All women with suspected stage IIIC or IV (FIGO Staging) invasive epithelial ovarian cancer should be evaluated by a gynecologic oncologist prior to initiation of therapy to determine whether they are candidates for primary cytoreductive surgery.

A primary clinical evaluation should include a CT of the abdomen and pelvis with oral and intravenous contrast and chest imaging (CT preferred) to evaluate the extent of disease and the feasibility of surgical resection. The use of other tools to refine this assessment may include laparoscopic evaluation or additional radiographic imaging (e.g. FDG-PET scan or diffusion-weighted MRI).

Women who have a high perioperative risk profile or a low likelihood of achieving cytoreduction to <1 cm (ideally to no visible disease) should receive neoadjuvant chemotherapy.

Decisions that women are not eligible for medical or surgical cancer treatment should be made after a consultation with a gynecologic oncologist and/or a medical oncologist with gynecologic expertise.

For women who are fit for primary cytoreductive surgery, with potentially resectable disease, either neoadjuvant chemotherapy or primary cytoreductive surgery may be offered based on data from phase III RCTs that demonstrate that neoadjuvant chemotherapy is noninferior to primary cytoreductive surgery with respect to progression-free and overall survival. Neoadjuvant chemotherapy is associated with less peri- and postoperative morbidity and mortality and shorter hospitalizations, but primary cytoreductive surgery may offer superior survival in selected patients.

For women with a high likelihood of achieving a cytoreduction to <1 cm (ideally to no visible disease) with acceptable morbidity, primary cytoreductive surgery is recommended over neoadjuvant chemotherapy.

For women who are fit for primary cytoreductive surgery but are deemed unlikely to have cytoreduction to <1 cm (ideally to no visible disease) by a gynecologic oncologist, neoadjuvant chemotherapy is recommended over primary cytoreductive surgery. Neoadjuvant chemotherapy is associated with less peri- and postoperative morbidity and mortality and shorter hospitalizations.

Before neoadjuvant chemotherapy is delivered, all patients should have histologic confirmation (core biopsy preferred) of an invasive ovarian, fallopian tube, or peritoneal cancer. In exceptional cases, when a biopsy cannot be performed, cytologic evaluation combined with a serum CA-125 to carcinoembryonic antigen (CEA) ratio >25 is acceptable to confirm the primary diagnosis and exclude cancers that are not ovarian, fallopian tube, or primary peritoneal carcinomas.

For neoadjuvant chemotherapy, a platinum/taxane doublet is recommended. However, alternate regimens, containing a platinum agent, may be selected based on individual patient factors.

RCTs tested surgery following three or four cycles of chemotherapy in women who had a response to neoadjuvant chemotherapy or stable disease. Interval cytoreductive surgery should be performed after ≤4 cycles of neoadjuvant chemotherapy for women with a response to chemotherapy or stable disease. Alternate timing of surgery has not been prospectively evaluated but may be considered based on patient-centered factors.

Patients with progressive disease on neoadjuvant chemotherapy have a poor prognosis. Options include alternative chemotherapy regimens, clinical trials, and/or discontinuation of active cancer therapy and initiation of end-of-life care. In general, there is little role for surgery and it is not typically advised, unless for palliation (e.g. relief of a bowel obstruction).