Key points
- Epithelial ovarian cancer is usually diagnosed at an advanced stage and is the leading cause of death from gynecologic cancers [1].
- Its most common and most aggressive type is high-grade serous carcinoma, which accounts for about 70% of cases and mostly arises from the epithelium of the fallopian tube [2].
- The cumulative risk of ovarian cancer by age 80 is estimated at about 44% for carriers of a BRCA1 mutation and about 17% for BRCA2 carriers [3]; BRCA testing is recommended at diagnosis for all patients with high-grade non-mucinous ovarian cancer [6].
- Screening of the general population with CA-125 and ultrasound has not reduced deaths from ovarian cancer and is not recommended [4].
- The backbone of treatment is surgery aimed at complete tumor removal plus carboplatin–paclitaxel chemotherapy [6]; maintenance therapy with PARP inhibitors in BRCA-mutated or HRD-positive tumors has greatly prolonged the time to recurrence [11, 13, 15].
What is ovarian cancer?
“Ovarian cancer” is an umbrella term for cancers that arise from the ovary, the fallopian tube or the peritoneum (the membrane lining the abdominal cavity), which are staged together in the FIGO staging system [5]. Most of these cancers are epithelial, and epithelial cancers in turn comprise different histologic subtypes with distinct genomic features [1]; the main subtypes are compared in the table below.
Because the early stages cause no symptoms, most patients are diagnosed when the cancer has already spread into the abdominal cavity [2]. Recurrent advanced disease is usually not curable, but with today’s treatments long-term disease control has become possible for many patients [1, 12].
| Subtype | Features | Treatment notes |
|---|---|---|
| High-grade serous (HGSOC) | About 70% of cases; aggressive; often originates in the fallopian tube; often bilateral and at an advanced stage [2] | Usually platinum-sensitive; a subset of tumors carry a BRCA mutation or HRD, which predicts response to PARP inhibitors [1, 2] |
| Endometrioid | Often arises in the ovary itself and is associated with endometriosis [2] | Treatment based on stage and grade; in low-grade stage IA with complete staging, adjuvant chemotherapy is not recommended [6] |
| Clear cell | Often arises in the ovary and is associated with endometriosis [2] | In stage IA–IC1, the benefit of adjuvant chemotherapy is uncertain and it is optional [6] |
| Mucinous | A histologically and molecularly distinct group [2] | In the expansile type at stage IA–IB with complete staging, adjuvant chemotherapy is not recommended [6] |
| Low-grade serous (LGSOC) | A histologically and molecularly distinct group [2] | Hormone therapy is recommended at recurrence; a MEK inhibitor (trametinib) can be considered after platinum chemotherapy and hormone therapy (not approved by the FDA or EMA) [6] |
The final treatment decision depends on the stage, grade, molecular test results and the patient’s circumstances, and should be made by a multidisciplinary team.
Signs and symptoms
The symptoms of ovarian cancer are usually vague and nonspecific and are often mistaken for benign conditions such as digestive problems; this is one of the reasons for delayed diagnosis [2]. Common symptoms include [2]:
- Abdominal bloating or an increase in abdominal size
- Pelvic or abdominal pain
- Feeling full quickly when eating
- Needing to urinate frequently or urgently
As the disease progresses, symptoms become more pronounced and may include weight loss, fatigue, changes in bowel habits and postmenopausal bleeding. Blood clots (thrombosis) and certain rare neurologic or skin symptoms (paraneoplastic syndromes) are also, rarely, the first manifestation of the disease [2].
When should I contact my doctor?
Occasional bloating or abdominal pain is very common and usually has a simple cause. But if these symptoms are new, happen almost every day and continue for several weeks — especially after age 50 or if you have a family history of breast or ovarian cancer — see your doctor for an examination and an ultrasound.
Risk factors, BRCA genes, prevention and screening
The most important known risk factors for high-grade serous ovarian cancer are [2]:
- Inherited mutations in the BRCA1 or BRCA2 genes or other DNA repair genes, and Lynch syndrome; a hereditary predisposition is found in about 15 to 25% of cases of this subtype.
- A family history of ovarian, breast or bowel cancer.
- Obesity, postmenopausal hormone therapy, endometriosis and reproductive factors (such as the total number of ovulatory cycles over a lifetime).
Conversely, use of oral contraceptive pills, tubal ligation, childbirth and breastfeeding are associated with a lower risk [2].
