Ovarian Cancer Treatment Regimens

Ovarian Cancer Treatment Regimens

Clinical Trials: The NCCN recommends cancer patient participation in clinical trials as the gold standard for treatment.

Cancer therapy selection, dosing, administration, and the management of related adverse events can be a complex process that should be handled by an experienced healthcare team. Clinicians must choose and verify treatment options based on the individual patient; drug dose modifications and supportive care interventions should be administered accordingly. The cancer treatment regimens below may include both U.S. Food and Drug Administration-approved and unapproved indications/regimens. These regimens are only provided to supplement the latest treatment strategies.


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These Guidelines are a work in progress that may be refined as often as new significant data becomes available. The National Comprehensive Cancer Network Guidelines® are a consensus statement of its authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult any NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The NCCN makes no warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way.

Note: All recommendations are category 2A unless otherwise indicated.

▶Primary Systemic Therapy for Epithelial Ovarian/Fallopian Tube/Primary Peritoneal Cancer1,a

REGIMEN

DOSING

Stage I Disease

Carboplatin + Liposomal Doxorubicin2,3

Day 1: Carboplatin AUC 5 IV

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat every 4 weeks for 3-6 cycles for stage I disease or 6 cycles for stage II-IV disease or high-grade stage I disease.

Docetaxel + Carboplatin4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles (stage I) or 6 cycles if stage II-IV or high grade serous.

Paclitaxel + Carboplatin (preferred)3,7

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles.b

OR

Days 1,8,15: Paclitaxel 80mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Stage II-IV Disease

IP/IV Regimens

Paclitaxel + Cisplatin10

Day 1: Paclitaxel 135mg/m2 IV over 3 hours or IV continuous infusion over 24 hours

Day 2: Cisplatin 75-100mg/m2 intraperitoneal (IP) infused as rapidly as possible via IP portd

Day 8: Paclitaxel 60mg/m2 IP infused as rapidly as possible via IP port.e

Repeat cycle every 3 weeks for 6 cycles.

IV Regimens

Carboplatin + Liposomal Doxorubicin2,3

Day 1: Carboplatin AUC 5 IV

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat every 4 weeks for 6 cycles.

Docetaxel + Carboplatin4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

Paclitaxel + Carboplatin3,7-9

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Days 1,8,15: Paclitaxel 80mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Paclitaxel + Carboplatin +Bevacizumab11-14,f

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes

Day 1: Bevacizumab 7.5mg/kg IV.

Repeat cycle every 3 weeks for 5-6 cycles and continue maintenance bevacizumab for up to 12 additional cycles.

OR

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 6 IV over 1 hour.

Repeat cycle every 3 weeks for 6 cycles.

Starting Day 1 of cycle 2: Bevacizumab 15mg/kg IV over 30-90 minutes every 3 weeks for up to 22 cycles.

Stage III Disease

Cisplatin (for Hyperthermic Intraperitoneal Chemotherapy [HIPEC])15

Cisplatin 100mg/m2 IP over 90 minutes at time of debulking surgery.d

Elderly Patients (>70 Years) and/or Those With Comorbidities

Carboplatin20,21

Day 1: Carboplatin AUC 5 IV over 30 minutes.

Repeat cycle every 3 weeks.

Paclitaxel + Carboplatin20,22

Day 1: Paclitaxel 135mg/m2 IV

Day 1: Carboplatin AUC 5 IV.

Repeat cycle every 3 weeks for 4 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 over 30 minutes.

Administer weekly for 18 weeks.

▶Maintenance Therapy for Epithelial Ovarian Cancer/Fallopian Tube/Primary Peritoneal Cancer1

Post-Primary Treatment When Bevacizumab Used as Primary Treatment

Stage II, III, IV

Bevacizumab (for patients with stable disease)11,13,14,16,f

Day 1: Bevacizumab 15mg/kg IV.

Repeat cycle every 3 weeks.

OR

Day 1: Bevacizumab 7.5mg/kg IV.

Repeat cycle every 3 weeks.

Olaparib (for patients with CR or PR and BRCA1/2 mutations; Category 1 for germline mutations; Category 2A for somatic mutations)17-19

Days 1-28: Olaparib 300mg (tablet formulation) twice daily.

Repeat cycle every 4 weeks.

Post-Primary Treatment When Bevacizumab Not Used in Primary Therapy

Stage II, III, IV

Olaparib (for patients with CR or PR and BRCA1/2 mutations; Category 1 for germline mutations; Category 2A for somatic mutations)17-19

Days 1-28: Olaparib 300mg (tablet formulation) twice daily.

Repeat cycle every 4 weeks.

▶Primary Systemic Therapy for Less Common Epithelial Ovarian Histopathologies1

Carcinosarcoma (Malignant Mixed Mullerian Tumor)g

Stage I Disease

Carboplatin + Liposomal Doxorubicin (preferred)2,3

Day 1: Carboplatin AUC 5 IV

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat every 4 weeks for 3-6 cycles.

Docetaxel + Carboplatin (preferred)4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles (stage I) or 6 cycles if stage II-IV or high grade serous.

Paclitaxel + Carboplatin (preferred)3,7-9

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles.b

OR

Days 1,8,15: Paclitaxel 80mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.

Stage II-IV Disease

IP/IV Regimens

Paclitaxel + Cisplatin (preferred)10

Day 1: Paclitaxel 135mg/m2 IV over 3 hours or IV continuous infusion over 24 hours

Day 2: Cisplatin 75-100mg/m2 intraperitoneal (IP) infused as rapidly as possible via IP portd

Day 8: Paclitaxel 60mg/m2 IP infused as rapidly as possible via IP port.e

Repeat cycle every 3 weeks for 6 cycles.

IV Regimens

Carboplatin + Liposomal Doxorubicin (preferred)2,3

Day 1: Carboplatin AUC 5 IV

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat every 4 weeks for 3-6 cycles.

Docetaxel + Carboplatin (preferred)4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

Paclitaxel + Carboplatin (preferred)3,7,8,22

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Days 1,8,15: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Paclitaxel + Carboplatin +Bevacizumab (preferred)12,13,f,g

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes

Day 1: Bevacizumab 7.5mg/kg IV.

Repeat cycle every 3 weeks for 5-6 cycles and continue maintenance bevacizumab for up to 12 additional cycles.

OR

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 6 IV over 1 hour.

Repeat cycle every 3 weeks for 6 cycles.

Starting Day 1 of cycle 2: Bevacizumab 15mg/kg IV over 30-90 minutes every 3 weeks for up to 22 cycles.

