Management of Platinum-Sensitive Recurrent Ovarian Cancer

Authored by Kathleen Moore, published on 2026-09-11 16:11:26.0

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-based combination therapy remains the preferred systemic backbone for platinum-sensitive recurrence when platinum is clinically feasible and appropriate. Assess prior platinum response, platinum-free interval, hypersensitivity, residual neuropathy, marrow reserve, renal function, prior toxicity, frailty/comorbidities, treatment burden and patient preference. A patient may remain platinum-sensitive but be clinically platinum-inappropriate because platinum cannot reasonably be administered due to significant hypersensitivity, cumulative marrow toxicity, poor prior tolerance, organ dysfunction, or another clinically meaningful limitation.
                    • 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 + PARPi appropriate per current local label?
                              Consider PARP inhibitor maintenance only after complete or partial response to platinum-based chemotherapy and when supported by the current product-specific indication and local regulatory guidance. U.S. context: recurrent ovarian cancer PARP maintenance indications are currently restricted to selected BRCA-mutated populations and differ by agent: Olaparib: germline or somatic BRCA-mutated recurrent ovarian cancer. Niraparib: germline BRCA-mutated recurrent ovarian cancer. Rucaparib: germline and/or somatic BRCA-mutated recurrent ovarian cancer. Outside the U.S., approved populations and availability may differ by jurisdiction; confirm the current local label before treatment selection. Prior PARP inhibitor exposure, prior duration of benefit, cumulative toxicity, marrow reserve and patient preference should also inform whether PARP maintenance remains clinically appropriate.
                              • PARPi appropriate → initiate maintenance per current product-specific/local label
                                For patients with platinum-sensitive recurrent ovarian cancer who achieve a complete or partial response to platinum-based chemotherapy, initiate PARP inhibitor maintenance only when the current product-specific indication and local regulatory requirements are met. In the U.S. recurrent maintenance setting, eligibility is currently restricted to selected BRCA-mutated populations and differs by agent. Confirm the required germline versus germline/somatic BRCA status before treatment selection. Consider prior PARP inhibitor exposure, prior duration of benefit, marrow reserve, cumulative hematologic toxicity, renal/hepatic function, concomitant medications, and patient preference. Continue treatment according to the selected product label until disease progression, unacceptable toxicity, or another label-directed reason for discontinuation. Do not assume class-wide eligibility; indications differ by agent and jurisdiction.
                                • PARPi-after-PARPi: clinical equipoise
                            • Prior PARPi exposure or non-BRCA disease → reassess maintenance strategy
                              Prior PARP inhibitor exposure: do not assume routine PARP inhibitor rechallenge. Consider prior duration of benefit, reason for discontinuation, cumulative toxicity, marrow reserve, BRCA/HRD status and clinical-trial availability. Non-BRCA disease: in the current U.S. recurrent-maintenance setting, PARP inhibitor maintenance is not routinely indicated for non-BRCA-mutated disease. Outside the U.S., confirm the current product-specific local indication. Alternatives may include bevacizumab maintenance when used with platinum-based therapy, observation, clinical trial, or another individualized strategy.
                              • 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 + PARPi appropriate per current local label?
                              Consider PARP inhibitor maintenance only after complete or partial response to platinum-based chemotherapy and when supported by the current product-specific indication and local regulatory guidance. U.S. context: recurrent ovarian cancer PARP maintenance indications are currently restricted to selected BRCA-mutated populations and differ by agent: Olaparib: germline or somatic BRCA-mutated recurrent ovarian cancer. Niraparib: germline BRCA-mutated recurrent ovarian cancer. Rucaparib: germline and/or somatic BRCA-mutated recurrent ovarian cancer. Outside the U.S., approved populations and availability may differ by jurisdiction; confirm the current local label before treatment selection. Prior PARP inhibitor exposure, prior duration of benefit, cumulative toxicity, marrow reserve and patient preference should also inform whether PARP maintenance remains clinically appropriate.
