Front-Line Treatment and Maintenance in Epithelial Ovarian Cancer

Authored by Natalia Gandur, published on 2026-07-23 03:07:20.0

The algorithm is broadly aligned with current frontline epithelial ovarian cancer practice: staging-based surgical approach (PDS vs NACT-IDS), platinum-taxane chemotherapy backbone, optional bevacizumab in appropriate advanced-stage patients, and biomarker-directed first-line maintenance using PARP inhibitors. The maintenance stratification by BRCA and HRD status reflects the pivotal trial evidence and major guideline recommendations. A key caveat is that PARP inhibitor benefit/risk in HRD-negative (and some HRD-unknown) populations has become more contentious due to overall survival signals and evolving regulatory/guideline language; local/regional approvals and updated guideline versions should be checked.

  1. Newly diagnosed epithelial ovarian cancer
    This pathway applies to newly diagnosed epithelial ovarian, fallopian tube, or primary peritoneal cancer. Suggested baseline assessment: Histologic subtype and tumor grade FIGO stage and disease distribution Surgical resectability assessment by gynecologic oncology Performance status, frailty, symptoms, ascites, bowel involvement CBC with differential and platelets Renal function, liver tests, electrolytes CA-125 if informative for that patient Baseline CT chest/abdomen/pelvis or appropriate imaging Germline BRCA1/2 testing Somatic tumor testing, including BRCA and HRD when clinically relevant Consider MMR/MSI, HER2, NTRK, FRα or other biomarkers when histology or clinical context supports it Management generally integrates surgery, platinum-taxane chemotherapy, and biomarker-directed maintenance when appropriate.
    • Stage I?
      • Stage I — early stage
        • Surgical staging complete?
          • Optimally staged stage I
            • Histology?
              • High-grade serous
                • Carboplatin + paclitaxel × 6 cycles
              • Clear cell / endometrioid / mucinous
                • Carboplatin + paclitaxel × 3 cycles
          • Suboptimally staged stage I
            • Carboplatin + paclitaxel × 6 cycles
        • BRCA-mutated, fully staged stage I: PARP maintenance = clinical equipoise; no prospective first-line data
      • Stage II–IV — advanced stage
        Stage II is treated as advanced disease
        • Candidate for primary debulking surgery?
          Typically stage III and resectable to no gross residual (R0)
          • Yes — likely R0
            • Primary debulking surgery (PDS)
              • Paclitaxel + carboplatin × 6 cycles
                Standard frontline chemotherapy generally includes carboplatin plus paclitaxel, with treatment duration individualized by stage, histology, surgical outcome, toxicity, and clinical context. Suggested monitoring during chemotherapy: Clinical assessment before each cycle CBC with differential and platelets before each cycle Renal function, liver tests, and electrolytes before each cycle Neuropathy assessment Hypersensitivity risk assessment CA-125 before each cycle if informative Imaging after completion of chemotherapy or earlier if clinically indicated
                • Add bevacizumab?
                  Consider bevacizumab in selected patients with advanced-stage disease when clinically appropriate. Factors supporting consideration: Stage III/IV disease High-risk disease features Residual disease after surgery Symptomatic or high-burden disease Need for disease control beyond chemotherapy alone Avoid or use caution with: Recent major surgery or impaired wound healing Uncontrolled hypertension Significant proteinuria High bleeding or thrombotic risk Bowel obstruction, bowel involvement, fistula, or high perforation risk Poorly controlled cardiovascular comorbidity Bevacizumab use should be individualized based on risk, benefit, access, and patient goals.
                  • Concurrent bevacizumab with chemotherapy
                    If bevacizumab is selected, it may be given with carboplatin/paclitaxel and then continued as maintenance when tolerated and clinically appropriate. Monitoring: Blood pressure Urine protein / proteinuria Bleeding or thrombotic events Wound healing Bowel symptoms or perforation risk Renal function Overall tolerability and patient preference
                    • Continue bevacizumab maintenance
                      Continue bevacizumab maintenance if clinically appropriate, tolerated, and consistent with the treatment plan. Monitor: Blood pressure at each visit Proteinuria at regular intervals Bleeding, thrombosis, wound-healing issues Abdominal pain, bowel symptoms, fistula or perforation risk Renal function and overall tolerability Stop, hold, or reassess bevacizumab for significant hypertension, clinically relevant proteinuria, bleeding/thrombosis, wound-healing complications, GI perforation/fistula, or unacceptable toxicity.