In a large prospective study, the cumulative risk of ovarian cancer by age 80 was about 44% for carriers of a BRCA1 mutation and about 17% for BRCA2 carriers [3]. For women with a BRCA mutation, removal of both ovaries and fallopian tubes (bilateral salpingo-oophorectomy) is recommended once childbearing is complete, preferably between ages 35 and 40 for BRCA1 and between 40 and 45 for BRCA2 [2].
In addition, all patients with high-grade non-mucinous ovarian cancer should be tested for germline and/or somatic BRCA1/2 mutations at diagnosis [6]; the result determines both the choice of treatment (PARP inhibitors) and prevention in family members.
The large UKCTOCS trial studied more than 200,000 postmenopausal women aged 50 to 74 with a median follow-up of 16.3 years. Although annual screening with CA-125 and transvaginal ultrasound detected the disease at earlier stages, it did not reduce deaths from ovarian cancer; therefore, screening of the general population is not recommended [4]. This finding applies to women at average risk; high-risk women (such as BRCA carriers) follow a separate program.
Diagnosis and staging
Diagnostic pathway for ovarian cancer
- 1
Initial assessment
Medical history, pelvic examination and measurement of serum CA-125, together with a pelvic ultrasound performed by an expert [6].
- 2
Imaging
CT scan of the chest, abdomen and pelvis to determine the extent of disease [6].
- 3
Tissue diagnosis
Pathologic diagnosis according to the 2020 World Health Organization classification by an oncologic pathologist, preferably a specialist in gynecologic pathology; tissue is obtained through surgery or biopsy [6].
- 4
FIGO staging
Stage I is confined to the ovary(ies) or fallopian tube(s), stage II involves spread within the pelvis, stage III involves spread to the peritoneum outside the pelvis and/or to the retroperitoneal lymph nodes, and stage IV is distant metastasis [5].
- 5
Molecular testing
BRCA1/2 mutation testing (germline and/or somatic) in all high-grade non-mucinous cases, and testing for homologous recombination deficiency (HRD) in advanced high-grade cancers [6].
- 6
Specialist team
Assessment by a specialist gynecologic oncology team to determine whether complete surgery is feasible upfront or chemotherapy is needed before surgery [6].
Treatment by stage
Pillars of treatment
Surgery
The main goal is complete removal of all visible tumor. If this is possible at the outset, primary surgery is recommended; otherwise, three cycles of chemotherapy are given before surgery, followed by interval surgery and three more cycles of chemotherapy [6]. Removing normal-appearing lymph nodes in advanced disease offers no benefit [8].
Chemotherapy
Bevacizumab
Overview of treatment by stage
- 1
- 2
Stages III and IV (advanced)
Primary surgery aiming for complete removal, or neoadjuvant chemotherapy and interval surgery; six cycles of carboplatin–paclitaxel ± bevacizumab; then maintenance therapy based on BRCA and HRD status [6].
- 3
Platinum-sensitive recurrence
Assessment for repeat surgery at an experienced center; in selected patients, repeat cytoreductive surgery followed by chemotherapy has increased overall survival [6, 18]. Platinum-based doublet chemotherapy with bevacizumab, or platinum-based chemotherapy followed by PARP inhibitor maintenance (olaparib) if not previously received [6, 22].
- 4
Platinum-resistant recurrence
Single-agent chemotherapy (weekly paclitaxel, liposomal doxorubicin or topotecan), preferably with bevacizumab [6, 21]; in PD-L1–expressing tumors, weekly paclitaxel plus pembrolizumab (with or without bevacizumab) [20, 23]; in tumors with high FRα expression, mirvetuximab soravtansine; and early integration of palliative care [6, 17].
Maintenance therapy with PARP inhibitors
The PARP enzyme helps cells repair DNA damage. In tumors that have lost the ability to carry out “homologous recombination repair” because of a BRCA mutation or other defects (HRD-positive), blocking PARP kills the cancer cell. This is why the results of BRCA and HRD testing are decisive in choosing maintenance therapy [1, 6].
In BRCA-mutated or HRD-positive tumors, olaparib tablets, alone or with bevacizumab, are used for up to 2 years after a response to chemotherapy [6, 11, 15]; in HRD-negative tumors, continuing bevacizumab or niraparib (for 3 years in the ESMO guideline), which has been studied regardless of BRCA and HRD status, can be considered [6, 13]. In platinum-sensitive recurrence with a BRCA mutation, maintenance olaparib after a response to platinum-based chemotherapy also increased progression-free survival [22].