Stage III Disease

Cisplatin (for HIPEC)15

Cisplatin 100mg/m2 IP over 90 minutes at the time of interval debulking surgery.d

Stage I-IV Disease – Other Regimens

Carboplatin + Ifosfamide23

Day 1: Carboplatin AUC 5 IV

Day 1: Ifosfamide 3,000mg/m2 IVh

Day 1: Mesna 1,000mg/m2 IV.

Repeat cycle every 3 weeks for 4-6 cycles.

Cisplatin + Ifosfamide24

Days 1-5: Cisplatin 20mg/m2 IV over 60 minutesd

Days 1-5: Ifosfamide 1,500mg/m2 IV over 30 minutesh

Days 1-5: Mesna 300mg/m2 IV over 15 minutes three times daily, one dose given once immediately prior to Ifosfamide and also 4 and 8 hours after each Ifosfamide dose.

Repeat cycle every 3 weeks for 8 cycles (if no prior radiation therapy).

OR

Days 1-5: Cisplatin 20mg/m2 IV over 60 minutesd

Days 1-5: Ifosfamide 1,200mg/m2 IV over 3 hoursh

Days 1-5: Mesna 240mg/m2 IV over 15 minutes three times daily, one dose given immediately prior to Ifosfamide and also 4 and 8 hours after each Ifosfamide dose.

Repeat cycle every 3 weeks for 8 cycles.

Paclitaxel + Ifosfamide (Category 2B)25

Day 1: Paclitaxel 135mg/m2 IV over 3 hours

Days 1-3: Ifosfamide 1,600mg/m2 IV over 3 hoursh

Days 1-3: Mesna 320mg/m2 IV over 15 minutes three times daily (one dose before Ifosfamide, then at 4 and 8 hours from the start of each Ifosfamide dose).

Repeat cycle every 3 weeks for 8 cycles.

Clear Cell Carcinoma

Stage I Disease

Carboplatin + Liposomal Doxorubicin2,3

Day 1: Carboplatin AUC 5 IV

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat every 4 weeks for 3-6 cycles.

Docetaxel + Carboplatin4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles (stage I) or 6 cycles if stage II-IV or high grade serous.

Paclitaxel + Carboplatin (preferred)3,7-9

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles.b

OR

Days 1,8,15: Paclitaxel 80mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Stage II-IV Disease

IP/IV Regimens

Paclitaxel + Cisplatin10

Day 1: Paclitaxel 135mg/m2 IV over 3 hours or IV continuous infusion over 24 hours

Day 2: Cisplatin 75-100mg/m2 IP infused as rapidly as possible via IP portd

Day 8: Paclitaxel 60mg/m2 IP infused as rapidly as possible via IP port.c

Repeat cycle every 3 weeks for 6 cycles.

IV Regimens

Carboplatin + Liposomal Doxorubicin2,3

Day 1: Carboplatin AUC 5 IV

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat every 4 weeks for 6 cycles.

Docetaxel + Carboplatin4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles (stage I) or 6 cycles if stage II-IV or high grade serous.

Paclitaxel + Carboplatin3,7-9

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Days 1,8,15: Paclitaxel 80mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Paclitaxel + Carboplatin + Bevacizumab12-14,f

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes

Day 1: Bevacizumab 7.5mg/kg IV.

Repeat cycle every 3 weeks for 5-6 cycles and continue maintenance bevacizumab for up to 12 additional cycles.

OR

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 6 IV over 1 hour.

Repeat cycle every 3 weeks for 6 cycles.

Starting Day 1 of cycle 2: Bevacizumab 15mg/kg IV over 30-90 minutes every 3 weeks for up to 22 cycles.

Mucinous Tumors

Stage IC Disease

Capecitabine + Oxaliplatin26

Day 1: Oxaliplatin 130mg/m2 IV over 2 hours

Days 1-14: Capecitabine 850mg/m2 orally twice daily.

Repeat cycle every 3 weeks for 6 cycles.

Carboplatin + Liposomal Doxorubicin2,3

Day 1: Carboplatin AUC 5 IV

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat every 4 weeks for 3-6 cycles for stage I disease or 6 cycles for stage II-IV disease or high-grade stage I disease.

Docetaxel + Carboplatin4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles (stage I) or 6 cycles if stage II-IV or high grade serous.

Fluorouracil + Leucovorin + Oxaliplatin27,28

Day 1: Oxaliplatin 85mg/m2 IV over 2 hours, with:

Day 1: Leucovorin 400mg/m2 IV over 2 hours, followed by:

Days 1: Fluorouracil 400mg/m2 IV push

Days 1-2: Fluorouracil 1,200mg/m2 IV as a continuous infusion over 24 hours.

Repeat cycle every 2 weeks.

Paclitaxel + Carboplatin (preferred)3,7-9

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles.b

OR

Days 1,8,15: Paclitaxel 80mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Stage II-IV Disease

IP/IV Regimens

Paclitaxel + Cisplatin10

Day 1: Paclitaxel 135mg/m2 IV over 3 hours or IV continuous infusion over 24 hours

Day 2: Cisplatin 75-100mg/m2 IP infused as rapidly as possible via IP portd

Day 8: Paclitaxel 60mg/m2 IP infused as rapidly as possible via IP port.e

Repeat cycle every 3 weeks for 6 cycles.

IV Regimens

Capecitabine + Oxaliplatin26

Day 1: Oxaliplatin 130mg/m2 IV over 2 hours

Days 1-14: Capecitabine 850mg/m2 orally twice daily.

Repeat cycle every 3 weeks for 6 cycles.

Capecitabine + Oxaliplatin + Bevacizumab (Category 2B)26,f

Day 1: Oxaliplatin 130mg/m2 IV over 2 hours

Days 1-14: Capecitabine 850mg/m2 orally twice daily

Day 1: Bevacizumab 15mg/kg IV.

Repeat cycle every 3 weeks for 6 cycles, followed by:

Day 1: Bevacizumab 15mg/m2 IV.

Repeat cycle every 3 weeks for 12 cycles.

Carboplatin + Liposomal Doxorubicin2,3

Day 1: Carboplatin AUC 5 IV

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat every 4 weeks for 3-6 cycles for stage I disease or 6 cycles for stage II-IV disease or high-grade stage I disease.

Docetaxel + Carboplatin4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles (stage I) or 6 cycles if stage II-IV or high grade serous.

Paclitaxel + Carboplatin3,7-9

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Days 1,8,15: Paclitaxel 80mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Paclitaxel + Carboplatin + Bevacizumab12-14,f

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes

Day 1: Bevacizumab 7.5mg/kg IV.

