Background:
Treatment of primary advanced epithelial ovarian cancer involves platinum-doublet chemotherapy and surgery, aiming to achieve complete cytoreduction of all macroscopic disease. The extent of tumour cytoreduction is considered an important prognostic factor. Cytoreductive surgery, however, is associated with risk of postoperative morbidity and mortality, particularly when extensive and/or radical resections are required. The administration of neo-adjuvant chemotherapy plays an important role in reducing the size and extent of the tumour to allow for complete macroscopic cytoreduction to be achieved with less extensive surgical resection. No significant difference in survival outcomes between patients who undergo primary debulking surgery and neoadjuvant chemotherapy followed by interval debulking surgery have been found. In addition, the administration of neoadjuvant chemotherapy was associated with reduced postoperative mortality and morbidity. Clinical quality registries play an important role in monitoring and driving improvements in the quality of healthcare provided to patients. Clinical quality registries collect data on quality indicators related to a particular disease and provide benchmarking for participating institutions, feeding back regarding performance in a fair and risk adjusted way against these benchmarks and thereby encouraging consistent, high-quality healthcare across participating institutions. The National Gynae-Oncology Registry (NGOR) is a clinical quality registry based within the cancer research program at Monash University. The Epithelial Ovarian/Tubal/Peritoneal (OTP) cancer module of the NGOR has been collecting data on quality indicators in the care of women with these cancers since 2017. These quality indicators include proportion of women obtaining optimal primary or interval cytoreduction and cytoreduction to no macroscopic disease and proportion of patients experiencing unplanned significant intraoperative and postoperative adverse events. This study will be the first to report data collected by the NGOR on surgical outcomes in patients with advanced epithelial OTP cancer. Understanding performance against quality indicators in addition to understanding up to date (2017 – 2022) practice in Australia and variation of this between institutions, is important in understanding how one might optimise perioperative care for and surgical decision making for women with advanced OTP cancer.
Aims:
This study aims to report rates of primary and interval cytoreduction, rates of complete and optimal cytoreduction and intraoperative and postoperative adverse events associated with primary and interval cytoreduction using data collected in the National Gynaecologic Oncology Registry (NGOR).
Methods:
The NGOR is a Clinical Quality Registry that collects uniform, observational, data from participating Australian centres offering care to women with gynaecologic cancer. All women with Stage III-IV epithelial OTP peritoneal cancer registered with the NGOR were included in this study (N=1084). The study was designed to report on quality indicators and outcomes including: rates of postoperative complications (Clavien-Dindo Grade III+), rates of primary and interval cytoreductive surgery, rates of complete and optimal cytoreduction, intraoperative complications, institutional variation in practice and outcomes, and the effects of rurality, ECOG, age, hospital type and socioeconomic status on the rates of postoperative complications, complete cytoreduction and whether primary or interval cytoreduction is undertaken.
Results:
Primary cytoreduction was undertaken in 470 (43%) women and interval cytoreduction in 614 (57%) who underwent cytoreductive surgery. Postoperative complications (Clavien-Dindo Grade III+) were significantly more common in those who underwent primary cytoreductive surgery (p=0.025). Intraoperative complications were also more common in those undergoing primary cytoreduction (p=0.009). Optimal cytoreduction (residual disease <1cm) was more commonly achieved in those who underwent interval cytoreduction (p=0.047) though no statistically significant difference was seen between groups for complete cytoreduction. Leading predictors of postoperative complications were receiving treatment at a public hospital, living in a regional area and later cancer stage at diagnosis. Institutional variation and the effect of socioeconomic status, ECOG, age and rurality are reported on in this study.
Conclusion:
Interval cytoreduction was associated with less intraoperative and postoperative morbidity, and increased rates of optimal cytoreduction when compared with primary cytoreduction in patients with Stage III-IV epithelial OTP cancer. This is consistent with international literature and this study uses national clinical quality registry data to report on current Australian practice. This NGOR currently has incomplete data on recurrence and survival, but it is anticipated that more complete data on these outcomes will be collected as the registry matures.