OBJECTIVE: Primary debulking surgery (PDS) with the goal of complete gross resection (R0) is the standard of care for advanced epithelial ovarian cancer (EOC), but advanced age is associated with increased surgical risk. Neoadjuvant chemotherapy (NACT) with interval debulking surgery (IDS) is an alternative strategy. We compared overall survival (OS) in elderly patients undergoing PDS, IDS, or chemotherapy alone, assessed surgical outcomes between PDS and IDS, and examined treatment patterns relative to younger patients.

METHODS: The National Cancer Database was queried for patients with stage IIIC–IV EOC from 2010–2017. Elderly patients were defined as those >70 years old. The primary outcome was OS; secondary outcomes included 90-day mortality and R0 resection rate. Cases were stratified based on the presence of residual disease and extent of surgery. Extensive debulking was defined as procedures beyond hysterectomy, salpingo-oophorectomy, and omentectomy. Outcomes were analyzed using Mann-Whitney U, chi-square/Fisher’s exact tests, and multivariable logistic regression with inverse propensity weighting.

RESULTS: Of 39,143 patients, 11,728 (30%) were elderly. The median age in the elderly group was 77. Compared with younger patients, elderly patients had a higher comorbidity index, more stage IV disease, were less likely to have high-grade serous histology, and were more often treated with chemotherapy alone (20.6% vs 6.4%, p<0.001). They were also less likely to undergo PDS (50% vs 68.1%, p<0.001). While rates of extensive surgery were similar across age groups, the rate of R0 resection was lower among the elderly (30.1% vs 37.6%, p<0.001).

In propensity-weighted analysis, PDS was associated with superior OS compared with IDS (median 39 months [95% CI, 37–40] vs 34 months [95% CI, 33–35]; p<0.001) and chemotherapy alone (10 months [95% CI, 6–18]; p<0.001, Figure 1). When stratified by residual disease, median OS was highest for PDS with R0 resection (51 months [95% CI, 49–54]), followed by PDS with residual disease (38.5 months [95% CI, 37–40]) and IDS with R0 (37.5 months [95% CI, 35–40]), and lowest for IDS with residual disease (33 months [95% CI, 32–35]). Extensive surgery was not associated with OS (HR 1.04, 95% CI, 0.96–1.10).

Elderly patients had higher 90-day mortality compared to younger patients (3.2% vs 1.5%, p<0.001), though rates did not differ between PDS and IDS (3.0% vs 3.5%, p=0.2). The R0 resection rate was higher in the IDS group (41.9% vs 35.6% p<0.001). Predictors of 90-day mortality in the elderly included residual disease, stage IV, non–high-grade serous histology, and comorbidity index >1.

CONCLUSIONS: In this large national cohort, PDS was associated with superior OS in elderly patients with advanced EOC without an increase in postoperative mortality compared with IDS. The survival benefit was driven by patients achieving R0 resection and was independent of surgical extent, emphasizing the importance of effective case selection