Management of Platinum-Sensitive Recurrent Ovarian Cancer

Authored by Kathleen Moore, published on 2026-08-19 15:04:59.0

The algorithm is broadly aligned with contemporary management of platinum-sensitive recurrent epithelial ovarian cancer: use of platinum-based combinations, consideration of secondary cytoreductive surgery in carefully selected first-relapse patients, and maintenance approaches after response. It appropriately emphasizes patient/prior-therapy factors and recognizes the evolving/limited evidence for some biomarker-directed non-platinum options in this setting. Key caveats are that PARP inhibitor maintenance indications have narrowed in many regions due to OS/benefit–risk updates, and immunotherapy in ovarian cancer remains limited outside specific biomarkers/histologies and clinical trials.

  1. Recurrent epithelial ovarian cancer
    High-level guidance for evaluation and treatment of recurrent epithelial ovarian cancer (including definitions of platinum sensitivity, systemic therapy options, and maintenance approaches) is best supported by major international guidelines.
    • Platinum-free interval > 6 months?
      The platinum-free interval is a foundational stratifier for recurrence management and is incorporated into major guidelines for defining platinum-sensitive disease and guiding re-treatment decisions.
      • Platinum-sensitive recurrence
        This pathway applies to recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer with a platinum-free interval >6 months. Suggested baseline assessment before treatment selection: Prior platinum response and platinum-free interval Prior bevacizumab exposure Prior PARP inhibitor exposure Prior toxicities, including neuropathy and cytopenias Performance status, symptoms, disease burden, ascites, bowel involvement Surgical resectability if first relapse BRCA/HRD status if available FRα, HER2, MSI/MMR, NTRK or other actionable biomarkers when clinically relevant CBC with differential and platelets Renal function, liver tests, electrolytes Blood pressure CA-125 if informative for that patient Baseline imaging to document measurable or evaluable disease
        • First relapse?
          • Assess for secondary cytoreductive surgery
            • Candidate for complete gross resection (R0)?
              • Refer for secondary cytoreduction at experienced center
                • Then proceed to systemic therapy
                  • Platinum re-treatment appropriate?
                    Platinum re-treatment is generally preferred when clinically appropriate in platinum-sensitive recurrence. Consider: Prior platinum response Platinum-free interval Residual neuropathy Marrow reserve Renal function Hypersensitivity risk Frailty and comorbidities Patient goals and treatment burden Prior bevacizumab exposure Prior PARP inhibitor exposure Need for rapid response If platinum is not appropriate, consider non-platinum therapy, biomarker-directed therapy, clinical trial, and supportive care integration.
                    • Platinum-based doublet ± bevacizumab
                      • Carboplatin + paclitaxel
                        • Response to platinum-based therapy?
                          Assess response using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have a complete or partial response to platinum-based chemotherapy before starting maintenance. Stable disease may still support continuation of bevacizumab maintenance in selected patients if bevacizumab was used with chemotherapy and there is no contraindication.
                          • Maintenance strategy
                            Select maintenance based on: Response to platinum-based therapy BRCA/HRD status Prior PARP inhibitor exposure Prior bevacizumab exposure Toxicity profile Residual neuropathy Hypertension/proteinuria risk Cytopenias and marrow reserve Patient preference, access, and goals of care Key practical rule:PARP inhibitor maintenance generally requires response to platinum-based chemotherapy, usually complete or partial response. Bevacizumab maintenance may be continued in appropriate patients, including those with stable disease, when bevacizumab was part of the platinum-based treatment strategy and there is no contraindication.
                            • If bevacizumab used
                              Continue bevacizumab maintenance if clinically appropriate and tolerated. Monitor: Blood pressure Proteinuria Bleeding or thrombotic risk Wound healing / recent surgery Bowel symptoms or perforation risk Renal function and overall tolerability Bevacizumab maintenance can be considered even with stable disease after platinum-based chemotherapy if bevacizumab was part of the treatment strategy.
                              • Continue bevacizumab maintenance
                            • BRCA-mutated and PARPi appropriate
                              Consider PARP inhibitor maintenance after response to platinum-based chemotherapy, especially in BRCA-mutated disease. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review prior PARP inhibitor exposure Assess CBC, platelets, marrow reserve, renal/hepatic function Discuss fatigue, nausea, anemia, neutropenia, thrombocytopenia, rare MDS/AML risk, and duration of therapy Consider patient preference and access For niraparib: Consider individualized starting dose based on baseline body weight and platelet count when applicable Monitor CBC weekly during the initial treatment period, then monthly once stable or as clinically indicated Monitor blood pressure and heart rate
                              • Consider PARP inhibitor maintenance
                                • PARPi-after-PARPi: clinical equipoise
                            • Prior PARPi or non-BRCA setting
                              Individualize maintenance or observation based on: Prior PARP inhibitor exposure and duration Reason for PARP discontinuation BRCA/HRD status Platinum response Residual toxicity Risk of cumulative myelosuppression Patient goals and access Options may include bevacizumab maintenance if used and appropriate, observation, clinical trial, or selected PARP inhibitor use depending on local guidance and expert review.