Repeat cycle every 3 weeks for 5-6 cycles and continue maintenance bevacizumab for up to 12 additional cycles.

OR

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 6 IV over 1 hour.

Repeat cycle every 3 weeks for 6 cycles.

Starting Day 1 of cycle 2: Bevacizumab 15mg/kg IV over 30-90 minutes every 3 weeks for up to 22 cycles.

5-Fluorouracil + Leucovorin + Oxalplatin27,28

Day 1: Oxaliplatin 85mg/m2 IV over 2 hours, with:

Day 1: Leucovorin 400mg/m2 IV over 2 hours, followed by:

Days 1: Fluorouracil 400mg/m2 IV push

Days 1-2: Fluorouracil 1,200mg/m2 IV as a continuous infusion over 24 hours.

Repeat cycle every 2 weeks.

5-Fluorouracil + Leucovorin + Oxaliplatin + Bevacizumab (Category 2B)29,30,f

Day 1: Oxaliplatin 85mg/m2 IV over 2 hours, with:

Day 1: Leucovorin 400mg/m2 IV over 2 hours, followed by:

Days 1: Fluorouracil 400mg/m2 IV push, followed by:

Days 1-2: Fluorouracil 1,200mg/m2 IV continuous infusion daily.

Day 1: Bevacizumab 5mg/kg IV.

Repeat cycle every 2 weeks for 6 cycles.

Low-Grade Serous or Grade 1 Endometrioid Epithelial Carcinoma

Cytotoxic Therapy

Stage IC Disease

Carboplatin + Liposomal Doxorubicin2,3

Day 1: Carboplatin AUC 5 IV

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat every 4 weeks for 3-6 cycles for stage I disease or 6 cycles for stage II-IV disease or high-grade stage I disease.

Docetaxel + Carboplatin4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles.

Paclitaxel + Carboplatin (preferred)3,7-9

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles.b

OR

Days 1,8,15: Paclitaxel 80mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Stage II-IV Disease

IP/IV Regimens

Paclitaxel + Cisplatin10

Day 1: Paclitaxel 135mg/m2 IV over 3 hours or IV continuous infusion over 24 hours

Day 2: Cisplatin 75-100mg/m2 IP infused as rapidly as possible via IP portd

Day 8: Paclitaxel 60mg/m2 IP infused as rapidly as possible via IP port.e

Repeat cycle every 3 weeks for 6 cycles.

IV Regimens

Docetaxel + Carboplatin4-6

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 3-6 cycles (stage I) or 6 cycles if stage II-IV or high grade serous.

Paclitaxel + Carboplatin3,7-9

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Days 1,8,15: Paclitaxel 80mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Paclitaxel + Carboplatin + Bevacizumab12-14,f

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes

Day 1: Bevacizumab 7.5mg/kg IV.

Repeat cycle every 3 weeks for 5-6 cycles and continue maintenance bevacizumab for up to 12 additional cycles.

OR

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 6 IV over 1 hour.

Repeat cycle every 3 weeks for 6 cycles.

Starting Day 1 of cycle 2: Bevacizumab 15mg/kg IV over 30-90 minutes every 3 weeks for up to 22 cycles.

Hormonal Therapy Stage IC-IV (Category 2B)

Anastrozole (Category 2B)31-34

Days 1-28: Anastrozole 1mg orally daily.

Repeat cycle every 4 weeks for 5 years or until disease progression or unacceptable toxicity.

Exemestane (Category 2B)35-37

Days 1-28: Exemestane 25mg orally daily after a meal.

Repeat cycle every 4 weeks.

Letrozole (Category 2B)36,38,39

Days 1-28: Letrozole 2.5mg orally daily.

Repeat cycle every 4 weeks.

Leuprolide Acetate (Category 2B)40,41

Day 1: Leuprolide 3.75mg IM.

Repeat cycle every 4 weeks.

OR

Day 1: Leuprolide 11.25mg IM.

Repeat cycle every 3 months.

Tamoxifen (Category 2B)42-43

Days 1-28: Tamoxifen 20mg orally twice daily.

Repeat cycle every 4 weeks.

Malignant Germ Cell Tumors

BEP (Bleomycin + Etoposide + Cisplatin)44,i

Days 1-5: Cisplatin 20mg/m2 IV over 60 minutesd

Days 1-5: Etoposide 100mg/m2 IV over 60 minutes

Days 1,8,15: Bleomycin 30 units IV over 10 minutes.

Repeat cycle every 3 weeks for 3-4 cycles.

Etoposide + Carboplatin (for patients with stage IB-III resected dysgerminoma for whom minimizing toxicity is critical)45

Day 1: Carboplatin 400mg/m2 IV over 30 minutes

Days 1-3: Etoposide 120mg/m2 IV over 60 minutes.

Repeat cycle every 4 weeks for 3 cycles.

Malignant Sex Cord-Stromal Tumors

BEP (Bleomycin + Etoposide + Cisplatin)46

Days 1-5: Cisplatin 20mg/m2 IV over 60 minutesd

Days 1-5: Etoposide 100mg/m2 IV over 60 minutes

Days 1,8,15: Bleomycin 30 units IV over 10 minutes.

Repeat cycle every 3 weeks for 3-4 cycles.

Paclitaxel + Carboplatin (Category 2B)47,48

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

▶Systemic Therapy for Recurrent Platinum-Sensitive Epithelial Ovarian (Including Less Common Ovarian Histopathologies)/Fallopian Tube/Primary Peritoneal Cancer1

Preferred Regimens

Cytotoxic Therapy

Carboplatin + Gemcitabine21

Days 1,8: Gemcitabine 800-1,000mg/m2 IV over 30 minutes, followed by:

Day 1: Carboplatin AUC 4 IV over 30 minutes.

Repeat cycle every 3 weeks.

Carboplatin + Gemicitabine + Bevacizumab11,49,f,j

Days 1,8: Gemcitabine 1,000mg/m2 IV over 30 minutes

Day 1: Carboplatin AUC 4 IV over 30 minutes

Day 1: Bevacizumab 15mg/kg IV.

Repeat cycle every 3 weeks for 6-10 cycles, followed by:

Day 1: Bevacizumab 15mg/kg IV.

Repeat cycle every 3 weeks.

Carboplatin + Liposomal Doxorubicin2,3

Day 1: Carboplatin AUC 5 IV over 30 minutes

Day 1: Liposomal Doxorubicin 30mg/m2 IV.

Repeat cycle every 4 weeks.

