From October 16 to 18, 2026, the 5th West Lake Gynecologic Oncology Conference, the 2026 Academic Annual Meeting of the Gynecologic Oncology Committee of the Zhejiang Anti-Cancer Association, and the 2026 Academic Conference of the Cervical Cancer Integrated Prevention and Screening Committee of the Chinese Anti-Cancer Association were held in Hangzhou, China. The events were organized by the Zhejiang Anti-Cancer Association and undertaken by Zhejiang Cancer Hospital and the Cervical Cancer Integrated Prevention and Screening Committee of the Chinese Anti-Cancer Association. The meetings focused on basic and clinical research in gynecologic oncology and advances in surgical techniques, with discussions addressing key challenges in precision and individualized treatment.During the conference, Oncology Frontier conducted an on-site interview with Professor Xiwa Zhao of Xuanwu Hospital, Capital Medical University. Drawing on his presentation, “The Optimal Surgical Approach for Cytoreductive Surgery in Advanced Ovarian Cancer,” Professor Zhao discussed the role of surgery in advanced ovarian cancer, the choice between primary debulking surgery (PDS) and interval debulking surgery (IDS), surgical decision-making after neoadjuvant chemotherapy (NACT), and the appropriate role of hyperthermic intraperitoneal chemotherapy (HIPEC). His insights offer clinicians a practical framework for surgical management that balances standardized care with individualized decision-making.
Oncology Frontier:
Your presentation is titled “The Optimal Surgical Approach for Cytoreductive Surgery in Advanced Ovarian Cancer.” From open ultra-radical surgery and laparoscopic-assisted procedures to robotic surgery, international guidelines have continued to debate the choice between PDS and NACT followed by IDS. In your view, what should define the “optimal” approach: the R0 resection rate, perioperative complications, or long-term survival?
Professor Xiwa Zhao:
Surgery is only one component of treatment for advanced ovarian cancer. Most experts recognize its critical role, and some even regard it as the cornerstone of treatment, but surgery has never been an isolated intervention. Open cytoreductive surgery, laparoscopy, and robot-assisted surgery each have their own advantages and disadvantages. No single surgical approach is universally appropriate for every patient.
The most suitable approach varies from patient to patient. Outcomes can also differ depending on the surgeon’s experience, proficiency, and technical capabilities, even when the same procedure is performed. Therefore, I prefer to interpret the term “optimal surgical approach” as the “most appropriate approach.” The best choice is the one that best suits the patient, the surgeon, and the surgical team.
The debate over PDS versus IDS has continued for many years. We now have several high-quality randomized controlled trials, including the TRUST study reported last year, which demonstrated a survival advantage for PDS in a selected patient population. The study enrolled patients with advanced ovarian cancer who had a good performance status (ECOG 0–1) and were considered suitable for surgery. The results suggested that, compared with IDS following NACT, PDS was associated with longer median progression-free survival and a higher rate of complete macroscopic resection. Although the difference in overall survival did not reach statistical significance, most experts still favor PDS when it is feasible and appropriate.
Of course, if preoperative assessment indicates that achieving R0 resection with immediate surgery is unlikely, NACT followed by IDS to pursue complete resection remains an excellent option.
The key is to individualize treatment within a framework of standardized diagnosis and care. We should rely on guideline-based assessment criteria while taking into account differences in the capabilities of individual centers and surgical teams. This allows us to select the appropriate level and type of surgery for each patient. Ultimately, the starting point and goal of surgical optimization are the same: improving patient survival.
I often emphasize that advocating for “optimized” surgery does not simply mean removing fewer organs. In advanced ovarian cancer, organs that need to be removed should be removed. However, when organ resection is optional, techniques such as dissection through peritoneal spaces and meticulous anatomical dissection can help preserve structures whenever possible. This benefits postoperative recovery and functional preservation.
A well-planned and meticulously performed operation aims to avoid unnecessary organ removal, reduce complications, and ensure that patients can proceed with postoperative chemotherapy, targeted therapy, and other adjuvant treatments without undue delay. These benefits can ultimately translate into improved survival.
For gynecologic oncologists, successful ovarian cancer surgery begins with understanding the patterns of disease spread, assessing the patient’s physical condition, and determining the distribution of the tumor. We must then develop an individualized plan within established standards, aiming to achieve R0 resection with the shortest feasible operating time and the least possible surgical trauma, while translating the immediate surgical outcome into postoperative and long-term survival benefits. This, I believe, is the true meaning of “optimization” in optimized surgery.
