P-POSSUM Falls Short: Predicting Morbidity in Ovarian Cancer (OC) Cytoreductive Surgery
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Authors
Sideris, Michail
Brincat, Mark R.
Blyuss, Oleg
Oxley, Samuel George
Sia, Jacqueline
Kalra, Ashwin
Wei, Xia
Fierheller, Caitlin T.
Ganesan, Subhasheenee
Miller, Rowan E.
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Issue Date
2025
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OBJECTIVE: The P-POSSUM scale is widely used in predicting perioperative morbidity and mortality. Evidence on the performance of P-POSSUM in predicting outcomes after cytoreductive surgery (CRS) for ovarian cancer (OC) is limited. In this study, we assess how well P-POSSUM predicts morbidity in OC CRS and explore whether incorporating additional clinical variables can enhance its predictive accuracy. We retrospectively collected data on consecutive patients undergoing OC CRS within a tertiary gynaecologic oncology network. The collected information included demographic characteristics, P-POSSUM morbidity and mortality scores, Edmonton Frail Scale (EFS) scores, preoperative serum albumin levels, and observed 30-day postoperative morbidity and mortality, classified using the Clavien-Dindo (CD) scale. The predictive performance of P-POSSUM was evaluated using receiver operating characteristic (ROC) curves to calculate sensitivity and specificity. A stepwise regression analysis was then applied to identify additional variables that could improve model performance, incorporating preoperative covariates. The final model incorporated parameters chosen through bootstrap investigation of the model variability (stepAIC). Predicted versus observed morbidity was calibrated and performance compared between P-POSSUM and the final model. RESULTS: Of 161 sequential OC patients, 95 (59%) underwent primary, 45 (28%) interval, and 21 (13%) delayed CRS. The mean age was 66.4 (95%CI: 60-75) and duration of surgery was 223 mins (95%CI: 142-279). Sixty-five (40.3%) patients had ≥1 postoperative complication. Two deaths were reported. Among the observed complications, 4 patients (6.1%) experienced CD4, 10 patients (15.3%) CD3, 38 patients (58.5%) CD2, and 11 patients (16.9%) CD1 events. The mean P-POSSUM-predicted morbidity and mortality were 59.5% (95%CI: 56.7-62.3%) and 5.86% (95%CI: 5.02-6.70%), respectively. The area under the curve (AUC) for P-POSSUM in predicting morbidity and mortality was 0.539 (p = 0.401) and 0.569 (p = 0.137), respectively. Given the small number of deaths, no robust conclusions regarding mortality are possible. EFS and BMI emerged as significant predictors of observed morbidity using a stepwise-model selection process. The AIC of this final model was 211.44. Our final model of PPOSSUM + EFS + BMI had AUC = 0.6551 (Delong's Z = 1.8845, p-value = 0.05949). CONCLUSIONS: The P-POSSUM scale shows poor performance for predicting morbidity in OC CRS. New validated and accurate model(s) are necessary for predicting surgical morbidity. Our proposed model incorporates additional variables to improve P-POSSUM's performance. This requires further development and validation.
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Journal
Cancers
Volume
17