Chinese Society of Obstetrics and Gynecology, Chinese Anti-Cancer Association Integrated Traditional Chinese and Western Medicine Ovarian Cancer Professional Committee, Obstetrics and Gynecology Hospital Branch of the Chinese Hospital Association, Gynecologic Oncology Group of the Obstetrics and Gynecology Branch of the Guangxi Medical Association

Chinese Library Classification: R737.31 Document Code: B

Advanced epithelial ovarian cancer (AEOC) accounts for approximately 70% of all epithelial ovarian cancers (EOC). At diagnosis, most patients are FIGO stage III–IV [1], with extensive pelvic and abdominal implantations and metastases, which greatly increase surgical difficulty and the incidence of surgery-related complications. Many AEOC patients have poor performance status and reduced tolerance to surgery compared with early-stage patients, particularly those who are predicted to require extensive combined organ resection. Consequently, decision-making regarding initial treatment for AEOC poses a significant challenge in the field of gynecologic oncology. Achieving satisfactory primary cytoreductive surgery (PCS) is fundamental to ovarian cancer management; inappropriate application can lead to severe perioperative complications, delay postoperative chemotherapy, and serve as an important factor contributing to poor patient outcomes [2]. Neoadjuvant chemotherapy (NACT) is a key therapeutic strategy for AEOC, especially for patients in whom achieving initial R0 cytoreduction is unfeasible or who have severe comorbidities. As an alternative approach, combining NACT with interval cytoreductive surgery (ICS) can reduce tumor volume, lower surgical risk and perioperative complications, and NACT plus ICS has been shown to yield survival outcomes non-inferior to PCS [3]. The recent SUROVA study found that among Asian patients, overall survival (OS) was significantly better with NACT (63.1 months vs. 52.6 months, P < 0.05) [4]. Given the low chemosensitivity of histologic subtypes such as low-grade serous, mucinous, and clear cell carcinomas of the ovary, the appropriateness of NACT remains controversial; this consensus statement addresses only high-grade serous carcinoma and poorly differentiated endometrioid carcinoma of the ovary. Therefore, accurate pathological diagnosis prior to considering NACT is crucial [5]. This consensus aims to provide recommendations on selection criteria for NACT, chemotherapy regimens, and timing of ICS, with the goal of standardizing NACT use and optimizing treatment strategies for AEOC.

This consensus statement was developed by experts in the field following a literature review and focused discussions, integrating the latest evidence-based medical evidence with expert experience to guide clinical practice. The core process includes: systematically collecting and evaluating evidence; grading the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system; forming a multidisciplinary team and rigorously managing conflicts of interest; and ultimately generating graded recommendations based on the strength of the evidence and the level of consensus. The development process balanced scientific rigor with clinical applicability, while also considering the specific needs of different patient populations. The recommendation grades and their corresponding meanings are presented in Table 1.

Table 1: Recommendation Grades and Their Meanings in This Consensus Statement

1 Initial Evaluation of Advanced Epithelial Ovarian Cancer

Assessment of the extent of disease and surgical resectability in patients with suspected AEOC should include at least carbohydrate antigen 125 (CA125), human epididymis protein 4 (HE4), carcinoembryonic antigen (CEA), CA199 (excluding mucinous carcinomas, etc.), contrast-enhanced abdominal and pelvic computed tomography (CT), and thoracic imaging (preferably CT). Chest CT can effectively identify pleural metastases or mediastinal lymph node involvement, providing critical information for surgical decision-making. Other imaging modalities—such as magnetic resonance imaging (MRI), fluorodeoxyglucose positron emission tomography (FDG-PET), or ultrasound—may also be used to some extent to evaluate surgical feasibility.

The following factors are risk factors for achieving satisfactory cytoreductive surgery in PCS: age ≥60 years, CA125 ≥500 U/ml, American Society of Anesthesiologists (ASA) classification III–IV, retroperitoneal lymph nodes above the renal hilum >1 cm, diffuse small bowel adhesions or thickening, mesenteric lesions >1 cm in diameter, lesions at the root of the superior mesenteric artery >1 cm in diameter, perisplenic region lesions >1 cm in diameter, and omental bursa lesions >1 cm in diameter [6]. Subsequent studies confirmed, via receiver operating characteristic (ROC) curve analysis, that a CA125 level ≥600 U/ml demonstrates greater accuracy in predicting surgical outcomes [6]. A Suidan multivariate assessment scale was constructed based on clinical factors and CT imaging features; see Table 2. When the model score is ≥3 points, NACT combined with ICS is recommended.