                              • PARPi appropriate → initiate maintenance per current product-specific/local label
                                For patients with platinum-sensitive recurrent ovarian cancer who achieve a complete or partial response to platinum-based chemotherapy, initiate PARP inhibitor maintenance only when the current product-specific indication and local regulatory requirements are met. In the U.S. recurrent maintenance setting, eligibility is currently restricted to selected BRCA-mutated populations and differs by agent. Confirm the required germline versus germline/somatic BRCA status before treatment selection. Consider prior PARP inhibitor exposure, prior duration of benefit, marrow reserve, cumulative hematologic toxicity, renal/hepatic function, concomitant medications, and patient preference. Continue treatment according to the selected product label until disease progression, unacceptable toxicity, or another label-directed reason for discontinuation. Do not assume class-wide eligibility; indications differ by agent and jurisdiction.
                                • PARPi-after-PARPi: clinical equipoise
                            • Prior PARPi exposure or non-BRCA disease → reassess maintenance strategy
                              Prior PARP inhibitor exposure: do not assume routine PARP inhibitor rechallenge. Consider prior duration of benefit, reason for discontinuation, cumulative toxicity, marrow reserve, BRCA/HRD status and clinical-trial availability. Non-BRCA disease: in the current U.S. recurrent-maintenance setting, PARP inhibitor maintenance is not routinely indicated for non-BRCA-mutated disease. Outside the U.S., confirm the current product-specific local indication. Alternatives may include bevacizumab maintenance when used with platinum-based therapy, observation, clinical trial, or another individualized strategy.
                              • 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 + PARPi appropriate per current local label?
                              Consider PARP inhibitor maintenance only after complete or partial response to platinum-based chemotherapy and when supported by the current product-specific indication and local regulatory guidance. U.S. context: recurrent ovarian cancer PARP maintenance indications are currently restricted to selected BRCA-mutated populations and differ by agent: Olaparib: germline or somatic BRCA-mutated recurrent ovarian cancer. Niraparib: germline BRCA-mutated recurrent ovarian cancer. Rucaparib: germline and/or somatic BRCA-mutated recurrent ovarian cancer. Outside the U.S., approved populations and availability may differ by jurisdiction; confirm the current local label before treatment selection. Prior PARP inhibitor exposure, prior duration of benefit, cumulative toxicity, marrow reserve and patient preference should also inform whether PARP maintenance remains clinically appropriate.
                              • PARPi appropriate → initiate maintenance per current product-specific/local label
                                For patients with platinum-sensitive recurrent ovarian cancer who achieve a complete or partial response to platinum-based chemotherapy, initiate PARP inhibitor maintenance only when the current product-specific indication and local regulatory requirements are met. In the U.S. recurrent maintenance setting, eligibility is currently restricted to selected BRCA-mutated populations and differs by agent. Confirm the required germline versus germline/somatic BRCA status before treatment selection. Consider prior PARP inhibitor exposure, prior duration of benefit, marrow reserve, cumulative hematologic toxicity, renal/hepatic function, concomitant medications, and patient preference. Continue treatment according to the selected product label until disease progression, unacceptable toxicity, or another label-directed reason for discontinuation. Do not assume class-wide eligibility; indications differ by agent and jurisdiction.
                                • PARPi-after-PARPi: clinical equipoise
                            • Prior PARPi exposure or non-BRCA disease → reassess maintenance strategy
                              Prior PARP inhibitor exposure: do not assume routine PARP inhibitor rechallenge. Consider prior duration of benefit, reason for discontinuation, cumulative toxicity, marrow reserve, BRCA/HRD status and clinical-trial availability. Non-BRCA disease: in the current U.S. recurrent-maintenance setting, PARP inhibitor maintenance is not routinely indicated for non-BRCA-mutated disease. Outside the U.S., confirm the current product-specific local indication. Alternatives may include bevacizumab maintenance when used with platinum-based therapy, observation, clinical trial, or another individualized strategy.