Treatment of platinum-resistant ovarian cancer
When ovarian cancer becomes resistant to platinum drugs (that is, the disease returns or progresses less than 6 months after the last platinum-based chemotherapy) [21], treatment options are more limited. The mainstay of treatment is single-agent chemotherapy (weekly paclitaxel, liposomal doxorubicin or topotecan), preferably given with bevacizumab; alongside it, palliative care should also begin early [6]. Adding bevacizumab to single-agent chemotherapy lengthened the time the disease stayed under control and increased the likelihood of responding to treatment [21].
In tumors that express the PD-L1 protein, adding the immunotherapy drug pembrolizumab to weekly paclitaxel increased overall survival [20].
A newer option for tumors with high FRα expression is mirvetuximab soravtansine, an antibody–drug conjugate that binds to folate receptor alpha (FRα) on cancer cells and delivers an anticancer drug directly into them [27]. Compared with chemotherapy, this drug increased overall survival and caused fewer severe side effects [17]. Mirvetuximab can damage the eyes (for example, visual impairment, keratopathy and dry eye); for this reason, an eye examination before starting and during treatment, and the use of prescribed eye drops, are required [27].
What should I do after diagnosis?
Treatment of ovarian cancer has advanced dramatically over the past decade. For example, among women with a BRCA mutation who received olaparib after chemotherapy, about 45% were alive and had not needed further treatment after seven years [12]. Ask your doctor whether taking part in a clinical trial is right for you.
Frequently asked questions
Does a Pap smear detect ovarian cancer?
No. The Pap smear and the HPV test are for cervical cancer screening and do not detect ovarian cancer. There is currently no effective screening method for ovarian cancer in the general population [4]; this is why paying attention to persistent symptoms is important.
Does a high CA-125 mean I have ovarian cancer?
Not necessarily. CA-125 can also be raised in many benign conditions (such as endometriosis or inflammation) and can be normal in some early-stage ovarian cancers. The test is interpreted together with an examination and ultrasound [6], and it has not reduced deaths when used for screening the general population [4].
Is ovarian cancer hereditary?
In some patients, yes. A hereditary predisposition (especially BRCA1 and BRCA2 mutations or Lynch syndrome) is found in about 15 to 25% of high-grade serous cancers [2]. For this reason, genetic testing is recommended for all patients with high-grade non-mucinous ovarian cancer [6], and if the result is positive, relatives can be tested too.
Why is chemotherapy sometimes given before surgery?
When the disease is very widespread and complete removal of the tumor is not possible at the outset, a few cycles of chemotherapy before surgery shrink the tumor. In a large trial, this approach was not inferior to primary surgery in terms of survival in bulky disease, and complications and deaths after surgery tended to be lower with it [7].
Do all patients benefit from PARP inhibitor tablets?
If the cancer comes back, can it be treated again?
Yes, there are several options: depending on when the cancer comes back and how it responded to platinum before, your doctor may suggest repeat surgery [18], platinum-based chemotherapy with bevacizumab or PARP inhibitor tablets [6], or, in platinum-resistant disease, chemotherapy with bevacizumab [21], the addition of the immunotherapy drug pembrolizumab [20] or newer drugs such as mirvetuximab [17]. Although recurrence is usually not curable, many patients live for years with a good quality of life [1].
Evidence and recent advances (for physicians)
For physicians
Surgery
In the EORTC 55971 trial, neoadjuvant chemotherapy followed by interval debulking surgery was noninferior to primary surgery in bulky stage IIIC–IV disease (HR for death 0.98), and complete resection of all macroscopic disease was the strongest predictor of survival [7]. In LION, systematic pelvic and para-aortic lymphadenectomy in patients with complete resection and clinically normal lymph nodes did not improve survival (median OS 65.5 vs 69.2 months) but increased mortality within 60 days of surgery (3.1% vs 0.9%) [8].
In OVHIPEC-1, adding cisplatin HIPEC to interval debulking surgery in stage III disease did not increase grade 3–4 adverse events [9], and in the final analysis with 10-year follow-up it improved progression-free survival (HR 0.63) and overall survival (median 44.9 vs 33.3 months; HR 0.70) [19]; however, because the evidence remains controversial, the Pan-Asian adapted ESMO guideline does not regard HIPEC [II, D] or intraperitoneal chemotherapy [I, E] as standard first-line treatment [6].
