive approach to screening, assessment and treatment is recommended. This can not only improve the nutritional status and psychological state of the patients but also further optimize their QoL and significantly improve their survival expectancy.

Nutrition screening and evaluation constitute the first step of nutritional intervention for patients with cancer. There are several tools available for examining malnutrition and nutritional assessment, the most common assessment tools include NRS-2002 and PG-SGA. In a study that included 442 patients with ovarian cancer, multivariate analysis showed that NRS-2002 predicted the 30-day readmission rates (P<0.05) (53). The PG-SGA has a high sensitivity in predicting nutritional status and is the standard for nutrition assessment among patients with cancer. A gynecological study (25% ovarian cancer) reported that PG-SGA was significantly correlated with subjective and objective parameters, especially in patients with partially normal albumin and skinfold thickness, suggesting a potential risk of malnutrition. Therefore, the study concluded that PG-SGA is more suitable for the nutritional assessment of patients with gynecological malignancies (5). Other nutritional screening and nutritional assessment tools are described in Table 3 (54-67).

Notably, PG-SGA is arguably the most appropriate for ovarian cancer patients. ovarian cancer patients frequently experience cancer-specific symptoms such as nausea, early satiety, and ascites, all of which are systematically evaluated in the PG-SGA. Furthermore, the tool’s dynamic nature makes it suitable for monitoring during prolonged treatment courses, including chemotherapy and PARP inhibitor-based maintenance therapy. Additionally, PG-SGA scores have been associated with critical clinical outcomes such as postoperative recovery and survival, further supporting its utility in this setting. In contrast, NRS-2002 and Global Leadership Initiative on Malnutrition (GLIM), while useful in broader contexts, may lack the necessary specificity or feasibility in routine gynecologic oncology practice. Given these strengths, PG-SGA is particularly well-suited for the ongoing nutritional evaluation of ovarian cancer patients.

Patients with advanced ovarian cancer often have ascites and pleural effusion and should be evaluated for weight correction and preferably for muscle mass. In addition to malnutrition risk examination and related assessment tools, nutrition can be assessed via the area of skeletal muscle through several methods. These include bioelectrical impedance analysis (BIA), dual-energy X-ray absorptiometry (DXA), and computed tomography (CT) imaging. C-reactive protein, lymphocytes, and other inflammation status indicators, such as neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and C-reactive protein-to-albumin ratio, are also highly informative.

Nutrition intervention during treatment for ovarian cancer

Patients at different stages of treatment need timely, comprehensive, and effective interventions to improve appetite and nutrition. This can include daily dietary supplements, nutritional supplementation, and pharmacologic interventions.

Dietary regulation

Nutritional education and dietary guidance are the first choice for nutritional treatment. A study has shown that high vegetable intake is associated with better survival (68). Cruciferous vegetables such as broccoli and cabbage are rich in antioxidants and fiber, which help improve gut health and overall immune function. Additionally, animal products and vitamin-rich dietary patterns have been associated with a reduced risk of ovarian cancer (69). Overall, beneficial diet choices consist of lean meats, fish, and eggs, as well as fruits and vegetables rich in vitamins C and E. Unsaturated fats from natural sources such as fish oil and olive oil are also helpful.

Cancer patients often face inadequate protein intake, which may affect the effectiveness of treatment and speed of recovery. It is recommended that adequate protein supply be ensured via an increased intake of fish, meat, eggs, and soy products (70).

In contrast, it has been shown that intake of red and white meat is positively associated with the risk of ovarian cancer (68). Therefore, reduction in the consumption these types of meat in favor of more plant-based protein sources such as beans and soy products is recommended. Moreover, high-starch dietary patterns have been associated with an increased risk of ovarian cancer (69). Thus, the intake of high-sugar and refined carbohydrates should be limited in favor of whole grains and foods with a low glycemic index.

Nutritional supplementation

When the patient’s oral intake is insufficient, supplementary enteral nutrition (EN) is recommended, and oral nutritional supplementation (ONS) is preferred. When oral feeding plus EN cannot meet the requirement, parenteral nutrition (PN) should be considered, and even total parenteral nutrition (TPN) if necessary.

