Identification of patient groups at highest risk from traditional approach to ovarian cancer treatment

ObjectiveDefine subgroups of patients at highest risk for major morbidity and mortality after a traditional approach of maximal surgical efforts followed by chemotherapy for advanced ovarian cancer (AOC).MethodsPreoperative health, intra-operative findings and outcomes were assessed in consecutive patients with primary AOC from 4 centers. Initial tumor dissemination was stratified into 3 groups based on volume of disease. Surgery was categorized using a previously described surgical complexity score (SCS). Statistical analysis was directed toward validating a multivariable risk-adjusted model.Results576 patients with stage IIIC (N = 447, 77.6%) or IV AOC (N = 129, 22.4%) were analyzed. Age (HR (per year): 1.02; 95%CI: 1.01–1.03), high tumor dissemination (HTD) (HR: 1.73; 95%CI: 1.19–2.56), residual disease (RD) > 1 cm (HR: 2.46; 95%CI: 1.74–3.53), and stage IV (HR: 1.93; 95% CI: 1.51–2.45), independently correlated with OS. We identified a small subgroup of patients who comprised a high-risk group (N = 38, 6.6%) characterized by all of the following characteristics: high initial tumor dissemination (HTD) or stage IV plus poor performance or nutritional status plus age ≥ 75. In this group, high SCS to achieve low RD was associated with morbidity of 63.6% and limited survival benefit.ConclusionsOptimal management of AOC requires accurate, risk-adjusted predictors of outcomes allowing a tailored approach starting with primary therapy. Complex surgical procedures to render low RD improve survival, and in the majority of cases, the benefits of such surgery appear to outweigh the morbidity. However careful analysis identifies a subgroup of patients in whom an alternative approach may be the better strategy.

Research Highlights
► Most patients with ovarian cancer benefit from aggressive surgery.
► We identified a subgroup of patients in whom an alternative approach may be the better strategy.
► Different subgroups of patients might benefit from different approaches.