Does aggressive surgery only benefit patients with less advanced ovarian cancer?

Abstract

5556 Background: The recent SCORPION trial showed that aggressive primary debulking surgery (PDS) did not improve survival outcomes in patients with advanced ovarian cancer and was associated with a high incidence of perioperative morbidity. We compared survival outcomes and morbidity between patients who underwent highly aggressive and less aggressive surgery at our hospital; patients with high tumor loads were treated with neoadjuvant chemotherapy (NACT), followed by aggressive surgery. Methods: This retrospective study included 209 patients with a surgical complexity score (SCS) ≥8, who underwent aggressive surgery between January 2008 and December 2018. PDS, followed by chemotherapy was performed in this study, and NACT followed by interval debulking surgery (IDS) was performed in patients with excessively high tumor loads, a poor general condition, or unresectable lesions in whom PDS was contraindicated. Based on the median SCS, patients were categorized into highly aggressive surgery and less aggressive surgery groups, and we performed an intergroup comparison of progression-free survival (PFS), overall survival (OS), and perioperative morbidity. Results: The median SCS was 13 in all cohorts. The less aggressive surgery group (SCS < 13) and the highly aggressive surgery group (SCS≥13) included 83 and 126 patients, respectively. The peritoneal cancer index in the highly aggressive surgery group was higher than that in the less aggressive surgery group (20 vs. 9). Notably, 52 patients (63%) underwent PDS in the less aggressive surgery group, and 104 patients (83%) underwent IDS after NACT in the highly aggressive surgery group. No intergroup difference was observed in patients without any residual disease (less aggressive surgery group: 74 patients [89%] vs. highly aggressive surgery group: 118 patients [94%], p = 0.245). The median PFS in the less- and highly aggressive surgery groups was 32 months (95% confidence interval [CI] 24–45) and 31 months (95% CI 27–34) (log-rank test, p = 0.622; Wilcoxon test, p = 0.926), respectively. The median OS in the less- and highly aggressive surgery groups was 99 months (95% CI 59–not reached) and 75 months (95% CI 56–106) (log-rank test, p = 0.390; Wilcoxon test, p = 0.799), respectively. Severe perioperative complications (Clavien-Dindo grade ≥IIIb) occurred in 4 patients (4.8%) and 8 patients (6.4%) in the less- and highly aggressive surgery groups, respectively (p = 0.767). Conclusions: Aggressive surgery benefits both patients with less advanced and advanced ovarian cancer. Selection of the optimal timing of debulking surgery may lead to better survival outcomes without an increase in perioperative morbidity in patients with high tumor loads, who undergo highly aggressive surgery.