Greater NACT Use at High-Volume Centers Linked to Lower Surgical Mortality, Longer Survival in Advanced Ovarian Cancer

Receiving treatment at high-volume cancer centers with greater use of neoadjuvant chemotherapy (NACT) is associated with lower 90-day surgical mortality and longer 60-month survival among patients with advanced-stage ovarian cancer, according to a study published in JAMA Network Open.¹

The researchers noted that perioperative mortality following cytoreductive surgery is more common among patients with ovarian cancer treated at low-volume centers. By comparison, NACT followed by interval cytoreductive surgery has been shown to reduce surgical complexity, postoperative complications, and mortality without impairing long-term survival. Because of its lower complication rates, NACT may also be more cost-effective than primary cytoreductive surgery.²

Although prior studies have linked centers with lower ovarian cancer surgical volumes to higher perioperative mortality, it remains unclear how the use of NACT may modify this association.¹ To address this, the researchers conducted a cross-sectional study examining how the relationship between cancer program-level NACT use, postoperative mortality, and long-term survival varies by surgical case volume across US cancer centers.

The study’s primary outcomes included 90-day mortality following cytoreductive surgery, measured by standardized rates and ORs, and life expectancy within 60 months of diagnosis, assessed as restricted mean survival time.

High-volume cancer centers utilizing neoadjuvant chemotherapy significantly reduce surgical mortality and enhance survival rates in patients with advanced ovarian cancer. | Image Credit: Spiroview Inc. - stock.adobe.com

“Understanding how NACT utilization and ovarian cancer case volume interact in their association with surgical and oncologic outcomes can help patients and clinicians make treatment setting–specific, evidence-based decisions about the risks and benefits of the different treatment strategies for advanced ovarian cancer,” the authors wrote.

The researchers analyzed data from the National Cancer Database, which captures about 70% of newly diagnosed cancer cases in the US across more than 1500 US facilities. Eligible patients included those newly diagnosed with stage III or IV epithelial ovarian cancer treated between January 2010 and December 2019 at Commission on Cancer–accredited programs. For analyses of postoperative mortality, only patients who underwent cytoreductive surgery with known 90-day mortality outcomes were included.

During the study period, 70,707 eligible patients (mean [SD] age, 63.1 [12.1] years) received treatment across 1333 cancer centers. Of whom, 24,157 were treated at 1089 low-volume centers, 24,095 at 175 average-volume centers, and 22,455 at 69 high-volume centers. Overall, 62,215 (87.9%) patients underwent surgery, including 20,114 at low-volume centers, 21,864 at average-volume centers, and 20,237 at high-volume centers.

After adjusting for demographic and clinical variables, the researchers found that 90-day surgical mortality was lower at centers with higher NACT utilization. However, the magnitude of benefit varied by hospital volume (P for interaction < .001).

At low-volume centers, high NACT use was associated with a 52% reduction in the odds of 90-day mortality (OR, 0.48; 95% CI, 0.39-0.60) compared with low NACT use (standardized 90-day mortality rate, 4.8% vs 9.5%). Similarly, at high-volume centers, high vs low NACT use was associated with a 74% reduction in odds of 90-day mortality (OR, 0.26; 95% CI, 0.17-0.41; standardized 90-day mortality rate, 2.9% vs 10.0%).

Long-term survival also varied by NACT use. At high-volume centers, patients treated at programs with high NACT use had a 4.0-month longer 60-month life expectancy than those treated at centers with low utilization (42.2 vs 38.1 months; 95% CI, 1.6-6.5). In contrast, no significant survival difference was observed at low- (37.9 vs 39.1 months) or average-volume (39.6 vs 39.4 months) centers.

The researchers concluded by acknowledging their limitations, including the exclusion of patients treated outside of Commission on Cancer–accredited programs; this may impact the generalizability of their findings. Still, they expressed confidence in their findings.

“The present study is consistent with randomized trials and observational studies demonstrating that NACT improves postoperative morbidity and mortality,” the authors wrote.

References

1. Abel MK, Mazina V, Bregar AJ, et al. Neoadjuvant chemotherapy, case volume, and mortality in advanced ovarian cancer. JAMA Netw Open. 2025;8(7):e2523434. doi:10.1001/jamanetworkopen.2025.23434
2. Coleridge SL, Bryant A, Kehoe S, Morrison J. Neoadjuvant chemotherapy before surgery versus surgery followed by chemotherapy for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev. 2021;7(7):CD005343. doi:10.1002/14651858.CD005343.pub6