Navigating Frontline Maintenance Options for Advanced Ovarian Cancer

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NCCN guidelines for advanced ovarian cancer provide structured treatment pathways incorporating bevacizumab and PARP inhibitor maintenance therapy. Rebecca C. Arend, MD, MPH, discusses her practice approach, typically avoiding bevacizumab upfront while utilizing PARP inhibitors like olaparib for homologous recombination deficiency (HRD)–deficient patients for 2-year maintenance periods. The guidelines recommend bevacizumab decisions at treatment initiation, with continuation in maintenance settings, and olaparib addition for HRD-deficient patients receiving bevacizumab.

Treatment duration for PARP inhibitor maintenance ranges from 2 to 3 years, with increasing recognition of potential long-term risks including myelodysplastic syndrome (MDS) and secondary leukemias. The panel discusses patient education challenges, noting that many patients initially resist discontinuing PARP inhibitors due to understanding of ovarian cancer’s aggressive nature. However, emerging data suggests potential benefits to stopping treatment after appropriate durations, including reduced toxicity and preserved response to subsequent therapies.

The discussion addresses PARP rechallenge strategies in recurrent disease, acknowledging limited evidence for repeat PARP inhibitor use. Recent trials like NIRVANA-R show modest benefits in platinum-sensitive recurrent disease, but experts remain cautious about routine PARP rechallenge. The panel emphasizes that while PARP maintenance has become standard care, optimal sequencing and duration remain active areas of investigation, with ongoing clinical trials examining treatment de-escalation strategies.