Bevacizumab
In ICON7, adding bevacizumab to carboplatin–paclitaxel improved progression-free survival (HR 0.81), and the benefit was greater in patients at high risk of progression (median OS 36.6 vs 28.8 months in this subgroup) [10].
Maintenance therapy: interpreting the overall survival data
Long-term data show that the benefit of PARP inhibitors depends strongly on tumor biology: a clinically meaningful improvement in overall survival was seen in BRCA-mutated (SOLO-1) and HRD-positive (PAOLA-1) disease [12, 16], whereas PRIMA showed no difference in overall survival in the overall population (HR 1.01), the HRD-positive population (HR 0.95) or the HR-proficient population (HR 0.93); this finding may be partly explained by PARP inhibitor use after progression in the placebo arm (37.8% in the overall population) [14]. The incidence of MDS/AML in PRIMA was below 2.5% [14]. The Pan-Asian adapted ESMO guideline recommends PARP inhibitor maintenance for BRCA-mutated and HRD-positive disease [I, A], whereas in HRD-negative disease bevacizumab [I, A] or niraparib [I, B] “can be considered” [6].
| Trial | Population | Intervention | Main result | Overall survival |
|---|---|---|---|---|
| SOLO-1 [11, 12] | Advanced, BRCA mutation, response to platinum | Olaparib for up to 2 years vs placebo | PFS: HR 0.30; progression-free at 3 years 60% vs 27% | Alive at 7 years 67.0% vs 46.5%; HR 0.55 (prespecified significance threshold not met) |
| PAOLA-1 [15, 16] | Advanced, receiving first-line bevacizumab | Olaparib + bevacizumab vs placebo + bevacizumab | PFS, overall population: 22.1 vs 16.6 months (HR 0.59); HRD-positive: 37.2 vs 17.7 months | HRD-positive: HR 0.62; 5-year 65.5% vs 48.4%; overall population HR 0.92 |
| PRIMA [13, 14] | Advanced, high risk, regardless of BRCA/HRD status | Niraparib for up to 3 years vs placebo | PFS in HRD-positive: 21.9 vs 10.4 months (HR 0.43); overall population: 13.8 vs 8.2 months (HR 0.62) | Overall population HR 1.01; no difference |
PFS: progression-free survival; HR: hazard ratio; HRD: homologous recombination deficiency. The overall survival analyses by HRD status in PAOLA-1 were exploratory.
Platinum-sensitive recurrence
In platinum-sensitive recurrence with a positive AGO score, DESKTOP III showed improved overall survival with secondary cytoreductive surgery (median 53.7 vs 46.0 months; HR 0.75), and patients with complete resection had the best outcome (median 61.9 months) [18].
Platinum-resistant recurrence
In the AURELIA trial, adding bevacizumab to single-agent chemotherapy increased median progression-free survival from 3.4 to 6.7 months (HR 0.48) and the response rate from 11.8% to 27.3% [21].
In the phase 3 KEYNOTE-B96 trial of 643 patients with platinum-resistant recurrence after 1 to 2 prior regimens, adding the immunotherapy agent pembrolizumab to weekly paclitaxel (with or without bevacizumab) increased median overall survival in patients with PD-L1 expression (CPS ≥1) from 14.0 to 18.2 months (HR 0.76) and also improved overall survival in the overall population (17.7 vs 14.0 months; HR 0.82); the progression-free survival benefit was smaller (8.3 vs 7.2 months in CPS ≥1), and grade 3 or higher treatment-related adverse events were more frequent (68% vs 55%) [20]. In February 2026, the FDA approved this regimen for patients with platinum-resistant disease and CPS ≥1 who have received 1 to 2 prior regimens [23].
In the phase 3 MIRASOL trial of 453 patients with platinum-resistant high-grade serous cancer and high FRα expression (75% or more of cells with staining intensity of 2+ or higher), mirvetuximab, compared with investigator’s choice chemotherapy, increased median overall survival from 12.75 to 16.46 months (HR 0.67) and the response rate from 15.9% to 42.3%; grade 3 or higher adverse events were also less frequent (41.7% vs 54.1%) [17]. The ESMO guideline (2025 Pan-Asian version) recommends it for patients with FRα expression and platinum-resistant recurrence after 1 to 3 prior regimens [6].