Table 2 Suidan Multifactor Assessment Scale

Diagnostic laparoscopy can reduce the incidence of unsatisfactory cytoreductive surgery. After pelvic and abdominal CT scans, as well as thoracic imaging studies, have ruled out extra-pelvic and extra-abdominal metastases, the rate of unsatisfactory cytoreduction in the laparoscopy group was 2.0%, significantly lower than the 11.1% observed in the group assessed by CT alone, indicating that laparoscopy helps avoid unnecessary laparotomies to some extent [7]. Additionally, the area under the curve (AUC) for laparoscopy in predicting satisfactory cytoreduction was 0.955, compared with 0.755 for CT, suggesting superior predictive accuracy for laparoscopy [8]. However, in clinical practice, for patients whose imaging studies suggest pleural effusion (with positive cytology) or extra-abdominal organ parenchymal metastases (e.g., liver or spleen parenchyma, lungs, bone, brain, or extra-pelvic/abdominal lymph nodes), laparoscopic evaluation does not alter the treatment strategy, and laparoscopy is therefore not recommended. Commonly used laparoscopic prediction models include the Fagotti score—a graded assessment system based on laparoscopic findings (see Table 3)—and Sugarbaker’s Peritoneal Cancer Index (PCI) (0–39 points; see Figure 1). The PCI is calculated by summing the individual scores listed in Table 3 to obtain a Laparoscopic Prediction Value (PIV). Patients with a PIV < 8 may proceed directly to PCS [9]. For those with a PIV ≥ 8, it is recommended to first undergo 3–4 cycles of neoadjuvant chemotherapy (NACT), followed by reassessment according to the Response Evaluation Criteria in Solid Tumors (RECIST), allowing for decision-making and triage based on different response categories. If disease progresses after NACT, switching to a second-line chemotherapy regimen is recommended; if there is a favorable response, particularly achieving complete remission (CR), intra-abdominal cisplatin-based chemotherapy (ICS) is advised. For patients who are non-responsive or show only partial response to NACT, repeat laparoscopic evaluation is suggested: those with a PIV < 4 should receive ICS, while those with a PIV ≥ 4 should continue standard chemotherapy with the original regimen or switch to a second-line regimen [9]. Furthermore, a PCI ≤ 10 indicates low tumor burden, 11–20 indicates moderate burden, and PCI > 20 indicates high burden. A PCI > 20 suggests significant surgical difficulty, recommending prior NACT [10].

Table 3 Grading Scale for Laparoscopic Exploration (Fagotti Score)

Figure 1 Sugarbaker PCI score

To optimize treatment regimens, assess genetic risk, and guide therapeutic decision-making, it is recommended that patients with AEOC undergo routine germline pathogenic variant testing for BRCA1/2 and other ovarian cancer susceptibility genes prior to NACT [11], to determine suitability for poly(ADP-ribose) polymerase inhibitor (PARPi) maintenance therapy, and to counsel family members regarding potential cancer risks, potentially influencing reproductive choices among relatives. In the absence of germline pathogenic variants in BRCA1/2, somatic pathogenic variant analysis and homologous recombination deficiency (HRD) testing are recommended.

Recommendation: All patients with suspected AEOC should undergo combined CA125 and HE4 testing, along with contrast-enhanced CT of the abdomen and pelvis and chest CT to comprehensively assess the extent of tumor spread. The Fagotti score on laparoscopy, the PCI score, and imaging studies (MRI, FDG-PET, ultrasound) each have specific advantages in guiding treatment decisions for AEOC. After CT excludes pleural effusion or extra‑peritoneal organ parenchymal metastases, laparoscopy is preferred for assessment (if the Fagotti PIV score ≥8 or PCI >20, NACT is recommended first); multimodal imaging (MRI, FDG-PET/CT, and specialized ultrasound) is used secondarily to help determine resectability (recommendation grade: 2A). Routine screening for germline BRCA1/2 mutations and HRD testing is recommended for patients with AEOC to guide PARPi maintenance therapy and genetic risk management (recommendation grade: 1).

