Selecting new upfront regimens for advanced ovarian cancer with biomarker guidance.

We have evaluated three clinical decision points with biomarker guidance that must be made in the upfront treatment of ovarian cancer. Our discussion provides a clinical pathway to guide clinicians on the selection of new upfront regimens for ovarian cancer incorporating bevacizumab and/or poly-adenosine diphosphate-ribose polymerase (PARP) inhibitors.

It is also important to recognize that the selection of upfront agents may influence treatment options at recurrence. For example, the addition of these novel agents may have marginal median progression-free survival (mPFS) benefit of only 3–6months; however, this clinical benefit may extend mPFS and categorize patients as “platinum-sensitive,” allow them to be eligible for the re-treatment of platinum combinations, or become eligible for more clinical trials.

Since clinicians have access to three PARPi (olaparib, niraparib, and rucaparib) in the platinum sensitive setting, they may choose to alternate the sequential use of these biologic agents from bevacizumab to PARPi or vice-versa depending on the initial response to these agents. Genetic and genomic testing serve as an important tool to triage patients towards maintenance therapy with biologic agents.

Further decision tree analysis with economic considerations are also warranted to evaluate sequential therapies beyond the upfront setting to reflect the overall ovarian cancer patient's treatment journey.