                      • Response to first-line platinum therapy?
                        Assess response after completion of first-line platinum-based chemotherapy using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have complete or partial response to platinum-based chemotherapy. If there is progression or no meaningful response to first-line platinum therapy, proceed to recurrence / subsequent-line management rather than routine frontline maintenance.
                        • Yes
                          • Biomarker-directed maintenance
                            Select maintenance based on: Response to platinum-based chemotherapy Germline and somatic BRCA status HRD status Bevacizumab use during chemotherapy Residual toxicity from chemotherapy Neuropathy Cytopenias and marrow reserve Hypertension/proteinuria or bevacizumab risk Patient preference, access, and local regulatory guidance Key principle: Maintenance should be selected after confirming response to first-line platinum-based therapy and reviewing biomarker status and toxicity risk.
                            • BRCA-mutated
                              BRCA-mutated disease strongly supports PARP inhibitor maintenance after response to first-line platinum-based chemotherapy. Confirm: Germline and/or somatic BRCA1/2 mutation Response to platinum-based chemotherapy Baseline CBC, platelets, renal and hepatic function Residual toxicity and patient preference Access and local regulatory guidance
                              • Olaparib maintenance
                                Consider olaparib maintenance for BRCA-mutated advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer after complete or partial response to first-line platinum-based chemotherapy. Practical considerations: Typical dose: olaparib 300 mg orally twice daily, adjusted according to prescribing information Review renal function and drug interactions Monitor CBC at baseline and periodically during treatment Counsel regarding fatigue, nausea, anemia, neutropenia, thrombocytopenia, and rare MDS/AML risk Reassess adherence, toxicity, and quality of life during follow-up
                                • If bevacizumab used: olaparib + bevacizumab
                                  If bevacizumab was part of the frontline strategy and the tumor is HRD-positive, consider olaparib plus bevacizumab maintenance when clinically appropriate and consistent with local access/regulatory guidance. Practical considerations: Olaparib dosing according to prescribing information Bevacizumab continuation according to the planned bevacizumab duration and tolerability Monitor CBC, renal function, blood pressure, proteinuria, bleeding/thrombotic risk, and GI/wound-healing risks Consider cumulative toxicity and patient preference
                            • BRCA wild-type, HRD-positive
                              For BRCA wild-type, HRD-positive disease with response to first-line platinum-based chemotherapy, consider PARP inhibitor maintenance strategy according to prior bevacizumab use, toxicity risk, access, and local regulatory guidance. If bevacizumab was used and tolerated, olaparib + bevacizumab may be considered in HRD-positive disease. If bevacizumab was not used or is not appropriate, niraparib may be considered when consistent with local guidance and patient factors.
                              • Niraparib
                                Consider niraparib maintenance after response to first-line platinum-based chemotherapy when clinically appropriate and consistent with local regulatory guidance. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review HRD/BRCA status and local indication Assess CBC with differential and platelets Assess baseline weight and platelet count for individualized starting dose when applicable Review blood pressure, heart rate, renal/hepatic function, marrow reserve, and prior cytopenias Monitoring: CBC weekly during the first month CBC monthly for the next months once stable, then periodically or as clinically indicated Blood pressure and heart rate regularly, especially early in treatment Monitor fatigue, nausea, anemia, thrombocytopenia, neutropenia, hypertension, and rare MDS/AML risk
                                • If bevacizumab used: olaparib + bevacizumab
                                  For HRD-positive/BRCA wild-type patients who received bevacizumab with frontline chemotherapy, olaparib + bevacizumab maintenance is supported by randomized evidence; positioning relative to niraparib depends on biomarkers, prior bevacizumab use, toxicity considerations, and guideline/approval specifics. If bevacizumab was part of the frontline strategy and the tumor is HRD-positive, consider olaparib plus bevacizumab maintenance when clinically appropriate and consistent with local access/regulatory guidance. Practical considerations: Olaparib dosing according to prescribing information Bevacizumab continuation according to the planned bevacizumab duration and tolerability Monitor CBC, renal function, blood pressure, proteinuria, bleeding/thrombotic risk, and GI/wound-healing risks Consider cumulative toxicity and patient preference
                            • HRD-negative / unknown
                              For HRD-negative or unknown disease, maintenance should be individualized. Options may include: Observation Bevacizumab maintenance if bevacizumab was used with chemotherapy and remains appropriate Clinical trial when available Reassessment of biomarker testing if incomplete or clinically important Frontline PARP inhibitor use in HRD-negative or unknown disease should be considered cautiously and according to local regulatory guidance, evolving evidence, toxicity risk, access, and expert review.
