Purpose:To compare mortality risk among long-term survivors of high-grade serous ovarian cancer (HGSOC) with that of the general U.S. population and to examine how mortality and recurrence trends have evolved under changing treatment approaches. Material and Methods:This is a retrospective cohort study including patients with histologically confirmed HGSOC treated at a single referral cancer center from 1991 to 2022. Mortality risk, expressed as standardized mortality ratios (SMRs, ratio of observed deaths in the study population to expected deaths in an age-matched U.S. population) was assessed at diagnosis and yearly on patients without events (disease persistence, recurrence, or death from any cause). Results:A total of 2,074 consecutive patients were included. Median follow-up was 12.5 years [interquartile range (IQR) 11.7-13.8]. Most patients were stage III (1396, 69.2%), 1299 (62.8%) underwent primary cytoreductive surgery, and 1688 (87.4%) received platinum-taxane as first-line therapy. At diagnosis, the mortality rate was 7.40 times higher than in the general population [95% confidence interval (CI) 7.04-7.77]. By 7 event-free years, the 95% confidence interval for the SMR included 1 for the first time, and at 10 years, the SMR was 1.05 [95% CI 0.72-1.49]), indicating no statistically significant excess mortality compared to the general population. In those event-free at 10 years, the 5-year cumulative incidence of ovarian cancer-related deaths (8.2% [95% CI 4.2-16.0]) was comparable to that of non-ovarian cancer-related deaths (6.3% [95% CI 2.9-13.8]). Conclusions:In this cohort, mortality risk steadily declined for patients who remained event-free, approaching that of the general population by 7 years post-diagnosis. These results emphasize the importance of individualized, long-term follow-up to address both recurrence risk and survivorship needs.

BACKGROUND:Complete gross resection (CGR) a key determinant of survival in advanced ovarian cancer (AOC). Preoperative imaging is used to predict residual disease (RD) and surgical complexity in the primary setting, but its performance after neoadjuvant chemotherapy (NACT) remains unclear. We evaluated the ability of computed tomography (CT)-based models in predicting RD and surgical complexity at interval debulking surgery (IDS). METHODS:This multicentre retrospective cohort study included 246 patients with FIGO stage IIIC-IV AOC undergoing NACT-IDS between 2016 and 2021. The Memorial Sloan Kettering (MSK) CT-based predictive model for RD was applied and recalibrated. Pre- and post-NACT CT scans were independently reviewed by six radiologists for 18 predefined disease sites. Logistic regression identified radiologic and clinical predictors of RD and advanced surgical procedures. RESULTS:CGR was achieved in 61% of patients; 35% had ≤1 cm RD, and 4% had >1 cm. The MSK model demonstrated limited discrimination for RD in the IDS setting (c-statistic 0.670). A revised model incorporating optimized age, CA-125 thresholds together with selected radiologic features improved discrimination (c-statistic 0.711). A model predicting the need for advanced surgical procedures achieved moderate performance (c-statistic 0.736). Subcapsular and perihepatic lesions were associated with diaphragm procedures; however absence on CT imaging did not preclude diaphragmatic stripping. CONCLUSIONS:MSK algorithm demonstrated limited discrimination in predicting CGR during IDS. A revised model incorporating optimized age and CA-125 thresholds improved performance. While specific CT findings may help anticipate the need for targeted surgical techniques and multidisciplinary involvement, their absence does not preclude the need for such procedures.

