CAF Heterogeneity in Ovarian Cancer: Implications for Chemoresistance and Treatment Strategies

Introduction: Cancer-Associated Fibroblasts (CAFs) are key players in the tumor microenvironment (TME) of ovarian cancer, influencing progression and chemoresistance. Their heterogeneous subtypes contribute distinctly to immune evasion, extracellular matrix (ECM) remodelling, and drug resistance. Methods: This review synthesizes evidence from recent single-cell and proteomic analyses to delineate CAF subtypes, including myCAFs, iCAFs, and apCAFs, and their associated gene signatures (e.g., VCAN, SULF1, COL11A1, CXCL12). The relationship between CAF-mediated pathways and resistance to platinum-based chemotherapies is explored. Results: High expression of CAF-associated genes correlates with platinum resistance in ovarian cancer. VCAN enhances ECM stiffness and immune suppression; SULF1 alters ECM sulfation, affecting drug uptake; COL11A1 activates Src/Akt pathways leading to EMT; and CXCL12 triggers Wnt/β-catenin signalling, increasing resistance. These mechanisms collectively impair treatment efficacy. Discussion: The dynamic and plastic nature of CAFs presents both a challenge and an opportunity in cancer therapy. While some CAF subsets promote chemoresistance, others may exert tumor-suppressive effects. This duality underscores the importance of precise molecular profiling to distinguish between pro-tumor and antitumor CAF populations. Current data suggest that therapeutic approaches targeting CAF-specific genes or pathways, particularly those influencing ECM remodelling and survival signalling, could significantly enhance the efficacy of standard chemotherapy. Personalized treatment strategies that selectively deplete or reprogram tumor- promoting CAFs while preserving supportive stromal elements may improve patient outcomes. Conclusion: Targeting specific CAF subtypes and their molecular pathways offers promise for overcoming chemoresistance. Future therapies should focus on eliminating tumor-promoting CAFs while preserving or reprogramming tumor-suppressive ones.