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An easy-to-use, risk-based algorithm proved useful for selecting advanced ovarian cancer patients with enough resilience to tolerate complex primary debulking surgery.

Using a retrospective dataset involving women with stage IIIC/IV tumors, mortality at 90 days was threefold lower for triage-appropriate women compared with those considered high-risk based on three key factors, at 2% versus 6.1%, respectively (P=0.03), reported Deepa M. Narasimhulu, MBBS, of the Mayo Clinic in Rochester, Minnesota.

And these triage-appropriate patients had a significantly lower risk for death following surgical complications (10% vs 25.9%, P=0.05), according to findings presented at the virtual Society of Gynecologic Oncology (SGO) annual meeting.

"The take-home message is that patient selection is key," said Narasimhulu.

"Our algorithm can identify women who are resilient and can tolerate complex surgery and recover from complications and have a low mortality," she added. "Use of our algorithm significantly decreased our 90-day mortality and allowed us to safely offer primary surgery to 70% of women with advanced ovarian cancer in our practice."

Under the algorithm, women are considered high-risk for surgical morbidity and mortality if any one of the following criteria is met: albumin levels below 3.5 g/dL; age 80 or over; or age 70 to 75 plus either stage IV disease, an expected complex surgery, or poor performance status (Eastern Cooperative Oncology Group [ECOG] status ≥2 or American Society of Anesthesiology score of 3-4).

High-risk women would be offered neoadjuvant chemotherapy followed by interval debulking surgery; women not at high risk (triage-appropriate) would be offered primary debulking surgery.

"Choice between these two options is often based on surgeon and institutional preference," said Narasimhulu. "But some patients who are fit and resilient might be able to tolerate primary surgery better, and patients who are not good surgery candidates might be better served with neoadjuvant chemotherapy."

The current findings involved an international high-surgical complexity cohort, and builds on a previous using the algorithm, as well as a involving a low-surgical complexity cohort. The 625 patients included underwent cytoreductive surgery from 2011 to 2019 for stage IIIC/IV ovarian cancer at the Università Cattolica del Sacro Cuore in Milan, Italy. About 80%-85% of patients required intermediate- to high-complexity surgery. The algorithm was retrospectively applied to classify women as either high-risk or triage appropriate.

"One of the criticisms with our algorithm is that people were concerned about labeling women with low albumin as high-risk, if that was their only high-risk factor," said Narasimhulu.

A subgroup analysis in the current study examined patients for whom low albumin was the only risk factor, with 90-day mortality reaching 5.6% versus 2% for those with higher levels.

As expected, women in the triage-appropriate group were younger compared with the high-risk group (median age 57 vs 64, respectively), had higher preoperative albumin (≥3.5 g/dL: 83.8% vs 26%), and were less likely to have poor ECOG performance status (≥2: 1.8% vs 7%).

"This could be potentially changing our practice," said SGO discussant Thomas Herzog, MD, of the University of Cincinnati Cancer Institute, noting that the factors used for patient selection have now been validated "internally, externally, nationally, and internationally."

He noted that one of the important points of the research was identifying patient resiliency.

"It's the ability to recover from these complications that are invariable with these very aggressive debulking surgeries," he said. "Just because we likely can achieve [complete gross resection] does not mean all patients should proceed with primary debulking surgery, but rather, we need to layer the information from this study into our decision."

He sounded one note of caution, which was whether the findings would apply to lower-volume treatment centers.

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