Importance:Decentralized clinical trials (DCTs) aim to increase trial access for underrepresented populations (URP) and ensure study outcomes, conclusions, and policy-related decisions are applicable to diverse populations. Objective:To assess trends in the percentage of accrued participants from more than 120 miles from the research site upon DCT program implementation. Design, Setting, and Participants:This descriptive quality improvement study was conducted from January 2024 to March 2025 at Mayo Clinic, a US multiregional, academic medical center (AMC) comprising 3 sites and an affiliated, community-based health care system. All individuals who consented and/or accrued to an institutional review board-approved clinical trial were included. Exposure:DCTs are defined as trials with at least 1 decentralized capability beyond remote consent. DCT program development began July 2022. By January 2024, remote consent, video telehealth visits, remote phlebotomy, and device services were implemented across all sites and departments. Remote monitoring and oral medication delivery were available on a limited basis. Prospective automated program and DCT participant data collection and quarterly reporting began in January 2024. Main Outcomes and Measures:Percentage of all DCT accrued participants with a residential zip code more than 120 miles from 1 of 3 AMC sites. Results:There were 7469 participants (median [IQR] age, 62 [51-70] years; 3594 [48.1%] female; 241 [3.2%] Asian, 391 [5.2%] Black or African American, and 6347 [85.0%] White individuals) accrued to 765 DCTs. During the study period, the percentage of DCT participants residing more than 120 miles from an AMC site ranged from 18.9% in the first quarter (Q1) of 2024 (383 of 2032 participants) to 29.6% in Q1 of 2025 (346 of 1170 participants). Of those accrued, 1147 (15.4%) were of a racial or ethnic URP, ranging from 12.5% in Q1 of 2024 (253 participants) to 17.4% in Q1 of 2025 (204 participants). There were 1554 (20.8%) participants from a rural location, ranging from 16.6% in Q1 of 2024 (338 participants) to 24.9% in Q1 of 2025 (291 participants). Additionally, by geospatial distance from an AMC site, the male-to-female ratio was nearly 50:50, and the age distribution appeared similar. Conclusions and Relevance:In this quality improvement study of a DCT program implementation, DCT accruals trended favorably among those residing more than 120 miles from an AMC site and those of rural or URP populations. While these findings cannot be directly attributed to program implementation, they are reassuring that this strategy may address some barriers to clinical trial access. Future studies should assess the sustained effectiveness and scalability of DCT models in improving equitable trial access.

BACKGROUND:This is the third updated enhanced recovery after surgery (ERAS®) society guideline presenting a consensus for optimal perioperative care in gynecologic oncology surgery. METHODS:A database search of publications using Embase and PubMed was performed (2018-2025). Studies for key elements within the ERAS gynecologic oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the grading of recommendations, assessment, development and evaluation (GRADE) system. RESULTS:All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS:The updated evidence base and recommendation for items within the ERAS gynecologic oncology perioperative care pathway are presented by the ERAS® society in this consensus review. Gynecologic surgeons may consider incorporating these recommendations into perioperative pathway design, with efforts to achieve consensus within their practice where feasible.

Introduction/Objective Opportunistic salpingectomy (OS) has been shown to reduce high-grade serous ovarian cancer (HGSOC) by 42-80%, yet awareness of this strategy outside of obstetrics and gynecology remains limited. The objective of this study was to assess awareness and counseling practices regarding OS for HGSOC prevention among primary care providers (PCPs). Methods We conducted a cross-sectional survey study using a 6-item electronic survey evaluating PCP knowledge and counseling practices related to HGSOC prevention through OS. The study was conducted at a single tertiary care center with gynecologic oncology services. Survey items assessed awareness of HGSOC origin, awareness of OS as a preventative strategy, counseling frequency in the setting of abdominal or pelvic surgery, counseling comfort, and resources needed to increase confidence in recommending OS. Response formats included Likert scales and Yes/No/Unsure options. The survey was distributed by email to attending physicians and advanced practice providers (APPs) in the Department of Family Medicine (FM) and Internal Medicine (IM). Results Of 398 providers surveyed, 136 responded (34% overall response rate; FM 44%, IM 28%), including 96 attending physicians and 40 APPs. Most PCPs were unaware that HGSOC originates in the fallopian tubes (60%) and were unaware of OS as a preventive strategy (71%). Counseling was uncommon: 11% had ever counseled on OS, while 74% had not and 15% reported it was outside their scope. Most respondents (63%) reported being not at all comfortable counseling patients about OS. Providers identified clinical guidelines (60%), CME or training modules (50%), eligibility criteria (48%), gynecology collaboration pathways (48%), and patient-friendly materials (44%) as key supports to improve counseling confidence. Conclusion PCP awareness and counseling regarding OS are limited. Given that guideline support for OS has solidified only in recent years, these gaps are not surprising—and they represent a clear, actionable opportunity. PCPs are well-positioned to lead the expansion of ovarian cancer prevention beyond specialty care with the right tools and support.