                              • Individualize by prior therapy, region, and benefit-risk
                          • Proceed to platinum-resistant / later-line algorithm
                      • Carboplatin + gemcitabine
                        Carboplatin/gemcitabine is an option for platinum-sensitive recurrence, particularly when avoiding taxane-related neuropathy or alopecia is important. Practical caveat: Gemcitabine dosing often requires individualization based on marrow reserve, baseline cytopenias, age, frailty, prior therapy, and early hematologic toxicity. Full-dose gemcitabine may be difficult to tolerate in some patients. Evidence note: carboplatin/gemcitabine is an evidence-based platinum doublet in platinum-sensitive recurrence and may be used with bevacizumab in selected patients.
                        • Response to platinum-based therapy?
                          Assess response using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have a complete or partial response to platinum-based chemotherapy before starting maintenance. Stable disease may still support continuation of bevacizumab maintenance in selected patients if bevacizumab was used with chemotherapy and there is no contraindication.
                          • Maintenance strategy
                            Select maintenance based on: Response to platinum-based therapy BRCA/HRD status Prior PARP inhibitor exposure Prior bevacizumab exposure Toxicity profile Residual neuropathy Hypertension/proteinuria risk Cytopenias and marrow reserve Patient preference, access, and goals of care Key practical rule:PARP inhibitor maintenance generally requires response to platinum-based chemotherapy, usually complete or partial response. Bevacizumab maintenance may be continued in appropriate patients, including those with stable disease, when bevacizumab was part of the platinum-based treatment strategy and there is no contraindication.
                            • If bevacizumab used
                              Continue bevacizumab maintenance if clinically appropriate and tolerated. Monitor: Blood pressure Proteinuria Bleeding or thrombotic risk Wound healing / recent surgery Bowel symptoms or perforation risk Renal function and overall tolerability Bevacizumab maintenance can be considered even with stable disease after platinum-based chemotherapy if bevacizumab was part of the treatment strategy.
                              • Continue bevacizumab maintenance
                            • BRCA-mutated and PARPi appropriate
                              Consider PARP inhibitor maintenance after response to platinum-based chemotherapy, especially in BRCA-mutated disease. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review prior PARP inhibitor exposure Assess CBC, platelets, marrow reserve, renal/hepatic function Discuss fatigue, nausea, anemia, neutropenia, thrombocytopenia, rare MDS/AML risk, and duration of therapy Consider patient preference and access For niraparib: Consider individualized starting dose based on baseline body weight and platelet count when applicable Monitor CBC weekly during the initial treatment period, then monthly once stable or as clinically indicated Monitor blood pressure and heart rate
                              • Consider PARP inhibitor maintenance
                                • PARPi-after-PARPi: clinical equipoise
                            • Prior PARPi or non-BRCA setting
                              Individualize maintenance or observation based on: Prior PARP inhibitor exposure and duration Reason for PARP discontinuation BRCA/HRD status Platinum response Residual toxicity Risk of cumulative myelosuppression Patient goals and access Options may include bevacizumab maintenance if used and appropriate, observation, clinical trial, or selected PARP inhibitor use depending on local guidance and expert review.
                              • Individualize by prior therapy, region, and benefit-risk
                          • Proceed to platinum-resistant / later-line algorithm
                      • Carboplatin + PLD
                        • Response to platinum-based therapy?
                          Assess response using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have a complete or partial response to platinum-based chemotherapy before starting maintenance. Stable disease may still support continuation of bevacizumab maintenance in selected patients if bevacizumab was used with chemotherapy and there is no contraindication.
                          • Maintenance strategy
                            Select maintenance based on: Response to platinum-based therapy BRCA/HRD status Prior PARP inhibitor exposure Prior bevacizumab exposure Toxicity profile Residual neuropathy Hypertension/proteinuria risk Cytopenias and marrow reserve Patient preference, access, and goals of care Key practical rule:PARP inhibitor maintenance generally requires response to platinum-based chemotherapy, usually complete or partial response. Bevacizumab maintenance may be continued in appropriate patients, including those with stable disease, when bevacizumab was part of the platinum-based treatment strategy and there is no contraindication.
