Age is an independent predictor of survival in advanced ovarian cancer. However, inadequate therapy appears to be a driver for decreased survival among elderly patients with cancer. Multiple randomized control trials have demonstrated equivalent oncologic outcomes with neoadjuvant chemotherapy compared to primary cytoreduction with reduced perioperative complications and mortality, decided by a gynecologic oncology surgeon. A national database study demonstrates an improvement in the receipt of both surgery and chemotherapy over time with high adoption of NACT contributing to an improvement in outcomes. In an elderly population, NACT results in a 70% reduction in perioperative mortality. All patients 75 years of age or older with one medical co-morbidity are the highest risk group for postoperative mortality (average 30-day post-operative mortality of 13% with primary surgery). These patients likely will benefit the most from NACT and should be considered routine practice for elderly patients with advanced ovarian cancer.