2 Pathological Basis of Neoadjuvant Chemotherapy

CT staging demonstrates high positive predictive value and sensitivity for stage III ovarian cancer, but its ability to detect limited extraperitoneal pelvic disease is poor; thus, relying solely on CT and other imaging findings provides insufficient evidence for diagnosing advanced epithelial ovarian cancer (AEOC). Among patients undergoing neoadjuvant chemotherapy (NACT), even with stringent inclusion criteria and diagnostic protocols, up to 3% still have their postoperative pathology reports ruling out an ovarian cancer diagnosis [12–13]. Therefore, assessment of NACT suitability must be grounded in accurate pathological diagnosis, with histopathological examination serving as the gold standard.

Both laparoscopic exploration and open laparotomy yielded pathology from tissue samples with a concordance rate of 96% compared with post-ICS pathological diagnosis; however, the laparoscopic group experienced less blood loss and required a shorter time to initiate NACT [14]. Ultrasound-guided core-needle or fine-needle biopsy can be used; the former obtains sufficient tissue for histological analysis and immunohistochemical testing, while the latter yields relatively less tissue but is still adequate for diagnostic purposes. Both approaches are highly safe, with overall complication rates not exceeding 1.5% [15]. Although there is no significant difference between core-needle and fine-needle biopsies in terms of specimen yield or diagnostic accuracy [16], core-needle biopsy is preferred because it provides more reliable assessment of tumor histology, particularly when distinguishing certain types such as low-grade serous carcinoma from serous borderline tumors. Fine-needle aspiration yields limited tissue, making diagnosis of mesenchymal or fibrotic lesions challenging [17]. Furthermore, molecular testing typically requires an adequate sample volume; therefore, obtaining tissue specimens via laparoscopic exploration or ultrasound-guided core-needle biopsy is recommended.

When obtaining tissue is difficult, or when a patient cannot tolerate tissue needle biopsy or laparoscopic exploration due to physical reasons, alternative diagnostic methods should be considered. Ascitic fluid cytology offers advantages such as minimal invasiveness, broad applicability, simplicity and speed, and avoidance of repeated punctures; techniques include conventional cytological smears, liquid-based thin-layer cytology smears, and ascitic fluid cell blocks. Ascitic fluid cell blocks combined with immunocytochemistry can be used to determine the cytopathological type, and a positive ascitic fluid cytology result together with a CA125/CEA ratio >25 may also substitute for histological biopsy [18]. When ascitic fluid cytology is positive but the CA125/CEA ratio ≤25, further specialized evaluation is recommended to rule out the possibility of metastatic tumors originating from the gastrointestinal tract, breast, or other sites.

Recommendation: Histopathological confirmation is required before NACT; core needle biopsy or laparoscopic exploration to obtain tissue specimens is recommended. Pathologic diagnosis was consistent with high-grade serous ovarian carcinoma and poorly differentiated endometrioid carcinoma. Ascitic fluid cytology and a CA125/CEA ratio >25 are appropriate only in special circumstances where biopsy is not feasible, and other metastatic tumors involving other organs must be ruled out (recommendation grade: 2A).

3 Indications for Neoadjuvant Chemotherapy

3.1 Patients with tumors that are extensively unresectable 　For AEOC patients in whom PCS is deemed unlikely to achieve satisfactory tumor debulking, neoadjuvant chemotherapy (NACT) is recommended. Based on data from the JCOG0602[19], SCORPION[20], EORTC 55971[12], and CHORUS[13] studies, the efficacy of NACT combined with interval cytoreductive surgery (ICS) versus PCS followed by chemotherapy was compared in AEOC patients. Patients in the PCS group received at least six cycles of postoperative chemotherapy, while those in the ICS group received three to four cycles preoperatively and three to four cycles postoperatively. Notably, in stage IV patients, NACT demonstrated a trend toward superior overall survival (OS) and progression-free survival (PFS) compared with PCS [12–13]. According to a pooled analysis of the EORTC 55971 and CHORUS trials, OS was 24.3 months in the NACT group versus 21.2 months in the PCS group (HR=0.76, P<0.05); PFS was 10.6 months in the NACT group versus 9.7 months in the PCS group (HR=0.77, P<0.05) [3]. NACT can alleviate disease-related symptoms, allow time to manage comorbidities, shorten operative duration, and reduce perioperative complications; its survival benefits are particularly pronounced in stage IV patients [21].

3.2 High-Risk Patients in the Perioperative Period 　ASA classification of grade III–IV, age ≥60 years, an Eastern Cooperative Oncology Group (ECOG) score >0, comorbidities, and ascites are high-risk factors for postoperative complications [22]. In patients with perioperative high-risk factors—such as advanced age, frailty, multiple chronic diseases, malnutrition, hypoproteinemia, or newly diagnosed venous thromboembolism—neoadjuvant chemotherapy combined with intra-arterial chemotherapy significantly reduces the risk of severe complications (P<0.05), making it a safer option [22].

