ASCO Publishes First Living Guideline for Systemic Treatment of Recurrent Ovarian Cancer

The American Society of Clinical Oncology (ASCO) has released its inaugural guideline on the systemic treatment of recurrent ovarian cancer. An ASCO Expert Panel voted to approve the document in June 2026, and it was published August 24, 2026, in the Journal of Clinical Oncology.¹

The guideline covers patients with recurrent epithelial ovarian cancer (EOC), primary peritoneal carcinoma, and fallopian tube carcinoma whose tumors are high-grade serous and/or endometrioid histology, and it is written for the full range of clinicians who manage this population, not gynecologic oncology specialists alone.

The recommendations rest on a systematic review of PubMed and Cochrane Library data covering randomized trials published between January 2004 and October 2024, later refreshed with a November 2025 search. Of 819 publications screened, 147 met eligibility criteria, and 36 directly shaped the final recommendations.

“This ASCO guideline on the management of recurrent ovarian cancer is designed to support standardized, evidence-based care across diverse clinical environments, with an emphasis on actionable implementation strategies. Recognizing the complexities involved in treating recurrent disease, the guideline encourages proactive integration of best practices into daily care,” the guideline authors wrote.¹

Regimens for Platinum-Sensitive Recurrence

For disease recurring more than 6 months after last platinum exposure, defined as platinum-sensitive, the panel endorses several platinum-based doublets with none preferred: pegylated liposomal doxorubicin (PLD) plus carboplatin, paclitaxel plus carboplatin, or gemcitabine plus carboplatin. Bevacizumab (Avastin) may be added to a platinum doublet followed by bevacizumab maintenance. Patients ineligible for platinum-based therapy should follow recommendations built for platinum-resistant disease.

Supporting trial data not detailed in ASCO's announcement include the Southwest Oncology Group's S0200 trial, in which PLD plus carboplatin produced a significant progression-free survival (PFS) gain over carboplatin alone before closing early with immature survival data.² A separate phase II study, GOTIC-003, found comparable PFS between PLD-carboplatin and gemcitabine-carboplatin.³ The phase III CALYPSO trial, comparing PLD-carboplatin with paclitaxel-carboplatin, found no significant PFS or overall survival (OS) difference.⁴

The bevacizumab recommendation is anchored by the OCEANS trial, in which adding bevacizumab to chemotherapy improved PFS (HR, 0.48; 95% CI, 0.39-0.61) without a significant OS gain (HR, 0.95; 95% CI, 0.77-1.18).⁵ In GOG-0213, bevacizumab improved PFS (HR, 0.82; P=.045) with an OS trend that fell short of significance (HR, 0.83; P =.056); a post hoc calculation error introduces some uncertainty into that OS estimate.⁶ A 2023 Cochrane review of angiogenesis inhibitors reinforced the PFS benefit (HR, 0.81; 95% CI, 0.74-0.89) without an OS advantage.⁷ Because bevacizumab carries added risk of hypertension, thromboembolism, and gastrointestinal perforation, the guideline calls for close monitoring.

Surgery and HIPEC Remain Unresolved

The panel found insufficient evidence to recommend for or against secondary cytoreductive surgery or hyperthermic intraperitoneal chemotherapy (HIPEC), citing conflicting trial results. The DESKTOP III trial found that surgery plus chemotherapy improved both PFS (HR, 0.66; 95% CI, 0.54-0.82) and OS (HR, 0.75; 95% CI, 0.59-0.96) versus chemotherapy alone, while the surgical arm of GOG-0213 showed no PFS benefit and a decrease in OS.^8,9 HIPEC data were similarly mixed: the CHIPOR trial found that adding HIPEC to maximal surgery improved 6-month PFS (HR, 0.79; 95% CI, 0.63-0.99) and OS (HR, 0.73; 95% CI, 0.56-0.96), while another trial found no PFS benefit and more deaths in the HIPEC arm.¹⁰ The panel attributes much of this discordance to patient selection, since women with isolated recurrences amenable to complete resection appear most likely to benefit.

Sequencing Platinum-Resistant Disease

For recurrence within 6 months of last platinum exposure, or platinum-refractory progression, the guideline favors non-platinum, biomarker-informed agents used sequentially. Mirvetuximab soravtansine, an antibody-drug conjugate targeting folate receptor alpha (FRα), receives the guideline's strongest recommendation, limited to high-grade tumors with validated FRα positivity by immunohistochemistry (at least 75% of cells with 2+ or 3+ staining). That recommendation rests on the phase III MIRASOL trial, in which the agent improved both PFS (HR, 0.72; 95% CI, 0.56-0.92) and OS (HR, 0.67; 95% CI, 0.50-0.89) versus chemotherapy in FRα-high patients, building on an earlier trial, FORWARD I, whose FRα-high subgroup had shown a similar signal without reaching the primary endpoint in its full population.^11,12

Additional options include PLD monotherapy, paclitaxel, bevacizumab plus chemotherapy, and relacorilant plus nab-paclitaxel, with gemcitabine as a conditional alternative. The phase III ROSELLA trial supports relacorilant plus nab-paclitaxel, which improved PFS (HR, 0.70; 95% CI, 0.54-0.91) and, later, OS (HR, 0.65; 95% CI, 0.51-0.83) versus nab-paclitaxel alone.¹³ Bevacizumab's role rests on the AURELIA trial, which showed a PFS benefit (HR, 0.82; 95% CI, 0.72-0.94) without a significant OS gain.¹⁴