                            • If bevacizumab used
                              Continue bevacizumab maintenance if clinically appropriate and tolerated. Monitor: Blood pressure Proteinuria Bleeding or thrombotic risk Wound healing / recent surgery Bowel symptoms or perforation risk Renal function and overall tolerability Bevacizumab maintenance can be considered even with stable disease after platinum-based chemotherapy if bevacizumab was part of the treatment strategy.
                              • Continue bevacizumab maintenance
                            • BRCA-mutated and PARPi appropriate
                              Consider PARP inhibitor maintenance after response to platinum-based chemotherapy, especially in BRCA-mutated disease. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review prior PARP inhibitor exposure Assess CBC, platelets, marrow reserve, renal/hepatic function Discuss fatigue, nausea, anemia, neutropenia, thrombocytopenia, rare MDS/AML risk, and duration of therapy Consider patient preference and access For niraparib: Consider individualized starting dose based on baseline body weight and platelet count when applicable Monitor CBC weekly during the initial treatment period, then monthly once stable or as clinically indicated Monitor blood pressure and heart rate
                              • Consider PARP inhibitor maintenance
                                • PARPi-after-PARPi: clinical equipoise
                            • Prior PARPi or non-BRCA setting
                              Individualize maintenance or observation based on: Prior PARP inhibitor exposure and duration Reason for PARP discontinuation BRCA/HRD status Platinum response Residual toxicity Risk of cumulative myelosuppression Patient goals and access Options may include bevacizumab maintenance if used and appropriate, observation, clinical trial, or selected PARP inhibitor use depending on local guidance and expert review.
                              • Individualize by prior therapy, region, and benefit-risk
                          • Proceed to platinum-resistant / later-line algorithm
                    • Platinum inappropriate
                      • Use non-platinum biomarker-directed options
                        Use this branch when platinum re-treatment is not appropriate, not feasible, declined, or when a biomarker-directed approach is clinically preferred. This branch should not automatically replace platinum-based chemotherapy in a platinum-sensitive patient who is fit for platinum. Consider biomarker-directed therapy based on tumor biology, prior therapy, platinum suitability, access, regulatory status, toxicity profile, and expert review.
                        • FRα positive / Consider MIRV ± bevacizumab
                          Confirm folate receptor-alpha positivity according to the relevant assay and indication. Mirvetuximab soravtansine is best established in FRα-positive platinum-resistant ovarian cancer. In platinum-sensitive recurrence, consider its role cautiously in selected platinum-ineligible patients, clinical trial settings, or based on expert review and local access. Ocular safety: Baseline ophthalmology or optometry assessment Repeat eye exams every other cycle through cycle 8 Use prophylactic lubricating and steroid eye drops according to label/local protocol Monitor for blurred vision, keratopathy, dry eye, photophobia, or eye pain Hold, reduce, or discontinue according to severity and prescribing information
                          • Consider MIRV + bevacizumab
                        • PD-L1 positive
                          • Consider cyclophosphamide + bevacizumab + pembrolizumab
                        • HER2 3+ / Consider trastuzumab deruxtecan
                          Consider trastuzumab deruxtecan for HER2-positive disease when clinically appropriate, particularly when there are no satisfactory alternative treatment options and access/regulatory criteria are met. Safety caveat: Interstitial lung disease / pneumonitis is a key toxicity. Obtain baseline chest assessment and monitor closely for cough, dyspnea, fever, or new/worsening respiratory symptoms. Low threshold for chest CT evaluation if symptoms develop, and consider periodic chest imaging surveillance as clinically appropriate, even when there are no known thoracic metastases. Permanently discontinue for grade 2 or higher ILD/pneumonitis according to prescribing information.
                          • Consider trastuzumab deruxtecan
                        • No actionable biomarker or unsuitable
                          If there is no actionable biomarker or biomarker-directed therapy is not suitable, consider: Non-platinum chemotherapy Clinical trial Symptom-directed local therapy when appropriate Early supportive care integration Reassessment of goals of care Choice should be individualized based on disease tempo, symptoms, prior toxicity, comorbidities, access, and patient preference.
                          • Clinical trial or non-platinum chemotherapy
              • Proceed directly to systemic therapy
                • Platinum re-treatment appropriate?
                  Platinum re-treatment is generally preferred when clinically appropriate in platinum-sensitive recurrence. Consider: Prior platinum response Platinum-free interval Residual neuropathy Marrow reserve Renal function Hypersensitivity risk Frailty and comorbidities Patient goals and treatment burden Prior bevacizumab exposure Prior PARP inhibitor exposure Need for rapid response If platinum is not appropriate, consider non-platinum therapy, biomarker-directed therapy, clinical trial, and supportive care integration.