Oncology Frontier:
The 2025 ASCO guidelines updated recommendations regarding interval debulking surgery following neoadjuvant chemotherapy. Based on your center’s real-world experience, what proportion of patients become eligible for R0 resection after NACT? Which patients may still be unsuitable for minimally invasive surgery despite responding well to chemotherapy?
Professor Xiwa Zhao:
When patients are admitted for consideration of neoadjuvant treatment, we first conduct a comprehensive assessment. This includes two main aspects. The first is the patient’s general condition, including age, nutritional status, and medical comorbidities. The second is the tumor status, including tumor burden and the extent of disease distribution. We then match these findings to the technical expertise and management capabilities of the surgical team.
If the assessment indicates that immediate surgery is feasible, we proceed with PDS followed by chemotherapy. If the likelihood of achieving R0 resection with PDS is low, or if the patient would require a prolonged operation with a high risk of postoperative complications, we opt for NACT followed by IDS.
With standard neoadjuvant regimens—generally a platinum-taxane doublet, sometimes combined with bevacizumab—the overall rate of conversion to operability is relatively high.
After treatment, patients generally fall into several categories. Some achieve a pathological complete response (pCR). Whether surgery is necessary after NACT in these patients remains controversial. Some may potentially avoid surgery and proceed directly to subsequent maintenance or targeted therapy, with favorable outcomes.
Others achieve a partial response (PR), with substantial tumor shrinkage. These patients may benefit considerably from IDS. Patients with stable disease (SD) may also be considered for active surgical intervention, followed by chemotherapy, to pursue favorable outcomes. Only a small proportion experience disease progression after chemotherapy; for these patients, the prognosis is generally poor regardless of whether surgery or other treatments are pursued.
When deciding between open surgery and laparoscopy for IDS, the first consideration is the distribution of the tumor. After approximately three cycles of NACT, we generally use CT or PET-CT to assess the extent of disease throughout the body.
If the lesions are confined to the pelvis or greater omentum, a minimally invasive laparoscopic approach may be considered to achieve R0 resection. This can facilitate faster recovery and earlier resumption of subsequent chemotherapy.
However, if there are occult lesions in the upper abdomen, lesions within the interbowel spaces or mesentery, or more widespread tumor dissemination, we still tend to favor open cytoreductive surgery. Laparoscopy has limitations in exploring lesions within the mesentery. That said, for gynecologic oncologists with extensive experience, laparoscopic cytoreductive surgery can also be a good option.
Therefore, the choice between open surgery and laparoscopy depends on both the patient’s condition and the surgeon’s expertise.
Oncology Frontier:
There is considerable variation among centers in the use of HIPEC during interval debulking surgery for stage III ovarian cancer. Do you routinely perform this procedure? Within your framework of the “optimal surgical approach,” is HIPEC an essential component or an optional addition?
Professor Xiwa Zhao:
Hyperthermic intraperitoneal chemotherapy is one treatment option for ovarian cancer and may provide a survival benefit in selected circumstances, but it is not mandatory for every patient. Based on the available evidence, some patients may be suitable candidates, while the role of HIPEC in other patient populations remains under investigation.
Patients who continue to have relatively extensive peritoneal disease after NACT, particularly those with ascites, may be appropriate candidates for HIPEC.
We do not use it routinely in clinical practice. If the tumor has responded well to NACT and the peritoneal cavity appears relatively clear, or if there are no relevant high-risk factors, we generally do not perform HIPEC.
However, if diffuse peritoneal lesions are identified during surgery—even when R0 resection has been achieved macroscopically—it can still be difficult to determine with the naked eye whether all areas have truly achieved a complete response. In this situation, HIPEC may be the most appropriate option, and we would consider using it.
In short, HIPEC is a treatment modality, not a mandatory component of therapy. It may offer an opportunity to further improve survival outcomes beyond surgery and systemic chemotherapy. The key is selecting the right clinical setting to maximize the likelihood of a meaningful survival benefit.
From open surgery and laparoscopy to robotic surgery, and from PDS to NACT followed by IDS and then HIPEC, Professor Xiwa Zhao repeatedly emphasizes the same principle: there is no universally optimal treatment approach for advanced ovarian cancer; the best strategy is an individualized choice that aligns the patient, surgeon, and surgical team. The “optimal surgical approach” is not simply the one with the most advanced-sounding name, but the outcome of making the right decisions at every stage of the treatment pathway
Professor Xiwa Zhao