Carboplatin + Liposomal Doxorubicin + Bevacizumab2,11,50,f

Day 1: Liposomal Doxorubicin 30mg/m2 IV

Day 1: Carboplatin AUC 5 IV over 30 minutes

Days 1,15: Bevacizumab 10mg/kg IV.

Repeat cycle every 4 weeks.

Carboplatin + Paclitaxel3,7-9

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.b

OR

Days 1,8,15: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle every 3 weeks for 6 cycles.

OR

Day 1: Paclitaxel 60mg/m2 IV over 1 hour, followed by:

Day 1: Carboplatin AUC 2 IV over 30 minutes.

Repeat cycle weekly for 18 weeks.c

Carboplatin + Paclitaxel + Bevacizumab11-14,f,j

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes

Day 1: Bevacizumab 7.5mg/kg IV.

Repeat cycle every 3 weeks for 5-6 cycles and continue maintenance bevacizumab for up to 12 additional cycles.

OR

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 6 IV over 1 hour.

Repeat cycle every 3 weeks for 6 cycles.

Starting Day 1 of cycle 2: Bevacizumab 15mg/kg IV over 30-90 minutes every 3 weeks for up to 22 cycles.

Cisplatin + Gemicitabine51,52

Days 1,8: Gemcitabine 600-750mg/m2 IV over 30 minutes

Days 1,8: Cisplatin 30mg/m2 IV over 60 minutes.

Repeat cycle every 3 weeks.

Targeted Therapy (Single Agents)

Bevacizumab53-54,f

Day 1: Bevacizumab 15mg/kg IV.

Repeat cycle every 3 weeks.

Niraparib55,56,k

Days 1-28: Niraparib 300mg orally daily.

Repeat cycle every 4 weeks.

Olaparib17,57,l

Days 1-28: Olaparib 300mg (tablet formulation) twice daily.

Repeat cycle every 4 weeks.

Rucaparib58-60,n

Days 1-28: Rucaparib 600mg orally twice daily.

Repeat cycle every 4 weeks.

Other Recommended Regimens

Cytotoxic Therapy

Albumin-Bound Paclitaxel61

Day 1: Albumin-Bound Paclitaxel 260mg/m2 IV over 30 minutes.

Repeat cycle every 3 weeks.

Carboplatin + Docetaxel4-6,62

Day 1: Docetaxel 60-75mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5-6 IV over 30 minutes.

Repeat cycle every 3 weeks.

Carboplatin + Paclitaxel (weekly)8

Days 1,8,15: Paclitaxel 80mg/m2 IV over 60 minutes, followed by:

Day 1: Carboplatin AUC 5 IV over 30 minutes.

Repeat every 3 weeks for 6 cycles.

Capecitabine63

Days 1-14: Capcitabine 1,000mg/m2 orally twice daily.

Repeat cycle every 3 weeks.

Carboplatin20,21

Day 1: Carboplatin AUC 5 IV over 30 minutes.

Repeat cycle every 3 weeks.

Cisplatin64

Day 1: Cisplatin 75mg/m2 IV over 60 minutes.d

Repeat cycle every 3 weeks.

Cyclophosphamide65

Day 1: Cyclophoshamide 750mg/m2 IV over 60 minutes.

Repeat cycle every 3 weeks.

Doxorubicin66,67

Day 1: Doxorubicin 60mg/m2 IV push.

Repeat cycle every 3 weeks.

Ifosfamide68

Days 1-5: Mesna 200-240mg/m2 IV over 15 minutes three times daily, one dose before Ifosfamide, then at 4 and 8 hours from the start of each Ifosfamide dose

Days 1-5: Ifosfamide 1,000-1,200mg/m2 IV over 3 hours.h

Repeat cycle every 4 weeks.

Irinotecan69

Days 1,8,15: Irinotecan 100mg/m2 IV over 30-90 minutes.

Repeat cycle every 4 weeks.

Melphalan70

Days 1-5: Melphalan 3.5mg/m2 orally twice daily.

Repeat cycle every 4 weeks.

Oxaliplatin71

Day 1: Oxaliplatin 130mg/m2 IV over 2 hours.

Repeat cycle every 3 weeks.

Paclitaxel64,72

Day 1: Paclitaxel 175mg/m2 IV over 3 hours.

Repeat cycle every 3 weeks.

OR

Days 1,8,15,22: Paclitaxel 80mg/m2 (Max BSA = 2m2) IV over 60 minutes.

Repeat cycle every 4 weeks for 3 cycles, followed by:

Days 1,8,15: Paclitaxel 80mg/m2 (Max BSA = 2m2) over 60 minutes beginning with cycle 4.

Repeat cycle every 4 weeks.

Pemetrexed73,74

Day 1: Pemetrexed 500-900mg/m2 IV over 10 minutes.

Repeat cycle every 3 weeks.

Vinorelbine75

Days 1,8: Vinorelbine 30mg/m2 IV over 5-10 minutes.

Repeat cycle every 3 weeks.

Targeted Therapy

Pazopanib (Category 2B)76,77

Days 1-28: Pazopanib 800mg orally once daily.

Repeat cycle every 4 weeks.

Niraparib + Bevacizumab56,78,f

Days 1-28: Niraparib 300mg orally once daily.

Repeat cycle every 4 weeks, with:

Day 1: Bevacizumab 15mg/kg IV.

Repeat cycle every 3 weeks.

Hormonal Therapy

Anastrozole31-34

Days 1-28: Anastrozole 1mg orally daily.

Repeat cycle every 4 weeks for 5 years or until disease progression or unacceptable toxicity.

Exemestane35-37

Days 1-28: Exemestane 25mg orally daily after a meal.

Repeat cycle every 4 weeks.

Letrozole36,38,39

Days 1-28: Letrozole 2.5mg orally daily.

Repeat cycle every 4 weeks.

Leuprolide Acetate40,41

Day 1: Leuprolide 3.75mg IM.

Repeat cycle every 4 weeks.

OR

Day 1: Leuprolide 11.25mg IM.

Repeat cycle every 3 months.

Megestrol Acetate79,80

See NCCN Ovarian Cancer Guidelines.1

Tamoxifen42,43

Days 1-28: Tamoxifen 20mg orally twice daily.

Repeat cycle every 4 weeks.

Useful in Certain Circumstances

Cytotoxic Therapy for Mucinous Carcinoma

Capecitabine + Oxaliplatin26

Day 1: Oxaliplatin 130mg/m2 IV over 2 hours

Days 1-14: Capecitabine 850mg/m2 orally twice daily.

Repeat cycle every 3 weeks.

