PS: Use the PPSP (to predict the prognosis of ovarian cancer)

Kawahara, N., Kawaguchi, R., Waki, K. et al. The prognosis predictive score around primary debulking surgery (PPSP) improves diagnostic efficacy in predicting the prognosis of ovarian cancer. Sci Rep 12, 22636 (2022). https://doi.org/10.1038/s41598-022-27333-1

When a patient develops ovarian cancer, it is due to a gradual build up of malignant (cancerous) cells, forming tumours in the ovaries. As cancer cells multiply at an uncontrollably high rate, they require excess energy and nutrients to maintain the expansion, hence absorbing broken down amino acids from the neighbouring healthy cells. By usurping all broken down sugars and proteins through the bloodstream, the cancerous cells are able to multiply exponentially, eventually forming malignant tumours that impair organs. Furthermore, as the severity of the patient’s condition increases, the cancer impairs multiple organs and sites all over the body, ceasing organ functions that are vital for survival. Thus, through a process known as metastasis, cancerous cells spread throughout a host’s body, infecting different tissues and organs, causing excess damage and eventually leading to organ failure.

When diagnosed with ovarian cancer, doctors conduct multiple tests to figure out how far the cancer has spread and how much it has progressed. This process, known as staging, helps medical experts identify how much cancer is in the body, its severity, survival statistics, and the optimum method of treating it.

Only 20% of patients are diagnosed with ovarian cancer in the early stages, as the symptoms are subtle and hard to detect. This delay in diagnosis and treatment allows the malignant cells to metastasize further, resulting in increasing severity of their condition. Thus, having earned its reputation as the “silent killer”, ovarian cancer is women’s 5th leading cause of cancer related death. However, when detected early, 94% of patients live longer than 5 years after diagnosis. This is why it is crucial to identify the cancer at an early stage and begin treatment as soon as possible.

After staging, patients with operable ovarian cancer undergo a primary debulking surgery, aka cytoreductive surgery, (PDS) where the tumours are largely removed, hence increasing the chance that chemotherapy or radiation can kill all remaining malignant cells. This is also done to relieve the patient’s symptoms and help them live longer and is often followed by postoperative adjuvant chemotherapy.

The tumour’s microenvironment has a significant effect on the systemic immune system as the cancerous cells can spread into the bone marrow (where the body makes cells to fight infections) and infect it. Furthermore, tumour cells destroy healthy cells, releasing the contents of the cells into the environment and thus causing the release of proinflammatory mediators (molecules secreted from immune cells that promote inflammation). However, when the tumour is removed, the body’s inflammatory status is reduced, due to fewer releases of proinflammatory mediators, which has a strong, positive impact on their prognosis after treatment. Hence, while pre-treatment inflammatory responses have been used to predict the prognosis for a patient’s condition, no existing report takes into account the post-surgical treatment factors. This means that no predictive scoring system analyses both pre and post-PDS results when creating a prognosis based on predictive factors. This is crucial as, if the inflammation status doesn’t reduce, the body’s inflammatory response can start damaging healthy cells and tissues, which can eventually link to the development of diseases such as cancer. This could be a pivotal factor in determining recurrent cases and more accurately creating a patient’s prognosis.

Moreover, a number of studies have proven that the systemic inflammatory response is related to the overall survival of surgically treated cancer patients. Systemic inflammatory response syndrome (SIRS) is “an exaggerated defence response of the body to trauma, surgery, or malignancy”. This causes the body’s cells to localise and then eliminate the source of the insult or trauma. However, when living with this chronic inflammation, the body’s response can often be misdirected and eventually cause it to attack healthy cells and tissues. This is a life-threatening complication linked to the development of diseases, such as cancer. Hence, according to numerous studies, the systemic inflammatory response can affect the survival of ovarian cancer patients who have undergone surgical treatment, such as PDS. This makes it even more crucial to analyse both pre and post-PDS factors to determine the prognosis of a patient.

This study aims to deduce the prognostic factors related to the recurrence of ovarian cancer post PDS, create the prognostic score predicting the prognosis of post-PDS ovarian cancer, and analyse the usefulness of the scoring.

Experts at the Nara Medical University wrote a report about the scoring system they created called the prognosis predictive scoring system around primary debulking surgery (PPSP) for progression free survival (the time a patient lives with a disease but the condition is not worsening). A system that analysed the combined inflammatory response from both pre and post surgical treatment in order to develop a more accurate prognosis scoring system was used.

Overall, out of the 235 patients who participated in the study, 183 underwent chemotherapy after their surgery, while, among the 52 patients who didn’t undergo chemo, 45 were Stage I cases. This is because the patients whose conditions were of a lower severity didn’t require additional treatment to remove malignant cells, as they were limited in their spread. Additionally, the 29% of recurrent cases showed trends in older age and advanced stages of cancer, while the non-recurrent cases comprised 71% of the patients.

In conclusion, the PPSP showed good prognostic efficacy not only in predicting progression-free survival but also in the overall survival of ovarian cancer patients compared to other methods of cancer staging (eg. the FIGO staging system). This is because the PPSP system takes into account both pre and post-PDS factors to create a patient’s prognosis.

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