ASCO Updates Its Ovarian Cancer Treatment Guideline

The American Society of Clinical Oncology (ASCO) is a leading organization providing internationally recognized guidelines based on the latest scientific evidence in cancer treatment. ASCO treatment guidelines help clinicians identify best practices and support evidence-based medicine. Independent expert panels prepare them and periodically revise them to incorporate new approaches. Generally updated every few years, ASCO guidelines are regarded as global references and are used by many national health authorities.

ASCO has published guidelines for patients with newly diagnosed stage III-IV epithelial ovarian, fallopian tube, and primary peritoneal cancer on the use of neoadjuvant chemotherapy. These updated guidelines , based on data from 61 studies, provide important recommendations for optimizing treatment options.

Initial Patient Assessment

ASCO recommends that patients with suspected stage III-IV epithelial ovarian cancer be evaluated by a gynecologic oncologist before treatment begins (strong recommendation, moderate-quality evidence). This assessment determines whether the patient is suitable for primary cytoreductive surgery.

The following tests are recommended to assess disease extent and surgical feasibility:

• CA-125 testing

• CT of the abdomen and pelvis with oral and intravenous contrast

• Chest imaging, preferably CT

The following may also be used (conditional recommendation, moderate-quality evidence):

• Laparoscopy

• Diffusion-weighted MRI

• FDG-PET

• Ultrasound

• Endometrial biopsy to exclude advanced endometrial cancer

At diagnosis or as soon as possible, ASCO also recommends germline and somatic testing for BRCA1 and BRCA2 and germline testing for other ovarian cancer susceptibility genes (strong recommendation, high-quality evidence). Somatic tumor testing should also include assessment of homologous recombination deficiency.

Primary Cytoreductive Surgery or Neoadjuvant Chemotherapy?

Patients Suitable for Surgery:

• Patients fit for surgery in whom complete cytoreduction is considered achievable should proceed directly to primary cytoreductive surgery (conditional recommendation, moderate-quality evidence).

Patients for Whom Neoadjuvant Chemotherapy Is Recommended:

• Patients unlikely to achieve complete cytoreduction

• Patients at high perioperative risk

• Patients unsuitable for primary surgery (strong recommendation, high-quality evidence)

The decision should be made together with a gynecologic oncologist (strong recommendation, high-quality evidence).

Neoadjuvant Chemotherapy Recommendations

Before neoadjuvant chemotherapy, histological confirmation of invasive epithelial ovarian, fallopian tube, or peritoneal cancer is required (conditional recommendation, moderate-quality evidence). The preferred biopsy method is core biopsy. If this is not possible, cytological evaluation together with a CA-125/CEA ratio greater than 25 is considered an acceptable alternative.

Recommended Neoadjuvant Chemotherapy Regimen:

• A platinum–taxane doubletis the most strongly recommended option, particularly for patients with high-grade serous or endometrioid ovarian cancer (strong recommendation, high-quality evidence).

• Alternative platinum-containing regimens may be selected according to age, frailty, stage, or rare tumor histology (conditional recommendation, moderate-quality evidence).

Subsequent Treatment Approaches

Interval Cytoreductive Surgery: Patients responding to neoadjuvant chemotherapy or with stable disease should undergo interval cytoreductive surgery after 4 or fewer cycles (conditional recommendation, low-quality evidence).

Use of HIPEC: For patients with FIGO stage III disease, good performance status, and treatment with neoadjuvant chemotherapy, hyperthermic intraperitoneal chemotherapy (HIPEC) may be offered during interval cytoreductive surgery (conditional recommendation, moderate-quality evidence). The decision should account for patient preferences, quality of life, and HIPEC availability.

Postoperative Chemotherapy: Patients who have received neoadjuvant chemotherapy should continue chemotherapy after interval cytoreductive surgery (strong recommendation, high-quality evidence).

• Recommended Chemotherapy: A platinum–taxane doublet

• Recommended Total Chemotherapy Duration (Before and After Surgery): 6 cycles

• Chemotherapy duration may vary by patient.

• For some patients, once adequate surgical healing has occurred, bevacizumab may be added.

Maintenance Treatments: Patients should be offered approved maintenance treatments such as bevacizumab or PARP inhibitors or undergo observation (strong recommendation, moderate-quality evidence). Patient preferences, quality of life, potential side effects, and treatment benefits should be considered.

What If Disease Progresses During Neoadjuvant Chemotherapy?

If disease progresses during neoadjuvant chemotherapy, a repeat biopsy to confirm the diagnosis and comprehensive genetic or molecular profiling should be offered (conditional recommendation, moderate-quality evidence).

Alternative Management Options:

• Alternative chemotherapy regimens

• Clinical trials

• Stopping cancer treatment and initiating palliative care (strong recommendation, moderate-quality evidence)

Surgery may be used only for palliation (for example, to relieve bowel obstruction).

Conclusion

These updated ASCO guidelines provide strong recommendations for defining best clinical practice in advanced epithelial ovarian cancer. They emphasize that gynecologic oncologists should make the decision between primary cytoreductive surgery and neoadjuvant chemotherapy. They also identify platinum–taxane chemotherapy as standard neoadjuvant treatment and state that HIPEC may be considered for selected patients. The guidelines further highlight the importance of patient-centered decision-making in cancer care.