In advanced ovarian cancer, complete cytoreductive surgery is a cornerstone of treatment, yet defining which patients are "fit for surgery" remains challenging. Although guidelines emphasize comprehensive pre-operative evaluation, standardized assessment tools are lacking, and clinical practices vary widely across institutions. This narrative review synthesizes current evidence on individual patient-related factors that influence surgical fitness, reviews risk-assessment algorithms designed to guide patient selection, and examines the emerging role of pre-habilitation in optimizing perioperative outcomes. A structured literature search of MEDLINE, Embase, and Cochrane databases (January 2004-September 2024), supplemented by targeted PubMed searches (January 2005-April 2025), identified studies evaluating aging, comorbidity, frailty, nutrition, sarcopenia, and pre-habilitation in relation to surgical outcomes. Eligible studies included systematic reviews, randomized controlled trials, and prospective or retrospective cohorts of patients undergoing primary or interval cytoreduction. After application of the inclusion criteria, 33 studies encompassing 41,580 patients were included. The evidence consistently demonstrates that older age (particularly ≥80 years), frailty, comorbidity burden, and malnutrition are associated with increased post-operative complications and mortality following cytoreductive surgery. Several predictive models and nomograms integrating these factors have been developed to estimate perioperative risk, though most lack multi-center external validation. Implementation of an evidence-based triage algorithm that incorporates key patient characteristics and anticipated surgical complexity has been associated with meaningful reductions in post-operative mortality in institutional practice. Emerging data on multi-modal pre-habilitation suggest feasibility and potential benefits, including lower complication rates, shorter hospital stays, and earlier initiation of chemotherapy, though evidence remains preliminary. Current evidence on surgical fitness in ovarian cancer is limited by heterogeneous definitions, retrospective study designs, lack of prospective validation, and inconsistent reliance on clinical judgment alone. Standardized, externally validated tools, consensus-based thresholds for surgical candidacy, and results from ongoing randomized pre-habilitation trials are needed to guide clinical decision-making and improve patient outcomes.

OBJECTIVE:The purpose of this video is to illustrate the operative steps and perioperative considerations of minimally-invasive HIPEC. SETTING:This procedure was performed at a tertiary academic medical center, within the Division of Gynecologic Oncology. PARTICIPANT:Case presentation: A 32-year-old woman presented with a complex pelvic mass. She underwent primary cytoreductive surgery, including exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-ophorectomy, pelvic peritoneal stripping and omentectomy, with no gross residual disease. Final pathology revealed FIGO stage IIIA2 small cell ovarian carcinoma, hypercalcemic type (SCCOHT) with somatic SMARCA4 mutation. The patient completed four cycles of adjuvant vinblastine, cisplatin, cyclophosphamide, bleomycin, doxorubicin and etoposide (VPBCAE), followed by second-look laparoscopy and HIPEC with 130 mg of cisplatin. The patient's treatment plan followed the Cincinnati protocol with surgical cytoreduction, VPBCAE, second-look HIPEC and bone marrow transplant. INTERVENTIONS:The procedure began with diagnostic laparoscopy and placement of bilateral lower quadrant 10 mm ports. The patient's body temperature was lowered to 34°C. Inflow tubing was placed through a lower quadrant port site. Perforations were made in the outflow tubing using a 3 mm punch biopsy, which was placed along the surface of the liver. The abdomen was rinsed with saline until outflow reached 40°C. The abdomen was instilled with cisplatin and agitated for 90 min. The patient's body temperature remained at 36-38°C throughout the procedure. The abdomen was rinsed with 2 L saline. Diagnostic laparoscopy was again performed prior to closure. CONCLUSION:HIPEC has emerged as a promising adjunct to cytoreductive surgery. Understanding its technical considerations and clinical application is essential.

