Abstract
Introduction
Ovarian cancer remains a leading cause of gynecologic cancer-related mortality worldwide. Identifying perioperative factors that influence survival outcomes is essential for optimizing care. This study evaluates the impact of perioperative factors such as intraoperative blood transfusions and hospital length of stay (LOS) on survival rates in ovarian cancer patients undergoing surgical debulking.
Methods
This retrospective study analyzed charts of 314 patients who underwent ovarian cancer surgery at a single institution between 2010 and 2018. Patients were grouped based on survival status: “Live” or “Death”. Variables included demographics, tumor size, comorbidity, anesthesia time, surgery time, estimated blood loss, transfusion, readmission, hospital stay length, and survival. Statistical analyses included log-rank tests and mean survival estimations: chi-square tests and Mann-Whitney U-test. Significance was set at P < .05.
Results
The mean follow-up was 50.5 months (95% CI, 47.8-53.2). Prolonged LOS (>3 days) was significantly associated with reduced survival (47.4 vs 52.4 months, P = .015). Patients requiring intraoperative blood transfusions had poorer survival outcomes (42.0 months 95% CI, 36.3-47.7 vs 53.1 months 95% CI, 50.3-55.9, P < .001). The “Death” group experienced greater blood loss, longer surgical/anesthesia times, and higher intraoperative fluid requirements.
Conclusion
Prolonged hospital stays and intraoperative blood transfusions are associated with worse survival outcomes in ovarian cancer patients undergoing surgery. These findings underscore the importance of perioperative optimization strategies, including minimizing transfusion requirements and reducing LOS through enhanced recovery protocols.
Plain Language Summary
Why was the study done? Ovarian cancer is a serious health issue for women worldwide. This study was conducted to explore how factors related to surgery and hospital care impact survival in ovarian cancer patients. We aim to improve patient outcomes and guide future care by identifying these factors. What did the researchers do? The research team reviewed medical records of 314 patients who had ovarian cancer surgery between 2010 and 2018. Data such as age, tumor size, surgery details, hospital stay length, and survival status were analyzed. Patients were sorted into groups based on whether they survived or died. Statistical tests were used to identify significant differences between the groups. What did the researchers find? The study found that longer hospital stays (over 3 days) were linked to lower survival rates. Additionally, patients who required blood transfusions during surgery had significantly poorer survival compared to those who did not. What do the findings mean? This study highlights the importance of minimizing hospital stay lengths and reducing the need for intraoperative blood transfusions to improve survival outcomes for ovarian cancer patients. These findings could help healthcare providers refine surgical and postoperative practices to enhance patient care.
Introduction
Ovarian cancer is a leading cause of gynecologic cancer-related mortality worldwide, with approximately 19, 710 new cases and 13, 270 deaths annually in the United States. 1 Early symptoms of bloating, abdominal pain, and urinary urgency often go unnoticed. The lack of appropriate screening tools often results in late-stage diagnoses, further contributing to the high mortality rates. 2 The 5-year relative survival rate for ovarian cancer varies dramatically by stage at diagnosis, with a 93% survival rate for stage I disease, but this drops to approximately 31% for patients diagnosed at stage IV. 3 Therefore, optimizing treatment approaches for ovarian cancer, especially surgical interventions, is crucial for improving patient outcomes.
The mainstay treatment for ovarian cancer typically involves surgical debulking, often preceded and/or followed by chemotherapy to improve outcomes. 4 Generally, the extent of the surgery and intraoperative conditions, including blood loss, transfusion requirements, and surgical time, play a crucial role in postoperative recovery and long-term survival.5,6 The amount of residual disease has been shown to affect survival outcomes negatively, and therefore, aggressive debulking is encouraged. 7 Surgical complexity has been linked to an increased need for postoperative intensive care and poorer surgical outcomes.8,9 Postoperative factors such as transfusion rates and length of hospital stay (LOS) have been linked to poorer survival rates. 10
Intraoperative procedures, such as minimizing blood loss, optimizing anesthesia duration, and reducing hospital stays, are paramount in reducing complications that can impact survival in ovarian cancer patients. This study explores the relationship between these perioperative factors and survival outcomes, identifying key predictors such as transfusion status and hospital stay length.