Recommendation: It is recommended that patients with AEOC undergo stratified assessment by a specialist gynecologic oncologist. For patients who, following assessment, are unlikely to achieve satisfactory PCS (Suidan score ≥3, Fagotti PIV score ≥8, or PCI >20), who have high perioperative risk (e.g., ASA class III–IV, advanced age, ECOG performance status >0, comorbidities, hypoproteinemia, or new-onset venous thromboembolism), and for those with stage IV AEOC, NACT is recommended (recommendation grade: 2A).

4 Neoadjuvant Chemotherapy Regimens

Platinum-based chemotherapy combined with paclitaxel is the standard adjuvant treatment regimen for patients with advanced epithelial ovarian cancer (AEOC), particularly those with high-grade serous or endometrioid carcinomas, following surgery. Patients receiving carboplatin–paclitaxel or cisplatin–paclitaxel did not show significant differences in progression-free survival (PFS) or overall survival (OS); however, the former group demonstrated superior overall quality-of-life outcomes compared to the latter [23]. Additionally, cisplatin was associated with higher incidences of neurotoxicity, gastrointestinal toxicity, nephrotoxicity, metabolic toxicity, anemia, and alopecia than carboplatin. Based on these findings, carboplatin is recommended as the preferred platinum agent for neoadjuvant chemotherapy (NACT). Four pivotal phase III trials evaluated the efficacy of 3 to 4 cycles of standard NACT regimens—carboplatin at an AUC of 5–6 combined with paclitaxel at 175 mg/m² every 3 weeks [12–13, 19–20]. The EORTC 55971 and CHORUS trials found [12–13] that NACT plus interval debulking surgery (IDS) was non-inferior to primary cytoreductive surgery (PCS) in terms of overall survival, while in the SCORPION trial [20], PFS was similar between NACT plus IDS and PCS (14 months vs. 15 months, P > 0.05).

The GINECO/GCIG trial compared the efficacy of three chemotherapy regimens in frail elderly patients aged ≥70 years with advanced epithelial ovarian cancer (EOC) (see Table 4) [24]. The median PFS and OS were 4.8 and 8.3 months, and 7.4 and 17.3 months, respectively, for the carboplatin monotherapy group and the weekly regimen group. In the standard regimen group, the median PFS was 12.5 months, and the median OS has not yet been reached, indicating that the efficacy and survival outcomes of the carboplatin monotherapy group were significantly inferior to those of the weekly regimen and standard groups [24]. Therefore, the carboplatin monotherapy regimen is not recommended for elderly patients and/or those with comorbidities. The MITO-7 and ICON8 trials compared the standard carboplatin–paclitaxel regimen with a weekly regimen (carboplatin AUC 2 combined with paclitaxel 60 mg/m² or 80 mg/m² on days 1, 8, and 15, with one cycle every 3 weeks). The results showed no statistically significant difference in efficacy between the two regimens [25–26]. Paclitaxel at 60 mg/m² resulted in a higher incidence of pulmonary toxicity but lower incidences of neutropenia, thrombocytopenia, neuropathy, alopecia, and vomiting, while significantly improving quality of life [25]. In contrast, the paclitaxel 80 mg/m² regimen led to higher rates of neutropenia and carboplatin hypersensitivity reactions, and overall quality of life was poorer compared with the standard regimen [26]. Therefore, for patients aged >70 years and/or with comorbidities, the recommended neoadjuvant chemotherapy (NACT) regimen is weekly carboplatin–paclitaxel: carboplatin AUC 2 combined with paclitaxel 60 mg/m² on days 1, 8, and 15, with one cycle every 3 weeks.

Table 4 Three Chemotherapy Regimens in the GINECO/GCIG Trial

For patients with initially unresectable advanced ovarian cancer, neoadjuvant chemotherapy (NACT) combined with bevacizumab—specifically, four cycles of carboplatin and paclitaxel concurrently administered with 3 to 4 cycles of bevacizumab at 15 mg/kg—significantly improved the complete macroscopic cytoreductive resection rate (CRR) without increasing the incidence of adverse events [27]. Compared with the group receiving NACT without bevacizumab, although the combination did not improve the complete macroscopic response rate or R0 resection rate, a higher proportion of patients in the combination group actually underwent interval debulking surgery (ICS) (89% vs. 67%, P<0.05), and grade ≥3 AEs were significantly lower than in the non‑bevacizumab group (29% vs. 61%, P<0.05) [28]. For NACT patients receiving bevacizumab, ICS should be performed at least 6 weeks after discontinuing bevacizumab (with NACT continuing during the washout period) to reduce risks such as bleeding, impaired wound healing, and enterocutaneous fistula.