                              • Observation or bevacizumab maintenance
                                In HRD-negative/unknown patients, observation is an accepted approach after response; bevacizumab maintenance is reasonable if initiated with chemotherapy per GOG-0218/ICON7. The statement that frontline PARP is not indicated in this group is increasingly reflected in more conservative recommendations, though guidance varies by region and timepoint. Observation is appropriate for selected patients after response to first-line platinum therapy, especially when biomarker-directed maintenance is not indicated, not accessible, or not preferred. Bevacizumab maintenance may be continued if it was used with chemotherapy and remains clinically appropriate. Follow-up should include: Clinical assessment Toxicity recovery CA-125 if informative Imaging based on symptoms, CA-125 trend, clinical concern, and local follow-up practice Reassessment of goals of care and survivorship needs
                                • Front-line PARP inhibitor not indicated
                                  If front-line PARP inhibitor maintenance is not indicated or not appropriate, consider observation, bevacizumab maintenance if already used and suitable, clinical trial, and routine follow-up. Reasons PARP inhibitor may not be appropriate: No response to platinum-based therapy Biomarker status not supportive under local guidance Significant unresolved cytopenias Poor marrow reserve Patient preference Access limitations Competing toxicity concerns
                        • No
                          • Proceed to recurrence / subsequent-line algorithm
                  • No bevacizumab
                    • Response to first-line platinum therapy?
                      Assess response after completion of first-line platinum-based chemotherapy using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have complete or partial response to platinum-based chemotherapy. If there is progression or no meaningful response to first-line platinum therapy, proceed to recurrence / subsequent-line management rather than routine frontline maintenance.
                      • Yes
                        • Biomarker-directed maintenance
                          Select maintenance based on: Response to platinum-based chemotherapy Germline and somatic BRCA status HRD status Bevacizumab use during chemotherapy Residual toxicity from chemotherapy Neuropathy Cytopenias and marrow reserve Hypertension/proteinuria or bevacizumab risk Patient preference, access, and local regulatory guidance Key principle: Maintenance should be selected after confirming response to first-line platinum-based therapy and reviewing biomarker status and toxicity risk.
                          • BRCA-mutated
                            BRCA-mutated disease strongly supports PARP inhibitor maintenance after response to first-line platinum-based chemotherapy. Confirm: Germline and/or somatic BRCA1/2 mutation Response to platinum-based chemotherapy Baseline CBC, platelets, renal and hepatic function Residual toxicity and patient preference Access and local regulatory guidance
                            • Olaparib maintenance
                              Consider olaparib maintenance for BRCA-mutated advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer after complete or partial response to first-line platinum-based chemotherapy. Practical considerations: Typical dose: olaparib 300 mg orally twice daily, adjusted according to prescribing information Review renal function and drug interactions Monitor CBC at baseline and periodically during treatment Counsel regarding fatigue, nausea, anemia, neutropenia, thrombocytopenia, and rare MDS/AML risk Reassess adherence, toxicity, and quality of life during follow-up
                              • If bevacizumab used: olaparib + bevacizumab
                                If bevacizumab was part of the frontline strategy and the tumor is HRD-positive, consider olaparib plus bevacizumab maintenance when clinically appropriate and consistent with local access/regulatory guidance. Practical considerations: Olaparib dosing according to prescribing information Bevacizumab continuation according to the planned bevacizumab duration and tolerability Monitor CBC, renal function, blood pressure, proteinuria, bleeding/thrombotic risk, and GI/wound-healing risks Consider cumulative toxicity and patient preference
                          • BRCA wild-type, HRD-positive
                            For BRCA wild-type, HRD-positive disease with response to first-line platinum-based chemotherapy, consider PARP inhibitor maintenance strategy according to prior bevacizumab use, toxicity risk, access, and local regulatory guidance. If bevacizumab was used and tolerated, olaparib + bevacizumab may be considered in HRD-positive disease. If bevacizumab was not used or is not appropriate, niraparib may be considered when consistent with local guidance and patient factors.