Materials and Methods
With approval from the University of South Florida Institutional Review Board (IRB ID: STUDY003521), the medical records of all patients who underwent surgery for ovarian cancer at the Moffitt Cancer Center between 2010 and 2018 were reviewed. The inclusion criterion for the study was a confirmed diagnosis of ovarian cancer via biopsy, with appropriate tumor staging recorded according to the FIGO (International Federation of Gynecology and Obstetrics) staging system. Data extraction was performed on patient charts and included demographic information (age, body mass index), clinical characteristics (tumor size, cancer stage), and intraoperative and postoperative measures, including the type of procedure performed, operative time, estimated blood loss, anesthesia duration, surgery duration, intravenous fluids volume, blood transfusion, urine outputs, and intraoperative temperature). Postoperative data encompassed patient readmissions, surgical complications, hospital stay duration, and overall survival rates. Survival status was determined using hospital records, and patients were classified into two groups: “Live” and “Death”. Length of Stay: Number of days between surgery and discharge. Follow-up Duration: Live: Days between surgery and last follow-up; Death: Days between surgery and death. Overall Survival (OS): Time from surgery to death or last follow-up, whichever occurs first. Overall survival was assessed using Kaplan Meier survival analysis; factors were compared using a log-rank test. The reporting of this study conforms to the STROBE guidelines for case-control studies. 11
The data extraction process involved converting patient chart data into Excel spreadsheets, which were later merged using R software for analysis. The data was summarized using descriptive statistics and reported as proportions or mean ± standard deviation. Categorical outcomes were compared using chi-square or Fisher’s exact tests, while continuous outcomes were compared using nonparametric Mann-Whitney U tests. P-values of < .05 were considered statistically significant.
Results
Clinical Characteristics of Ovarian Cancer Patients.
Note: Values are presented as N (%) for categorical variables or mean ± standard deviation (SD) for continuous variables.
Clinical Factors Affected Overall Survival.
Note: Values are presented as N (%) for categorical variables or mean ± standard deviation (SD) for continuous variables.
Intraoperative Measurements Between Live Group and Death Group.
Mean ± SD.
Discussion
This study evaluated the impact of perioperative factors on survival outcomes in patients undergoing surgical debulking for ovarian cancer. Our findings revealed that prolonged hospital length of stay (LOS) and intraoperative blood transfusions were significantly associated with decreased survival rates, suggesting potential areas for intervention to improve patient outcomes.
The association between prolonged LOS and poorer survival underscores the potential impact of postoperative complications, such as infections or thromboembolic events. Specifically, a prolonged LOS may lead to increased exposure to nosocomial infections, which are known to negatively impact survival outcomes.12,13 Longer hospital stays may also reflect the complexity of the surgical procedures, increased patient frailty, postoperative complications, or inadequate postoperative care, highlighting the need for optimized recovery protocols and proactive management of comorbidities. Our length of hospital stay (LOS) was strongly associated with worse survival, where patients staying more than three days postoperatively had significantly lower survival rates (P = .015). Nearly two-thirds of patients who stayed three days or less in the hospital were found to still be alive, but two-thirds of patients who stayed over three days were found to be dead at the time of data collection. A prolonged stay could reflect disease factors such as advanced-stage linked to surgical complexity and/or surgical factors in higher-stage patients, leading to complex surgical approaches delaying postoperative recovery.
Patients requiring intraoperative blood transfusions experienced significantly reduced survival, indicating that transfusions may be a marker for more extensive surgical procedures, increased blood loss, or underlying patient vulnerability. In line with these findings, previous studies have demonstrated similar associations between transfusions and adverse outcomes in cancer surgery. For instance, a meta-analysis demonstrated a link between intraoperative transfusions and increased mortality in colorectal cancer patients, highlighting the potential immunosuppressive effects of allogeneic blood. 14 Our results underscore the importance of employing transfusion-sparing techniques, such as cell salvage and meticulous surgical hemostasis, to mitigate potential complications. In this study, intraoperative blood transfusion administration was associated with worse survival (P < .001). This occurred despite noting similar tumor sizes between the live and dead groups. Anesthesia times of over 60 minutes were also noted in the dead vs live groups (P < .004). This could be due to the presence of higher-stage disease and higher estimated blood losses noted in the dead group, suggesting a more complex distribution of disease and/or surgical technique requiring blood transfusion. Further, the increased use of intraoperative electrolytes and albumin as volume replacement in the dead group reflects a need for volume expansion intraoperatively and an evolving need for postoperative blood transfusion.
