Advanced High-Grade Serous Ovarian Cancer

Sequencing for newly diagnosed advanced high-grade serous ovarian cancer: platinum-taxane induction (with or without bevacizumab), then homologous-recombination-guided maintenance (olaparib for BRCA-mutant, olaparib + bevacizumab for HRD-positive, niraparib for HR-proficient), followed by platinum-sensitivity-guided therapy at relapse.

1L: Carboplatin + paclitaxel ± bevacizumab

Platinum-taxane induction after maximal cytoreductive surgery (primary or interval). Add bevacizumab for high-risk disease (stage IV, residual disease); it is then continued into maintenance. Obtain germline and somatic BRCA plus HRD testing to plan maintenance.

Homologous-recombination status after platinum response?

maintenance: Olaparib maintenance

BRCA1/2 mutation (germline or somatic) after response to platinum-based therapy. Sustained progression-free survival benefit; monitor CBC for cytopenias and rare MDS/AML.

Evidence: SOLO-1

maintenance: Olaparib + bevacizumab maintenance

HRD-positive, BRCA-wild-type disease already receiving bevacizumab. Monitor for hypertension, proteinuria, and PARP-inhibitor cytopenias.

Evidence: PAOLA-1

maintenance: Niraparib maintenance

Option for HR-proficient / biomarker-negative disease (all-comers benefit, largest in HRD-positive). Use individualized (weight- and platelet-based) starting dose; monitor for thrombocytopenia.

Platinum-free interval at relapse?

2L: Platinum-based doublet (carboplatin + gemcitabine or liposomal doxorubicin) ± bevacizumab

Platinum-free interval ≥6 months. Re-challenge with a platinum doublet; consider secondary cytoreduction in selected patients and PARP-inhibitor maintenance if not previously used.

2L: Non-platinum single agent (liposomal doxorubicin, weekly paclitaxel, or topotecan) ± bevacizumab

Platinum-free interval <6 months. Sequential single agents; adding bevacizumab improves progression-free survival (AURELIA). Prioritize a clinical trial and consider mirvetuximab soravtansine for FRα-high disease.