                  • Platinum-based doublet ± bevacizumab
                    • Carboplatin + paclitaxel
                      • Response to platinum-based therapy?
                        Assess response using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have a complete or partial response to platinum-based chemotherapy before starting maintenance. Stable disease may still support continuation of bevacizumab maintenance in selected patients if bevacizumab was used with chemotherapy and there is no contraindication.
                        • Maintenance strategy
                          Select maintenance based on: Response to platinum-based therapy BRCA/HRD status Prior PARP inhibitor exposure Prior bevacizumab exposure Toxicity profile Residual neuropathy Hypertension/proteinuria risk Cytopenias and marrow reserve Patient preference, access, and goals of care Key practical rule:PARP inhibitor maintenance generally requires response to platinum-based chemotherapy, usually complete or partial response. Bevacizumab maintenance may be continued in appropriate patients, including those with stable disease, when bevacizumab was part of the platinum-based treatment strategy and there is no contraindication.
                          • If bevacizumab used
                            Continue bevacizumab maintenance if clinically appropriate and tolerated. Monitor: Blood pressure Proteinuria Bleeding or thrombotic risk Wound healing / recent surgery Bowel symptoms or perforation risk Renal function and overall tolerability Bevacizumab maintenance can be considered even with stable disease after platinum-based chemotherapy if bevacizumab was part of the treatment strategy.
                            • Continue bevacizumab maintenance
                          • BRCA-mutated and PARPi appropriate
                            Consider PARP inhibitor maintenance after response to platinum-based chemotherapy, especially in BRCA-mutated disease. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review prior PARP inhibitor exposure Assess CBC, platelets, marrow reserve, renal/hepatic function Discuss fatigue, nausea, anemia, neutropenia, thrombocytopenia, rare MDS/AML risk, and duration of therapy Consider patient preference and access For niraparib: Consider individualized starting dose based on baseline body weight and platelet count when applicable Monitor CBC weekly during the initial treatment period, then monthly once stable or as clinically indicated Monitor blood pressure and heart rate
                            • Consider PARP inhibitor maintenance
                              • PARPi-after-PARPi: clinical equipoise
                          • Prior PARPi or non-BRCA setting
                            Individualize maintenance or observation based on: Prior PARP inhibitor exposure and duration Reason for PARP discontinuation BRCA/HRD status Platinum response Residual toxicity Risk of cumulative myelosuppression Patient goals and access Options may include bevacizumab maintenance if used and appropriate, observation, clinical trial, or selected PARP inhibitor use depending on local guidance and expert review.
                            • Individualize by prior therapy, region, and benefit-risk
                        • Proceed to platinum-resistant / later-line algorithm
                    • Carboplatin + gemcitabine
                      Carboplatin/gemcitabine is an option for platinum-sensitive recurrence, particularly when avoiding taxane-related neuropathy or alopecia is important. Practical caveat: Gemcitabine dosing often requires individualization based on marrow reserve, baseline cytopenias, age, frailty, prior therapy, and early hematologic toxicity. Full-dose gemcitabine may be difficult to tolerate in some patients. Evidence note: carboplatin/gemcitabine is an evidence-based platinum doublet in platinum-sensitive recurrence and may be used with bevacizumab in selected patients.
                      • Response to platinum-based therapy?
                        Assess response using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have a complete or partial response to platinum-based chemotherapy before starting maintenance. Stable disease may still support continuation of bevacizumab maintenance in selected patients if bevacizumab was used with chemotherapy and there is no contraindication.
                        • Maintenance strategy
                          Select maintenance based on: Response to platinum-based therapy BRCA/HRD status Prior PARP inhibitor exposure Prior bevacizumab exposure Toxicity profile Residual neuropathy Hypertension/proteinuria risk Cytopenias and marrow reserve Patient preference, access, and goals of care Key practical rule:PARP inhibitor maintenance generally requires response to platinum-based chemotherapy, usually complete or partial response. Bevacizumab maintenance may be continued in appropriate patients, including those with stable disease, when bevacizumab was part of the platinum-based treatment strategy and there is no contraindication.
                          • If bevacizumab used
                            Continue bevacizumab maintenance if clinically appropriate and tolerated. Monitor: Blood pressure Proteinuria Bleeding or thrombotic risk Wound healing / recent surgery Bowel symptoms or perforation risk Renal function and overall tolerability Bevacizumab maintenance can be considered even with stable disease after platinum-based chemotherapy if bevacizumab was part of the treatment strategy.
