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The literature search was limited to publications in English. Priority was given to high-quality systematic
reviews and meta-analyses but lower levels of evidence were also evaluated. The search strategy excluded
editorials, letters, case reports and in vitro studies. The reference list of each identified article was reviewed for
other potentially relevant papers. The bibliography was also be supplemented by additional references provided
by the international development group.
3.4 Evaluation of the potential QIs
The 15 possible QIs were formated as a questionnaire, and were sent by email to the international development
group. Experts were asked to evaluate each indicator according to relevance and feasibility in clinical pratice
evaluation #1. Responses were pooled and organized according to consens us about relevance and feasibility.
The results of this first evaluation was sent to experts who convened during the first one-day meeting May 19,
2015. Acceptance, rejection or the need for further consideration of each indicator was discussed during th e
meeting evaluation #2. Candidate QIs were retained if they were supported by sufficient high level scientific
evidence and/or when a large consensus among experts was obtained. Finally, ten QIs for advanced ovarian
cancer surgery were retained by the international development group. The 5 remaining indicators were not
retained, as a result of lack of evidence, or of duplication of quality information:
1. Inclusion in the medical team of a medical oncologist: this potential QI has been incorporated in the number
5 QI;
2. Delay between the decision to treat and treatment: no evidence of impact was found and no consensus has
been reached within the international experts panel;
3. Midline laparotomy: this potential QI will be considered in recommendations to avoid rupture of early
ovarian cancer; in advanced ovarian cancer, midline laparotomy is the mainstay of comprehensive
description of tumor extent and of complete surgery, which are two retained QIs number 1 and 8 ;
4. Intraoperative frozen sections: this potential QI will be considered in the management of suspicious adnexal
masses; in advanced ovarian cancer, the differential diagnosis between peritoneal carcinomatosis secondary
to genital tract malignancy and other conditions may be difficult ; however, availability of frozen section
examination by a specialized pathologist is strongly encouraged;
5. Pelvic and para-aortic lymphadenectomy: removal of enlarged nodes is part of complete cytoreduction ; as
the current literature does not provide evidence of increased overall survival OS when routine
comprehensive node dissection is performed after complete intraperitoneal cytoreduction, the international
experts panel concluded that it is more appropriate to wait for the publication of the results of ongoing
clinical trials on this topic. Comprehensive pelvic and aortic lymph node dissection is the standard in
patients with stage III based on lymph node involvement only.
3.5 Synthesis of scientific evidence
For the 10 retained QIs, the systematic literature search as described above has been extended until July 1, 2015
in order to update the documentation for the 2nd one-day meeting. All retrieved articles have been
methodologically and clinically appraised. After the selection and critical appraisal of the articles, a summary of
the scientific evidence has been developed. To classify the risk of bias or confounding in the identified studies,
we used the levels of evidence described in Appendix 3.
3.6 External evaluation of the retained QIs - International review
The ESGO Council established a large panel of practicing clinicians that provide care to advanced ovarian
cancer patients and patients. These international reviewers were independent from the development group.
Another requirement was a balanced representativity of countries across Europe. The 10 retained QIs were
formated as a questionnaire, and were sent by email to the international reviewers who were asked to evaluate
each indicator according to relevance and feasibility in clinical pratice only physicians.
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