                              • Individualize by prior therapy, region, and benefit-risk
                          • Proceed to platinum-resistant / later-line algorithm
                    • Platinum-sensitive but platinum-inappropriate
                      This branch applies to patients whose disease remains platinum-sensitive but for whom platinum re-treatment is not clinically appropriate or feasible. Examples may include: clinically significant platinum hypersensitivity not reasonably manageable with rechallenge or desensitization; cumulative or clinically important marrow toxicity; poor prior platinum tolerance; organ dysfunction or comorbidity limiting safe platinum administration; other patient-specific limitations making platinum re-treatment inappropriate. Non-platinum options in this branch are not intended to replace platinum-based chemotherapy when platinum remains feasible and appropriate.
                      • Platinum-inappropriate → select non-platinum or biomarker-directed therapy
                        For patients with platinum-sensitive recurrence in whom platinum re-treatment is not clinically appropriate, select therapy according to tumor biology, prior treatment exposure, available biomarkers, toxicity profile, performance status, comorbidities, access, regional regulatory status, and patient preference. Consider: biomarker-directed therapy when supported by appropriate evidence and the current local indication; an appropriate non-platinum systemic regimen; clinical trial participation when available. These strategies are not intended to replace platinum-based combination therapy when platinum remains feasible and appropriate.
                        • FRα-high + platinum-inappropriate → consider mirvetuximab soravtansine where clinically appropriate
                          Confirm FRα-high expression using the validated assay and threshold relevant to the intended treatment and jurisdiction. PICCOLO provides direct phase II evidence for mirvetuximab soravtansine monotherapy in heavily pretreated FRα-high recurrent platinum-sensitive ovarian cancer. In PICCOLO, ORR was 51.9%, median duration of response was 8.25 months, and median PFS was 6.93 months. In the U.S., mirvetuximab soravtansine is established and approved for FRα-positive platinum-resistant disease; use in platinum-sensitive/platinum-inappropriate disease should therefore be individualized according to local labeling, access and clinical context. Mirvetuximab + bevacizumab has supportive combination data, but that evidence should not be considered equivalent to PICCOLO evidence in platinum-sensitive disease.
                          • Consider MIRV + bevacizumab
                            Mirvetuximab soravtansine + bevacizumab has demonstrated clinical activity in prospective studies; however, the Gilbert et al. dataset was generated in platinum-resistant ovarian cancer. In the platinum-sensitive/platinum-inappropriate setting, this combination should therefore be considered supportive/extrapolated evidence rather than direct evidence equivalent to PICCOLO monotherapy, and use should reflect local regulatory status and clinical context.
                        • 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-based combination therapy remains the preferred systemic backbone for platinum-sensitive recurrence when platinum is clinically feasible and appropriate. Assess prior platinum response, platinum-free interval, hypersensitivity, residual neuropathy, marrow reserve, renal function, prior toxicity, frailty/comorbidities, treatment burden and patient preference. A patient may remain platinum-sensitive but be clinically platinum-inappropriate because platinum cannot reasonably be administered due to significant hypersensitivity, cumulative marrow toxicity, poor prior tolerance, organ dysfunction, or another clinically meaningful limitation.
                  • 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 + PARPi appropriate per current local label?
                            Consider PARP inhibitor maintenance only after complete or partial response to platinum-based chemotherapy and when supported by the current product-specific indication and local regulatory guidance. U.S. context: recurrent ovarian cancer PARP maintenance indications are currently restricted to selected BRCA-mutated populations and differ by agent: Olaparib: germline or somatic BRCA-mutated recurrent ovarian cancer. Niraparib: germline BRCA-mutated recurrent ovarian cancer. Rucaparib: germline and/or somatic BRCA-mutated recurrent ovarian cancer. Outside the U.S., approved populations and availability may differ by jurisdiction; confirm the current local label before treatment selection. Prior PARP inhibitor exposure, prior duration of benefit, cumulative toxicity, marrow reserve and patient preference should also inform whether PARP maintenance remains clinically appropriate.
                            • PARPi appropriate → initiate maintenance per current product-specific/local label
                              For patients with platinum-sensitive recurrent ovarian cancer who achieve a complete or partial response to platinum-based chemotherapy, initiate PARP inhibitor maintenance only when the current product-specific indication and local regulatory requirements are met. In the U.S. recurrent maintenance setting, eligibility is currently restricted to selected BRCA-mutated populations and differs by agent. Confirm the required germline versus germline/somatic BRCA status before treatment selection. Consider prior PARP inhibitor exposure, prior duration of benefit, marrow reserve, cumulative hematologic toxicity, renal/hepatic function, concomitant medications, and patient preference. Continue treatment according to the selected product label until disease progression, unacceptable toxicity, or another label-directed reason for discontinuation. Do not assume class-wide eligibility; indications differ by agent and jurisdiction.