Recommendation: For patients with high-grade serous ovarian cancer or poorly differentiated endometrioid carcinoma who are suitable for neoadjuvant chemotherapy (NACT), the preferred regimen is carboplatin AUC 5–6 combined with paclitaxel 175 mg/m², administered every 3 weeks. For elderly, frail patients or those with poor tolerance to chemotherapy, a regimen of carboplatin AUC on a weekly schedule combined with paclitaxel 60 mg/m² (days 1, 8, and 15, one cycle every 3 weeks) may be considered. Bevacizumab can be selectively used in patients with substantial ascites or pleural effusion; intraperitoneal chemotherapy should be initiated after a 6-week washout period following discontinuation of bevacizumab (recommendation grade: 2A).

5 Evaluation of Neoadjuvant Chemotherapy Efficacy and Timing of Interval Cytoreductive Surgery

There is ongoing debate regarding the optimal number of neoadjuvant chemotherapy (NACT) cycles for patients with advanced ovarian cancer. The recent GOGER-01 study confirmed that, when comparing 3 versus 6 NACT cycles, there were no statistically significant differences in either the complete clinical response rate (CRR) or the pathological complete response rate; thus, extending the number of cycles did not further improve surgical outcomes [29]. Moreover, compared with 6 cycles, 3 cycles of NACT did not result in statistically significant differences in progression-free survival (PFS) or overall survival (OS) [29]; indeed, patients receiving fewer cycles (≤4 cycles) had better OS, suggesting that increasing the number of cycles may diminish survival benefits [30]. Additionally, adjustments to the NACT regimen due to adverse events—such as treatment delays, dose reductions, or drug switches—did not significantly affect efficacy or PFS, indicating a degree of flexibility in cycle scheduling [31]. Currently, most randomized controlled trials still recommend 3–4 cycles of NACT, and if satisfactory tumor debulking is achieved after this interval, interval cytoreductive surgery (ICS) should be performed promptly [12–13, 19–20]. It is important to emphasize that, regardless of the number of NACT cycles administered, achieving R0 resection remains critical for improving patient prognosis.

AEOC response to NACT is a critical factor in predicting the optimal timing for ICS. Imaging studies should be performed after 2–3 cycles of NACT and compared with baseline, followed by reassessment according to RECIST criteria. Clinical evaluation and CA125 testing should be conducted after each cycle of NACT. The CA125 clearance rate constant K (KELIM) serves as a biomarker of chemotherapy sensitivity in ovarian cancer; patients in the favorable KELIM score group (score > 1.00) achieved a significantly higher rate of R0 resection compared with those in the unfavorable (score < 0.50) and intermediate groups (score 0.50–1.00) (AUC = 0.76), and overall survival was significantly prolonged in the favorable-score group versus the unfavorable group [32]. If clinical response to NACT is observed and assessment indicates that satisfactory debulking may be achievable, ICS should be initiated no later than after four cycles of NACT [3].

ICS combined with hyperthermic intraperitoneal chemotherapy (HIPEC) (cisplatin 100 mg/m²) significantly prolongs survival in patients with ovarian cancer compared with ICS alone [33]; a significant overall survival (OS) benefit was observed (52 months vs. 45 months, HR=0.05) [34], and disease-free survival (DFS) improved to 18 months (12 months in the control group, HR=0.12) [34]. In these studies, most patients achieved R0 resection with ICS [33–34], and R0 resection is a prerequisite for subsequent HIPEC. HIPEC is recommended for AEOC patients who achieve R0 resection following NACT combined with ICS, but patients must be informed of the associated risks; particular caution is advised in those with renal impairment, diabetes, peripheral neuropathy, or advanced age. Its implementation requires multidisciplinary team collaboration—including pharmacy, nursing, anesthesiology, and surgery—to ensure the safety of intraoperative chemotherapy. Baseline laboratory tests (renal function, complete blood count) should be completed within one week preoperatively; goal-directed fluid therapy should be employed during surgery to prevent nephrotoxicity, and antiemetic regimens should be provided. Postoperatively, renal function, electrolytes, blood glucose, and blood pressure require close monitoring.

