Access to Minimally Invasive Surgery for Advanced Ovarian Cancer Varies Widely by Facility

Significant facility-level disparities exist in the adoption of minimally invasive interval debulking surgery among patients with advanced epithelial ovarian cancer, and these gaps may widen if no action is taken as the procedure becomes more commonly utilized.1

The authors of the study published in Gynecologic Oncology explained that surgical deescalation, defined as the use of less invasive surgical approaches, is emerging as an optimal strategy to minimize morbidity and reduce treatment burden without compromising oncologic outcomes.2 Consequently, minimally invasive surgery has become an effective modality among patients with advanced epithelial ovarian cancer receiving neoadjuvant chemotherapy to decrease perioperative morbidity, shorten hospital stays, and potentially enable earlier initiation of adjuvant chemotherapy.1

Although no randomized data currently confirm the oncologic safety of minimally invasive interval debulking surgery, nearly one-third of all interval debulking surgeries in the US were performed using this approach by 2018.3 As surgical deescalation through minimally invasive interval debulking surgery becomes more widely adopted, the researchers raised concerns about potential care access inequities.1

Despite national efforts to eliminate well-established health disparities among patients with gynecologic cancers, significant gaps persist. However, the extent to which hospital characteristics influence racial disparities in gynecologic cancer care remains poorly understood.

Facility-level disparities in adopting minimally invasive interval debulking surgery for ovarian cancer highlight urgent needs for equitable care access. | Image Credit: Spiroview Inc. - stock.adobe.com

To address this gap, the researchers investigated the differential adoption of minimally invasive interval debulking surgery among patients with advanced ovarian cancer across Commission on Cancer–accredited programs in the US. They used data from the National Cancer Database, a multi-institutional cancer registry of more than 1500 Commission on Cancer–accredited cancer programs, encompassing over 70% of all incident cancer cases in the US.

Because not all programs increased their use of minimally invasive interval debulking surgery, the researchers implemented a difference-in-differences analysis to evaluate whether medically underserved patients were more likely to be treated at facilities with lower utilization of this surgical method.

The researchers included patients diagnosed with stage IIIC or IV epithelial ovarian cancer between January 2010 and December 2021 who had serous, mucinous, endometrioid, clear cell carcinoma, or other adenocarcinomas on histologic examination, as classified by the International Classification of Diseases for Oncology, Third Edition.

A prior publication reported a significant and sustained increase in the use of minimally invasive strategies beginning in 2015, with the approach accounting for more than 15% of interval debulking surgeries from that year onward.3 Because of this, 2010 to 2014 was designated as the preadoption period and 2015 to 2021 as the postadoption period.1

Using patient-level data from the postadoption period, the researchers estimated hospital-level variation in minimally invasive interval debulking surgery adoption, categorizing programs as either adopters or nonadopters. Adopter programs significantly increased their use of minimally invasive techniques after 2015, while nonadopter programs continued to use them sparingly. They then identified and matched adopter programs with nonadopter programs with similar rates of minimally invasive interval debulking surgery use during the preadoption period but diverged after 2015.

To assess facility characteristics, the researchers ranked hospitals by the proportion of Black patients treated, with the top 5% categorized as Black-serving facilities. The top 5% of facilities serving uninsured patients were similarly designated. Also, high-volume institutions were defined as those in the top quartile of interval debulking surgery volume among patients with advanced ovarian cancer. Lastly, institutions were classified as either academic or nonacademic.

The researchers initially identified 96,957 eligible patients. After they matched adopter facilities with nonadopter facilities that had similar annual case volumes and minimally invasive interval debulking surgery use in the preadoption period, the study population consisted of 5464 patients treated in 141 adopter facilities and 4820 treated in 141 nonadopter facilities.

Nonadopter facilities used minimally invasive interval debulking surgery among 14.8% (95% CI, 11.7-17.9) of patients in the preadoption period, with a marginal increase to 15.3% (95% CI, 13.3-17.3) in the postadoption period. In contrast, adopter facilities used minimally invasive interval debulking surgery in 19.7% (95% CI, 16.3-23.0) of patients in the preadoption period and significantly increased their use to 46.9% (95% CI, 43.2-50.6) of patients in the postadoption period (difference-in-differences, 26.7%; 95% CI, 21.6-31.9).

Black patients comprised an average of 42.7% of patients at Black-serving facilities vs 8.4% at non–Black-serving facilities, which had a patient population that was, on average, 80.2% White. Additionally, at facilities that cared for the highest proportion of uninsured patients, they accounted for an average of 34.1% of all patients. At all other facilities, only 1.6% of patients were uninsured.

The researchers found that adopter facilities were less likely to be Black-serving (OR, 0.66; 95% CI, 0.55-0.79; P < .001) and to have a high proportion of uninsured patients (OR, 0.73; 95% CI, 0.61-0.87; P < .001). However, adopter facilities were more likely to be high-volume centers (OR, 1.48; 95% CI, 1.35-1.60; P < .001) and academic institutions (OR, 1.89; 95% CI, 1.74-2.04; P < .001).

The researchers concluded by acknowledging their study’s limitations, including that the results are not generalizable to institutions not accredited by the Commission on Cancer, as these are not represented in the National Cancer Database. Consequently, the study likely underestimates the true extent of disparities in the US. Nonetheless, they expressed confidence in their findings and called for urgent action to close this disparity gap.

“Efforts should be made to ensure equitable access of this modality to patients based on their individualized characteristics, as recommended by national guidelines, and not based on where they receive their cancer care,” the authors wrote.

References

1. Wilke RN, Wu CF, Kanbergs A, et al. Disparities in facility-level adoption of minimally invasive interval debulking surgery for advanced ovarian cancer. Gynecol Oncol. 2025;197:11-18. doi:10.1016/j.ygyno.2025.04.518
2. Kanbergs A, Melamed A, Viveros-Carreño D, et al. Surgical deescalation within gynecologic oncology. JAMA Netw Open. 2025;8(1):e2453604. doi:10.1001/jamanetworkopen.2024.53604
3. Jorgensen K, Melamed A, Wu CF, et al. Minimally invasive interval debulking surgery for advanced ovarian cancer after neoadjuvant chemotherapy. Gynecol Oncol. 2023;172:130-137. doi:10.1016/j.ygyno.2023.01.017