Cytoreductive surgery in advanced epithelial ovarian cancer: a real-world analysis guided by clinical variables, homologous recombination, and BRCA status

ObjectivesGuidelines endorse both interval and primary debulking cytoreductive surgeries in the treatment of epithelial ovarian cancer, emphasizing that the treatment strategy should be tailored to the patient's clinical condition and tumor burden. Despite these recommendations, experts have yet to agree on a definitive surgical approach.MethodsA retrospective longitudinal analysis of 929 women diagnosed with advanced-stage (International Federation of Gynecology and Obstetrics stage III-IV) epithelial ovarian cancer between January 2002 and January 2025 was conducted. The effects of interval debulking surgery versus primary debulking surgery on median overall survival and progression-free survival were evaluated. Additionally, we aimed to identify patients who may benefit from a particular surgical approach based on clinical variables, mutation in either of the BRCA1 or BRCA2 genes, and homologous recombination profile.ResultsA total of 929 patients were diagnosed with stage III to IV disease (87.2%) and underwent either primary debulking (n = 389, 41.9%) or interval debulking surgery following neoadjuvant chemotherapy (n = 540, 58.1%). Patients treated with primary debulking had a longer median overall survival than those treated with interval debulking surgery (68.40 months, 95% CI 62.92 to 76.45 vs 52.01 months, 95% CI 47.15 to 57.86, HR 1.2, p = .0004). However, when adjusted for age at diagnosis, stage, histology, BRCA status, and tumor resectability, multivariate analysis demonstrated no significant difference in survival between the two surgical groups (HR 1.15, 95% CI 0.96 to 1.39, p = .12). Younger women (<69 years), stage III, and BRCA-wild-type and/or homologous recombination proficient had longer survival with primary debulking than with interval debulking surgery (74.55 months, 95% CI 65.35 to 93.27 vs 55.98 months, 95% CI 48.10 to 64.79, HR 1.38, p = .03). Patients with a pathogenic BRCA variant or homologous recombination deficient profile had similar survival outcomes with either debulking approach, regardless of age and disease stage (p > .05). Propensity score analysis demonstrated comparable median overall survival with the two surgical timings (64.39 months, 95% CI 58.38 to 71.23 vs 57.69 months, 95% CI 50.66 to 64.79, HR 1.33, p = .27).ConclusionsOur findings support the use of neoadjuvant chemotherapy followed by interval debulking surgery without compromising survival outcomes, regardless of age and stage, particularly among harder-to-treat patients. We identified a specific subset of patients who may benefit from primary debulking surgery as the optimal intervention. These findings advocate for a personalized treatment approach and the potential for tailored surgical strategies guided by patient clinical variables, homologous recombination, and genetic factors

Survivorship in advanced ovarian cancer: a prognostic model for overall survival and risk of recurrence

OBJECTIVE: Advanced epithelial ovarian cancer (EOC) poses a significant clinical challenge due to its typically late diagnosis and poor prognosis. However, a subset of patients exhibit remarkably prolonged survival. Identifying prognostic factors and developing tools for estimating outcomes may provide tailored strategies for treatment escalation or de-escalation. This study aimed to identify prognostic factors associated with patient survival and develop a prognostic model estimating EOC patients' overall survival and risk of recurrence (ROR). METHODS: We conducted a retrospective analysis of 1049 women diagnosed with EOC from January 2002 until June 2024. Clinical, pathological, and molecular data, including germline BRCA pathogenic variants (PVs), and homologous recombination repair analysis were performed. Long-term survivors (LTS), defined as those surviving over 7 or 10 years, and short-term survivors (STS), defined as those surviving less than 2 years were compared. A prognostic model was developed using multivariable logistic regression to estimate survival probabilities and recurrence risk. RESULTS: Among the study cohort with advanced disease (FIGO stage III-IV), 20.3% survived beyond 7 years and 9.8% beyond 10 years. Factors significantly associated with LTS included younger age, lower disease stage, complete tumor resection, BRCA PV, and treatment with poly (ADP-ribose) polymerase inhibitors. The prognostic model, integrating age, stage, BRCA status, and tumor resection, provided survival estimates and ROR for 2, 5, 7, and 10 years from diagnosis. This tool is based on retrospective logistic regression analysis of long-term and STS across all stages (I-IV). CONCLUSIONS: This study reaffirms established prognostic factors of LTS with advanced EOC and introduces a novel prognostic calculator integrating clinical variables. The tool may assist in personalizing treatment plans and guiding clinical decisions. Validation in multi-institutional cohorts is necessary to confirm its universal utility and applicability