                            • Niraparib
                              Consider niraparib maintenance after response to first-line platinum-based chemotherapy when clinically appropriate and consistent with local regulatory guidance. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review HRD/BRCA status and local indication Assess CBC with differential and platelets Assess baseline weight and platelet count for individualized starting dose when applicable Review blood pressure, heart rate, renal/hepatic function, marrow reserve, and prior cytopenias Monitoring: CBC weekly during the first month CBC monthly for the next months once stable, then periodically or as clinically indicated Blood pressure and heart rate regularly, especially early in treatment Monitor fatigue, nausea, anemia, thrombocytopenia, neutropenia, hypertension, and rare MDS/AML risk
                              • If bevacizumab used: olaparib + bevacizumab
                                For HRD-positive/BRCA wild-type patients who received bevacizumab with frontline chemotherapy, olaparib + bevacizumab maintenance is supported by randomized evidence; positioning relative to niraparib depends on biomarkers, prior bevacizumab use, toxicity considerations, and guideline/approval specifics. If bevacizumab was part of the frontline strategy and the tumor is HRD-positive, consider olaparib plus bevacizumab maintenance when clinically appropriate and consistent with local access/regulatory guidance. Practical considerations: Olaparib dosing according to prescribing information Bevacizumab continuation according to the planned bevacizumab duration and tolerability Monitor CBC, renal function, blood pressure, proteinuria, bleeding/thrombotic risk, and GI/wound-healing risks Consider cumulative toxicity and patient preference
                          • HRD-negative / unknown
                            For HRD-negative or unknown disease, maintenance should be individualized. Options may include: Observation Bevacizumab maintenance if bevacizumab was used with chemotherapy and remains appropriate Clinical trial when available Reassessment of biomarker testing if incomplete or clinically important Frontline PARP inhibitor use in HRD-negative or unknown disease should be considered cautiously and according to local regulatory guidance, evolving evidence, toxicity risk, access, and expert review.
                            • Observation or bevacizumab maintenance
                              In HRD-negative/unknown patients, observation is an accepted approach after response; bevacizumab maintenance is reasonable if initiated with chemotherapy per GOG-0218/ICON7. The statement that frontline PARP is not indicated in this group is increasingly reflected in more conservative recommendations, though guidance varies by region and timepoint. Observation is appropriate for selected patients after response to first-line platinum therapy, especially when biomarker-directed maintenance is not indicated, not accessible, or not preferred. Bevacizumab maintenance may be continued if it was used with chemotherapy and remains clinically appropriate. Follow-up should include: Clinical assessment Toxicity recovery CA-125 if informative Imaging based on symptoms, CA-125 trend, clinical concern, and local follow-up practice Reassessment of goals of care and survivorship needs
                              • Front-line PARP inhibitor not indicated
                                If front-line PARP inhibitor maintenance is not indicated or not appropriate, consider observation, bevacizumab maintenance if already used and suitable, clinical trial, and routine follow-up. Reasons PARP inhibitor may not be appropriate: No response to platinum-based therapy Biomarker status not supportive under local guidance Significant unresolved cytopenias Poor marrow reserve Patient preference Access limitations Competing toxicity concerns
                      • No
                        • Proceed to recurrence / subsequent-line algorithm
          • No — NACT-IDS preferred
            • Neoadjuvant chemotherapy + interval debulking surgery (NACT-IDS)
              • Paclitaxel + carboplatin × 6 cycles total
                • Add bevacizumab?
                  Consider bevacizumab in selected patients with advanced-stage disease when clinically appropriate. Factors supporting consideration: Stage III/IV disease High-risk disease features Residual disease after surgery Symptomatic or high-burden disease Need for disease control beyond chemotherapy alone Avoid or use caution with: Recent major surgery or impaired wound healing Uncontrolled hypertension Significant proteinuria High bleeding or thrombotic risk Bowel obstruction, bowel involvement, fistula, or high perforation risk Poorly controlled cardiovascular comorbidity Bevacizumab use should be individualized based on risk, benefit, access, and patient goals.
