Maimonides Evening of Research
Fellow Winner
Kelly Lamiman MD
Trends in Surgical Outcomes and Overall Survival among Women Undergoing Debulking Surgery for Advanced Ovarian Cancer in the U.S: Analysis of the National Cancer Database
Background
Since 2010, three randomized controlled trials have shown that interval debulking surgery (IDS) is associated with similar survival and improved surgical outcomes compared to primary debulking surgery (PDS) for advanced epithelial ovarian cancer (EOC). This has led to increasing adoption of IDS. However, retrospective studies indicate that PDS may be associated with better overall survival (OS).
Objective
To assess trends in OS, complete gross resection (R0), and postoperative mortality rates following debulking surgery for advanced EOC in the context of rising use of neoadjuvant chemotherapy (NACT).
Methods
Data from the U.S. National Cancer Database (NCDB) was analyzed to identify patients with stage IIIC and IV EOC diagnosed between January 1, 2010, and December 31, 2017, who underwent either PDS or IDS. The annual proportions of patients receiving IDS versus PDS were calculated, with 95% confidence intervals (CIs). Median OS was estimated using the Kaplan-Meier method for each diagnosis year. Join point models were fitted to evaluate trends in treatment type, OS, R0 resection rates, postoperative mortality, and extensive surgery rates. Extensive surgery was defined as debulking that involved procedures beyond hysterectomy, salpingoophorectomy, and omentectomy. Statistical analyses were performed using SPSS Version 29.0 and Joinpoint Regression Program, Version 5.0.2, with a two-sided p-value of <0.05 considered significant.
Results
Of 34,982 eligible patients, 10,460 (29.9%) underwent IDS. Patients undergoing IDS were older (65 vs. 61 years, p<0.001), more likely to have stage IV disease (51.3% vs. 25.4%, p<0.001), and more likely to be non-white. Median OS was higher in the PDS group (54 vs. 38.8 months, p<0.001). Postoperative mortality at 90 days was higher in the IDS group (2.4% vs. 1.7%, p<0.001), though IDS patients had a lower 30-day readmission rate (6.2% vs. 3.1%, p<0.001). Patients undergoing IDS were less likely to undergo extensive surgery (27.4% vs. 36.7%, p<0.001) but more likely to achieve R0 resection (42% vs. 38.6%, p<0.001).
Over the study period, the rate of IDS increased from 18.9% to 40.6% (annual change: 11.8%, p<0.05), while OS for the entire cohort improved from 46.6 to 51 months (annual change: 1.9%, p<0.05). The R0 resection rate for the entire cohort rose from 34.8 to 41% (annual change: 2.65%, p<0.01), driven by improvements in PDS patients (annual change: 2.83%, p<0.01), with no significant change in the IDS group. Postoperative 90-day mortality decreased from 2.4% to 1.5% (annual change: -4.64%, p<0.05), primarily due to a reduction in PDS patients (annual change: -6.83%, p<0.05), while IDS patients showed no significant change. There was no significant trend in the rate of extensive surgery across either group.
Conclusion
During the study period, the increased triage of patients to NACT was accompanied by higher rates of R0 resection and reduced postoperative mortality in PDS patients, with no observed detriment to OS. This data suggests improvement in case selection between IDS and PDS.