Treatment regimens and dosing (for physicians)
Treatment regimens and doses: index11 regimens
Paclitaxel (all paclitaxel-containing regimens): premedication with a corticosteroid (e.g., dexamethasone 20 mg orally approximately 12 and 6 hours before), diphenhydramine 50 mg IV and an IV H2 antagonist 30 to 60 minutes before; do not administer if neutrophils are below 1,500/µL, and give the next cycle only when neutrophils are above 1,500 and platelets above 100,000 [29].
Carboplatin: the total dose is calculated with the Calvert formula: dose (mg) = target AUC × (GFR + 25) [30].
Bevacizumab (all bevacizumab-containing regimens): withhold at least 28 days before elective surgery, and do not start until 28 days after major surgery and complete wound healing [24]. Monitoring: blood pressure and proteinuria by urine dipstick; withhold for proteinuria of 2 g or more per 24 hours and permanently discontinue for nephrotic syndrome; permanently discontinue for gastrointestinal perforation, fistula, grade 3–4 hemorrhage or severe arterial thromboembolism; dose reduction is not recommended [24].
For physicians
First line: chemotherapy and surgery
Carboplatin + paclitaxel every 3 weeks
Epithelial ovarian, fallopian tube or peritoneal cancer; advanced disease (after primary surgery or as neoadjuvant therapy) and adjuvant therapy for stages I–IIBCycle length: Every 21 days
Epithelial ovarian, fallopian tube or peritoneal cancer; advanced disease (after primary surgery or as neoadjuvant therapy) and adjuvant therapy for stages I–IIB [6]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Paclitaxel | 175 mg/m² | IV, 3-hour infusion | Day 1 |
| Carboplatin | AUC 5 to 6 (dose in mg = AUC × [GFR + 25]) | IV | Day 1, after paclitaxel |
Pan-Asian ESMO guideline: standard first-line treatment for advanced disease [I, A]; in frail patients, a weekly schedule of paclitaxel 60 mg/m² + carboplatin AUC 2 is an alternative that can be considered [I, B]; in early-stage disease, carboplatin alone (6 cycles) is also an option [I, A] [6].
Carboplatin + paclitaxel + bevacizumab, then maintenance bevacizumab (GOG-0218, ICON7)
Stage III–IV after primary surgery (greater benefit in patients at high risk of progression)Cycle length: Every 21 days
Stage III–IV after primary surgery (greater benefit in patients at high risk of progression) [6, 10, 24]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Cycles 1 to 6 | |||
| Carboplatin + paclitaxel | AUC 6 + 175 mg/m² | IV | Day 1 |
| From cycle 2 | |||
| Bevacizumab | 15 mg/kg | IV | Day 1 |
| Maintenance | |||
| Bevacizumab | 15 mg/kg | IV | Day 1, up to a total of 22 cycles |
In GOG-0218, bevacizumab was started from cycle 2 because of the required interval after surgery [24]. If maintenance olaparib is planned, bevacizumab 15 mg/kg for a total of 15 months (PAOLA-1 regimen) [25].
Evidence: ICON7 (2011), GOG-0218 (2011)
HIPEC with cisplatin at interval debulking surgery (OVHIPEC-1)
Stage III with at least stable disease after 3 cycles of neoadjuvant chemotherapy, when complete or optimal cytoreduction (residual disease 10 mm or less) is feasible
Stage III with at least stable disease after 3 cycles of neoadjuvant chemotherapy, when complete or optimal cytoreduction (residual disease 10 mm or less) is feasible [9]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Before surgery: 3 cycles | |||
| Carboplatin + paclitaxel | AUC 5–6 + 175 mg/m² | IV | Day 1 every 21 days |
| During interval debulking surgery | |||
| Cisplatin (HIPEC) | 100 mg/m² | Intraperitoneal, hyperthermic | Once |
| After surgery: 3 cycles | |||
| Carboplatin + paclitaxel | AUC 5–6 + 175 mg/m² | IV | Day 1 every 21 days |
Grade 3–4 adverse events were similar in the two groups (27% vs 25%) [9]. The Pan-Asian ESMO guideline does not consider HIPEC a first-line standard [II, D] [6]; only at experienced centers.