Capecitabine + Oxaliplatin + Bevacizumab (Category 2B)26,f

Day 1: Oxaliplatin 130mg/m2 IV over 2 hours

Days 1-14: Capecitabine 850mg/m2 orally twice daily.

Day 1: Bevacizumab 15mg/kg IV.

Repeat cycle every 3 weeks for 6 cycles, followed by:

Day 1: Bevacizumab 15mg/kg IV for 12 cycles

Fluorouracil + Leucovorin + Oxaliplatin27,28

Day 1: Oxaliplatin 85mg/m2 IV over 2 hours, with:

Day 1: Leucovorin 400mg/m2 IV over 2 hours, followed by:

Days 1: Fluorouracil 400mg/m2 IV push

Days 1-2: Fluorouracil 1,200mg/m2 IV as a continuous infusion over 24 hours.

Repeat cycle every 2 weeks.

Fluorouracil + Leucovorin + Oxaliplatin + Bevacizumab (Category 2B)29,30,f

Day 1: Oxaliplatin 85mg/m2 IV over 2 hours, with:

Day 1: Leucovorin 400mg/m2 IV over 2 hours, followed by:

Days 1: Fluorouracil 400mg/m2 IV push, followed by:

Days 1-2: Fluorouracil 1,200mg/m2 IV continuous infusion daily.

Day 1: Bevacizumab 5mg/kg IV.

Repeat cycle every 2 weeks.

Carboplatin + Albumin-Bound Paclitaxel (for confirmed hypersensitivity)61,81

Days 1,8,15: Albumin-Bound Paclitaxel 100mg/m2 IV over 30 minutes

Day 1: Carboplatin AUC 5 IV over 30 minutes.

Repeat cycle every 4 weeks.

Cytotoxic Therapy for Patients Aged >70 Years

Carboplatin + Paclitaxel20,22

Day 1: Paclitaxel 135mg/m2 IV

Day 1: Carboplatin AUC 5 IV.

Repeat cycle every 3 weeks.

Cytotoxic Therapy for Clear Cell Carcinoma

Irinotecan + Cisplatin82

Days 1,8,15: Irinotecan 60mg/m2 IV over 90 minutes

Day 1: Cisplatin 60mg/m2 IV over 1 hour.d

Repeat cycle every 4 weeks.

Hormone Therapy for Low-Grade Serous Carcinoma”

Fulvestrant83,84

Day 1 (Cycle 1): Fulvestant 500mg IM

Day 15 (Cycle 1): Fulvestant 250mg IM.

Administer for one 4-week cycle, followed by:

Day 1 (Cycle 2 and beyond): Fulvestrant 250mg IM.

Repeat cycle every 4 weeks.

Immunotherapy

Pembrolizumab (for MSI-H or dMMR solid tumors)85-87

Day 1: Pembrolizumab 200mg IV over 30 minutes.

Repeat cycle every 3 weeks.

Targeted Therapy (single agents)

Entrectinib (for NTRK gene-fusion positive tumors)88-91

Days 1-28: Entrectinib 600mg orally once daily.

Repeat cycle every 4 weeks.

Larotrectinib (for NTRK gene-fusion positive tumors)92,93

Days 1-28: Larotrectinib 100mg orally twice daily.

Repeat cycle every 4 weeks.

Trametinib (for low-grade serous carcinoma)94,95

Days 1-28: Trametinib 2mg orally once daily.

Repeat cycle every 4 weeks

▶Systemic Therapy for Recurrent Platinum-Resistant Epithelial Ovarian (Including Less Common Ovarian Histopathologies)/Fallopian Tube/Primary Peritoneal Cancer1

Preferred Regimens

Cytotoxic Therapy

Cyclophosphamide (oral) + Bevacizumab11,96,f

Days 1: Bevacizumab 10mg/kg IV.

Repeat cycle every 2 weeks, with:

Days 1-28: Cyclophosphamide 50mg orally daily.

Repeat cycle every 4 weeks.

Docetaxel97

Day 1: Docetaxel 100mg/m2 IV over 60 minutes.

Repeat cycle every 3 weeks.

Etoposide (oral)98

Days 1-21: Etoposide 50mg/m2 orally daily (titrated as patient tolerates to a maximum of 60mg/m2 orally daily).

Repeat cycle every 4 weeks.

OR

Days 1-21: Etoposide 30mg/m2 orally (titrated as patient tolerates to a maximum of 60mg/m2 orally daily).

Repeat cycle every 4 weeks.

Gemcitabine99,100

Days 1,8,15: Gemcitabine 1000mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks.

OR

Days 1,8: Gemcitabine 1,000mg/m2 over 30 minutes.

Repeat cycle every 3 weeks.

Liposomal Doxorubicin99,100

Day 1: Liposomal Doxorubicin 40-50mg/m2 IV.

Repeat cycle every 4 weeks.

Liposomal Doxorubicin + Bevacizumab101,f

Day 1: Liposomal Doxorubicin 40mg/m2 IV.

Days 1,15: Bevacizumab 10mg/kg IV.

Repeat cycle every 4 weeks.

Paclitaxel (weekly)72

Days 1,8,15,22: Paclitaxel 80mg/m2 (Max BSA=2m2) IV over 60 minutes.

Repeat every 4 weeks for cycles 1-3, followed by:

Days 1,8,15: Paclitaxel 80mg/m2 (Max BSA=2m2) IV over 60 minutes.

Repeat every 4 weeks beginning with cycle 4.

Paclitaxel (weekly) + Bevacizumab11,101,f

Days 1,8,15,22: Paclitaxel 80mg/m2 IV over 60 minutes.

Days 1,15: Bevacizumab 10mg/kg IV.

Repeat cycle every 4 weeks.

Topotecan102,103

Days 1-5: Topotecan 1.5mg/m2 IV over 30 minutes.

Repeat cycle every 3 weeks.

OR

Days 1,8,15: Topotecan 3-4mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks.

Topotecan + Bevacizumab11,101,f

Days 1,8,15: Topotecan 4mg/m2 IV over 30 minutes

Days 1,15: Bevacizumab 10mg/kg IV.

Repeat cycle every 4 weeks.

Targeted Therapy (Single Agents)

Bevacizumab53-54,f

Day 1: Bevacizumab 15mg/kg IV.

Repeat cycle every 3 weeks.

Niraparib55,56,k

Days 1-28: Niraparib 300mg orally daily.

Repeat cycle every 4 weeks.

Olaparib17,57,l

Days 1-28: Olaparib 300mg (tablet formulation) twice daily.

Repeat cycle every 4 weeks.