                              • PARPi-after-PARPi: clinical equipoise
                          • Prior PARPi exposure or non-BRCA disease → reassess maintenance strategy
                            Prior PARP inhibitor exposure: do not assume routine PARP inhibitor rechallenge. Consider prior duration of benefit, reason for discontinuation, cumulative toxicity, marrow reserve, BRCA/HRD status and clinical-trial availability. Non-BRCA disease: in the current U.S. recurrent-maintenance setting, PARP inhibitor maintenance is not routinely indicated for non-BRCA-mutated disease. Outside the U.S., confirm the current product-specific local indication. Alternatives may include bevacizumab maintenance when used with platinum-based therapy, observation, clinical trial, or another individualized strategy.
                            • 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 + PARPi appropriate per current local label?
                            Consider PARP inhibitor maintenance only after complete or partial response to platinum-based chemotherapy and when supported by the current product-specific indication and local regulatory guidance. U.S. context: recurrent ovarian cancer PARP maintenance indications are currently restricted to selected BRCA-mutated populations and differ by agent: Olaparib: germline or somatic BRCA-mutated recurrent ovarian cancer. Niraparib: germline BRCA-mutated recurrent ovarian cancer. Rucaparib: germline and/or somatic BRCA-mutated recurrent ovarian cancer. Outside the U.S., approved populations and availability may differ by jurisdiction; confirm the current local label before treatment selection. Prior PARP inhibitor exposure, prior duration of benefit, cumulative toxicity, marrow reserve and patient preference should also inform whether PARP maintenance remains clinically appropriate.
                            • PARPi appropriate → initiate maintenance per current product-specific/local label
                              For patients with platinum-sensitive recurrent ovarian cancer who achieve a complete or partial response to platinum-based chemotherapy, initiate PARP inhibitor maintenance only when the current product-specific indication and local regulatory requirements are met. In the U.S. recurrent maintenance setting, eligibility is currently restricted to selected BRCA-mutated populations and differs by agent. Confirm the required germline versus germline/somatic BRCA status before treatment selection. Consider prior PARP inhibitor exposure, prior duration of benefit, marrow reserve, cumulative hematologic toxicity, renal/hepatic function, concomitant medications, and patient preference. Continue treatment according to the selected product label until disease progression, unacceptable toxicity, or another label-directed reason for discontinuation. Do not assume class-wide eligibility; indications differ by agent and jurisdiction.
                              • PARPi-after-PARPi: clinical equipoise
                          • Prior PARPi exposure or non-BRCA disease → reassess maintenance strategy
                            Prior PARP inhibitor exposure: do not assume routine PARP inhibitor rechallenge. Consider prior duration of benefit, reason for discontinuation, cumulative toxicity, marrow reserve, BRCA/HRD status and clinical-trial availability. Non-BRCA disease: in the current U.S. recurrent-maintenance setting, PARP inhibitor maintenance is not routinely indicated for non-BRCA-mutated disease. Outside the U.S., confirm the current product-specific local indication. Alternatives may include bevacizumab maintenance when used with platinum-based therapy, observation, clinical trial, or another individualized strategy.
                            • 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 + PARPi appropriate per current local label?
                            Consider PARP inhibitor maintenance only after complete or partial response to platinum-based chemotherapy and when supported by the current product-specific indication and local regulatory guidance. U.S. context: recurrent ovarian cancer PARP maintenance indications are currently restricted to selected BRCA-mutated populations and differ by agent: Olaparib: germline or somatic BRCA-mutated recurrent ovarian cancer. Niraparib: germline BRCA-mutated recurrent ovarian cancer. Rucaparib: germline and/or somatic BRCA-mutated recurrent ovarian cancer. Outside the U.S., approved populations and availability may differ by jurisdiction; confirm the current local label before treatment selection. Prior PARP inhibitor exposure, prior duration of benefit, cumulative toxicity, marrow reserve and patient preference should also inform whether PARP maintenance remains clinically appropriate.