BACKGROUND:Several ovarian cancer studies have suggested that a body mass index (BMI) of 30 or higher is associated with lower compliance with National Comprehensive Cancer Network-recommended chemotherapy but primarily involved treatment before 2012, when dose capping was recommended for patients with higher body surface areas. Updated analyses in the contemporary treatment era are warranted. METHODS:In a retrospective cohort of patients with newly diagnosed ovarian cancer receiving curative-intent carboplatin plus paclitaxel in the Yale-Smilow Cancer Network (2012-2022), we evaluated BMI at diagnosis in relation to relative dose intensity (RDI)-the ratio of completed chemotherapy dose intensity to the National Comprehensive Cancer Network-recommended dose intensity-which reflects dose modification both before and during treatment. We also assessed starting RDI (which reflects modifications before treatment) and received RDI (which reflects modifications during treatment). Data on hospitalizations and hematological chemotoxicities were collected. We examined the association between BMI (<25, 25-30, ≥30) and chemotherapy completion, hospitalizations, and toxicities using multivariable linear and logistic regressions. RESULTS:Among 327 patients, the average RDI was 79.7%, and 44.3% had an RDI below 85%. Mean (SD) starting and received RDI were 97.9% (9.1%) and 81.8% (25.7%), respectively. Higher BMI was associated with higher RDI (Paggregate = .03) and received RDI (Paggregate = .04). Body mass index was not associated with starting RDI, dose reductions, delays, hospitalizations, or hematological toxicities. CONCLUSIONS:Among patients with ovarian cancer treated since 2012, the overall RDI was low. Relative dose intensity was higher among patients with a BMI of 25 or higher compared with a BMI below 25. Most dose modifications occurred during treatment and not before initiation. Studies with body composition data and interventions that maximize chemotherapy completion during treatment are warranted.

Objective To evaluate the association between of a structured, multimodal prehabilitation program during neoadjuvant chemotherapy (NACT) on chemotherapy delivery, treatment tolerability, and surgical candidacy in patients with advanced-stage ovarian cancer (OC). Methods This was a matched-cohort study of patients with stage IIIC/IV OC receiving NACT at a single tertiary center. The intervention group participated in a prospective multimodal prehabilitation trial during NACT, and a historical control group was matched 1:1 based on age, FIGO stage, and indication for NACT. Primary endpoints included relative dose intensity (RDI) for carboplatin and paclitaxel and surgical outcomes. Results A total of 116 patients were included. In the overall cohort, median RDI was higher in the prehabilitation group for paclitaxel (99% vs. 92%, p = 0.05) and similar for carboplatin (93% vs. 91%, p = 0.3). The proportion achieving RDI ≥85% was 84.0% vs. 75.4% for paclitaxel (p = 0.3) and 74.1% vs. 65.5% for carboplatin (p = 0.3). Failure to proceed to interval debulking surgery (IDS) was lower in the prehabilitation group (6.9% vs. 22.4%, p = 0.03).In patients aged ≥70 years (n = 60), prehabilitation was associated with higher median RDI for paclitaxel (98% vs. 86%, p < 0.001) and carboplatin (92.5% vs. 87%, p = 0.04), as well as a higher proportion achieving RDI ≥85% for paclitaxel (88.5% vs. 59.3%, p = 0.02). Failure to proceed to IDS was also lower (12.5% vs. 42.9%, p = 0.007). Conclusion Multimodal prehabilitation during NACT was associated with improved chemotherapy delivery and higher rates of IDS, particularly in patients aged ≥70 years. These preliminary findings suggest a potential role for prehabilitation as a strategy to enhance treatment adherence in advanced OC.

