Could Risk-Based Triage System Alter Surgical Practice in Ovarian Cancer?

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A simple, risk-assessment algorithm may change practice when it comes to selecting patients with advanced ovarian who can tolerate complex primary debulking surgery, according to data presented during the virtual edition of the Society of Gynecologic Oncology (SGO) 2021 Annual Meeting on Women’s Cancer.1

A retrospective analysis of a cohort of women with stage IIIC or IV ovarian cancer showed that 90-day mortality was threefold lower for triage-appropriate women compared with those with high-risk features. These triage-appropriate patients also had a significantly lower risk for death following surgical complications.

“Patient selection is key,” said lead study author Deepa M. Narasimhulu, MD, a gynecologic oncology fellow at the Mayo Clinic, Rochester, Minnesota. “Our algorithm can identify women who are resilient, can tolerate complex surgery and recover from complications, and have a low mortality. Use of our algorithm significantly decreased 90-day mortality and allowed us to safely offer primary surgery to 70% of women with advanced ovarian cancer in our practice.”

Findings showed that 90-day mortality was significantly lower for the triage-appropriate women, and there was a consistent, threefold difference.
— Deepa M. Narasimhulu, MD

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As Dr. Narasimhulu explained, there are two options when it comes to the management of advanced ovarian cancer: primary surgery or neoadjuvant chemotherapy followed by interval surgery. The choice between these two options is often based on surgeon and institutional preferences, she said. However, some patients who are fit and resilient might be able to tolerate primary surgery better, whereas those who are not good surgical candidates might be better served with neoadjuvant chemotherapy.

Background on Triage Algorithm

Dr. Narasimhulu and colleagues at the Mayo Clinic led by Dr. William Cliby have been studying outcomes after complex surgery for more than a decade and have developed a triage algorithm that predicts the risk of morbidity and mortality after surgery. The simple algorithm contains three criteria: albumin level < 3.5 g/dL; age ≥ 80 years; and age between 75 and 79 plus an Eastern Cooperative Oncology Group performance status higher than 1, stage IV disease (multiple liver parenchymal or lung metastasis), or complex surgery likely (more than hysterectomy/bilateral salpingo-oophorectomy/omentectomy). Women who meet any of these criteria are considered to be high risk and are triaged to neoadjuvant chemotherapy, whereas those who are not at high risk are offered primary surgery.

Previous internal analysis demonstrated a decrease in 90-day mortality from 8.9% to 2.6% when this algorithm was used to select patients for primary debulking surgery. When compared with a historic cohort, these women also showed greater resiliency following a postoperative complication. Although 28% of women with a severe complication died within 90 days of surgery in the historic cohort, commented Dr. Narasimhulu, just 2.4% of women died following a severe complication in the contemporary cohort.

“Our triage algorithm selects for women who are resilient and better able to recover from complications,” said Dr. ­Narasimhulu.

High-Complexity Surgical Setting

After validating their algorithm in a low-complexity surgical setting via data from the American College of Surgeons National Surgical Quality Improvement Program, Dr. Narasimhulu and colleagues collaborated with Dr. Anna Fagotti and Dr. Giovanni Scambia in a high-complexity surgical setting. For this study, the researchers included 625 women who underwent cytoreductive surgery for stage IIIC or IV ovarian cancer between 2011 and 2019 at the Università Cattolica del Sacro Cuore in Italy.

Dr. Narasimhulu and colleagues retrospectively applied the triage algorithm to these women and classified them as high risk or triage appropriate. They then compared 30-day grade 3 or greater complications and 90-day mortality between the two groups.


  • Use of an evidence-based triage algorithm identifies patients at very high risk of surgical morbidity and mortality after high-complexity debulking surgery for ovarian cancer.
  • These patients are not ideal candidates for surgery when a high-complexity operation is anticipated.

“As expected, based on the variables in our algorithm, the triage-appropriate women were younger, had higher albumin levels, and had better performance status,” said Dr. Narasimhulu. She also noted that 80% of women in this cohort had intermediate- or high-complexity surgery.

“Findings showed that 90-day mortality was significantly lower for the triage-appropriate women, and there was a consistent, threefold difference.”

According to Dr. Narasimhulu, one of the criticisms of the algorithm is that women with low albumin levels are labeled as high risk, even if that is their sole high-risk factor. However, 90-day mortality in this subgroup of 89 women with low albumin levels as a sole risk factor was 5.6%, she said, which is much higher than the 2% for triage-appropriate women.

Analysis of recovery from severe complications also showed significantly higher mortality for high-risk women vs triage-appropriate women. Although 90-day mortality for high-risk women experiencing a grade 3 or greater complication was 25.9%, just 10.0% of triage-appropriate women died of severe complications within 90 days of surgery.

“Our algorithm works,” said Dr. Narasimhulu. “We previously validated our algorithm within our institutional setting and externally using a national data set in a low-complexity surgical setting. Now, we’ve validated our algorithm using an international high-complexity surgical cohort, so we’ve found reproducible results.” 

DISCLOSURE: Dr. Narasimhulu reported no conflicts of interest.


1. Narasimhulu D, Fagotti A, Scambia G, et al: Risk based triage for complex surgery in ovarian cancer: Ready for prime time. SGO 2021 Annual Meeting on Women’s Cancer. Abstract 102. Presented March 25, 2021.


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