                            • PARPi appropriate → initiate maintenance per current product-specific/local label
                              For patients with platinum-sensitive recurrent ovarian cancer who achieve a complete or partial response to platinum-based chemotherapy, initiate PARP inhibitor maintenance only when the current product-specific indication and local regulatory requirements are met. In the U.S. recurrent maintenance setting, eligibility is currently restricted to selected BRCA-mutated populations and differs by agent. Confirm the required germline versus germline/somatic BRCA status before treatment selection. Consider prior PARP inhibitor exposure, prior duration of benefit, marrow reserve, cumulative hematologic toxicity, renal/hepatic function, concomitant medications, and patient preference. Continue treatment according to the selected product label until disease progression, unacceptable toxicity, or another label-directed reason for discontinuation. Do not assume class-wide eligibility; indications differ by agent and jurisdiction.
                              • PARPi-after-PARPi: clinical equipoise
                          • Prior PARPi exposure or non-BRCA disease → reassess maintenance strategy
                            Prior PARP inhibitor exposure: do not assume routine PARP inhibitor rechallenge. Consider prior duration of benefit, reason for discontinuation, cumulative toxicity, marrow reserve, BRCA/HRD status and clinical-trial availability. Non-BRCA disease: in the current U.S. recurrent-maintenance setting, PARP inhibitor maintenance is not routinely indicated for non-BRCA-mutated disease. Outside the U.S., confirm the current product-specific local indication. Alternatives may include bevacizumab maintenance when used with platinum-based therapy, observation, clinical trial, or another individualized strategy.
                            • Individualize by prior therapy, region, and benefit-risk
                        • Proceed to platinum-resistant / later-line algorithm
                  • Platinum-sensitive but platinum-inappropriate
                    This branch applies to patients whose disease remains platinum-sensitive but for whom platinum re-treatment is not clinically appropriate or feasible. Examples may include: clinically significant platinum hypersensitivity not reasonably manageable with rechallenge or desensitization; cumulative or clinically important marrow toxicity; poor prior platinum tolerance; organ dysfunction or comorbidity limiting safe platinum administration; other patient-specific limitations making platinum re-treatment inappropriate. Non-platinum options in this branch are not intended to replace platinum-based chemotherapy when platinum remains feasible and appropriate.
                    • Platinum-inappropriate → select non-platinum or biomarker-directed therapy
                      For patients with platinum-sensitive recurrence in whom platinum re-treatment is not clinically appropriate, select therapy according to tumor biology, prior treatment exposure, available biomarkers, toxicity profile, performance status, comorbidities, access, regional regulatory status, and patient preference. Consider: biomarker-directed therapy when supported by appropriate evidence and the current local indication; an appropriate non-platinum systemic regimen; clinical trial participation when available. These strategies are not intended to replace platinum-based combination therapy when platinum remains feasible and appropriate.
                      • FRα-high + platinum-inappropriate → consider mirvetuximab soravtansine where clinically appropriate
                        Confirm FRα-high expression using the validated assay and threshold relevant to the intended treatment and jurisdiction. PICCOLO provides direct phase II evidence for mirvetuximab soravtansine monotherapy in heavily pretreated FRα-high recurrent platinum-sensitive ovarian cancer. In PICCOLO, ORR was 51.9%, median duration of response was 8.25 months, and median PFS was 6.93 months. In the U.S., mirvetuximab soravtansine is established and approved for FRα-positive platinum-resistant disease; use in platinum-sensitive/platinum-inappropriate disease should therefore be individualized according to local labeling, access and clinical context. Mirvetuximab + bevacizumab has supportive combination data, but that evidence should not be considered equivalent to PICCOLO evidence in platinum-sensitive disease.