                  • Concurrent bevacizumab with chemotherapy
                    If bevacizumab is selected, it may be given with carboplatin/paclitaxel and then continued as maintenance when tolerated and clinically appropriate. Monitoring: Blood pressure Urine protein / proteinuria Bleeding or thrombotic events Wound healing Bowel symptoms or perforation risk Renal function Overall tolerability and patient preference
                    • Continue bevacizumab maintenance
                      Continue bevacizumab maintenance if clinically appropriate, tolerated, and consistent with the treatment plan. Monitor: Blood pressure at each visit Proteinuria at regular intervals Bleeding, thrombosis, wound-healing issues Abdominal pain, bowel symptoms, fistula or perforation risk Renal function and overall tolerability Stop, hold, or reassess bevacizumab for significant hypertension, clinically relevant proteinuria, bleeding/thrombosis, wound-healing complications, GI perforation/fistula, or unacceptable toxicity.
                      • Response to first-line platinum therapy?
                        Assess response after completion of first-line platinum-based chemotherapy using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have complete or partial response to platinum-based chemotherapy. If there is progression or no meaningful response to first-line platinum therapy, proceed to recurrence / subsequent-line management rather than routine frontline maintenance.
                        • Yes
                          • Biomarker-directed maintenance
                            Select maintenance based on: Response to platinum-based chemotherapy Germline and somatic BRCA status HRD status Bevacizumab use during chemotherapy Residual toxicity from chemotherapy Neuropathy Cytopenias and marrow reserve Hypertension/proteinuria or bevacizumab risk Patient preference, access, and local regulatory guidance Key principle: Maintenance should be selected after confirming response to first-line platinum-based therapy and reviewing biomarker status and toxicity risk.
                            • BRCA-mutated
                              BRCA-mutated disease strongly supports PARP inhibitor maintenance after response to first-line platinum-based chemotherapy. Confirm: Germline and/or somatic BRCA1/2 mutation Response to platinum-based chemotherapy Baseline CBC, platelets, renal and hepatic function Residual toxicity and patient preference Access and local regulatory guidance
                              • Olaparib maintenance
                                Consider olaparib maintenance for BRCA-mutated advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer after complete or partial response to first-line platinum-based chemotherapy. Practical considerations: Typical dose: olaparib 300 mg orally twice daily, adjusted according to prescribing information Review renal function and drug interactions Monitor CBC at baseline and periodically during treatment Counsel regarding fatigue, nausea, anemia, neutropenia, thrombocytopenia, and rare MDS/AML risk Reassess adherence, toxicity, and quality of life during follow-up
                                • If bevacizumab used: olaparib + bevacizumab
                                  If bevacizumab was part of the frontline strategy and the tumor is HRD-positive, consider olaparib plus bevacizumab maintenance when clinically appropriate and consistent with local access/regulatory guidance. Practical considerations: Olaparib dosing according to prescribing information Bevacizumab continuation according to the planned bevacizumab duration and tolerability Monitor CBC, renal function, blood pressure, proteinuria, bleeding/thrombotic risk, and GI/wound-healing risks Consider cumulative toxicity and patient preference
                            • BRCA wild-type, HRD-positive
                              For BRCA wild-type, HRD-positive disease with response to first-line platinum-based chemotherapy, consider PARP inhibitor maintenance strategy according to prior bevacizumab use, toxicity risk, access, and local regulatory guidance. If bevacizumab was used and tolerated, olaparib + bevacizumab may be considered in HRD-positive disease. If bevacizumab was not used or is not appropriate, niraparib may be considered when consistent with local guidance and patient factors.