Rucaparib58-60,m

Days 1-28: Rucaparib 600mg orally twice daily.

Repeat cycle every 4 weeks.

Other Recommended Regimens

Cytotoxic Therapy

Albumin-Bound Paclitaxel61

Day 1: Albumin-Bound Paclitaxel 260mg/m2 IV over 30 minutes.

Repeat cycle every 3 weeks.

Capecitabine63

Days 1-14: Capecitabine 1000mg/m2 orally twice daily.

Repeat cycle every 3 weeks.

Cyclophosphamide65

Day 1: Cyclophoshamide 750mg/m2 IV over 60 minutes.

Repeat cycle every 3 weeks.

Doxorubicin66,67

Day 1: Doxorubicin 60mg/m2 IV push.

Repeat cycle every 3 weeks.

Ifosfamide68

Days 1-5: Mesna 200-240mg/m2 IV over 15 minutes three times daily, one dose before Ifosfamide, then at 4 and 8 hours from the start of each Ifosfamide dose

Days 1-5: Ifosfamide 1,000-1,200mg/m2 IV over 3 hours.h

Repeat cycle every 4 weeks.

Irinotecan69

Days 1,8,15: Irinotecan 100mg/m2 IV over 30-90 minutes.

Repeat cycle every 4 weeks.

Melphalan70

Days 1-5: Melphalan 3.5mg/m2 orally twice daily.

Repeat cycle every 4 weeks.

Oxaliplatin71

Day 1: Oxaliplatin 130mg/m2 IV over 2 hours.

Repeat cycle every 3 weeks.

Paclitaxel64,72

Day 1: Paclitaxel 175mg/m2 IV over 3 hours.

Repeat cycle every 3 weeks.

OR

Days 1,8,15,22: Paclitaxel 80mg/m2 (Max BSA = 2m2) IV over 60 minutes for cycles 1-3, followed by:

Days 1,8,15: Paclitaxel 80mg/m2 (Max BSA =2m2) IV over 60 minutes beginning with cycle 4.

Repeat cycle every 4 weeks.

Pemetrexed73,74

Day 1: Pemetrexed 500-900mg/m2 IV over 10 minutes.

Repeat cycle every 3 weeks.

Sorafenib + Topotecan104,105

Days 1-5: Topotecan 1.25mg/m2 IV over 30 minutes

Days 6-15: Sorafenib 400mg twice daily.

Repeat cycle every 3 weeks for 6 cycles, followed by:

Days 1-28: Sorafenib 400mg twice daily.

Repeat cycle every 4 weeks.

Vinorelbine75

Days 1,8: Vinorelbine 30mg/m2 IV over 5-10 minutes.

Repeat cycle every 3 weeks.

Hormonal Therapy

Anastrozole31-34

Days 1-28: Anastrozole 1mg orally daily.

Repeat cycle every 4 weeks for 5 years or until disease progression or unacceptable toxicity.

Exemestane35-37

Days 1-28: Exemestane 25mg orally daily after a meal.

Repeat cycle every 4 weeks.

Letrozole36,38,39

Days 1-28: Letrozole 2.5mg orally daily.

Repeat cycle every 4 weeks.

Leuprolide Acetate40,41

Day 1: Leuprolide 3.75mg IM.

Repeat cycle every 4 weeks.

OR

Day 1: Leuprolide 11.25mg IM.

Repeat cycle every 3 months.

Megestrol Acetate79,80

See NCCN Ovarian Cancer Guidelines.1

Tamoxifen42,43

Days 1-28: Tamoxifen 20mg orally twice daily.

Repeat cycle every 4 weeks.

Targeted Therapy (Single Agents)

Pazopanib (Category 2B)76,77

Day 1-28: Pazopanib 800mg orally once daily.

Repeat cycle every 4 weeks.

Useful in Certain Circumstances

Hormonal Therapy

Fulvestrant (for low-grade serous carcinoma)83,84

Day 1 (Cycle 1): Fulvestant 500mg IM

Day 15 (Cycle 1): Fulvestant 250mg IM.

Administer for one 4-week cycle, followed by:

Day 1 (Cycle 2 and beyond): Fulvestrant 250mg IM.

Repeat cycle every 4 weeks.

Immunotherapy

Pembrolizumab (for MSI-H or dMMR solid tumors)86,87

Day 1: Pembrolizumab 200mg IV over 30 minutes.

Repeat cycle every 3 weeks.

Targeted Therapy (single agents)

Entrectinib (for NTRK gene-fusion positive tumors)88-91

Days 1-28: Entrectinib 600mg orally once daily.

Repeat cycle every 4 weeks.

Larotrectinib (for NTRK gene-fusion positive tumors)92,93

Days 1-28: Larotrectinib 100mg orally twice daily.

Repeat cycle every 4 weeks.

Trametinib (for low-grade serous carcinoma)94,95

Days 1-28: Trametinib 2mg orally daily.

Repeat cycle every 4 weeks.

▶Systemic Therapy for Recurrent Malignant Germ Cell Tumors1

Potentially Curative Cytotoxic Therapy

High-dose chemotherapyn

See NCCN Ovarian Cancer Guidelines.1

TIP (Paclitaxel + Ifosfamide + Cisplatin)106

Day 1: Paclitaxel 250mg/m2 IV continuous infusion over 24 hours

Days 2-5: Ifosfamide 1,500mg/m2 IV over 3 hoursh

Days 2-5: Mesna 300mg/m2 IV over 15 minutes three times daily, one dose before Ifosfamide, then at 4 and 8 hours from the start of each Ifosfamide dose

Days 2-5: Cisplatin 25mg/m2 IV over 60 minutes.d

Repeat cycle every 3 weeks.

Palliative Cytotoxic Therapy

Cisplatin + Etoposide107

Days 1-5: Cisplatin 20mg/m2 IV over 60 minutes

Days 1-5: Etoposide 100mg/m2 IV over 60 minutes.

Repeat cycle every 3 weeks.

Docetaxel108

Day 1: Docetaxel 75mg/m2 IV over 60 minutes.

Repeat cycle every 3 weeks.

Docetaxel + Carboplatin108

Day 1: Docetaxel 75mg/m2 over 60 minutes, followed by:

Day 1: Carboplatin AUC 5 IV over 30 minutes.

Repeat cycle every 3 weeks.

Paclitaxel109

Day 1: Paclitaxel 175-225mg/m2 IV over 3 hours.

Repeat cycle every 3 weeks.

Paclitaxel + Carboplatin64

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5 IV over 30 minutes.

Repeat cycle every 3 weeks.