                        • Consider MIRV + bevacizumab
                          Mirvetuximab soravtansine + bevacizumab has demonstrated clinical activity in prospective studies; however, the Gilbert et al. dataset was generated in platinum-resistant ovarian cancer. In the platinum-sensitive/platinum-inappropriate setting, this combination should therefore be considered supportive/extrapolated evidence rather than direct evidence equivalent to PICCOLO monotherapy, and use should reflect local regulatory status and clinical context.
                      • 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-based combination therapy remains the preferred systemic backbone for platinum-sensitive recurrence when platinum is clinically feasible and appropriate. Assess prior platinum response, platinum-free interval, hypersensitivity, residual neuropathy, marrow reserve, renal function, prior toxicity, frailty/comorbidities, treatment burden and patient preference. A patient may remain platinum-sensitive but be clinically platinum-inappropriate because platinum cannot reasonably be administered due to significant hypersensitivity, cumulative marrow toxicity, poor prior tolerance, organ dysfunction, or another clinically meaningful limitation.
              • 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 + PARPi appropriate per current local label?
                        Consider PARP inhibitor maintenance only after complete or partial response to platinum-based chemotherapy and when supported by the current product-specific indication and local regulatory guidance. U.S. context: recurrent ovarian cancer PARP maintenance indications are currently restricted to selected BRCA-mutated populations and differ by agent: Olaparib: germline or somatic BRCA-mutated recurrent ovarian cancer. Niraparib: germline BRCA-mutated recurrent ovarian cancer. Rucaparib: germline and/or somatic BRCA-mutated recurrent ovarian cancer. Outside the U.S., approved populations and availability may differ by jurisdiction; confirm the current local label before treatment selection. Prior PARP inhibitor exposure, prior duration of benefit, cumulative toxicity, marrow reserve and patient preference should also inform whether PARP maintenance remains clinically appropriate.
                        • PARPi appropriate → initiate maintenance per current product-specific/local label
                          For patients with platinum-sensitive recurrent ovarian cancer who achieve a complete or partial response to platinum-based chemotherapy, initiate PARP inhibitor maintenance only when the current product-specific indication and local regulatory requirements are met. In the U.S. recurrent maintenance setting, eligibility is currently restricted to selected BRCA-mutated populations and differs by agent. Confirm the required germline versus germline/somatic BRCA status before treatment selection. Consider prior PARP inhibitor exposure, prior duration of benefit, marrow reserve, cumulative hematologic toxicity, renal/hepatic function, concomitant medications, and patient preference. Continue treatment according to the selected product label until disease progression, unacceptable toxicity, or another label-directed reason for discontinuation. Do not assume class-wide eligibility; indications differ by agent and jurisdiction.
                          • PARPi-after-PARPi: clinical equipoise
                      • Prior PARPi exposure or non-BRCA disease → reassess maintenance strategy
                        Prior PARP inhibitor exposure: do not assume routine PARP inhibitor rechallenge. Consider prior duration of benefit, reason for discontinuation, cumulative toxicity, marrow reserve, BRCA/HRD status and clinical-trial availability. Non-BRCA disease: in the current U.S. recurrent-maintenance setting, PARP inhibitor maintenance is not routinely indicated for non-BRCA-mutated disease. Outside the U.S., confirm the current product-specific local indication. Alternatives may include bevacizumab maintenance when used with platinum-based therapy, observation, clinical trial, or another individualized strategy.
                        • 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 + PARPi appropriate per current local label?
                        Consider PARP inhibitor maintenance only after complete or partial response to platinum-based chemotherapy and when supported by the current product-specific indication and local regulatory guidance. U.S. context: recurrent ovarian cancer PARP maintenance indications are currently restricted to selected BRCA-mutated populations and differ by agent: Olaparib: germline or somatic BRCA-mutated recurrent ovarian cancer. Niraparib: germline BRCA-mutated recurrent ovarian cancer. Rucaparib: germline and/or somatic BRCA-mutated recurrent ovarian cancer. Outside the U.S., approved populations and availability may differ by jurisdiction; confirm the current local label before treatment selection. Prior PARP inhibitor exposure, prior duration of benefit, cumulative toxicity, marrow reserve and patient preference should also inform whether PARP maintenance remains clinically appropriate.
