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Risk of Death After Cytoreduction of Advanced Ovarian Cancer Differs by Age

Key findings

  • Cytoreductive surgery for advanced ovarian surgery has been associated with a substantial risk of complications and death
  • In this retrospective study, 90-day mortality was 7.2% among 37,024 women who underwent primary cytoreduction for advanced ovarian cancer and 3.1% among 10,153 who received neoadjuvant chemotherapy and interval cytoreduction
  • Women who underwent primary cytoreduction incurred an age-associated risk of 90-day mortality from a younger age, and at a larger magnitude, than those who received neoadjuvant chemotherapy

Cytoreduction—resection of all visible tumor with curative intent—is associated with improved long-term survival of women with advanced-stage ovarian cancer. It is considered a key component of primary therapy in such cases. However, cytoreductive surgery carries a substantial risk of complications and death.

In a research letter published in JAMA Surgery, gynecologic oncologist Marcela del Carmen, MD, chief medical officer of the Massachusetts General Physicians Organization, and clinician in the Mass General Cancer Center and the Division of Gynecologic Oncology at Massachusetts General Hospital, and colleagues report on a retrospective study suggesting that, among older women, administering chemotherapy before cytoreductive surgery may substantially reduce the risk of postoperative mortality.

A Nationwide Cohort

The research team reviewed 47,117 women in the National Cancer Database who had stage IIIC or IV epithelial ovarian cancer treated with cytoreduction surgery between 2004 and 2013. Of those, 37,024 (79%) underwent primary cytoreduction and the others underwent interval cytoreductive surgery performed after neoadjuvant chemotherapy.

Patients undergoing primary surgery were younger and were significantly less likely to have comorbidities than those who underwent interval cytoreductive surgery. Even so, 90-day mortality was higher after primary surgery than after interval surgery (7.2% vs. 3.1% of patients).

There were differences in the risk of death as a function of age:

  • Before age 47, there was no age-associated increase in the risk of 90-day mortality after primary or interval cytoreduction
  • After primary cytoreductive surgery, the odds of 90-day postoperative mortality began rising at age 47, increasing by 5.7% per year of age until age 71, after which the risk accelerated to 9.9% per year
  • After interval cytoreductive surgery, in contrast, the odds of 90-day mortality did not begin to increase until age 62, and the risk increased steadily by 5.7% per year without evidence of accelerating among the oldest patients
  • By age 75, the probability of 90-day postoperative mortality was 4.2% after interval cytoreduction but 12.3% after primary cytoreduction
  • By age 85, those probabilities had increased to 7.2% and 26.0%, respectively

Thus, among older women, administering neoadjuvant chemotherapy before cytoreductive surgery may substantially reduce the risk of postoperative mortality.

4.1%
greater 90-day mortality among women who underwent primary cytoreduction for advanced ovarian cancer than those who received neoadjuvant chemotherapy and interval cytoreduction

5.7%
annual increase in 90-mortality after primary cytoreductive surgery between age 47 - 71

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