Defining surgical fitness in advanced ovarian cancer: a critical review of predictors, algorithms, and pre-habilitation

In advanced ovarian cancer, complete cytoreductive surgery is a cornerstone of treatment, yet defining which patients are “fit for surgery” remains challenging. Although guidelines emphasize comprehensive pre-operative evaluation, standardized assessment tools are lacking, and clinical practices vary widely across institutions. This narrative review synthesizes current evidence on individual patient-related factors that influence surgical fitness, reviews risk-assessment algorithms designed to guide patient selection, and examines the emerging role of pre-habilitation in optimizing perioperative outcomes. A structured literature search of MEDLINE, Embase, and Cochrane databases (January 2004-September 2024), supplemented by targeted PubMed searches (January 2005-April 2025), identified studies evaluating aging, comorbidity, frailty, nutrition, sarcopenia, and pre-habilitation in relation to surgical outcomes. Eligible studies included systematic reviews, randomized controlled trials, and prospective or retrospective cohorts of patients undergoing primary or interval cytoreduction. After application of the inclusion criteria, 33 studies encompassing 41,580 patients were included. The evidence consistently demonstrates that older age (particularly ≥80 years), frailty, comorbidity burden, and malnutrition are associated with increased post-operative complications and mortality following cytoreductive surgery. Several predictive models and nomograms integrating these factors have been developed to estimate perioperative risk, though most lack multi-center external validation. Implementation of an evidence-based triage algorithm that incorporates key patient characteristics and anticipated surgical complexity has been associated with meaningful reductions in post-operative mortality in institutional practice. Emerging data on multi-modal pre-habilitation suggest feasibility and potential benefits, including lower complication rates, shorter hospital stays, and earlier initiation of chemotherapy, though evidence remains preliminary. Current evidence on surgical fitness in ovarian cancer is limited by heterogeneous definitions, retrospective study designs, lack of prospective validation, and inconsistent reliance on clinical judgment alone. Standardized, externally validated tools, consensus-based thresholds for surgical candidacy, and results from ongoing randomized pre-habilitation trials are needed to guide clinical decision-making and improve patient outcomes.