Evidence: OVHIPEC-1 (2023), OVHIPEC-1 (2018)
Doses follow the trial protocol, guideline or official drug label (source given in the notes of each regimen). Before prescribing, check blood counts, renal and hepatic function, drug interactions and the patient’s condition, and adjust the dose according to the drug label.
First line: maintenance therapy (based on BRCA and HRD)
Olaparib maintenance (SOLO-1)
BRCA mutation (germline or somatic), advanced disease, with complete or partial response to first-line platinum-based chemotherapyCycle length: Continuous
BRCA mutation (germline or somatic), advanced disease, with complete or partial response to first-line platinum-based chemotherapy [11, 25]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Olaparib | 300 mg twice daily (tablets) | Oral | Continuously |
Dose modification: 250 mg, then 200 mg twice daily; CrCl 31 to 50 mL/min: 200 mg twice daily; avoid strong or moderate CYP3A inhibitors (if unavoidable, 100 or 150 mg twice daily) [25]. Monitoring: start after hematologic toxicity from chemotherapy has recovered to grade 1 or lower; complete blood count at baseline and monthly; prolonged cytopenia: evaluate for MDS/AML [25].
Evidence: SOLO1/GOG 3004 (2023), SOLO-1 (GOG 3004) (2018)
Olaparib + bevacizumab maintenance (PAOLA-1)
HRD-positive (BRCA mutation and/or genomic instability), advanced disease, with complete or partial response to first-line platinum-based chemotherapy plus bevacizumabEach drug’s schedule in the table
HRD-positive (BRCA mutation and/or genomic instability), advanced disease, with complete or partial response to first-line platinum-based chemotherapy plus bevacizumab [15, 25]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Olaparib | 300 mg twice daily | Oral | Continuously |
| Bevacizumab | 15 mg/kg | IV | Day 1 every 21 days |
Olaparib monitoring and dose modification as in the previous row [25]. Pan-Asian ESMO guideline: for BRCA-mutated and HRD-positive disease [I, A] [6].
Evidence: PAOLA-1/ENGOT-ov25 (2023), PAOLA-1 (ENGOT-ov25) (2019)
Niraparib maintenance (PRIMA)
Advanced disease with complete or partial response to first-line platinum; current FDA label: HRD-positive only; ESMO: can also be considered in HRD-negative disease [I, B]Cycle length: Continuous
Advanced disease with complete or partial response to first-line platinum; current FDA label: HRD-positive only; ESMO: can also be considered in HRD-negative disease [I, B] [6, 26]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Niraparib | Weight less than 77 kg or platelets less than 150,000: 200 mg; weight 77 kg or more and platelets 150,000 or more: 300 mg | Oral, once daily (taking it at bedtime helps reduce nausea) | Continuously |
Monitoring: complete blood count weekly for the first month, monthly for the next 11 months and periodically thereafter; blood pressure and heart rate at least weekly for the first 2 months, then monthly for the first year [26]. Platelets below 100,000: withhold for up to 28 days with weekly blood counts [26]. Dose reduction: 200 → 100 mg; 300 → 200 → 100 mg; moderate hepatic impairment: 200 mg [26]. In PRIMA, overall survival did not differ (HR 1.01) [14].
Evidence: PRIMA/ENGOT-OV26/GOG-3012 (2024), PRIMA (2019), PRIMA (2011)
Before prescribing, check each dose against the drug label, laboratory tests and the patient’s condition.
Platinum-sensitive recurrence
Platinum doublet + bevacizumab (GOG-0213, OCEANS)
Platinum-sensitive recurrence (more than 6 months after the last platinum)Cycle length: Every 21 days
Platinum-sensitive recurrence (more than 6 months after the last platinum) [6, 24]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Regimen A: 6 to 8 cycles | |||
| Carboplatin + paclitaxel | AUC 5 + 175 mg/m² (3-hour infusion) | IV | Day 1 |
| Regimen B: 6 to 10 cycles | |||
| Carboplatin + gemcitabine | AUC 4 (day 1) + 1,000 mg/m² (days 1 and 8) | IV | Days 1 and 8 |
| With either regimen, then maintenance | |||
| Bevacizumab | 15 mg/kg | IV | Day 1 |
Pan-Asian ESMO guideline: platinum doublet (with PLD, gemcitabine or paclitaxel) plus bevacizumab [I, A], or a platinum doublet followed by PARP inhibitor maintenance if there is a response and no prior PARP inhibitor use [I, A]; bevacizumab should be continued until progression [I, A] [6]. Assess for secondary cytoreductive surgery at an experienced center before chemotherapy [6, 18].