                              • Niraparib
                                Consider niraparib maintenance after response to first-line platinum-based chemotherapy when clinically appropriate and consistent with local regulatory guidance. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review HRD/BRCA status and local indication Assess CBC with differential and platelets Assess baseline weight and platelet count for individualized starting dose when applicable Review blood pressure, heart rate, renal/hepatic function, marrow reserve, and prior cytopenias Monitoring: CBC weekly during the first month CBC monthly for the next months once stable, then periodically or as clinically indicated Blood pressure and heart rate regularly, especially early in treatment Monitor fatigue, nausea, anemia, thrombocytopenia, neutropenia, hypertension, and rare MDS/AML risk
                                • If bevacizumab used: olaparib + bevacizumab
                                  For HRD-positive/BRCA wild-type patients who received bevacizumab with frontline chemotherapy, olaparib + bevacizumab maintenance is supported by randomized evidence; positioning relative to niraparib depends on biomarkers, prior bevacizumab use, toxicity considerations, and guideline/approval specifics. If bevacizumab was part of the frontline strategy and the tumor is HRD-positive, consider olaparib plus bevacizumab maintenance when clinically appropriate and consistent with local access/regulatory guidance. Practical considerations: Olaparib dosing according to prescribing information Bevacizumab continuation according to the planned bevacizumab duration and tolerability Monitor CBC, renal function, blood pressure, proteinuria, bleeding/thrombotic risk, and GI/wound-healing risks Consider cumulative toxicity and patient preference
                            • HRD-negative / unknown
                              For HRD-negative or unknown disease, maintenance should be individualized. Options may include: Observation Bevacizumab maintenance if bevacizumab was used with chemotherapy and remains appropriate Clinical trial when available Reassessment of biomarker testing if incomplete or clinically important Frontline PARP inhibitor use in HRD-negative or unknown disease should be considered cautiously and according to local regulatory guidance, evolving evidence, toxicity risk, access, and expert review.
                              • Observation or bevacizumab maintenance
                                In HRD-negative/unknown patients, observation is an accepted approach after response; bevacizumab maintenance is reasonable if initiated with chemotherapy per GOG-0218/ICON7. The statement that frontline PARP is not indicated in this group is increasingly reflected in more conservative recommendations, though guidance varies by region and timepoint. Observation is appropriate for selected patients after response to first-line platinum therapy, especially when biomarker-directed maintenance is not indicated, not accessible, or not preferred. Bevacizumab maintenance may be continued if it was used with chemotherapy and remains clinically appropriate. Follow-up should include: Clinical assessment Toxicity recovery CA-125 if informative Imaging based on symptoms, CA-125 trend, clinical concern, and local follow-up practice Reassessment of goals of care and survivorship needs
                                • Front-line PARP inhibitor not indicated
                                  If front-line PARP inhibitor maintenance is not indicated or not appropriate, consider observation, bevacizumab maintenance if already used and suitable, clinical trial, and routine follow-up. Reasons PARP inhibitor may not be appropriate: No response to platinum-based therapy Biomarker status not supportive under local guidance Significant unresolved cytopenias Poor marrow reserve Patient preference Access limitations Competing toxicity concerns
                        • No
                          • Proceed to recurrence / subsequent-line algorithm
                  • No bevacizumab
                    • Response to first-line platinum therapy?
                      Assess response after completion of first-line platinum-based chemotherapy using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have complete or partial response to platinum-based chemotherapy. If there is progression or no meaningful response to first-line platinum therapy, proceed to recurrence / subsequent-line management rather than routine frontline maintenance.
                      • Yes
                        • Biomarker-directed maintenance
                          Select maintenance based on: Response to platinum-based chemotherapy Germline and somatic BRCA status HRD status Bevacizumab use during chemotherapy Residual toxicity from chemotherapy Neuropathy Cytopenias and marrow reserve Hypertension/proteinuria or bevacizumab risk Patient preference, access, and local regulatory guidance Key principle: Maintenance should be selected after confirming response to first-line platinum-based therapy and reviewing biomarker status and toxicity risk.