For patients at risk of malnutrition, early introduction of oral nutritional counseling and recommendation of oral nutritional supplements have been shown to reduce mortality, complications, and shorten hospital stays. Oral feeing early in the perioperative period may stimulate intestinal hormones and increase intestinal motility, which would promote normal recovery of bowel motility and tolerance of oral intake and improve nutritional status. EN is the preferred approach because it is more physiologic, has fewer complications, is less expensive, and is easier to monitor than is PN. EN can increase energy intake and nutritional status while reducing the gastrointestinal toxicity caused by cancer treatment. Branched chain amino acids (BCAAs) appear to reduce hospital stay, reduce morbidity, and improve QoL. However, there is no reduction in mortality for the long-term benefit of the patient (71).

PN in terminal patients has been demonstrated to improve the QoL, energy balance, and body composition while also prolonging survival. Omega-3 fatty acid supplementation provides clear benefits at the biochemical, clinical, and functional levels, while glutamine supplementation appears to enhance the efficacy of chemotherapy and radiotherapy while reducing tissue toxicity and improving outcomes (72).

The use of TPN is controversial. A retrospective cohort study included 55 patients with advanced epithelial ovarian cancer and compared the survival of patients treated with TPN after bowel obstruction with that of patients who did not receive TPN. The results showed that OS was 35 months for patients treated with TPN and 23 months for patients not treated with TPN (P=0.05); moreover, patients receiving TPN after obstruction were more likely to undergo concurrent chemotherapy (64% vs. 26%; P=0.004) (73). However, in another study, 147 patients with ovarian cancer were enrolled, 69 of whom received TPN and 78 conservative treatment. The results showed that patients in the TPN group had a longer time to regain bowel function (5.77 vs. 4.70 days; P<0.001), and longer hospitalization (11.46 vs. 7.14 days; P<0.001) (74). Therefore, the use of TPN needs to be evaluated in the context of the patient’s specific situation.

Pharmacologic interventions

Pharmacotherapy plays a key role in the treatment of cancer-caused anorexia nervosa and has the primary goal of targeting etiologic mechanisms.

Progestogens are capable of targeting the synthesis of inflammatory factors and have been shown to be effective therapeutic options (75). Megestrol acetate (MA) exerts anti-inflammatory effects and is able to reduce the levels of inflammatory factors such as IL-1, IL-6, and TNF-α. In addition, MA can improve appetite in patients cancer by activating proappetite neurons in the hypothalamic region through increasing the levels of neuropeptide Y, an appetite stimulant in the central nervous system (76,77). The efficacy of MA is positively correlated with its dose, and 800 mg is recommended by guidelines (78,79). Indeed, several studies have shown significant improvements in appetite and body weight in patients with cancer following MA administration, particularly with a daily dose of 800 mg and a treatment duration of 12 weeks, with effects observed at higher doses or after a certain duration of treatment (80-83). The third generation of nanocrystal MA oral suspension significantly improves the solubility and dissolution rate of megestrol, enhances the bioadhesion effect, and increases the absorption pathway. This improvement eliminates the need for patients to rely on a high-fat, high-calorie diet and is effective both before and after meals (84,85). Clinical studies have also demonstrated that compared to the regular dosage form, patients with nanocrystal MA oral suspension gain weight significantly faster. Specifically, the mean time to weight gain was shortened from 14 to 3 days, and the average weight gain over 12 weeks was 5.4 kg, which was 1.5 times higher than that achieved by the conventional dosage form (86,87). International guidelines are unanimous in considering MA as the preferred treatment option for cancer-related anorexia cachexia syndrome (CACS) (78,88-90).

Corticosteroids, such as dexamethasone, are not as efficacious as megestrol, although they have been shown to improve appetite (91). In addition, corticosteroid use is associated with side effects such as muscle atrophy, glucose intolerance, and immunosuppression, which may lead to decreased efficacy with long-term treatment. The potential nutritional advantages of long-term use are often outweighed by the risk of their adverse effects (92). Therefore, given the higher frequency of adverse effects, corticosteroids should be applied with caution and limited mainly to the treatment of patients with end-stage tumors (93).