                            • Continue bevacizumab maintenance
                          • BRCA-mutated and PARPi appropriate
                            Consider PARP inhibitor maintenance after response to platinum-based chemotherapy, especially in BRCA-mutated disease. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review prior PARP inhibitor exposure Assess CBC, platelets, marrow reserve, renal/hepatic function Discuss fatigue, nausea, anemia, neutropenia, thrombocytopenia, rare MDS/AML risk, and duration of therapy Consider patient preference and access For niraparib: Consider individualized starting dose based on baseline body weight and platelet count when applicable Monitor CBC weekly during the initial treatment period, then monthly once stable or as clinically indicated Monitor blood pressure and heart rate
                            • Consider PARP inhibitor maintenance
                              • PARPi-after-PARPi: clinical equipoise
                          • Prior PARPi or non-BRCA setting
                            Individualize maintenance or observation based on: Prior PARP inhibitor exposure and duration Reason for PARP discontinuation BRCA/HRD status Platinum response Residual toxicity Risk of cumulative myelosuppression Patient goals and access Options may include bevacizumab maintenance if used and appropriate, observation, clinical trial, or selected PARP inhibitor use depending on local guidance and expert review.
                            • Individualize by prior therapy, region, and benefit-risk
                        • Proceed to platinum-resistant / later-line algorithm
                    • Carboplatin + PLD
                      • Response to platinum-based therapy?
                        Assess response using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have a complete or partial response to platinum-based chemotherapy before starting maintenance. Stable disease may still support continuation of bevacizumab maintenance in selected patients if bevacizumab was used with chemotherapy and there is no contraindication.
                        • Maintenance strategy
                          Select maintenance based on: Response to platinum-based therapy BRCA/HRD status Prior PARP inhibitor exposure Prior bevacizumab exposure Toxicity profile Residual neuropathy Hypertension/proteinuria risk Cytopenias and marrow reserve Patient preference, access, and goals of care Key practical rule:PARP inhibitor maintenance generally requires response to platinum-based chemotherapy, usually complete or partial response. Bevacizumab maintenance may be continued in appropriate patients, including those with stable disease, when bevacizumab was part of the platinum-based treatment strategy and there is no contraindication.
                          • If bevacizumab used
                            Continue bevacizumab maintenance if clinically appropriate and tolerated. Monitor: Blood pressure Proteinuria Bleeding or thrombotic risk Wound healing / recent surgery Bowel symptoms or perforation risk Renal function and overall tolerability Bevacizumab maintenance can be considered even with stable disease after platinum-based chemotherapy if bevacizumab was part of the treatment strategy.
                            • Continue bevacizumab maintenance
                          • BRCA-mutated and PARPi appropriate
                            Consider PARP inhibitor maintenance after response to platinum-based chemotherapy, especially in BRCA-mutated disease. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review prior PARP inhibitor exposure Assess CBC, platelets, marrow reserve, renal/hepatic function Discuss fatigue, nausea, anemia, neutropenia, thrombocytopenia, rare MDS/AML risk, and duration of therapy Consider patient preference and access For niraparib: Consider individualized starting dose based on baseline body weight and platelet count when applicable Monitor CBC weekly during the initial treatment period, then monthly once stable or as clinically indicated Monitor blood pressure and heart rate
                            • Consider PARP inhibitor maintenance
                              • PARPi-after-PARPi: clinical equipoise
                          • Prior PARPi or non-BRCA setting
                            Individualize maintenance or observation based on: Prior PARP inhibitor exposure and duration Reason for PARP discontinuation BRCA/HRD status Platinum response Residual toxicity Risk of cumulative myelosuppression Patient goals and access Options may include bevacizumab maintenance if used and appropriate, observation, clinical trial, or selected PARP inhibitor use depending on local guidance and expert review.
                            • Individualize by prior therapy, region, and benefit-risk
                        • Proceed to platinum-resistant / later-line algorithm
                  • Platinum inappropriate
                    • Use non-platinum biomarker-directed options
                      Use this branch when platinum re-treatment is not appropriate, not feasible, declined, or when a biomarker-directed approach is clinically preferred. This branch should not automatically replace platinum-based chemotherapy in a platinum-sensitive patient who is fit for platinum. Consider biomarker-directed therapy based on tumor biology, prior therapy, platinum suitability, access, regulatory status, toxicity profile, and expert review.
