Unraveling the Treatment Algorithm for Ovarian Cancer
Key Points
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The standard of care for ovarian cancer typically starts with upfront surgery to stage and debulk the tumor.
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Platinum-based chemotherapy, with or without bevacizumab, is considered standard of care in both the neoadjuvant and adjuvant settings.
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Baseline homologous recombination deficiency (HRD) and next-generation sequencing (NGS) testing are recommended to guide additional therapy selection.
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Upfront genetic testing is essential for selecting therapies both in the maintenance and relapsed or refractory settings.
Ovarian Cancer Treatment Pathway in 2025
Sharyn Lewin, MD, FACS, FACOG, of Holy Name Medical Center, joined the Oncology Brothers podcast with Rahul Gosain, MD, MBA, of Wilmot Cancer Institute, and Rohit Gosain, MD, of Roswell Park Comprehensive Cancer Center, to discuss the current treatment algorithm for patients with ovarian cancer.
The standard of care for ovarian cancer is upfront debulking surgery, during which the tumor is staged according to the Federation of Gynecology and Obstetrics criteria. After surgery, adjuvant therapy is administered for a defined number of cycles, after which patients transition to maintenance therapy regimens. For patients who are ineligible for upfront surgery, systemic therapies can be initiated in the neoadjuvant setting to bridge to surgery or other adjuvant therapy.
Systemic Treatments for Ovarian Cancer
Platinum-based chemotherapy doublets are the standard of care in systemic therapy for ovarian cancer, whether in the neoadjuvant or adjuvant setting. They can also be combined with the VEGF inhibitor, bevacizumab.
When using platinum-based chemotherapy neoadjuvantly in any patient, physicians should collect enough samples for diagnosis confirmation as well as HRD and NGS testing, Dr. Lewin said. Her practice advocates for 6 to 8 core passes with an 18-gauge needle. Similarly, when using bevacizumab in the neoadjuvant setting, it must be discontinued 4 to 6 weeks prior to surgery to avoid surgical complications.
After adjuvant therapy, maintenance regimens are administered based on disease characteristics. If bevacizumab was given in the neoadjuvant or adjuvant setting, it should be continued during maintenance. For patients with germline or somatic BRCA mutations or HRD-positive disease, standard of care maintenance includes starting one of the three approved PARP inhibitors: olaparib, niraparib, or rucaparib.
Between the PARP inhibitors, Dr. Lewin prefers to use olaparib based on its favorable safety profile. Notably, PARP inhibitors are only indicated for patients with a BRCA mutation or HRD positivity, emphasizing the need for upfront biomarker testing.
Treating Relapsed or Refractory Ovarian Cancer
Relapsed or refractory ovarian cancer is categorized as either platinum resistant or platinum sensitive, with resistance defined as recurrence during or within 6 months of completing the last platinum-based therapy. For platinum-sensitive patients, the standard of care is to rechallenge using platinum-based chemotherapy with or without bevacizumab. A PARP inhibitor can also be included if the patient was not previously exposed or did not progress during PARP inhibitor therapy.
Unfortunately, all patients in this setting eventually become platinum resistant, Dr. Lewin said. For platinum-resistant patients, the following genomic alterations have corresponding approved targeted therapies.
| Targetable Alteration | Approved Treatments |
| BRAF V600 mutation | Dabrafenib plus trametinib |
| NTRK gene fusion | Entrectinib, larotrectinib, or repotrectinib |
| HER2 IHC2/3 mutation | Trastuzumab deruxtecan |
| Folate receptor alpha overexpression | Mirvetuximab with or without bevacizumab |
| RET gene fusion | Selpercatinib |
The currently available data for immunotherapy agents do not strongly support their use in advanced ovarian cancer compared with other diseases like endometrial cancer, Dr. Lewin said.
As a final takeaway, Dr. Lewin noted that not all HRD tests are the same, and using the FDA-approved companion diagnostic is necessary to not miss any patients—especially because PARP inhibitors are approved only for BRCA-mutated and HRD-positive disease.