Anamorelin is an orally active, high-affinity, selective ghrelin-receptor agonist. Ghrelin is the natural ligand for the G-protein-coupled ghrelin receptor, and when activated, it exerts anabolic and appetite-stimulating effects. These effects are partly mediated through transient increases in growth hormone and insulin-like growth factor 1 (IGF-1). Several double-blind, randomized phase 2 clinical studies in patients with advanced cancer have shown that anamorelin is effective in increasing lean body mass, body weight, and appetite. However, some subgroups (such as patients with a BMI ≤18.5 kg/m²) showed no improvement in lean body mass (89,94). Additionally, anamorelin may increase IGF-1, which theoretically could promote tumor progression. Therefore, the long-term benefits and safety of anamorelin require further assessment and validation (95).

The research on cannabinoids for the treatment of CACS is limited and inconsistent. Their effectiveness in terms of appetite improvement, weight gain, and QoL enhancement appears to be less than that of other drugs (89,96).

Other therapeutic agents have been studied, including olanzapine (92), androgens or selective androgen receptor modulators (89,90), cyproheptadine, hydralazine sulfate, melatonin, and TNF inhibitors (89,92,96); however, these either provide little benefit or are not supported by a sufficient evidence to justify their routine use. More research is therefore needed to clarify the efficacy and safety of these agents.

Nutritional intervention and results

Accurate evaluation of perioperative nutrition in patients with ovarian cancer is crucial in clinical settings. Preoperative nutritional management is critical to improving the clinical outcomes of patients with ovarian cancer. A study has shown that preoperative nutritional management can optimize patients’ nutritional status and surgical prognosis by providing personalized nutritional intervention, monitoring and evaluation, and increasing physical activity (97). Early postoperative nutritional intervention, including innovative nutritional strategies such as chewing gum, drinking coffee, ketogenic diet, or supplementation with fruit and vegetable juice concentrates, has been shown to reduce hospital stay and improve postoperative intestinal recovery (98). The findings of other studies on perioperative nutritional interventions are provided in Table 4 (99-106).

Prehabilitation during neoadjuvant chemotherapy (NACT) has been associated with improved nutritional parameters and postoperative recovery, further supporting the integration of nutritional interventions at various stages of the treatment continuum (107). The BENITA study examined a holistic approach that integrated exercise and nutrition interventions during and after first-line chemotherapy, which had high acceptance and safety among patients (108).

A study has shown that for patients with ovarian cancer undergoing chemotherapy, the use of nutritional risk screening combined with EN support can significantly improve the patient’s body weight and BMI while improving their nutritional status and QoL (97).

Despite the well-established role of nutritional interventions in improving outcomes for ovarian cancer patients, a major limitation in current research is the lack of high-quality RCTs. This gap leads to uncertainty in the clinical decision-making regarding the ideal timing (e.g., preoperative vs. postoperative), delivery route (e.g., oral vs. enteral vs. parenteral), and specific nutrient composition (e.g., protein, omega-3, or immunonutrients). To address this, future research should prioritize well-designed, multicenter RCTs with standardized nutritional endpoints, which would allow for better comparability and integration of evidence into clinical guidelines. Additionally, studies should explore patient subgroups to assess whether different nutritional strategies are needed based on disease stage, treatment regimen, or baseline nutritional status.

Conclusions

Patients with ovarian cancer are often encountered at an advanced stage and are likely to be malnourished, a state which is strongly associated with poor clinical outcomes. Tumor progression, surgery, chemotherapy, and PARP inhibitors can lead to loss of appetite and malnutrition. Early nutritional risk assessment and individualized and comprehensive nutritional management are thus essential for these patients. However, the means to accurately defining malnutrition in patients with ovarian cancer and the optimal timing and regimen selection for nutritional therapy still require further investigation. In the future, high-quality clinical studies are needed to clarify the mechanisms of malnutrition and optimize nutritional treatment strategies to provide comprehensive and integrated treatment for patients with ovarian cancer.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-758/rc

Peer Review File: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-758/prf

Funding: This work was supported by the Zhejiang Provincial Health Science and Technology Program (No. 2022ky625).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-758/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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