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Published by American Society of Clinical Oncology (ASCO) · GRADE
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.
Key Takeaways
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.
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.
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.
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.
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).
For patients who are fit for PCS but are deemed unlikely to have complete cytoreduction by a gynecologic oncologist, NACT is recommended over PCS.
Patients with newly diagnosed advanced EOC who have a high peri-operative risk profile should receive NACT.
Decisions that patients are not eligible for primary cytoreductive surgery should be made after a consultation with a gynecologic oncologist.
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.
For NACT, a platinum-taxane doublet is recommended, especially for patients with high-grade serous or endometrioid ovarian cancer.
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.
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.
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.
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.
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.
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.
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.
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
Therapeutic Area
OncologyGuideline Scope
Inclusion Criteria
Care Settings
Special Populations
System: GRADE
Evidence Levels
Recommendation Strength
Contraindications
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.
Difficulty
advanced
Learning Paths