Paclitaxel + Gemcitabine110

Days 1,8,15: Paclitaxel 110mg/m2 IV over 3 hours, followed by:

Days 1,8,15: Gemcitabine 1,000mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks.

Paclitaxel + Ifosfamide106

Day 1: Paclitaxel 250mg/m2 IV continuous infusion over 24 hours

Days 2-5: Ifosfamide 1,500mg/m2 IV over 3 hours dailyh

Days 2-5: Mesna 300mg/m2 IV over 15 minutes three times daily, one dose before Ifosfamide, then at 4 and 8 hours from the start of each Ifosfamide dose

Repeat cycle every 3 weeks.

TIP (Paclitaxel + Ifosfamide + Cisplatin)106

Day 1: Paclitaxel 250mg/m2 IV continuous infusion over 24 hours

Days 2-5: Ifosfamide 1,500mg/m2 IV over 3 hoursh

Days 2-5: Mesna 300mg/m2 IV over 15 minutes three times daily, one dose before ifosfamide, then at 4 and 8 hours from the start of each Ifosfamide dose

Days 2-5: Cisplatin 25mg/m2 IV over 60 minutes.d

Repeat cycle every 3 weeks.

VAC (Vincristine + Dactinomycin + Cyclophosphanide)111

Days 1,8,15,22: Vincristine 1.5mg/m2 (maximum 2mg) IV over 5-10 minutes

Days 1-5: Dactinomycin 300mcg/m2 IV push

Days 1-5: Cyclophosphamide 150mg/m2 IV over 60 minutes.

Repeat cycle every 4 weeks.

VeIP (Vinblastine + Ifosfamide + Cisplatin)112

Days 1-2: Vinblastine 0.11mg/kg IV over 5-10 minutes

Days 1-5: Ifosfamide 1,200mg/m2 IV over 3 hoursh

Days 1-5: Mesna 240mg/m2 IV over 15 minutes three times daily, one dose before Ifosfamide, then at 4 and 8 hours from the start of each Ifosfamide dose

Days 1-5: Cisplatin 20mg/m2 IV over 60 minutes.d

Repeat cycle every 3 weeks.

VIP (Etoposide + Ifosfamide + Cisplatin)113,114

Days 1-5: Etoposide 75mg/m2 IV over 60 minutes

Days 1-5: Ifosfamide 1,200mg/m2 IV over 3 hoursh

Days 1-5: Mesna 240mg/m2 IV over 15 minutes three time daily, one dose before Ifosfamide, then at 4 and 8 hours from the start of each Ifosfamide dose

Days 1-5: Cisplatin 20mg/m2 IV over 60 minutes.d

Repeat cycle every 3 weeks.

▶Systemic Therapy for Recurrent Malignant Sex Cord-Stromal Tumors1

Cytotoxic Therapy

Docetaxel108

Day 1: Docetaxel 75mg/m2 IV over 60 minutes.

Repeat cycle every 3 weeks.

Paclitaxel47,115

Day 1: Paclitaxel 135-175mg/m2 IV over 3 hours.

Repeat cycle every 3 weeks.

Paclitaxel + Carboplatin47,48

Day 1: Paclitaxel 175mg/m2 IV over 3 hours, followed by:

Day 1: Carboplatin AUC 5 IV over 30 minutes.

Repeat cycle every 3 weeks.

Paclitaxel + Ifosfamide116

Day 1: Paclitaxel 135mg/m2 IV continuous infusion over 3 hours

Days 1-3: Ifosfamide 1,600mg/m2 IV over 3 hoursh

Days 2-5: Mesna 320mg/m2 IV over 15 minutes three times daily, one dose before Ifosfamide, then at 4 and 8 hours from the start of each Ifosfamide dose

Repeat cycle every 3 weeks.

VAC (Vincristine + Dactinomycin + Cyclophosphanide)111

Days 1,8,15,22: Vincristine 1.5mg/m2 (maximum 2mg) over 5-10 minutes

Days 1-5: Dactinomycin 300mg/m2 IV push daily

Days 1-5: Cyclophosphamide 150mg/m2 IV over 60 minutes.

Repeat cycle every 4 weeks.

Hormonal Therapy

Anastrozole31-34

Days 1-28: Anastrozole 1mg orally daily.

Repeat cycle every 4 weeks for 5 years or until disease progression or unacceptable toxicity.

Exemestane35-37

Days 1-28: Exemestane 25mg orally daily after a meal.

Repeat cycle every 4 weeks.

Letrozole36,38,39

Days 1-28: Letrozole 2.5mg orally daily.

Repeat cycle every 4 weeks.

Leuprolide Acetate (for granulosa cell tumors)117,118

Day 1: Leuprolide 7.5mg IM.

Repeat cycle every 4 weeks.

OR

Day 1: Leuprolide 22.5mg IM.

Repeat cycle every 84 days.

Tamoxifen42,43

Days 1-28: Tamoxifen 20mg orally twice daily.

Repeat cycle every 4 weeks.

Targeted Therapy

Bevacizumab (single agent)11,119,120,f

Day 1: Bevacizumab 15mg/kg IV.

Repeat cycle every 3 weeks.

 a.  Any of the primary IV regimens for stage II-IV disease can be used as neoadjuvant therapy before interval debulking surgery for confirmed poor surgical candidate or low likelihood of optimal cytoreduction. After neoadjuvant therapy and interval debulking any of the primary IV or IV/IP options can be considered as adjuvant therapy. A minimum of 6 cycles of treatment is recommended, including at least 3 cycles of adjuvant therapy after interval debulking surgery.

 b.  6 cycles for stage I high-grade serous disease; 3-6 cycles for all other histologies.

 c.  Regimen may be considered for those with poor performance status.

 d.  Hydration is required with supplemental electrolytes pre- and post-administration of Cisplatin.

 e.  The published randomized trial regimen used IV continuous infusion paclitaxel over 24 hours.

  f.  An FDA-approved biosimilar is an appropriate substitute for bevacizumab.

 g.  Chemotherapy as per epithelial ovarian cancer is preferred over other regimens.

 h.  Hydration is required pre- and postadministration of Ifosfamide.

  i.  3 cycles for good risk disease (Category 2B); 4 cycles for poor risk disease.

  j.  If response after chemotherapy, bevacizumab can be continued as maintenance therapy until disease progression or unacceptable toxicity. Discontinue bevacizumab before initiating maintenance therapy with a PARP inhibitor.

 k.  For patients treated with 3 or more prior chemotherapy regimens and whose cancer is associated with homologous recombination deficient (HRD)-positive status defined by either: (1) a deleterious or suspected deleterious BRCA mutation; or (2) genomic instability and progression >6months after response to the last platinum-based chemotherapy.

  l.  For patients with deleterious germline BRCA-mutated (as detected by an FDA-approved test or other validated test performed in a CLIA-approved facility) advanced ovarian cancer who have been treated with 3 or more lines of chemotherapy.

m. For patients with deleterious germline and/or somatic BRCA mutated (as detected by an FDA-approved test or other validated test performed in a CLIA-approved facility) advanced ovarian cancer who have been treated with two or more lines of chemotherapy.

 n. High-dose chemotherapy regimens vary among institutions.

