Risk based triage for complex surgery in ovarian cancer: ready for prime time

Abstract

<h3>Objectives:</h3> We developed a triage algorithm (Figure) that identifies patients who are at highest risk of severe morbidity/mortality (M/M) after cytoreductive surgery for advanced ovarian cancer (OC). We previously validated our algorithm in a separate internal validation cohort as well as a low complexity national dataset (National Surgical Quality Improvement Program database). We wanted to test the validity of the algorithm in an international high complexity surgical setting. <h3>Methods:</h3> We included patients who underwent cytoreductive surgery in the primary (PDS) or interval (IDS) setting for stage IIIC/IV OC at a single institution between 10/2011 and 11/2019. This cohort included SCORPION trial patients until 5/2016 and non-trial patients thereafter. The data was prospectively obtained. Surgical complexity was classified as low, intermediate and high using the Aletti Score as previously described. Using the algorithm we retrospectively classified patients as ‘high risk' or ‘triage appropriate' and compared outcomes (30-day Accordion grade 3+ complications, 90-day mortality) between the two groups using the chi-square test or Fisher's exact test. <h3>Results:</h3> We included 625 patients; the mean age was 58.7 years, 73.6% were stage IIIC, 63.0% underwent PDS and 21.0% (131/625) were classified as high risk. Surgical complexity was intermediate or high in 82.6% of patients (95.7% of PDS patients and 60.2% of IDS patients) and mean operative time was 377 (SD, 140) minutes. We observed that high risk patients i) had a 3-fold higher rate of 90-day mortality (6.1% vs 2.0%, p=0.03), ii) were more likely to experience 90-day mortality following an Accordion grade 3+ complication (25.9% vs. 10.0%, p=0.05), and iii) had comparable rates of Accordion grade 3+ complications (20.6% vs 16.2%) when compared to triage appropriate patients. Rates of complete cytoreduction were 72.5% and 80.5% (p=0.05) for high risk and triage appropriate patients, respectively. <h3>Conclusions:</h3> Use of our evidence-based triage algorithm identifies patients at very high risk of surgical M/M after high complexity debulking surgery. These patients are not ideal candidates for surgery when a high complexity operation is anticipated. Given the validation of the algorithm in varied settings, risk-based decision making should be standard of care when considering cytoreductive surgery for patients with advanced OC.