                        • PARPi appropriate → initiate maintenance per current product-specific/local label
                          For patients with platinum-sensitive recurrent ovarian cancer who achieve a complete or partial response to platinum-based chemotherapy, initiate PARP inhibitor maintenance only when the current product-specific indication and local regulatory requirements are met. In the U.S. recurrent maintenance setting, eligibility is currently restricted to selected BRCA-mutated populations and differs by agent. Confirm the required germline versus germline/somatic BRCA status before treatment selection. Consider prior PARP inhibitor exposure, prior duration of benefit, marrow reserve, cumulative hematologic toxicity, renal/hepatic function, concomitant medications, and patient preference. Continue treatment according to the selected product label until disease progression, unacceptable toxicity, or another label-directed reason for discontinuation. Do not assume class-wide eligibility; indications differ by agent and jurisdiction.
                          • PARPi-after-PARPi: clinical equipoise
                      • Prior PARPi exposure or non-BRCA disease → reassess maintenance strategy
                        Prior PARP inhibitor exposure: do not assume routine PARP inhibitor rechallenge. Consider prior duration of benefit, reason for discontinuation, cumulative toxicity, marrow reserve, BRCA/HRD status and clinical-trial availability. Non-BRCA disease: in the current U.S. recurrent-maintenance setting, PARP inhibitor maintenance is not routinely indicated for non-BRCA-mutated disease. Outside the U.S., confirm the current product-specific local indication. Alternatives may include bevacizumab maintenance when used with platinum-based therapy, observation, clinical trial, or another individualized strategy.
                        • 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 + PARPi appropriate per current local label?
                        Consider PARP inhibitor maintenance only after complete or partial response to platinum-based chemotherapy and when supported by the current product-specific indication and local regulatory guidance. U.S. context: recurrent ovarian cancer PARP maintenance indications are currently restricted to selected BRCA-mutated populations and differ by agent: Olaparib: germline or somatic BRCA-mutated recurrent ovarian cancer. Niraparib: germline BRCA-mutated recurrent ovarian cancer. Rucaparib: germline and/or somatic BRCA-mutated recurrent ovarian cancer. Outside the U.S., approved populations and availability may differ by jurisdiction; confirm the current local label before treatment selection. Prior PARP inhibitor exposure, prior duration of benefit, cumulative toxicity, marrow reserve and patient preference should also inform whether PARP maintenance remains clinically appropriate.
                        • PARPi appropriate → initiate maintenance per current product-specific/local label
                          For patients with platinum-sensitive recurrent ovarian cancer who achieve a complete or partial response to platinum-based chemotherapy, initiate PARP inhibitor maintenance only when the current product-specific indication and local regulatory requirements are met. In the U.S. recurrent maintenance setting, eligibility is currently restricted to selected BRCA-mutated populations and differs by agent. Confirm the required germline versus germline/somatic BRCA status before treatment selection. Consider prior PARP inhibitor exposure, prior duration of benefit, marrow reserve, cumulative hematologic toxicity, renal/hepatic function, concomitant medications, and patient preference. Continue treatment according to the selected product label until disease progression, unacceptable toxicity, or another label-directed reason for discontinuation. Do not assume class-wide eligibility; indications differ by agent and jurisdiction.
                          • PARPi-after-PARPi: clinical equipoise
                      • Prior PARPi exposure or non-BRCA disease → reassess maintenance strategy
                        Prior PARP inhibitor exposure: do not assume routine PARP inhibitor rechallenge. Consider prior duration of benefit, reason for discontinuation, cumulative toxicity, marrow reserve, BRCA/HRD status and clinical-trial availability. Non-BRCA disease: in the current U.S. recurrent-maintenance setting, PARP inhibitor maintenance is not routinely indicated for non-BRCA-mutated disease. Outside the U.S., confirm the current product-specific local indication. Alternatives may include bevacizumab maintenance when used with platinum-based therapy, observation, clinical trial, or another individualized strategy.