Recommendation: After three cycles of NACT, perform contrast-enhanced CT or MRI. Assess NACT efficacy according to RECIST solid tumor criteria, in conjunction with decreases in CA125 and KELIM scores, and symptom improvement (e.g., reduced ascites, marked improvement in performance status). Ideally, initiate ICS after 3–4 cycles of NACT; however, this should be guided by the gynecologic oncologist’s clinical judgment, and individualized timing may allow ICS after 4–6 cycles of NACT. Aim for safe R0 resection as the surgical goal (recommendation grade: 2A). For stage III–IV patients with good performance status and normal renal function who achieve R0 resection following NACT combined with ICS, HIPEC may be performed concurrently with ICS (recommendation grade: 2B).

6. Chemotherapy following interval cytoreductive surgery for ovarian cancer

Patients with ICS‑achieved R0 resection should receive at least three cycles of adjuvant chemotherapy postoperatively (paclitaxel 175 mg/m² combined with carboplatin AUC 5–6, administered every 3 weeks is preferred), or the total number of chemotherapy cycles (including NACT) should reach 6–8 [3,12-13,19-20]. For high‑risk patients (e.g., those without ICS‑achieved R0 resection or with stage IV disease), routine escalation of adjuvant chemotherapy cycles after NACT followed by ICS is not recommended [35]. When platinum‑based chemotherapy exceeds six cycles (e.g., 8–10 cycles), there is no significant improvement in PFS or OS compared with 5–6 cycles, but the risk of neurotoxicity increases [35]. This consensus recommends that for high‑risk patients who do not achieve R0 resection after ICS or who are stage IV, if the patient tolerates chemotherapy well, the total number of cycles may be cautiously limited to 6–8; exceeding eight cycles is generally not advised. At the same time, the patient’s tolerance to chemotherapy should be comprehensively assessed; if bone marrow suppression is severe and difficult to recover from, chemotherapy should be discontinued based on the individual patient’s condition.

Currently, regarding high-risk patients, only studies conducted in the context of PCS have investigated the optimal timing and number of cycles for adjuvant chemotherapy combined with bevacizumab after ICS; however, existing evidence still supports this regimen [36–37]. For patients with stage IV EOC who are at high risk and either did not achieve R0 resection following PCS or remain unresectable, compared with 6 cycles of chemotherapy alone after PCS, the full-course bevacizumab group—receiving 6 cycles of chemotherapy followed by continuous bevacizumab maintenance (total treatment duration of 21 cycles)—demonstrated a significantly prolonged median PFS by nearly 4 months [36]. The ICON7 trial confirmed that, among high-risk patients with stage IV, unresectable stage III, or those who failed to achieve R0 resection after PCS, sequential maintenance therapy following 6 cycles of standard chemotherapy plus bevacizumab at 7.5 mg/kg provided a significant overall survival (OS) benefit compared with standard chemotherapy alone (39.7 months vs. 30.2 months), while also extending PFS by approximately 50% (16.0 months vs. 10.5 months, P<0.05) [37]. Moreover, the associated risks were manageable, without significantly compromising patients’ long-term quality of life [37]. If bevacizumab is added, it should be initiated during the second postoperative cycle (with a minimum interval of 4 weeks after ICS surgery) to allow adequate healing of the surgical wound.

Regarding the timing of initiating adjuvant chemotherapy after ICS, although no dedicated studies have yet evaluated this, most RCTs begin chemotherapy within 6 weeks postoperatively [12–13, 19–20]. Given that delayed adjuvant chemotherapy after PCS may adversely affect prognosis, it is recommended to start adjuvant chemotherapy within 2–3 weeks after ICS, provided the patient’s condition permits.

Recommendation: When the patient’s physical condition permits, initiate adjuvant chemotherapy within 2–3 weeks after ICS (recommendation grade: 2B). For patients achieving R0 resection with ICS, 3 cycles of postoperative adjuvant chemotherapy or a total of 6–8 cycles are recommended; the specific regimen should be determined based on the patient’s tolerance to chemotherapy (recommendation grade: 2A). For patients who do not achieve R0 resection with ICS or who have high-risk features such as stage IV disease, a total of 8 cycles is recommended (recommendation grade: 2B). In high-risk patients, bevacizumab is recommended in combination after ICS surgery, but a 4-week interval after surgery is required to avoid delayed wound healing (recommendation grade: 2A).

