Sociodemographic Factors Impact Cytoreductive Surgery Decisions in Advanced Ovarian Cancer

Declining cytoreductive surgery is associated with significantly poorer survival in patients with advanced epithelial ovarian cancer (EOC), with sociodemographic factors playing a key role in surgical decision-making, a new study suggests.¹

The authors of the World Journal of Surgical Oncology study explained that cytoreductive, or debulking, surgery is considered the foundation of initial management for patients with advanced EOC. Although achieving optimal cytoreduction is a crucial predictor of improved survival outcomes, some patients who receive a recommendation for surgery do not undergo the procedure.²

Patients may decide to forego cytoreductive surgery for various reasons.¹ For example, socioeconomic factors, such as health care access and income, can prevent patients from getting surgery. Also, frailty and comorbidities, like diabetes or heart disease, may make surgery seem too risky. On the other hand, physician biases based on age or race could influence whether they recommend cytoreductive surgery to a patient.

Consequently, the researchers assessed the clinical outcomes of patients with advanced EOC who were recommended for surgery yet did not undergo the procedure to gain more insight into treatment disparities among this population. Additionally, they evaluated sociodemographic and clinicopathologic characteristics to determine those associated with the decision to decline surgery.

Patients with advanced epithelial ovarian cancer (EOC) who were non-Hispanic Black, older, had lower household income, resided in nonmetropolitan areas, and were unmarried had higher odds of refusing cytoreductive surgery. | Image Credit: Dr_Microbe - stock.adobe.com

The researchers conducted their study using data spanning 2004 and 2021 from the Surveillance, Epidemiology, and End Results (SEER) database, which compiles extensive cancer-related statistics from across the US. Eligible patients included those with stage III or IV EOC who were recommended for surgery. The researchers categorized patients into surgical and non-surgical cohorts and used propensity score matching (PSM) to adjust for baseline differences.

Also, they compared survival outcomes using Kaplan-Meier and Cox proportional hazards models. Lastly, a logistic regression analysis was performed to identify predictors of surgery declination.

The study population consisted of 21,988 patients with advanced EOC. Of the 363 patients in the non-surgery cohort, 256 (70.5%) refused surgery and 104 (29.5%) did not undergo surgery for reasons not specified in their records. As for the 21,625 patients in the surgery cohort, 19,248 (89.0%) received both surgery and chemotherapy, while 2377 (11.0%) underwent surgery alone.

During a median follow-up of 33 (range, 1-215) months, the researchers observed a mean overall survival (OS) of 17.8 months for patients in the non-surgery cohort (95% CI, 13.4-22.2) and 45.8 months (95% CI, 41.5-50.1) for those in the surgery cohort. At the end of the study, mortality was documented in 326 patients in the non-surgery group (89.8%) and in 14,791 of those in the surgery cohort (68.4%).

Among the non-surgery group, the observed mean OS was 13.4 months for patients who declined surgery (95% CI, 11.2-15.6) and 18.2 months (95% CI, 14.2-22.2) for those with unspecified reasons for not receiving the procedure. As for the surgery cohort, the observed mean OS was 39.8 months (95% CI, 34.9-44.7) for patients who underwent surgical treatment alone and 46.6 months (95% CI, 42.1-51.1) for those who received combined surgery and chemotherapy.

Following 1:2 PSM, 726 patients in the surgery group were successfully matched to those in the non-surgery group, with comparable baseline demographic and clinical characteristics across groups; this indicated that PSM effectively mitigated potential selection bias (P > .05). In the matched cohort, the researchers found that OS remained significantly lower among the non-surgery group vs the surgery group (P < .001).

With the multivariable Cox proportional hazards model, they identified a significantly increased mortality risk for patients with advanced EOC in the non-surgery group, both before (HR, 2.74; 95% CI, 2.44-3.07; P < .001) and after (HR, 1.87; 95% CI, 1.62-2.15; P < .001) PSM.

Additionally, the multivariable logistic regression analysis demonstrated that non-Hispanic Black patients (adjusted odds ratio [AOR], 1.64; 95% CI, 1.10-2.37) had a higher likelihood of declining surgery than non-Hispanic White patients. The researchers hypothesized that higher refusal rates among non-Hispanic Black patients may be influenced by a combination of factors, including a systemic distrust of health care and historical and ongoing negative experiences with providers.

The researchers also found that advanced age was strongly associated with a greater likelihood of surgery refusal, particularly among those aged 80 or older. Other factors associated with higher odds of surgery refusal include having a lower household income, being unmarried, and residing in nonmetropolitan areas.

Lastly, they acknowledged their study’s limitations, including its retrospective design and use of SEER database data, which may introduce selection and reporting biases. To address these limitations and build upon their findings, the researchers suggested areas for further research.

“Future research should prioritize prospective, multicenter studies to understand patient decision-making and barriers to surgery and develop targeted interventions, such as patient navigation programs, financial assistance for underinsured individuals, and culturally sensitive educational campaigns to improve access to surgical care for all patients with advanced EOC,” the authors concluded.

References

1. Zhao L, Cheng G, Zhou X, Xu C, Ge M, Zhou Q. Factors associated with declining cytoreductive surgery in advanced epithelial ovarian cancer: a population-based study. World J Surg Oncol. 2025;23(1):119. doi:10.1186/s12957-025-03769-3
2. Liu YL, Filippova OT, Zhou Q, et al. Characteristics and survival of ovarian cancer patients treated with neoadjuvant chemotherapy but not undergoing interval debulking surgery. J Gynecol Oncol. 2020;31(1):e17. doi:10.3802/jgo.2020.31.e17