                      • FRα positive / Consider MIRV ± bevacizumab
                        Confirm folate receptor-alpha positivity according to the relevant assay and indication. Mirvetuximab soravtansine is best established in FRα-positive platinum-resistant ovarian cancer. In platinum-sensitive recurrence, consider its role cautiously in selected platinum-ineligible patients, clinical trial settings, or based on expert review and local access. Ocular safety: Baseline ophthalmology or optometry assessment Repeat eye exams every other cycle through cycle 8 Use prophylactic lubricating and steroid eye drops according to label/local protocol Monitor for blurred vision, keratopathy, dry eye, photophobia, or eye pain Hold, reduce, or discontinue according to severity and prescribing information
                        • Consider MIRV + bevacizumab
                      • PD-L1 positive
                        • Consider cyclophosphamide + bevacizumab + pembrolizumab
                      • HER2 3+ / Consider trastuzumab deruxtecan
                        Consider trastuzumab deruxtecan for HER2-positive disease when clinically appropriate, particularly when there are no satisfactory alternative treatment options and access/regulatory criteria are met. Safety caveat: Interstitial lung disease / pneumonitis is a key toxicity. Obtain baseline chest assessment and monitor closely for cough, dyspnea, fever, or new/worsening respiratory symptoms. Low threshold for chest CT evaluation if symptoms develop, and consider periodic chest imaging surveillance as clinically appropriate, even when there are no known thoracic metastases. Permanently discontinue for grade 2 or higher ILD/pneumonitis according to prescribing information.
                        • Consider trastuzumab deruxtecan
                      • No actionable biomarker or unsuitable
                        If there is no actionable biomarker or biomarker-directed therapy is not suitable, consider: Non-platinum chemotherapy Clinical trial Symptom-directed local therapy when appropriate Early supportive care integration Reassessment of goals of care Choice should be individualized based on disease tempo, symptoms, prior toxicity, comorbidities, access, and patient preference.
                        • Clinical trial or non-platinum chemotherapy
          • Systemic therapy selection by prior exposure and patient factors
            • Platinum re-treatment appropriate?
              Platinum re-treatment is generally preferred when clinically appropriate in platinum-sensitive recurrence. Consider: Prior platinum response Platinum-free interval Residual neuropathy Marrow reserve Renal function Hypersensitivity risk Frailty and comorbidities Patient goals and treatment burden Prior bevacizumab exposure Prior PARP inhibitor exposure Need for rapid response If platinum is not appropriate, consider non-platinum therapy, biomarker-directed therapy, clinical trial, and supportive care integration.
              • Platinum-based doublet ± bevacizumab
                • Carboplatin + paclitaxel
                  • Response to platinum-based therapy?
                    Assess response using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have a complete or partial response to platinum-based chemotherapy before starting maintenance. Stable disease may still support continuation of bevacizumab maintenance in selected patients if bevacizumab was used with chemotherapy and there is no contraindication.
                    • Maintenance strategy
                      Select maintenance based on: Response to platinum-based therapy BRCA/HRD status Prior PARP inhibitor exposure Prior bevacizumab exposure Toxicity profile Residual neuropathy Hypertension/proteinuria risk Cytopenias and marrow reserve Patient preference, access, and goals of care Key practical rule:PARP inhibitor maintenance generally requires response to platinum-based chemotherapy, usually complete or partial response. Bevacizumab maintenance may be continued in appropriate patients, including those with stable disease, when bevacizumab was part of the platinum-based treatment strategy and there is no contraindication.
                      • If bevacizumab used
                        Continue bevacizumab maintenance if clinically appropriate and tolerated. Monitor: Blood pressure Proteinuria Bleeding or thrombotic risk Wound healing / recent surgery Bowel symptoms or perforation risk Renal function and overall tolerability Bevacizumab maintenance can be considered even with stable disease after platinum-based chemotherapy if bevacizumab was part of the treatment strategy.
                        • Continue bevacizumab maintenance
                      • BRCA-mutated and PARPi appropriate
                        Consider PARP inhibitor maintenance after response to platinum-based chemotherapy, especially in BRCA-mutated disease. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review prior PARP inhibitor exposure Assess CBC, platelets, marrow reserve, renal/hepatic function Discuss fatigue, nausea, anemia, neutropenia, thrombocytopenia, rare MDS/AML risk, and duration of therapy Consider patient preference and access For niraparib: Consider individualized starting dose based on baseline body weight and platelet count when applicable Monitor CBC weekly during the initial treatment period, then monthly once stable or as clinically indicated Monitor blood pressure and heart rate
                        • Consider PARP inhibitor maintenance
                          • PARPi-after-PARPi: clinical equipoise
                      • Prior PARPi or non-BRCA setting
                        Individualize maintenance or observation based on: Prior PARP inhibitor exposure and duration Reason for PARP discontinuation BRCA/HRD status Platinum response Residual toxicity Risk of cumulative myelosuppression Patient goals and access Options may include bevacizumab maintenance if used and appropriate, observation, clinical trial, or selected PARP inhibitor use depending on local guidance and expert review.
