We investigated URS and impact on survival in whole patient cohorts with AOC treated within gynaecological cancer centres that participated in the previously presented SOCQER 2 study. National cancer registry datasets were used to identify FIGO Stage 3,4 and unknown stage patients from 11 cancer centres that had previously participated in the SOCQER2 study. Patient outcomes’ association with surgical ethos were evaluated using logistic regression and Cox proportional hazards. Centres were classified into three groups based on their surgical complexity scores (SCS); those practicing mainly low complexity, (5/11 centres with >70% low SCS procedures, 759 patients), mainly intermediate (3/11, 35–50% low SCS, 356 patients), or mainly high complexity surgery (3/11, >35% high SCS, 356 patients). Surgery rates were 43.2% vs. 58.4% vs. 60.9%. across mainly low, intermediate and high SCS centres, respectively, p < 0.001. Combined surgery and chemotherapy rates were 39.2% vs. 51.8% vs. 38.3% p < 0.000 across mainly low, intermediate and high complexity groups, respectively. Median survival was 23.1 (95% CI 19.0 to 27.2) vs. 22.0 (95% CI 17.6 to 26.3) vs. 17.9 months (95% CI 15.7 to 20.1), p = 0.043 in mainly high SCS, intermediate, and low SCS centres, respectively. In an age and deprivation adjusted model, compared to patients in the high SCS centres, patients in the low SCS group had an HR of 1.21 (95% CI 1.03 to 1.40) for death. Mainly high/intermediate SCS centres have significantly higher surgery rates and better survival at a population level. Centres that practice mainly low complexity surgery should change practice. This study provides support for the utilization of URS for patients with advanced OC.

Background: The surgical and medical management of recurrent ovarian cancer is complex and requires a personalized approach based on several factors, including the timing of recurrence, the patient’s performance status, previous treatment regimens, and the tumor’s histology and molecular characteristics. Objectives: Five randomized trials—GOG-0213, DESKTOP III, SOC 1, HORSE, and CHIPOR—have been conducted and shed light on our practice. Results: Both the DESKTOP III and the SOC 1 trials support the benefit of secondary surgery. The GOG-0213 trial, however, did not show an overall survival benefit, confirming that surgery should not be offered to all patients with platinum-sensitive recurrent ovarian cancer and highlighting the importance of strict patient selection using evidence-based selection criteria including the AGO or iMODEL scores. In patients with a negative score, there may be a place for cytoreductive surgery plus HIPEC in BRCA-negative cases following a course of chemotherapy, although current evidence shows no additional benefit for HIPEC when cytoreductive surgery is performed as an adjuvant procedure. Conclusions: Secondary surgery is recommended for platinum-sensitive patients when respecting AGO or iModel criteria. In addition, surgery plus HIPEC can be considered in BRCA-negative patients with an initial negative AGO or iMODEL score who show sufficient response following a course of neoadjuvant chemotherapy to then be considered operable.

George Papanikolaou is famously quoted as saying “the first observation of cancer cells in the smear of the uterine cervix gave me one of the greatest thrills I ever experienced during my scientific career”