Pan-Asia adapted ESMO Clinical Practice Guideline for the management of patients with newly diagnosed and relapsed epithelial ovarian cancer

Key guideline recommendations

1. All patients with high-grade non-mucinous ovarian cancer should be tested for germline and/or somatic BRCA1/2 mutations at diagnosis.

   I, A

2. Homologous recombination deficiency (HRD) testing is recommended in advanced high-grade cancers.

   I, A

3. Patients with advanced ovarian cancer should be assessed by a specialist team for primary cytoreductive surgery aiming at complete resection (no macroscopic residual disease). If complete surgery is feasible, primary surgery is recommended.

   III, A

4. If complete cytoreductive surgery is not feasible, three cycles of neoadjuvant chemotherapy followed by interval surgery and three cycles of paclitaxel–carboplatin are recommended.

   I, A

5. Paclitaxel (175 mg/m²)–carboplatin (AUC 5–6) every 3 weeks for six cycles is the standard first-line chemotherapy in advanced ovarian cancer.

   I, A

6. Bevacizumab improves progression-free survival in patients with stage III–IV disease and should be considered with paclitaxel–carboplatin (ESMO-MCBS v1.1 score: 1).

   I, A

7. Because intraperitoneal chemotherapy [I, E] and HIPEC [II, D] remain controversial, these approaches are not considered standard first-line treatment.

   I, E / II, D

8. Maintenance therapy with a PARP inhibitor, with or without bevacizumab, is recommended for patients with BRCA1/2-mutated or BRCA1/2 wild-type/HRD-positive tumours who have no evidence of disease at the end of chemotherapy or have a complete or partial response to first-line platinum–paclitaxel chemotherapy. For BRCA1/2 mutation: olaparib for 2 years, niraparib for 3 years, olaparib–bevacizumab (olaparib for 2 years and bevacizumab for 15 months) or rucaparib for 2 years. For BRCA wild-type/HRD-positive: niraparib for 3 years, olaparib–bevacizumab or rucaparib for 2 years.

   I, A

9. In HRD-negative tumours, maintenance with bevacizumab [I, A], niraparib for 3 years [I, B] or rucaparib for 2 years [I, B] (the last two after a complete or partial response to first-line chemotherapy) can be considered; the choice should be based on disease and patient characteristics.

   I, A / I, B

10. Patients with a first relapse more than 6 months after the last platinum dose should be assessed at a gynaecological oncology centre experienced in ovarian cancer surgery to identify potential candidates for cytoreductive surgery.

    I, A

11. Patients who previously responded to platinum and did not have an early symptomatic relapse should be treated with a platinum doublet plus bevacizumab, or a platinum doublet followed by PARP inhibitor maintenance (if they respond and have not previously been exposed to a PARP inhibitor).

    I, A

12. Bevacizumab should be recommended with weekly paclitaxel, pegylated liposomal doxorubicin or topotecan in patients without contraindications to bevacizumab who have not previously received it (ESMO-MCBS v1.1: 4).

    I, A

13. Mirvetuximab soravtansine is recommended as a treatment option for patients with FRα expression (75% or more with ‎2+‎ intensity on immunohistochemistry) and platinum-resistant relapse after 1 to 3 prior systemic regimens (ESMO-MCBS v1.1: 3).

    I, A

14. Long-term BRCA1/2 mutation carriers who have survived ovarian cancer should be referred to high-risk breast cancer clinics for follow-up.

    I, A

Study population

Clinical significance and place in guidelines

Limitations