The need for more than one postoperative readmission was associated with an increased risk of death (P = .021). This suggests that increasing the number of readmissions leads to an increased risk of death. The subsequent need for readmission was not evaluated but could reflect both operative and nonoperative parameters, such as an adjuvant chemotherapy issue or disease progression, to account for readmission. In the management of ovarian cancer, cytoreductive surgery plays a crucial role, especially when combined with chemotherapy. Achieving complete or optimal cytoreduction is associated with improved survival outcomes. 15 However, the extent of cytoreduction must be balanced against the potential for surgical morbidity and mortality. Experienced multidisciplinary teams in tertiary referral hospitals are best suited to achieve high rates of complete cytoreduction while managing the associated complications. The decision to pursue aggressive cytoreduction should consider the patient’s overall health, the extent of disease, and the likelihood of achieving complete resection.15,16
Several limitations must be considered when interpreting our findings. The retrospective design is subject to inherent biases, including selection bias and information bias. Specifically, the decision to transfuse patients was not randomized and may have been influenced by unmeasured factors, such as surgeon preference or perceived patient risk. Furthermore, the reliance on a single institution’s data limits the generalizability of our results to other populations or healthcare settings with different practices. However, this also allows for a consistent approach in surgical technique, perioperative management, and data collection, which strengthens the internal validity of our findings. This study is consistent with previously published data showing that increasing cancer stage is a key prognostic factor affecting ovarian cancer survival.17-19 In our study, higher-stage disease (stage III and IV) was significantly associated with poorer survival outcomes (P < .001); stage 3 disease was the most prevalent at the time of diagnosis in either the live or dead cohorts (45.6% vs 60.9%). Higher-stage disease has been associated with a higher degree of surgical complexity. 9 It has been previously associated with an increased need for resuscitative efforts intraoperatively and postoperatively in ovarian cancer. Prior studies evaluating blood transfusion to morbidity and survival have assessed the need for intraoperative and postoperative blood transfusion as a singular variable combining intraoperative and postoperative blood transfusions. In this case, some have found that perioperative blood loss is associated with increased mortality, while others have noted no increased median survival. 20 Despite these limitations, our study provides valuable insights into the impact of perioperative factors on survival in ovarian cancer patients undergoing surgical debulking. The key takeaway is that modifiable factors, such as reducing LOS and minimizing blood transfusions, may have a positive impact on patient outcomes.
Our study did not specifically evaluate the prognostic impact of microscopic residual disease after neoadjuvant chemotherapy (NACT) in patients undergoing interval debulking surgery (IDS). However, emerging evidence suggests that even in the absence of macroscopic disease, the presence of microscopic residuals can predict a poorer prognosis.21-23 One study found that patients with microscopic residual disease after NACT had significantly reduced progression-free survival. 22 Therefore, future studies should incorporate detailed pathological assessments to evaluate the impact of microscopic residual disease on survival outcomes.
In conclusion, prolonged hospital stays and intraoperative blood transfusions are associated with worse survival outcomes in ovarian cancer patients. Our findings support the implementation of strategies such as enhanced recovery protocols and transfusion-sparing techniques to optimize perioperative care. To further validate these findings and explore the efficacy of targeted interventions, we recommend future prospective, multi-center studies that incorporate detailed assessments of patient frailty, surgical complexity, and adherence to established perioperative guidelines.
Footnotes
Ethical Statement
Ethical Approval
Ethical approval was obtained from the University of South Florida Institutional Review Board (IRB ID: STUDY003521). This study was a retrospective review of anonymized patient data and did not require patient consent.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data used in this study were obtained through a retrospective chart review of patient records at Moffitt Cancer Center. Due to institutional policies and patient confidentiality regulations, the data are not publicly available. However, aggregated and de-identified data may be shared upon request.