Evidence: DESKTOP III (AGO-OVAR OP.4) (2021)
PARP inhibitor maintenance after response to platinum at recurrence (SOLO2)
Platinum-sensitive recurrence with complete or partial response to platinum-based chemotherapy; olaparib: germline or somatic BRCA mutation; niraparib: germline BRCA mutationCycle length: Continuous
Platinum-sensitive recurrence with complete or partial response to platinum-based chemotherapy; olaparib: germline or somatic BRCA mutation; niraparib: germline BRCA mutation [22, 25, 26]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| One of the two | |||
| Olaparib | 300 mg twice daily | Oral | Continuously |
| Niraparib | 300 mg once daily | Oral | Continuously; start no later than 8 weeks after the last platinum dose |
Monitoring and dose modification as in the first-line olaparib and niraparib rows [25, 26]. ESMO: continue the PARP inhibitor until progression or the start of the next treatment [I, A] [6].
Evidence: SOLO2/ENGOT-Ov21 (2017)
Before prescribing, check each dose against the drug label, laboratory tests and the patient’s condition.
Platinum-resistant recurrence
Single-agent chemotherapy + bevacizumab (AURELIA)
Platinum-resistant recurrence (less than 6 months after the last platinum), no more than 2 prior regimens; in the trial, rectosigmoid or bowel involvement and symptoms of bowel obstruction were exclusion criteria
Platinum-resistant recurrence (less than 6 months after the last platinum), no more than 2 prior regimens; in the trial, rectosigmoid or bowel involvement and symptoms of bowel obstruction were exclusion criteria [21, 24]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| One of the three | |||
| Paclitaxel | 80 mg/m² | IV | Days 1, 8, 15 and 22 every 4 weeks |
| Pegylated liposomal doxorubicin (PLD) | 40 mg/m² | IV | Day 1 every 4 weeks |
| Topotecan | 4 mg/m² (days 1, 8 and 15 every 4 weeks) or 1.25 mg/m² (days 1 to 5 every 3 weeks) | IV | As scheduled |
| Concurrent | |||
| Bevacizumab | 10 mg/kg every 2 weeks (with paclitaxel, PLD or weekly topotecan) or 15 mg/kg every 3 weeks (with topotecan every 3 weeks) | IV | Day 1 |
Chemotherapy doses are from the AURELIA (MO22224) regimen in the bevacizumab label [24]; the single-agent label doses differ: PLD 50 mg/m² every 4 weeks [31] and topotecan 1.5 mg/m² days 1 to 5 every 21 days [32]. PLD: assess left ventricular function before starting (risk of cardiomyopathy with cumulative anthracycline dose) [31]. ESMO: early palliative care [6].
Evidence: AURELIA (2014)
Pembrolizumab + weekly paclitaxel ± bevacizumab (KEYNOTE-B96)
Platinum-resistant recurrence (progression within 6 months after the last platinum) after 1 to 2 prior regimens, PD-L1 CPS ≥1 (22C3); no autoimmune disease requiring systemic treatment in the past 2 years
Platinum-resistant recurrence (progression within 6 months after the last platinum) after 1 to 2 prior regimens, PD-L1 CPS ≥1 (22C3); no autoimmune disease requiring systemic treatment in the past 2 years [20, 28]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Pembrolizumab | 400 mg every 6 weeks (or 200 mg every 3 weeks) | IV, 30 minutes; before paclitaxel | Day 1 |
| Paclitaxel | 80 mg/m² | IV | Days 1, 8 and 15 every 3 weeks |
| Optional | |||
| Bevacizumab | 10 mg/kg | IV | Day 1 every 2 weeks |
Grade 3 or higher treatment-related adverse events: 68% vs 55% [20]. Monitor liver enzymes, creatinine and thyroid function at baseline and periodically [28].