References

   1.  Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology™. Ovarian Cancer v3.2019. https://nccn.org/professionals/physician_gls/pdf/ovarian.pdf. Accessed December 23, 2019.

   2.  Pujade-Lauraine E, Wagner U, et al. Pegylated liposomal doxorubicin and carboplatin compared with paclitaxel and carboplatin for patients with platinum-sensitive recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer in late relapse. J Clin Oncol. 2010;28:3322-3329.

   3.  Pignata S, Scambia G, Ferrandina G, et al. Carboplatin plus paclitaxel versus carboplatin plus pegylated liposomal doxorubicin as first-line treatment for patients with ovarian cancer: the MITO-2 randomized phase III trial. J Clin Oncol. 2011;29:3628-3635.

   4.  Vasey PA, Jayson GC, Gordon A, et al. Phase III randomized trial of docetaxel- carboplatin versus paclitaxel-carboplatin as first-line chemotherapy for ovarian carcinoma. J Natl Cancer Inst. 2004;96:1682-1691.

   5.  Markman M, Kennedy A, Webster K, et al. Combination chemotherapy with carboplatin and docetaxel in the treatment of cancers of the ovary and fallopian tube and primary carcinoma of the peritoneum. J Clin Oncol. 2001;19:1901-1905.

   6.  Strauss HG, Henze A, Teichmann A, et al. Phase II trial of docetaxel and carboplatin in recurrent platinum-sensitive ovarian, peritoneal and tubal cancer. Gynecol Oncol. 2007;104:612-616.

   7.  Ozols RF, Bundy BN, Greer BE, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. J Clin Oncol. 2003;21:3194-3200.

   8.  Katsumata N, Yasuda M, Takahashi F, et al. Dose-dense paclitaxel once a week in combination with carboplatin every 3 weeks for advanced ovarian cancer: a phase 3, open-label, randomised controlled trial. Lancet. 2009;374:1331-1338.

   9.  Pignata S, Scambia G, Katsaros D, et al. Carboplatin plus paclitaxel once a week versus every 3 weeks in patients with advanced ovarian cancer (MITO-7): a randomised, multicenter, open-label, phase 3 trial. Lancet Oncol. 2014;15:395-405.

 10.  Armstrong DK, Bundy B, Wenzel L, et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med. 2006;354:34-43.

 11.  Bevacizumab (Avastin) [package insert]. South San Francisco, CA: Genentech, Inc: 2019.

 12.  Perren TJ, Swart AM, Pfisterer J, et al. A phase 2 trial of bevacizumab in ovarian cancer. N Engl J Med. 2011;365:2484-2496.

 13.  Oza AM, Cook AD, Pfisterer J, et al. Standard chemotherapy with or without bevacizumab for women with newly diagnosed ovarian cancer (ICON7): overall survival results of a phase 3 randomised trial. Lancet Oncol. 2015;16:928-936.

 14.  Burger RA, Brady MF, Bookman MA, et al. Incorporation of bevacizumab in the primary treatment of ovarian cancer. N Engl J Med. 2011;365:2473-2483.

 15.  Van Driel WJ, Koole SN, Sikorska K, et al. Hyperthermic intraperiotoneal chemotherapy in ovarian cancer. N Engl J Med. 2018;378:230-240.

 16.  Marchetti C, Muzii L, Romito A, Benedetti Panici P. First-line treatment of women with advanced ovarian cancer: focus on bevacizumab. Onco Targets Ther. 2019;12:1095–1103.

 17.  Olaparib (Lynparza) [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP: 2019.

 18.  Moore K, Colombo N, Scambia G, et al. Maintenance olaparib in patients with newly diagnosed advanced ovarian cancer. N Engl J Med. 2018;27:2495-2505.

 19.  Pujade-Lauraine E, Ledermann JA, Selle F, et al. Olaparib tablets as maintenance therapy in patients with platinum-sensitive, relapsed ovarian cancer and a BRCA1/2 mutation ((SOLO2/ENGOT-Ov21): a double-blind, randomised, placebo- controlled, phase 2 trial. Lancet Oncol. 2017;18:1274-1284.

 20.  Von Gruenigen VE, Huang HQ, Beumer JH, et al. Chemotherapy completion in elderly women with ovarian, primary peritoneal or fallopian tube cancer — An NRG Oncology/Gynecologic Oncology Group study. Gynecol Oncol. 2017;144:459-467.

 21.  Pfisterer J, Plante M, Vergote I, et al. Gemcitabine plus carboplatin compared with carboplatin in patients with platinum-sensitive recurrent ovarian cancer: an intergroup trial of the AGO-OVAR, the NCIC CTG, and the EORTC GCG. J Clin Oncol. 2006;24:4699-4707.

 22.  Pignata S, Breda E, Scambia G, et al. A phase II study of weekly carboplatin and paclitaxel as first-line treatment of elderly patients with advanced ovarian cancer. A Multicentre Italian Trial in Ovarian cancer (MITO-5) study. Crit Rev Oncol Hematol. 2008;66:229-236.

 23.  Dandamudi RK, Aslam S, Walji N, et al. Chemotherapy for uterine carcinosarcoma with carboplatin, ifosfamide and mesna. Anticancer Res. 2015;35:4841-4847.

 24.  24.Sutton G, Brunetto VL, Kilgore L, et al. A phase III trial of ifosfamide with or without cisplatin in carcinosarcoma of the uterus: A Gynecologic Oncology Group Study. Gynecol Oncol. 2000;79:147-153.

 25.  Homesley HD, Filiaci V, Markman M,et al. Phase III trial of ifosfamide with or without paclitaxel in advanced uterine carcinosarcoma: a Gynecologic Oncology Group Study. J Clin Oncol. 2007;10;25:526-531.

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(Revised 2/2020; NCCN Ovarian Cancer Guidelines v3.2019) © 2020 by Haymarket Media, Inc.

This article originally appeared on Cancer Therapy Advisor