                        • Individualize by prior therapy, region, and benefit-risk
                    • Proceed to platinum-resistant / later-line algorithm
                • Carboplatin + gemcitabine
                  Carboplatin/gemcitabine is an option for platinum-sensitive recurrence, particularly when avoiding taxane-related neuropathy or alopecia is important. Practical caveat: Gemcitabine dosing often requires individualization based on marrow reserve, baseline cytopenias, age, frailty, prior therapy, and early hematologic toxicity. Full-dose gemcitabine may be difficult to tolerate in some patients. Evidence note: carboplatin/gemcitabine is an evidence-based platinum doublet in platinum-sensitive recurrence and may be used with bevacizumab in selected patients.
                  • Response to platinum-based therapy?
                    Assess response using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have a complete or partial response to platinum-based chemotherapy before starting maintenance. Stable disease may still support continuation of bevacizumab maintenance in selected patients if bevacizumab was used with chemotherapy and there is no contraindication.
                    • Maintenance strategy
                      Select maintenance based on: Response to platinum-based therapy BRCA/HRD status Prior PARP inhibitor exposure Prior bevacizumab exposure Toxicity profile Residual neuropathy Hypertension/proteinuria risk Cytopenias and marrow reserve Patient preference, access, and goals of care Key practical rule:PARP inhibitor maintenance generally requires response to platinum-based chemotherapy, usually complete or partial response. Bevacizumab maintenance may be continued in appropriate patients, including those with stable disease, when bevacizumab was part of the platinum-based treatment strategy and there is no contraindication.
                      • If bevacizumab used
                        Continue bevacizumab maintenance if clinically appropriate and tolerated. Monitor: Blood pressure Proteinuria Bleeding or thrombotic risk Wound healing / recent surgery Bowel symptoms or perforation risk Renal function and overall tolerability Bevacizumab maintenance can be considered even with stable disease after platinum-based chemotherapy if bevacizumab was part of the treatment strategy.
                        • Continue bevacizumab maintenance
                      • BRCA-mutated and PARPi appropriate
                        Consider PARP inhibitor maintenance after response to platinum-based chemotherapy, especially in BRCA-mutated disease. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review prior PARP inhibitor exposure Assess CBC, platelets, marrow reserve, renal/hepatic function Discuss fatigue, nausea, anemia, neutropenia, thrombocytopenia, rare MDS/AML risk, and duration of therapy Consider patient preference and access For niraparib: Consider individualized starting dose based on baseline body weight and platelet count when applicable Monitor CBC weekly during the initial treatment period, then monthly once stable or as clinically indicated Monitor blood pressure and heart rate
                        • Consider PARP inhibitor maintenance
                          • PARPi-after-PARPi: clinical equipoise
                      • Prior PARPi or non-BRCA setting
                        Individualize maintenance or observation based on: Prior PARP inhibitor exposure and duration Reason for PARP discontinuation BRCA/HRD status Platinum response Residual toxicity Risk of cumulative myelosuppression Patient goals and access Options may include bevacizumab maintenance if used and appropriate, observation, clinical trial, or selected PARP inhibitor use depending on local guidance and expert review.
                        • Individualize by prior therapy, region, and benefit-risk
                    • Proceed to platinum-resistant / later-line algorithm
                • Carboplatin + PLD
                  • Response to platinum-based therapy?
                    Assess response using imaging, symptoms, performance status, toxicity, and CA-125 when informative. For PARP inhibitor maintenance, patients should generally have a complete or partial response to platinum-based chemotherapy before starting maintenance. Stable disease may still support continuation of bevacizumab maintenance in selected patients if bevacizumab was used with chemotherapy and there is no contraindication.
                    • Maintenance strategy
                      Select maintenance based on: Response to platinum-based therapy BRCA/HRD status Prior PARP inhibitor exposure Prior bevacizumab exposure Toxicity profile Residual neuropathy Hypertension/proteinuria risk Cytopenias and marrow reserve Patient preference, access, and goals of care Key practical rule:PARP inhibitor maintenance generally requires response to platinum-based chemotherapy, usually complete or partial response. Bevacizumab maintenance may be continued in appropriate patients, including those with stable disease, when bevacizumab was part of the platinum-based treatment strategy and there is no contraindication.
                      • If bevacizumab used
                        Continue bevacizumab maintenance if clinically appropriate and tolerated. Monitor: Blood pressure Proteinuria Bleeding or thrombotic risk Wound healing / recent surgery Bowel symptoms or perforation risk Renal function and overall tolerability Bevacizumab maintenance can be considered even with stable disease after platinum-based chemotherapy if bevacizumab was part of the treatment strategy.
