The combination of cytoreductive surgery when it can safely be performed to residual disease <1 cm followed by platinum-based chemotherapy is the standard of care for patients with advanced epithelial ovarian cancer (EOC) [1]. Achievement of effective cytoreduction requires complex surgical procedures and is associated with high morbidity and mortality [2,3]. The associated morbidity can lead to prolonged postoperative recovery, delayed adjuvant chemotherapy, poor quality of life, and shortened overall survival [4]. The balance of oncologic benefit with potential morbidity is at the crux of shared decision making for treatment planning at the time of the diagnosis of advanced EOC.

The number of people living in the United States aged 65 years and older is projected to nearly double from 52 million in 2018 to 95 million by 2060, with the share of the total population rising from 16% to 55% [5]. As the population ages, the prevalence of age-related diseases, especially cancers such as epithelial ovarian cancers will increase [6]. Frailty is an age-related clinical condition characterized by a decrease in reserve and an increase in vulnerability to stressors [7]. As previously published frailty is a better predictor of survival than chronologic age after primary cytoreductive surgery (PCS) in advanced EOC [[8], [9], [10]]. Frailty is also associated with poor postoperative outcomes such as non-home discharge, longer length of stay, and delay to adjuvant chemotherapy [11]. To provide the best individualized approach to ovarian cancer care to the aging population, it is imperative to understand interactions between aging and frailty and the collective impact on surgical outcomes.

We have previously shown that poor nutritional status, as quantified by low preoperative serum albumin (<3.5 g/dL) is a critical predictor of poor surgical outcomes. In our institution, we have employed a triage system to evaluate newly diagnosed advanced EOC patients and determine whether a PCS or neoadjuvant chemotherapy (NACT) is the best approach [12]. Recognizing the association between poor outcomes and low albumin, patients with a preoperative serum albumin <3.5 g/dL would be triaged to NACT. In the present study we investigate the relationship between frailty and preoperative serum albumin and the associated impact on surgical outcomes. Specifically, we sought to determine if non-frail patients with low albumin (<3.5 g/dL) had acceptable rates of morbidity and mortality and could reasonably undergo PCS. We hypothesized that non-frail patients with albumin <3.5 g/dL would have similar rates of 90-day mortality to those with normal albumin(≥3.5 g/dL) and would be candidates for PCS.