Objective: This study examines the association of socioeconomic status (SES) with delays in care and treatment timeline for endometrial cancer (EC) patients receiving primary surgery.Methods: This was a retrospective cohort study of patients who underwent surgical management of EC between 2018 and 2024. SES was determined by Area Deprivation Index (ADI) national percentile rank. Demographics, dates of symptom onset, provider visits, tissue diagnosis, and surgery were abstracted from the electronic medical record.Results: Of the 2191 patients who had surgical management for EC, we analyzed 185 (ADI1, most advantaged) and 257 (ADI4, least advantaged). Patients in ADI1 had a lower mean BMI (31.1 kg/m2 vs 35.6 kg/m2, p < 0.001). Although the majority of the cohort was White (91.0%), ADI4 included more Black patients (6.6% vs 1.1%, p = 0.003).Time from symptom onset to surgery was 30 days longer in ADI4 compared to ADI1 (126.0 days vs 96.0 days, p = 0.003). Specifically, time from symptom onset to first visit with a healthcare provider differed significantly between ADI1 and ADI4, with a median of 20.5 days versus 50.0 days (p < 0.001). There were no statistically significant differences in intervals between other care timepoints.Conclusions: The discrepancy in time to surgical management of EC was driven by delays in first provider visit, indicating that disparities are related to symptom recognition and access to initial evaluation rather than delays within specialty care. These findings can inform interventions for reducing socioeconomic and geographic disparities in endometrial cancer care.

OBJECTIVE:Textbook Oncologic Outcome (TOO) is a composite measure that strongly predicts survival after surgery for advanced epithelial ovarian cancer (AEOC), regardless of approach: primary (PDS) or interval debulking surgery (IDS). We aimed to identify risk factors associated with failure to achieve TOO and to receive standard treatment (surgery and chemotherapy) for AEOC. METHODS:Patients diagnosed with AEOC between 2008 and 2019 were identified using the National Cancer Database. TOO was defined as achieving complete cytoreduction, hospital stay <10 days, no 30-day readmission, adjuvant chemotherapy initiation <42 days, and 90-day survival. Logistic regression models were used to identify factors associated with TOO and receipt of standard treatment. RESULTS:Among 58,635 AEOC patients, 49% received standard treatment. Of the 21,657 patients who underwent surgery, 51.4% received PDS and 48.6% IDS. For PDS multivariable analysis, factors associated with lower likelihood to achieve TOO included age >75 years (vs <60; OR 0.47, 95% CI 0.38-0.58), Black race (vs White; OR 0.73, 95% CI 0.59-0.90), government insurance (vs private; OR 0.82, 95% CI 0.73-0.92), high surgical complexity (vs low; OR 0.62, 95% CI 0.56-0.68), and median surgical volume ≤5 cases/year (vs ≥20; OR 0.75, 95% CI 0.63-0.89). For IDS, similar associations were observed for government insurance (OR 0.87, 95% CI, 0.80-0.96), high surgical complexity (OR 0.61, 95% CI 0.55-0.66), and median surgical volume ≤5 cases/year (OR 0.60, 95% CI 0.52-0.70). CONCLUSIONS:Several factors are associated with lower likelihood of achieving TOO after treatment for AEOC. Some of these factors (age, race, payor type) reflect disparities in care; others (facility volume, surgical complexity) highlight the need for referral to high-volume centers for initial treatment planning.

Several tools have been proposed for assessing frailty in multiple myeloma (MM), but most are based on clinical trial data sets. There are also limited data on the association between frailty and patient-reported outcomes and on the prognostic value of social determinants of health. This study evaluates the prognostic impact of frailty, based on the cumulative deficit frailty index (FI), and relationship and socioeconomic status (SES) in patients with newly diagnosed MM. This retrospective study included 515 patients with MM seen at Mayo Clinic (Rochester, MN) at diagnosis between 2005 and 2018. The FI was calculated using patientreported data on activities of daily living and comorbidity data, with items scored as 0, 0.5, or 1, in which 1 indicated a deficit. The FI was calculated by dividing the total score by the number of nonmissing items. Frailty was defined as FI >= 0.15; 61% were nonfrail, and 39% were frail. Frailty and nonmarried/relationship status were associated with higher disease stage, decreased the likelihood of early transplantation, and independently associated with decreased survival. SES was not independently associated with survival. Frail patients reported worse scores for fatigue, pain, and quality of life. Approximately a quarter of patients had a deterioration in frailty status at 3 to 12 months, and <10% had improvement. In conclusion, a cumulative deficit FI was associated with higher symptom burden and decreased survival in a real-world cohort of patients with newly diagnosed MM. Frailty status is dynamic and should be reassessed during treatment. Social support has prognostic value and should be evaluated in clinical practice.