Surveillance Without a Preferred Protocol

The guideline recommends case-by-case post-treatment monitoring and specialty survivorship care but does not endorse one surveillance strategy, since comparative evidence is lacking. A landmark trial of biochemical (CA-125) monitoring found no OS benefit to treating recurrence early based on rising marker levels, with some negative effects on quality of life.¹⁵ A smaller trial of individualized nurse-led follow-up found a significant quality-of-life benefit over conventional follow-up, though that evidence remains low-certainty.¹⁶

Built to Evolve

The document flags areas likely to be revisited soon, including a pending PARP inhibitor guideline update and pembrolizumab (Keytruda) plus paclitaxel, which the FDA approved in February 2026 for a biomarker-selected platinum-resistant population.

References

1. Lesnock JL, Temin S, Bouberhan S, et al. Systemic treatment of ovarian cancer recurrence: ASCO Living Guideline, Version 2026.1.0. J Clin Oncol. Published online August 24, 2026. doi:10.1200/JCO-26-01591

2. Alberts DS, Liu PY, Wilczynski SP, et al. Randomized trial of pegylated liposomal doxorubicin (PLD) plus carboplatin versus carboplatin in platinum-sensitive patients with recurrent ovarian or peritoneal carcinoma after failure of initial platinum-based chemotherapy (Southwest Oncology Group Protocol S0200). Gynecol Oncol. 2008;108:90-94.

3. Fujiwara H, Ushijima K, Nagao S, et al. A phase II randomized trial of single agent versus combination carboplatin plus pegylated liposomal doxorubicin (GOTIC-003/Intergroup Study) in patients with platinum-sensitive recurrent ovarian cancer in late relapse. Gynecol Oncol. 2019;154:283-289.

4. Pujade-Lauraine E, Wagner U, Aavall-Lundqvist E, et al. Pegylated liposomal doxorubicin and carboplatin compared with paclitaxel and carboplatin for patients with platinum-sensitive ovarian cancer in late relapse (CALYPSO). J Clin Oncol. 2010;28:3323-3329.

5. Aghajanian C, Blank SV, Goff BA, et al. OCEANS: a randomized, double-blind, placebo-controlled phase III trial of chemotherapy with or without bevacizumab in patients with platinum-sensitive recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer. J Clin Oncol. 2012;30:2039-2045.

6. Coleman RL, Brady MF, Herzog TJ, et al. Bevacizumab and paclitaxel-carboplatin chemotherapy and secondary cytoreduction in recurrent, platinum-sensitive ovarian cancer (NRG Oncology/Gynecologic Oncology Group study GOG-0213): a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2017;18:779-791.

7. Gaitskell K, Rogozinska E, Platt S, et al. Angiogenesis inhibitors for the treatment of epithelial ovarian cancer. Cochrane Database Syst Rev. 2023;(7):CD007930.

8. Harter P, Sehouli J, Vergote I, et al. Randomized trial of cytoreductive surgery for relapsed ovarian cancer (DESKTOP III). N Engl J Med. 2021;385:2123-2131.

9. Coleman RL, Spirtos NM, Enserro D, et al. Secondary surgical cytoreduction for recurrent ovarian cancer. N Engl J Med. 2019;381:1929-1939.

10. Classe JM, Meeus P, Hudry D, et al. Hyperthermic intraperitoneal chemotherapy for recurrent ovarian cancer (CHIPOR): a randomised, open-label, phase 3 trial. Lancet Oncol. 2024;25:1551-1562.

11. Moore KN, Angelergues A, Konecny GE, et al. Mirvetuximab soravtansine in FRα-positive, platinum-resistant ovarian cancer (MIRASOL). N Engl J Med. 2023;389:2162-2174.

12. Moore KN, Oza AM, Colombo N, et al. Phase III, randomized trial of mirvetuximab soravtansine versus chemotherapy in patients with platinum-resistant ovarian cancer: FORWARD I. Ann Oncol. 2021;32:757-765.

13. Lorusso D, Gladieff L, O'Malley DM, et al. Relacorilant and nab-paclitaxel in patients with platinum-resistant ovarian cancer (ROSELLA): an open-label, randomised, controlled, phase 3 trial. Lancet. 2025;405:2205-2216.

14. Pujade-Lauraine E, Hilpert F, Weber B, et al. Bevacizumab combined with chemotherapy for platinum-resistant recurrent ovarian cancer: the AURELIA open-label randomized phase III trial. J Clin Oncol. 2014;32:1302-1308.

15. Rustin GJ, van der Burg ME, Griffin CL, et al. Early versus delayed treatment of relapsed ovarian cancer (MRC OV05/EORTC 55955): a randomised trial. Lancet. 2010;376:1155-1163.

16. Lanceley A, Berzuini C, Fauri-Burnell M, et al. Ovarian cancer follow-up: a preliminary comparison of two approaches. Int J Gynecol Cancer. 2013;23:57-64.