                        • Continue bevacizumab maintenance
                      • BRCA-mutated and PARPi appropriate
                        Consider PARP inhibitor maintenance after response to platinum-based chemotherapy, especially in BRCA-mutated disease. Before starting: Confirm complete or partial response to platinum-based chemotherapy Review prior PARP inhibitor exposure Assess CBC, platelets, marrow reserve, renal/hepatic function Discuss fatigue, nausea, anemia, neutropenia, thrombocytopenia, rare MDS/AML risk, and duration of therapy Consider patient preference and access For niraparib: Consider individualized starting dose based on baseline body weight and platelet count when applicable Monitor CBC weekly during the initial treatment period, then monthly once stable or as clinically indicated Monitor blood pressure and heart rate
                        • Consider PARP inhibitor maintenance
                          • PARPi-after-PARPi: clinical equipoise
                      • Prior PARPi or non-BRCA setting
                        Individualize maintenance or observation based on: Prior PARP inhibitor exposure and duration Reason for PARP discontinuation BRCA/HRD status Platinum response Residual toxicity Risk of cumulative myelosuppression Patient goals and access Options may include bevacizumab maintenance if used and appropriate, observation, clinical trial, or selected PARP inhibitor use depending on local guidance and expert review.
                        • Individualize by prior therapy, region, and benefit-risk
                    • Proceed to platinum-resistant / later-line algorithm
              • Platinum inappropriate
                • Use non-platinum biomarker-directed options
                  Use this branch when platinum re-treatment is not appropriate, not feasible, declined, or when a biomarker-directed approach is clinically preferred. This branch should not automatically replace platinum-based chemotherapy in a platinum-sensitive patient who is fit for platinum. Consider biomarker-directed therapy based on tumor biology, prior therapy, platinum suitability, access, regulatory status, toxicity profile, and expert review.
                  • FRα positive / Consider MIRV ± bevacizumab
                    Confirm folate receptor-alpha positivity according to the relevant assay and indication. Mirvetuximab soravtansine is best established in FRα-positive platinum-resistant ovarian cancer. In platinum-sensitive recurrence, consider its role cautiously in selected platinum-ineligible patients, clinical trial settings, or based on expert review and local access. Ocular safety: Baseline ophthalmology or optometry assessment Repeat eye exams every other cycle through cycle 8 Use prophylactic lubricating and steroid eye drops according to label/local protocol Monitor for blurred vision, keratopathy, dry eye, photophobia, or eye pain Hold, reduce, or discontinue according to severity and prescribing information
                    • Consider MIRV + bevacizumab
                  • PD-L1 positive
                    • Consider cyclophosphamide + bevacizumab + pembrolizumab
                  • HER2 3+ / Consider trastuzumab deruxtecan
                    Consider trastuzumab deruxtecan for HER2-positive disease when clinically appropriate, particularly when there are no satisfactory alternative treatment options and access/regulatory criteria are met. Safety caveat: Interstitial lung disease / pneumonitis is a key toxicity. Obtain baseline chest assessment and monitor closely for cough, dyspnea, fever, or new/worsening respiratory symptoms. Low threshold for chest CT evaluation if symptoms develop, and consider periodic chest imaging surveillance as clinically appropriate, even when there are no known thoracic metastases. Permanently discontinue for grade 2 or higher ILD/pneumonitis according to prescribing information.
                    • Consider trastuzumab deruxtecan
                  • No actionable biomarker or unsuitable
                    If there is no actionable biomarker or biomarker-directed therapy is not suitable, consider: Non-platinum chemotherapy Clinical trial Symptom-directed local therapy when appropriate Early supportive care integration Reassessment of goals of care Choice should be individualized based on disease tempo, symptoms, prior toxicity, comorbidities, access, and patient preference.
                    • Clinical trial or non-platinum chemotherapy
      • PFI ≤ 6 months
        • Proceed to platinum-resistant / partially sensitive algorithm
tosprivacyZEJULA (niraparib) prescribing information. DailyMed. Revised May 2024.Pujade-Lauraine E, Ledermann JA, Selle F, et al. Olaparib tablets as maintenance therapy in patients with platinum-sensitive, relapsed ovarian cancer and a BRCA1/2 mutation: SOLO2/ENGOT-Ov21. Lancet Oncology. 2017.Alvarez Secord A, et al. PICCOLO: mirvetuximab soravtansine in FRα-high platinum-sensitive ovarian cancer after prior platinum therapy.Moore KN, Angelergues A, Konecny GE, et al. Mirvetuximab soravtansine in FRα-positive, platinum-resistant ovarian cancer. New England Journal of Medicine. 2023.