Evidence: KEYNOTE-B96 (ENGOT-ov65) (2026)
Mirvetuximab soravtansine (MIRASOL)
Platinum-resistant high-grade serous cancer with high FRα expression (75% or more of cells with 2+ intensity or higher); label: FRα-positive by an approved test, after 1 to 3 prior regimensCycle length: Every 21 days
Platinum-resistant high-grade serous cancer with high FRα expression (75% or more of cells with 2+ intensity or higher) [17]; label: FRα-positive by an approved test, after 1 to 3 prior regimens [27]
Before prescribing: Common safety considerations| Drug | Dose | Route | Schedule |
|---|---|---|---|
| Mirvetuximab soravtansine | 6 mg/kg based on adjusted ideal body weight (AIBW) | IV, diluted only in 5% dextrose (incompatible with normal saline) | Day 1 |
Dose calculation: AIBW = IBW + 0.4 × (actual weight − IBW); IBW for women = 0.9 × height (cm) − 92 [27]. Premedication (at least 30 minutes before): dexamethasone 10 mg IV, diphenhydramine 25 to 50 mg and acetaminophen 325 to 650 mg, plus an antiemetic (5-HT3 antagonist) [27]. Eyes (boxed warning for visual impairment, keratopathy and dry eye): ophthalmic examination with visual acuity and slit-lamp examination before starting, every other cycle for the first 8 cycles and as needed; steroid eye drops, 1 drop in each eye 6 times daily from the day before the infusion until day 4, then 4 times daily on days 5 to 8 of each cycle; artificial tears at least 4 times daily [27]. Grade 3–4 pneumonitis: permanently discontinue; monitor for peripheral neuropathy [27].
Evidence: MIRASOL (GOG-3045/ENGOT-ov55) (2023)
Before prescribing, check each dose against the drug label, laboratory tests and the patient’s condition.
Scientific evidence
Key studies
14 itemsOverall Survival With Maintenance Olaparib at a 7-Year Follow-Up in Patients With Newly Diagnosed Advanced Ovarian Cancer and a BRCA Mutation: The SOLO1/GOG 3004 Trial
Olaparib plus bevacizumab first-line maintenance in ovarian cancer: final overall survival results from the PAOLA-1/ENGOT-ov25 trial
Olaparib plus Bevacizumab as First-Line Maintenance in Ovarian Cancer
A phase 3 trial of bevacizumab in ovarian cancer
Cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy in patients with advanced ovarian cancer (OVHIPEC-1): final survival analysis of a randomised, controlled, phase 3 trial
A Randomized Trial of Lymphadenectomy in Patients with Advanced Ovarian Neoplasms
Randomized Trial of Cytoreductive Surgery for Relapsed Ovarian Cancer
Olaparib tablets as maintenance therapy in patients with platinum-sensitive, relapsed ovarian cancer and a BRCA1/2 mutation (SOLO2/ENGOT-Ov21): a double-blind, randomised, placebo-controlled, phase 3 trial
Bevacizumab Combined With Chemotherapy for Platinum-Resistant Recurrent Ovarian Cancer: The AURELIA Open-Label Randomized Phase III Trial
Pembrolizumab plus weekly paclitaxel in platinum-resistant recurrent ovarian cancer (ENGOT-ov65/KEYNOTE-B96): a multicentre, randomised, double-blind, phase 3 study
Niraparib in Patients with Newly Diagnosed Advanced Ovarian Cancer
Mirvetuximab Soravtansine in FRα-Positive, Platinum-Resistant Ovarian Cancer
Maintenance Olaparib in Patients with Newly Diagnosed Advanced Ovarian Cancer
Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer
Clinical guidelines
1 itemPan-Asia adapted ESMO Clinical Practice Guideline for the management of patients with newly diagnosed and relapsed epithelial ovarian cancer
References
32 referencesShow all references, 22 with a study cardClose the reference list
Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
- 1
- 2
- 3Risks of Breast, Ovarian, and Contralateral Breast Cancer for BRCA1 and BRCA2 Mutation Carriers
- 4
- 5Staging classification for cancer of the ovary, fallopian tube, and peritoneum
- 6Pan-Asia adapted ESMO Clinical Practice Guideline for the management of patients with newly diagnosed and relapsed epithelial ovarian cancer
- 7Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer
- 8A Randomized Trial of Lymphadenectomy in Patients with Advanced Ovarian Neoplasms
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19Cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy in patients with advanced ovarian cancer (OVHIPEC-1): final survival analysis of a randomised, controlled, phase 3 trial
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29Paclitaxel injection: prescribing information
- 30Carboplatin injection: prescribing information
- 31
- 32HYCAMTIN (topotecan) for injection, for intravenous use: prescribing information
This page is based on reputable scientific sources and was last updated on 21 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.