Neoadjuvant Chemotherapy, Case Volume, and Mortality in Advanced Ovarian Cancer

Death after cytoreductive surgery for advanced-stage ovarian cancer is more frequent in low-volume hospitals. Neoadjuvant chemotherapy (NACT) has been shown to reduce surgical complexity, complications, and surgical mortality without compromising oncologic outcomes.

To measure whether more frequent NACT utilization is associated with postoperative mortality and overall survival after cytoreductive surgery, especially in low-volume hospitals.

This cross-sectional study included patients treated for newly diagnosed stage III or IV epithelial ovarian cancer at Commission on Cancer-accredited cancer programs in the United States between January 2010 and December 2019. Data were analyzed from August 2023 to April 2025.

The main exposures of interest were cancer program-level rates of NACT and tertile of program mean annual volume of cytoreductive surgery (<12.0, 12.0-23.9, or ≥24.0 cases/y).

Standardized rates and odds ratios (ORs) for 90-day perioperative morality and differences in 60-month life expectancy (restricted mean survival time).

A total of 70 707 patients (mean [SD] age, 63.1 [12.1] years; 5807 [8.2%] Black, 4745 [6.7%] Hispanic, and 56 336 [79.7%] White) treated in 1333 programs were identified. After adjusting for observed demographic and clinical covariates, 90-day surgical mortality was lower in centers with higher NACT rates, and the magnitude of this association differed by hospital volume (P for interaction < .001). High utilization of NACT (59%) compared with low utilization (22%) was associated with a larger decrease in 90-day mortality in high-volume centers (OR, 0.26; 95% CI, 0.17-0.41; rates, 10.0% vs 2.9%) compared with average-volume centers (OR, 0.49; 95% CI, 0.33-0.72; rates, 7.3% vs 3.7%) or low-volume centers (OR, 0.48; 95% CI, 0.39-0.60; rates, 9.5% vs 4.8%). Among high-volume centers, high utilization was associated with a 4.0 month (95% CI, 1.6-6.5 month)-improvement in 60-month life expectancy compared with low NACT utilization (42.2 vs 38.1 months).

In this cross-sectional study, treatment in high-volume centers with high NACT utilization was associated with the lowest 90-day surgical mortality and longest 60-month survival for patients with advanced stage ovarian cancer.