Prognia
Back to Guidelines
American Society of Clinical OncologyGynecologic Oncology2025advanced

Neoadjuvant Chemotherapy for Newly Diagnosed, Advanced Ovarian Cancer

Published by American Society of Clinical Oncology (ASCO) · GRADE

16Recommendations
145References
5Tables
3Figures
Read Full Guideline

Summary

AI-generated

The identification and treatment of patients with ovarian cancer remains a critical challenge. For advanced stages, primary cytoreductive surgery (PCS) has historically been the cornerstone. The emergence of neoadjuvant chemotherapy (NACT) offers an alternative approach to potentially optimize surgical outcomes and reduce perioperative morbidity.

ovarian cancerneoadjuvant chemotherapyASCOgynecologic oncologyplatinum‑taxaneprimary cytoreductive surgeryHIPECbevacizumab

Key Takeaways

  • 1
    Patients with suspected stage III-IV EOC should be evaluated by a gynecologic oncologist.
  • 2
    All EOC patients should be offered germline and somatic testing for BRCA1/BRCA2 and other susceptibility genes.
  • 3
    PCS is recommended for fit patients highly likely to achieve complete cytoreduction with acceptable morbidity.
  • 4
    NACT is recommended for patients fit for PCS but unlikely to have complete cytoreduction, or who possess a high perioperative risk profile.
  • 5
    A platinum-taxane doublet is the preferred NACT regimen.
  • 6
    ICS should ideally occur after ≤ 4 cycles of NACT for patients with response or stable disease.
  • 7
    HIPEC may be considered during ICS for eligible stage III patients.
  • 8
    Post-ICS chemotherapy should continue to complete a total of six cycles.
  • 9
    Maintenance therapy with FDA-approved agents (e.g., bevacizumab, PARPi) should be offered after primary chemotherapy.

What's New in This Version

New evidence published since the 2016 iteration includes updates on initial assessment to guide treatment, selection criteria for NACT versus PCS, preferred chemotherapy regimens, timing of surgical intervention, the role of hyperthermic intraperitoneal chemotherapy (HIPEC), the role of maintenance therapy after completion of primary chemotherapy, and the management approach for patients who do not have a clinical response to NACT.

Key Recommendations

Initial Assessment

  • 1.1

    All patients with suspected stage III or IV EOC should be evaluated by a gynecologic oncologist prior to initiation of therapy to determine whether they are candidates for PCS.

    StrongEvidence: ModerateClinical Evaluation
  • 1.2

    A primary clinical evaluation should include CA-125 and a CT of the abdomen and pelvis with oral and intravenous contrast (if not contraindicated) and chest imaging (CT preferred) to evaluate the extent of disease and the feasibility of surgical resection. Other tools to refine this assessment may include laparoscopy, diffusion-weighted MRI, FDG-PET scan, ultrasound, and endometrial biopsy.

    StrongEvidence: ModerateDiagnostic Evaluation
  • 1.3

    All patients with EOC should be offered germline and somatic testing for BRCA1 and BRCA2. Germline testing for other ovarian cancer susceptibility genes is recommended. Somatic tumor testing should include measure(s) of homologous recombination. Testing should occur at the time of diagnosis or as soon as feasibly possible.

    StrongEvidence: HighGenetic/Molecular Testing

Primary Cytoreductive Surgery

  • 2.1

    For patients with newly diagnosed advanced EOC who are fit for surgery and who have a high likelihood of achieving complete cytoreduction with acceptable morbidity, PCS is recommended over neoadjuvant therapy (NACT).

    ConditionalEvidence: ModerateTreatment Guidance

Neoadjuvant Chemotherapy

  • 3.1

    For patients who are fit for PCS but are deemed unlikely to have complete cytoreduction by a gynecologic oncologist, NACT is recommended over PCS.

    StrongEvidence: HighTreatment Guidance
  • 3.2

    Patients with newly diagnosed advanced EOC who have a high peri-operative risk profile should receive NACT.

    StrongEvidence: HighTreatment Guidance
  • 3.3

    Decisions that patients are not eligible for primary cytoreductive surgery should be made after a consultation with a gynecologic oncologist.

    StrongEvidence: HighClinical Evaluation

Tests Before NACT

  • 4.1

    Before NACT is delivered, all patients should have histologic confirmation (core biopsy is strongly preferred) of an invasive ovarian, fallopian tube, or peritoneal cancer. In exceptional cases, cytologic evaluation combined with a serum CA-125 to CEA ratio >25 is acceptable.

    ConditionalEvidence: ModerateDiagnostic Evaluation

Chemotherapy Regimens

  • 5.1

    For NACT, a platinum-taxane doublet is recommended, especially for patients with high-grade serous or endometrioid ovarian cancer.