                          • BRCA-mutated
                            BRCA-mutated disease strongly supports PARP inhibitor maintenance after response to first-line platinum-based chemotherapy. Confirm: Germline and/or somatic BRCA1/2 mutation Response to platinum-based chemotherapy Baseline CBC, platelets, renal and hepatic function Residual toxicity and patient preference Access and local regulatory guidance
                            • Olaparib maintenance
                              Consider olaparib maintenance for BRCA-mutated advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer after complete or partial response to first-line platinum-based chemotherapy. Practical considerations: Typical dose: olaparib 300 mg orally twice daily, adjusted according to prescribing information Review renal function and drug interactions Monitor CBC at baseline and periodically during treatment Counsel regarding fatigue, nausea, anemia, neutropenia, thrombocytopenia, and rare MDS/AML risk Reassess adherence, toxicity, and quality of life during follow-up
                              • If bevacizumab used: olaparib + bevacizumab
                                If bevacizumab was part of the frontline strategy and the tumor is HRD-positive, consider olaparib plus bevacizumab maintenance when clinically appropriate and consistent with local access/regulatory guidance. Practical considerations: Olaparib dosing according to prescribing information Bevacizumab continuation according to the planned bevacizumab duration and tolerability Monitor CBC, renal function, blood pressure, proteinuria, bleeding/thrombotic risk, and GI/wound-healing risks Consider cumulative toxicity and patient preference
                          • BRCA wild-type, HRD-positive
                            For BRCA wild-type, HRD-positive disease with response to first-line platinum-based chemotherapy, consider PARP inhibitor maintenance strategy according to prior bevacizumab use, toxicity risk, access, and local regulatory guidance. If bevacizumab was used and tolerated, olaparib + bevacizumab may be considered in HRD-positive disease. If bevacizumab was not used or is not appropriate, niraparib may be considered when consistent with local guidance and patient factors.
                            • Niraparib
                              Consider niraparib maintenance after response to first-line platinum-based chemotherapy when clinically appropriate and consistent with local regulatory guidance. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review HRD/BRCA status and local indication Assess CBC with differential and platelets Assess baseline weight and platelet count for individualized starting dose when applicable Review blood pressure, heart rate, renal/hepatic function, marrow reserve, and prior cytopenias Monitoring: CBC weekly during the first month CBC monthly for the next months once stable, then periodically or as clinically indicated Blood pressure and heart rate regularly, especially early in treatment Monitor fatigue, nausea, anemia, thrombocytopenia, neutropenia, hypertension, and rare MDS/AML risk
                              • If bevacizumab used: olaparib + bevacizumab
                                For HRD-positive/BRCA wild-type patients who received bevacizumab with frontline chemotherapy, olaparib + bevacizumab maintenance is supported by randomized evidence; positioning relative to niraparib depends on biomarkers, prior bevacizumab use, toxicity considerations, and guideline/approval specifics. If bevacizumab was part of the frontline strategy and the tumor is HRD-positive, consider olaparib plus bevacizumab maintenance when clinically appropriate and consistent with local access/regulatory guidance. Practical considerations: Olaparib dosing according to prescribing information Bevacizumab continuation according to the planned bevacizumab duration and tolerability Monitor CBC, renal function, blood pressure, proteinuria, bleeding/thrombotic risk, and GI/wound-healing risks Consider cumulative toxicity and patient preference
                          • HRD-negative / unknown
                            For HRD-negative or unknown disease, maintenance should be individualized. Options may include: Observation Bevacizumab maintenance if bevacizumab was used with chemotherapy and remains appropriate Clinical trial when available Reassessment of biomarker testing if incomplete or clinically important Frontline PARP inhibitor use in HRD-negative or unknown disease should be considered cautiously and according to local regulatory guidance, evolving evidence, toxicity risk, access, and expert review.
                            • Observation or bevacizumab maintenance
                              In HRD-negative/unknown patients, observation is an accepted approach after response; bevacizumab maintenance is reasonable if initiated with chemotherapy per GOG-0218/ICON7. The statement that frontline PARP is not indicated in this group is increasingly reflected in more conservative recommendations, though guidance varies by region and timepoint. Observation is appropriate for selected patients after response to first-line platinum therapy, especially when biomarker-directed maintenance is not indicated, not accessible, or not preferred. Bevacizumab maintenance may be continued if it was used with chemotherapy and remains clinically appropriate. Follow-up should include: Clinical assessment Toxicity recovery CA-125 if informative Imaging based on symptoms, CA-125 trend, clinical concern, and local follow-up practice Reassessment of goals of care and survivorship needs
                              • Front-line PARP inhibitor not indicated
                                If front-line PARP inhibitor maintenance is not indicated or not appropriate, consider observation, bevacizumab maintenance if already used and suitable, clinical trial, and routine follow-up. Reasons PARP inhibitor may not be appropriate: No response to platinum-based therapy Biomarker status not supportive under local guidance Significant unresolved cytopenias Poor marrow reserve Patient preference Access limitations Competing toxicity concerns
                      • No
                        • Proceed to recurrence / subsequent-line algorithm
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