Front-Line Treatment and Maintenance in Epithelial Ovarian Cancer

Authored by Natalia Gandur, published on 2026-06-23 01:18:34.0

  1. Newly diagnosed epithelial ovarian cancer
    • 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
                • Add bevacizumab?
                  • Concurrent bevacizumab with chemotherapy
                    • Continue bevacizumab maintenance
                      • Response to first-line platinum therapy?
                        • Yes
                          • Biomarker-directed maintenance
                            • BRCA-mutated
                              • Olaparib maintenance
                                • If bevacizumab used: olaparib + bevacizumab
                            • BRCA wild-type, HRD-positive
                              • Niraparib
                                • If bevacizumab used: olaparib + bevacizumab
                            • HRD-negative / unknown
                              • Observation or bevacizumab maintenance
                                • Front-line PARP inhibitor not indicated
                        • No
                          • Proceed to recurrence / subsequent-line algorithm
                  • No bevacizumab
                    • Response to first-line platinum therapy?
                      • Yes
                        • Biomarker-directed maintenance
                          • BRCA-mutated
                            • Olaparib maintenance
                              • If bevacizumab used: olaparib + bevacizumab
                          • BRCA wild-type, HRD-positive
                            • Niraparib
                              • If bevacizumab used: olaparib + bevacizumab
                          • HRD-negative / unknown
                            • Observation or bevacizumab maintenance
                              • Front-line PARP inhibitor not indicated
                      • 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?
                  • Concurrent bevacizumab with chemotherapy
                    • Continue bevacizumab maintenance
                      • Response to first-line platinum therapy?
                        • Yes
                          • Biomarker-directed maintenance
                            • BRCA-mutated
                              • Olaparib maintenance
                                • If bevacizumab used: olaparib + bevacizumab
                            • BRCA wild-type, HRD-positive
                              • Niraparib
                                • If bevacizumab used: olaparib + bevacizumab
                            • HRD-negative / unknown
                              • Observation or bevacizumab maintenance
                                • Front-line PARP inhibitor not indicated
                        • No
                          • Proceed to recurrence / subsequent-line algorithm
                  • No bevacizumab
                    • Response to first-line platinum therapy?
                      • Yes
                        • Biomarker-directed maintenance
                          • BRCA-mutated
                            • Olaparib maintenance
                              • If bevacizumab used: olaparib + bevacizumab
                          • BRCA wild-type, HRD-positive
                            • Niraparib
                              • If bevacizumab used: olaparib + bevacizumab
                          • HRD-negative / unknown
                            • Observation or bevacizumab maintenance
                              • Front-line PARP inhibitor not indicated
                      • No
                        • Proceed to recurrence / subsequent-line algorithm
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