The historic city of Xi’an became a gathering place for top global oncologists as the 2024 Chinese Congress of Holistic Integrative Oncology (CCHIO) and the Asian Oncology Socitey (AOS) took place from November 14 to 17. This event symbolized a significant integration of the global oncology community. During the gynecologic oncology session at CCHIO, Dr. Xiaohua Wu from Fudan University Shanghai Cancer Center delivered a presentation titled "Enhancing Preoperative Evaluation Strategies for Advanced Ovarian Cancer Patients." In an exclusive interview with Oncology Frontier, he shared Fudan's experience in advancing preoperative evaluation methods for ovarian cancer.

Oncology Frontier: Ovarian cancer has the highest mortality rate among gynecologic malignancies, with about 70% of patients diagnosed at an advanced stage. In recent years, advances in targeted therapies and immunotherapies have transformed the treatment landscape for advanced ovarian cancer. Against this backdrop, what role does surgery play in ovarian cancer treatment?

Dr. Xiaohua Wu: This is a crucial question that many are concerned about. Ovarian cancer is often diagnosed at an advanced stage when the disease has already spread beyond the pelvis. Despite breakthroughs in new drugs such as PARP inhibitors and antibody-drug conjugates (ADCs), surgery remains indispensable in treatment. Surgical debulking outcomes are categorized into three levels:

• R0: No visible residual tumor
• R1: Residual tumor ≤ 1 cm
• R2: Residual tumor > 1 cm

Data from prospective studies and statistical analyses show stark differences in 5-year survival rates between these groups. The cleaner the tumor resection, the longer the patient survives. For instance, patients achieving R0 have a 5-year survival rate 2.7 times higher than R1 patients and 4 times higher than R2 patients. Thus, R0 is the ultimate goal of surgery for advanced ovarian cancer.

Even with the widespread application of PARP inhibitors in first- and second-line treatment, and the use of ADCs in later-line therapy, the importance of achieving R0 resection remains unchanged. Clean surgical resection minimizes recurrence risk and reduces the need for subsequent ADC or other drug therapies. This underscores that achieving R0 resection is still critical, and surgery remains a cornerstone of ovarian cancer treatment, emphasizing prevention over cure.

Oncology Frontier: Improving the proportion of successful surgical debulking has always been a challenge for gynecologic oncologists. Is it possible to accurately evaluate the resectability of advanced ovarian cancer in patients? Could you elaborate on the key elements of preoperative evaluation strategies?

Dr. Xiaohua Wu: For advanced ovarian cancer, the surgical options include primary debulking surgery (PDS) or neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). If R0 is achievable, we proceed directly with surgery. If R0 is unlikely, we begin with NACT before performing IDS.

How can we determine whether R0 resection is possible when the disease’s extent isn’t directly visible? This is where preoperative evaluation comes into play. Allow me to share the experience of Fudan University Shanghai Cancer Center.

Ten years ago, our center adopted a two-step method involving imaging scoring and, when necessary, laparoscopic evaluation. Initially, we used CT or PET-CT for imaging evaluation, assessing clinical characteristics and upper abdominal tumor spread based on the MSKCC scoring system. A score of ≥3 indicated only a 30% chance of achieving R0, making such patients unsuitable for direct surgery. Patients scoring between 3–5 would undergo laparoscopic evaluation.

With this approach, our R0 resection rate increased from approximately 31% to 57.8%—a significant leap. Since 2018, we’ve improved the imaging tools used in evaluations, replacing CT with enhanced MRI and whole-abdominal diffusion-weighted MRI (DWI MRI). This technology better detects mesenteric and diaphragmatic tumors and identifies small lesions, greatly enhancing the accuracy of preoperative assessments.

After years of refinement, our R0 rate has further risen to 77.8%. Previously, only patients with scores of 0–3 could achieve R0 resection; now, even those scoring 0–5 can undergo direct surgery. This demonstrates how advancements in imaging and evaluation models significantly improve outcomes.

Additionally, this year, we published the Modified Suidan Scoring System (MSSKCC) in the American Journal of Obstetrics & Gynecology, which evaluates two critical areas—the diaphragm and mesentery—with a scoring range of 0–4. This has drawn attention from international peers and represents a substantial step forward.

In summary, robust preoperative evaluation systems enable clinicians to better determine the feasibility of achieving R0 resection. Improving surgical R0 rates also relies on advancements in surgical techniques developed over the past decade.

Oncology Frontier: Beyond preoperative evaluation, what other factors should clinicians focus on to maximize the chances of complete resection in advanced ovarian cancer?

Dr. Xiaohua Wu: Whether the approach involves PDS or NACT+IDS, the ultimate goal is achieving R0. It’s crucial to have specialized gynecologic oncologists perform these surgeries. Both domestic and international guidelines, including the NCCN Guidelines, recommend that advanced ovarian cancer surgeries be conducted by gynecologic oncology specialists, coupled with rigorous preoperative evaluation. This strategy has been proven to improve patient survival rates.

At this year’s CCHIO conference, I highlighted the Chinese Anti-Cancer Association (CACA) Gynecologic Oncology Committee’s initiative to launch the Chinese Gynecologic Oncology Specialist Training and Certification Program. This program aligns with international standards, aiming to enhance the diagnostic and treatment capabilities of Chinese ovarian cancer specialists and improve patient survival outcomes. The initiative has been enthusiastically welcomed by gynecologic oncologists across the country.