Comparative outcomes of primary debulking surgery vs neoadjuvant chemotherapy in advanced ovarian cancer: Insights from a single institution

Andrew Polio; Ruth Bondurant; Vaughan Schwob; Bradley Loeffler; Michael Goodheart

doi:10.1016/j.ygyno.2026.01.220

Objectives Ovarian cancer remains the most lethal gynecologic malignancies in the United States. The standard management for advanced-stage ovarian cancer is traditionally primary debulking surgery (PDS) followed by adjuvant chemotherapy with a surgical goal of complete cytoreduction to improve overall survival (OS). More recently, there is continued debate of the utility of neoadjuvant chemotherapy with interval debulking surgery (NACT/IDS). Several trials have demonstrated non-inferior survival with lower perioperative morbidity, while a more recent trial demonstrated a modest PFS benefit for PDS, but no improvement in OS over NACT/IDS. Given the continued debate, the objective of this study was to evaluate the single site outcomes of patients with advanced stage epithelial ovarian cancer undergoing PDS or NACT/IDS. Methods This was a single center retrospective cohort study conducted at a large teaching hospital in the Midwest, evaluating patients with advanced stage III or IV epithelial ovarian, fallopian tube, or primary peritoneal carcinoma who underwent PDS or NACT/IDS from 2013 to 2024. Patients were identified through an institutional registry and demographic and clinicopathologic data were abstracted from the electronic medical record. Overall survival (OS) and recurrence-free survival (RFS) were estimated using the Kaplan-Meier method. Univariable and multivariable analyses of OS and RFS were performed using Cox proportional hazard models. Results Among 250 patients included for analysis, 62.0% received primary debulking surgery (PDS) and 38.0% underwent neoadjuvant chemotherapy/interval debulking surgery (NACT/IDS). The majority had stage III disease (72.4%) and high-grade serous histology (81.2%). Complete or optimal cytoreduction was achieved in 85.6% of patients. Median recurrence-free survival (RFS) was significantly longer for the PDS cohort compared to NACT/IDS (15.9 vs. 8.8 months, HR 0.71 95% CI 0.51–0.98, p = 0.04). Median OS longer for PDS compared to NACT/IDS (50.7 vs 34.2 months, HR 0.71 95% CI 0.49–1.03, p = 0.07). In multivariable analysis, complete cytoreductive surgery is associated with an improved OS (HR 0.35, 95% CI 0.20–0.61) and RFS (HR 0.41, 95% CI 0.25–0.66) compared to suboptimal cytoreduction. IV/IP + IV chemotherapy was associated with a 52% reduction in risk of death compared to IV chemotherapy alone (HR 0.48, p = 0.05). Conclusions Primary debulking surgery is associated with significant improvements in both recurrence-free and overall survival compared to neoadjuvant chemotherapy/interval debulking surgery in this patient cohort. Complete cytoreduction emerged as the strongest predictor of favorable outcomes, while suboptimal debulking was linked to worse survival. Use of intraperitoneal chemotherapy improved survival compared to intravenous chemotherapy. These findings highlight the crucial role of primary debulking surgery and tailored chemotherapy approaches for women with advanced epithelial ovarian cancer.

Comparative outcomes of primary debulking surgery vs neoadjuvant chemotherapy in advanced ovarian cancer: Insights from a single institution

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