    StrongEvidence: HighTreatment Guidance
  • 5.2

    Alternate regimens containing a platinum agent may be selected based on individual patient factors, such as advanced age or frailty, or disease factors, such as stage or rare histology.

    ConditionalEvidence: ModerateTreatment Guidance

NACT and ICS

  • 6.1

    ICS should be performed after ≤4 cycles of NACT for patients with a response to chemotherapy or stable disease. Alternative timing of surgery has not been prospectively evaluated but may be suggested based on patient-centered factors.

    ConditionalEvidence: LowTreatment Guidance

HIPEC

  • 7.1

    For patients diagnosed with FIGO stage III disease who have good PS, adequate renal function, and treated with NACT, HIPEC may be offered during ICS through a shared decision-making process.

    ConditionalEvidence: ModerateTreatment Guidance

Chemotherapy After ICS

  • 8.1

    For patients treated with NACT, post-ICS chemotherapy (preferably with a platinum-taxane doublet) is recommended. A total of six cycles of treatment is recommended (NACT plus post-ICS), but exact numbers may be adjusted.

    StrongEvidence: HighTreatment Guidance

Maintenance Therapy

  • 9.1

    Patients diagnosed with EOC should be offered maintenance treatments that are US FDA-approved under their labeled indication, such as bevacizumab or PARPi, or observation weighing potential for benefit, patient preferences, potential adverse effects, and quality of life.

    StrongEvidence: ModerateTreatment Guidance

Progression on NACT

  • 10.1

    Patients with progressive disease on NACT should have their diagnosis reconfirmed via tissue biopsy, if appropriate. Patients who have not had comprehensive genetic or molecular profiling at the time of diagnosis should be offered testing as soon as possible.

    ConditionalEvidence: ModerateDiagnostic Evaluation
  • 10.2

    Treatment options include alternative chemotherapy regimens, clinical trials, and/or discontinuation of active cancer therapy and initiation of end-of-life care. In general, there is little role for surgery, and it is not typically advised, unless for palliation.

    StrongEvidence: ModerateTreatment Guidance

Scope & Objectives

Clinical Topic

Neoadjuvant Chemotherapy for Advanced Ovarian Cancer

Objectives

To provide updated guidance regarding neoadjuvant chemotherapy (NACT) and primary cytoreductive surgery (PCS) among patients with stage III-IV epithelial ovarian, fallopian tube, or primary peritoneal cancer.

Target Patient Population

Patients with newly diagnosed stage III or stage IV epithelial ovarian, fallopian tube, or primary peritoneal cancer (EOC).

Diagnostic Criteria

Histologic confirmation (core biopsy strongly preferred) of invasive ovarian, fallopian tube, or peritoneal cancer; or cytologic evaluation combined with a serum CA-125 to CEA ratio >25 in exceptional cases.

Target Providers

Gynecologic oncologistsMedical oncologistsClinicians involved in gynecologic cancer care

Patient Criteria & Setting

Therapeutic Area

Oncology

Guideline Scope

Treatment GuidanceDiagnostic Evaluation

Inclusion Criteria

  • Newly diagnosed stage III or stage IV EOC
  • Fallopian tube cancer
  • Primary peritoneal cancer

Care Settings

HospitalOutpatient

Special Populations

Older adultsFrail patientsPatients with high perioperative risk profile

Evidence Grading

System: GRADE

Evidence Levels

LowOur confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
HighWe are very confident that the true effect lies close to that of the estimate of the effect.
ModerateWe are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Very LowWe have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

Recommendation Strength

StrongThe desirable effects of an intervention outweigh its undesirable effects. All or almost all informed people would make the recommended choice for or against an intervention.
ConditionalThe desirable effects probably outweigh the undesirable effects, but appreciable uncertainty exists. Most informed people would choose the recommended course of action, but a substantial number would not.

Safety & Contraindications

Contraindications

  • Significant renal dysfunction (Creatinine Clearance <30 or serum Creatinine <1.5) excludes HIPEC administration.

Monitoring Guidance

Close clinical assessments and CA-125 measurements with each cycle (every 3 weeks). Radiographic imaging should be performed early, preferably after three cycles of NACT, and compared to baseline.

Authors & Contributors

Stéphanie GaillardChristina LacchettiDeborah K. ArmstrongWilliam A. ClibyMitchell I. EdelsonAgustin A. GarciaRahel G. GhebreGregory M. GresselJamie L. LesnockLarissa A. MeyerKathleen N. MooreRoisin E. O’CearbhaillAlexander B. OlawaiyeRitu SalaniDee SparacioWillemien J. van DrielWilliam P. Tew

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

advanced

Learning Paths

Gynecologic OncologyOvarian CancerNeoadjuvant ChemotherapyCytoreductive SurgeryHIPECClinical Practice GuidelinesOncology