Turning global estimates into surgical service planning: a surgical lens on ovarian cancer projections: a correspondence

To the Editor, We read with interest the report by Xie and colleagues describing the global, regional, and national burden of ovarian cancer from 1990 to 2021, with projections to 2050 using Global Burden of Disease (GBD) 2021 estimates and a Bayesian age–period–cohort forecasting approach1. The authors highlight that in 2021 ovarian cancer accounted for approximately 293 000 incident cases and 201 000 deaths worldwide, with substantial geographic and sociodemographic heterogeneity. The projected increase in absolute burden toward 2050 underscores an urgent need to translate epidemiologic forecasts into surgical system preparedness. A completed TITAN 2025 checklist has been provided as a supplementary file2. From a surgical oncology perspective, the most immediate pressure point is not only the expected growth in case numbers, but also the complexity of care pathways required for optimal outcomes. The survival benefit of maximal or complete cytoreduction in advanced epithelial ovarian cancer has been consistently demonstrated, with residual disease remaining one of the strongest modifiable prognostic factors3,4. Therefore, burden projections could be translated into surgical workload models, such as expected volumes of primary or interval debulking surgery, the need for upper abdominal procedures, ICU utilization, and blood-product requirements, rather than being used solely for screening or medical oncology planning. Pairing GBD-derived estimates with local stage distribution and respectability patterns could help hospitals and regions forecast the true operative and perioperative load that ovarian cancer imposes. Second, the epidemiologic gradients shown in this work invite a clinically actionable discussion on where complex ovarian cancer surgery should be performed. Outcomes in advanced-stage disease are influenced by the experience and volume of both hospitals and surgeons, and access to high-volume providers is often unequal across sociodemographic groups5. Contemporary consensus guidance also emphasizes that optimal outcomes require coordinated multidisciplinary care that includes gynecologic oncology, anesthesia, critical care, and medical oncology6. In this context, the GBD maps and inequality analyses in the present study could support rational centralization strategies, while simultaneously identifying regions where referral pathways and transportation or financial barriers must be addressed to avoid widening disparities. Third, beyond centralization, surgical systems need measurable quality targets to ensure that increasing volume does not dilute standards. The European Society of Gynecological Oncology quality indicators for advanced ovarian cancer surgery provide concrete benchmarks for case volume, complete cytoreduction rates, operative and pathology reporting elements, multidisciplinary review, and prospective complication tracking7. Embedding such indicators into national or regional ovarian cancer plans would allow burden estimates, meaning how many cases, to connect with quality metrics, meaning how well care is delivered, enabling audit-and-feedback cycles that are familiar to surgeons and hospital administrators. Finally, the projected burden underscores the importance of selecting the right initial strategy, either primary debulking surgery or neoadjuvant chemotherapy followed by interval debulking, based on respectability, patient fitness, and expected morbidity. Randomized trials have shown non-inferior survival with neoadjuvant approaches in selected advanced-stage patients and have highlighted differences in perioperative risk profiles8,9. Thus, the practical response to rising burden is not only more surgery, but also better triage. This includes ensuring that patients most likely to achieve complete macroscopic resection undergo upfront surgery in expert centers, while those at high operative risk or with a low likelihood of optimal cytoreduction are directed to neoadjuvant strategies with planned interval surgery. In summary, Xie et al offer a robust epidemiologic foundation for ovarian cancer planning. We suggest that the next step is to explicitly bridge GBD burden projections with surgical organization and quality frameworks, including centralized multidisciplinary care, validated quality indicators, strategy selection for maximal benefit and safety, and standardized perioperative pathways. Such integration would make epidemiologic signals directly actionable in the operating theater and the surgical ward, ultimately improving outcomes while safeguarding equity.