From the Guidelines
Cancer debulking surgery should not be performed in patients who are not good candidates due to advanced age, frailty, poor performance status, comorbidities, or disease that is unlikely to be optimally cytoreduced. This is based on the recommendations from the NCCN Guidelines for Ovarian Cancer, which suggest that primary debulking surgery (PDS) is only recommended if optimal cytoreduction appears feasible and the patient is a surgical candidate 1.
When considering debulking surgery, several factors must be taken into account to determine if the procedure is likely to improve outcomes. These include:
- The extent of disease spread and whether complete or meaningful tumor removal is possible
- The patient's overall health and ability to tolerate a major surgical procedure
- The potential benefits and risks of the surgery, including the risk of severe functional impairment
- The responsiveness of the cancer to debulking surgery
- The involvement of vital structures that cannot be safely resected
In cases where debulking surgery is not recommended, alternative approaches such as neoadjuvant chemotherapy (NACT) with interval debulking surgery (IDS) may be considered, as outlined in the NCCN Guidelines 1. Ultimately, the decision to perform debulking surgery should be based on the principle that the procedure should offer a reasonable chance of improving survival or quality of life.
Key considerations for avoiding debulking surgery include:
- Extensive involvement of vital structures
- Malignant ascites with widespread peritoneal carcinomatosis
- Extensive liver metastases
- Distant metastases that would not be addressed by the surgery
- Poor performance status or significant comorbidities that make the patient unable to tolerate the procedure 1.
From the Research
Debulking Surgery Limitations
- Debulking surgery may not be beneficial for patients with advanced malignant tumors if complete R0 resection is not possible 2
- The surgery may not be feasible for patients with poor response to chemotherapy, comorbidities, or patient decision 3
- CT scans can be used to predict the success of debulking surgery, and a high score may indicate that the surgery will not be beneficial 4
- Debulking surgery may not be suitable for patients with advanced or recurrent endometrial cancer, unless all gross evidence of disease can be resected 5
Contraindications for Debulking Surgery
- Poor response to chemotherapy after 3-4 cycles of neoadjuvant chemotherapy 3
- Comorbidities that make surgery risky 3
- Patient decision to not undergo surgery 3
- Advanced age, with a median age of 70 years 3
- Presence of ascites, high serum CA-125 level, or other factors that indicate poor prognosis 4
Alternative Treatment Options
- Chemotherapy alone can provide reasonable disease control in patients unsuitable for debulking surgery 3
- Hormonal and chemotherapeutic treatments may be used for patients with recurrent disease, although they typically do not provide durable responses 5
- Pelvic radiotherapy may be effective for patients with isolated pelvic recurrences 5
- Pelvic exenteration may be an option for carefully selected patients with isolated central recurrences 5