                        • Individualize by prior therapy, region, and benefit-risk
                    • Proceed to platinum-resistant / later-line algorithm
              • Platinum-sensitive but platinum-inappropriate
                This branch applies to patients whose disease remains platinum-sensitive but for whom platinum re-treatment is not clinically appropriate or feasible. Examples may include: clinically significant platinum hypersensitivity not reasonably manageable with rechallenge or desensitization; cumulative or clinically important marrow toxicity; poor prior platinum tolerance; organ dysfunction or comorbidity limiting safe platinum administration; other patient-specific limitations making platinum re-treatment inappropriate. Non-platinum options in this branch are not intended to replace platinum-based chemotherapy when platinum remains feasible and appropriate.
                • Platinum-inappropriate → select non-platinum or biomarker-directed therapy
                  For patients with platinum-sensitive recurrence in whom platinum re-treatment is not clinically appropriate, select therapy according to tumor biology, prior treatment exposure, available biomarkers, toxicity profile, performance status, comorbidities, access, regional regulatory status, and patient preference. Consider: biomarker-directed therapy when supported by appropriate evidence and the current local indication; an appropriate non-platinum systemic regimen; clinical trial participation when available. These strategies are not intended to replace platinum-based combination therapy when platinum remains feasible and appropriate.
                  • FRα-high + platinum-inappropriate → consider mirvetuximab soravtansine where clinically appropriate
                    Confirm FRα-high expression using the validated assay and threshold relevant to the intended treatment and jurisdiction. PICCOLO provides direct phase II evidence for mirvetuximab soravtansine monotherapy in heavily pretreated FRα-high recurrent platinum-sensitive ovarian cancer. In PICCOLO, ORR was 51.9%, median duration of response was 8.25 months, and median PFS was 6.93 months. In the U.S., mirvetuximab soravtansine is established and approved for FRα-positive platinum-resistant disease; use in platinum-sensitive/platinum-inappropriate disease should therefore be individualized according to local labeling, access and clinical context. Mirvetuximab + bevacizumab has supportive combination data, but that evidence should not be considered equivalent to PICCOLO evidence in platinum-sensitive disease.
                    • Consider MIRV + bevacizumab
                      Mirvetuximab soravtansine + bevacizumab has demonstrated clinical activity in prospective studies; however, the Gilbert et al. dataset was generated in platinum-resistant ovarian cancer. In the platinum-sensitive/platinum-inappropriate setting, this combination should therefore be considered supportive/extrapolated evidence rather than direct evidence equivalent to PICCOLO monotherapy, and use should reflect local regulatory status and clinical context.
                  • 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
tosprivacyLesnock JL, Temin S, Bouberhan S, et al. Systemic Treatment of Ovarian Cancer Recurrence: ASCO Living Guideline, Version 2026.1.0. J Clin Oncol. 2026. doi:10.1200/JCO-26-01591. Updated June 8, 2026.ZEJULA (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.Lesnock JL, Temin S, Bouberhan S, et al. Systemic Treatment of Ovarian Cancer Recurrence: ASCO Living Guideline, Version 2026.1.0. J Clin Oncol. 2026. doi:10.1200/JCO-26-01591.LYNPARZA® (olaparib) tablets. U.S. Prescribing Information. AstraZeneca.RUBRACA® (rucaparib) tablets. U.S. Prescribing Information. Revised December 2025.Pujade-Lauraine E, Selle F, Scambia G, et al. Maintenance olaparib rechallenge in patients with platinum-sensitive relapsed ovarian cancer previously treated with a PARP inhibitor (OReO/ENGOT-ov38): a phase IIIb trial. Ann Oncol. 2023.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.Alvarez Secord A, Lewin SN, Murphy CG, et al. The efficacy and safety of mirvetuximab soravtansine in FRα-positive, third-line and later, recurrent platinum-sensitive ovarian cancer: the single-arm phase II PICCOLO trial. Ann Oncol. 2025;36(3):321-330. doi:10.1016/j.annonc.2024.11.011.Gilbert L, Oaknin A, Matulonis UA, et al. Safety and efficacy of mirvetuximab soravtansine, a folate receptor alpha-targeting antibody-drug conjugate, in combination with bevacizumab in patients with platinum-resistant ovarian cancer. Gynecol Oncol. 2023;170:241-247. doi:10.1016/j.ygyno.2023.01.020.