A retrospective study was conducted to determine the influence of subspecialty training in gynecologic oncology as well as several other covariates on the feasibility, operative mortality, and survival benefits of cytoreductive surgery for 263 patients with stages IIIC and IVA epithelial ovarian cancer. Covariates most predictive of an optimal (< or = 1 cm) cytoreductive outcome were the diameter of the largest metastases before cytoreduction (< or = 10 cm vs > 10 cm, P < 0.001) and the specialty training of the physicians present at surgery (gynecologic oncologists vs other, P < 0.001). Age influenced operative mortality most (< 60 vs > or = 60, P < 0.001). Covariates found to most significantly influence survival time include the specialty training of the physicians present at surgery (gynecologic oncologists vs other, P < 0.0001), cytoreductive outcome (complete vs optimal, P = 0.001, optimal vs suboptimal, P < 0.0001), grade of tumor (grade 1 vs grades 2 and 3, P = 0.01), and pelvic disease status (frozen pelvis vs mobile primary tumor, P = 0.03). We conclude that patients with advanced epithelial ovarian cancer should undergo aggressive cytoreductive surgery by gynecologic oncologists, with the objective to remove all macroscopic disease. Subsequent treatment with platinum-based chemotherapy offers the best chance for long-term survival or cure.