7 Management of Patients with No Clinical Response to Neoadjuvant Chemotherapy

Patients who experience disease progression during NACT often have a poor prognosis, with a median OS of less than one year. Currently, there is a lack of RCTs comparing treatment strategies for patients who progress during NACT; it is generally considered appropriate to use chemotherapeutic agents with mechanisms of action distinct from carboplatin or paclitaxel, such as gemcitabine, pegylated liposomal doxorubicin, or bevacizumab [38]. Results from studies exploring novel therapies have been discouraging; for example, although the combination of sorafenib and topotecan significantly prolonged PFS, its severe toxicity and limited clinical benefit still require further investigation [39].

For patients who experience disease progression during NACT, a repeat tissue biopsy should be considered to confirm the diagnosis and perform additional molecular testing (e.g., molecular profiling, folate receptor status), while also verifying whether germline BRCA testing has been completed. Patients who develop disease progression during NACT are generally no longer recommended to receive ICS; when feasible, they may be offered participation in a clinical trial, alternative agents for palliative chemotherapy, or initiation of hospice care. Even if a PR or CR is achieved after changing the treatment regimen, ICS should be used with extreme caution.

Recommendation: For patients with platinum‑resistant or platinum‑refractory ovarian cancer who experience disease progression during NACT, repeat tissue biopsy to confirm the diagnosis is recommended; molecular testing is encouraged; switching to chemotherapy agents with a different mechanism of action is advised; and participation in clinical trials is encouraged. Palliative care should be initiated early to relieve symptoms and improve quality of life, alongside active psychological support (recommendation grade: 2B).

8 Multidisciplinary Collaboration and Comprehensive Management

For patients with AEOC, first-line treatment decisions should be jointly developed by a multidisciplinary team (MDT) comprising gynecologic oncologists, surgeons, radiologists, pathologists, medical oncologists, anesthesiologists, and nutrition support staff. Clinicians must clearly communicate the benefits and risks of evidence-based treatment options, fully respect the patient’s goals and preferences, and foster a supportive environment that encourages patients to ask questions and discuss their concerns or uncertainties. Additionally, given that patients may obtain information through online sources, social media, and family members, clinicians should guide patients toward reliable resources and emphasize the importance of collaborative, transparent decision-making.

Among patients who achieved satisfactory debulking, 37% sought care at large medical institutions or cancer centers with comprehensive treatment capabilities, compared to only 31% of those who were dissatisfied with their debulking; this suggests that such institutions have greater experience in performing debulking surgery [40]. Furthermore, hospitals with high surgical volumes reported a higher complete resection rate (CRR) (43.3%) than those with medium (41.6%) or low (41.0%) volumes [41], indicating better conditions for achieving satisfactory debulking. Conversely, ovarian cancer patients treated by surgeons with low surgical volume had significantly shorter median overall survival (OS) compared to those treated by surgeons with medium or high volumes (32.8 months vs. 41.9 months; 32.8 months vs. 42.1 months), a higher risk of death (HR = 1.25), and lower chemotherapy adherence [42]. Regarding regional disparities, rural patients were less likely than urban patients to undergo surgery performed by a gynecologic oncologist (OR = 0.48) [43]. Notably, among rural patients, surgery performed by a gynecologic oncology specialist significantly improved 3-year disease-specific survival compared with surgery performed by non-specialists (HR = 0.57) [43]. These advantages are closely linked to the experience of surgical teams, multidisciplinary team (MDT) support, and abundant medical resources available at large medical institutions or cancer centers. General hospitals and non-gynecologic oncology centers need to enhance professional expertise, optimize resource allocation, and strengthen multidisciplinary collaboration to improve patient outcomes.

In response to the relative lack of data in China, prospective studies are encouraged (e.g., NACT combined with immunotherapy, and molecular subtyping–guided treatment). For patients who must choose between PCS and NACT, clinicians should first explain the diagnostic findings, including disease extent, stage, and prognostic implications, and share data on incidence, survival, and quality of life in plain language to aid decision-making.

The screening pathway and end-to-end management are shown in Figure 2.

Figure 2: Flowchart of the Full-course Management Process for NACT in AEOC Patients

Recommendation: When the admitting medical facility lacks the capacity to perform optimal debulking surgery, patients should be promptly referred to a higher-level medical institution, an oncology center, or a regional medical center. Multidisciplinary team (MDT) collaboration is essential in the management of AEOC, enabling the development of individualized, comprehensive treatment plans for patients (recommendation grade: 2A).

9 Conclusion

This consensus document, drawing on recent domestic and international literature and guidelines and integrating the clinical experience of gynecologic oncology experts, emphasizes the importance of individualized treatment and aims to provide guidance for the clinical application of neoadjuvant chemotherapy (NACT) in advanced epithelial ovarian cancer (AEOC) in China. However, results from some prospective studies have not yet been published, and certain recommendations lack high-quality evidence-based support, which may give rise to some controversy. Many questions regarding the clinical use of NACT in AEOC remain to be explored, including the optimal number of NACT cycles, immune and targeted therapies guided by genomic testing, and alternative treatment strategies for patients who do not respond to NACT. With advances in molecular biology and ongoing prospective research, precision diagnosis and treatment of AEOC are expected to improve further. This consensus will be continuously updated to better serve clinical practice.

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44.  

Author: Liang Xuzhi (The First Affiliated Hospital of Guangxi Medical University); Fan Jiangtao (The First Affiliated Hospital of Guangxi Medical University); Wang Jiandong (Beijing Obstetrics and Gynecology Hospital, Capital Medical University); Zhang Shiqian (Qilu Hospital of Shandong University); Li Ning (Cancer Hospital, Chinese Academy of Medical Sciences); Sun Yang (Fujian Provincial Tumor Hospital); Zhang Yi (The First Affiliated Hospital of China Medical University); Wang Yingmei (Tianjin Medical University General Hospital); Xu Tianmin (The Second Hospital of Jilin University); Wang Gang (Sichuan Provincial Maternal and Child Health Care Institute); Li Li (Affiliated Tumor Hospital of Guangxi Medical University); Kong Beihua (Qilu Hospital of Shandong University)

Members of the expert panel who participated in the development and discussion of the consensus (listed in order of surname pinyin): Chen Gang (Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology); Fang Ziyu (The Fourth Affiliated Hospital of Guangxi Medical University); Fan Jiangtao (The First Affiliated Hospital of Guangxi Medical University); Ha Chunfang (General Hospital of Ningxia Medical University); Guo Liyuan (Affiliated Tumor Hospital of Harbin Medical University); Hou Wenjie (Dushu Lake Hospital, Soochow University); Li Li (Affiliated Tumor Hospital of Guangxi Medical University); Kong Beihua (Qilu Hospital of Shandong University); Kong Weimin (Beijing Obstetrics and Gynecology Hospital, Capital Medical University); Li Changzhong (Shenzhen Hospital of Peking University); Li Dapeng (Affiliated Tumor Hospital of Shandong First Medical University); Li Ning (Cancer Hospital of the Chinese Academy of Medical Sciences); Lu Huaiwu (Sun Yat-sen Memorial Hospital of Sun Yat-sen University); Liu Shujuan (The First Affiliated Hospital of Air Force Medical University); Liang Xuzhi (The First Affiliated Hospital of Guangxi Medical University); Sun Yang (Fujian Provincial Cancer Hospital); Wang Gang (Sichuan Provincial Maternal and Child Health Care Institute); Wang Jiandong (Beijing Obstetrics and Gynecology Hospital, Capital Medical University); Wang Yudong (International Peace Maternity and Child Health Institute, School of Medicine, Shanghai Jiao Tong University); Wang Yingmei (General Hospital of Tianjin Medical University); Wen Hao (Fudan University Shanghai Cancer Center); Xu Tianmin (The Second Hospital of Jilin University); Yang Zhijun (Affiliated Tumor Hospital of Guangxi Medical University); Yao Liangqing (Women and Children’s Medical Center, Guangzhou Medical University); Yi Ping (The First Affiliated Hospital of Chongqing Medical University); Zhang Hui (The Fourth Hospital of Hebei Medical University); Zhang Shiqian (Qilu Hospital of Shandong University); Zhang Shiyu (The Fourth Affiliated Hospital of Guangxi Medical University)

Funding Project: Key Project of the Guangxi Natural Science Foundation (No.: 2025GXNSFDA069002); Key R&D Program of Guangxi (No.: GuiKeAB22080045); Clinical Research Advancement Program of the First Affiliated Hospital of Guangxi Medical University (No.: YYZS2024006)

Corresponding author: Kong Beihua, E-mail: kongbeihua@sdu.edu.cn; Zhang Shiqian, E-mail: r370112@126.com; Fan Jiangtao, E-mail: jt_fan2018@163.com