Underuse of Maintenance Therapies Highlights Need for Improved Care Strategies in Advanced Ovarian Cancer

Despite the availability of first-line maintenance options like bevacizumab and poly (ADP-ribose) polymerase (PARP) inhibitors, fewer than half of eligible patients with advanced ovarian cancer (aOC) receive maintenance treatment, according to a study published in Future Oncology.¹

The standard of care for newly diagnosed aOC includes either primary or interval cytoreductive surgery followed by platinum-based chemotherapy, with or without bevacizumab.² To reduce the risk of recurrence, patients may receive first-line maintenance treatment with bevacizumab.¹ Those who respond to initial treatment may also receive a PARP inhibitor.

Bevacizumab monotherapy was the first maintenance therapy approved by the FDA for newly diagnosed aOC in 2018. The FDA later approved 2 PARP inhibitors, olaparib and niraparib, for first-line maintenance treatment following surgery and/or chemotherapy in aOC.

Fewer than half of eligible patients with advanced ovarian cancer receive first-line maintenance treatments, highlighting care gaps. | Image Credit: Queenmoonlite Studio - stock.adobe.com

To assess the real-world uptake of these therapies overall and by BRCA mutation status, the researchers conducted a retrospective study using data from the nationwide Flatiron Health database, which includes longitudinal, deidentified patient-level structured and unstructured data from about 280 cancer clinics, representing an estimated 800 sites of mostly community-based care across the US.

Eligible patients were 18 years or older with stage III or IV epithelial ovarian cancer. These patients initiated first-line platinum-based chemotherapy, either with or without bevacizumab, between January 1, 2020, and February 28, 2023. Patients were followed from the index date, defined as the start of first-line platinum-based chemotherapy, until death, last clinical activity, or the end of the study period, whichever came first.

The researchers identified 599 eligible patients. Of these, 358 (59.8%) were White, and the median (IQR) age at index was 67 (59-74) years. Overall, the median follow-up duration was 13.8 (6.8-23.7) months.

Among the cohort, 285 (47.6%) underwent interval cytoreductive surgery and neoadjuvant chemotherapy, 168 had primary cytoreductive surgery and adjuvant chemotherapy, and 146 had no surgery or an unknown surgery status.

Regarding initial treatment, 348 patients (58.1%) received chemotherapy alone, and 251 (41.9%) received chemotherapy with bevacizumab. In total, 289 patients (48.2%) received a first-line maintenance treatment regimen.

Among these patients, 140 (23.4%) received PARP inhibitor monotherapy, 88 (14.7%) received bevacizumab monotherapy, 47 (7.8%) received a combination of bevacizumab and a PARP inhibitor, and 14 (2.3%) received another type of first-line maintenance therapy. The remaining 310 patients (51.8%) were managed with active surveillance.

The researchers suggested that the relatively low uptake of first-line maintenance treatment is likely influenced by various factors. These include a time lag between the publication of clinical trial results and their adoption in clinical practice, as well as treatment-related costs. However, the study was not designed to investigate reasons behind treatment decisions.

“…more work is needed to investigate this question and determine whether there is room for improved first-line maintenance treatment uptake among patients with aOC,” the authors wrote.

Regarding BRCA status, 433 patients (72.3%) had a BRCA wild-type (BRCAwt) status, 93 (15.5%) had a BRCA-mutated (BRCAm) status, and 73 (12.2%) had an unknown BRCA status. The uptake of first-line maintenance therapies varied significantly among these subgroups.

PARP inhibitor monotherapy was most common among patients with a BRCAm status (n = 44; 47.3%) compared with those with a BRCAwt (n = 94; 21.7%) or an unknown BRCA status (n = 2; 2.7%). Similarly, combination therapy with bevacizumab plus a PARP inhibitor was most frequently used in patients with a BRCAm status (n = 15; 16.1%) vs those with a BRCAwt (n = 32; 7.4%) or an unknown status (n = 0; 0%).

Additionally, bevacizumab monotherapy was most often used among patients with a BRCAwt status (n = 81; 18.7%) compared with those with a BRCAm (n = 3; 3.2%) or an unknown BRCA status (n = 4; 5.5%). In contrast, active surveillance was more common among patients with an unknown BRCA status (n = 4; 87.7%) than those with a BRCAwt (n = 217; 50.1%) or a BRCAm (n = 29; 31.2%) status.

The researchers acknowledged their limitations, including that the study period overlapped with the COVID-19 pandemic, which may have affected care delivery and influenced maintenance treatment decisions. Still, they expressed confidence in their findings and identified directions for future research.

“These data may be a useful landmark, against which future treatment patterns can be compared to identify changes in the treatment landscape for patients with aOC,” the authors concluded. “Future studies should examine potential underlying reasons for real-world treatment selection, including increased understanding of potential barriers and patient and physician preferences.”

References

1. Chase DM, Kalilani L, Cooney MA, et al. Real-world post-2020 first-line maintenance treatment patterns in patients with advanced ovarian cancer in the US. Future Oncol. Published online July 14, 2025. doi:10.1080/14796694.2025.2526273
2. González-Martín A, Harter P, Leary A, et al. Newly diagnosed and relapsed epithelial ovarian cancer: ESMO clinical practice guideline for diagnosis, treatment and follow-up. Ann Oncol. 2023;34(10):833-848. doi:10.1016/j.annonc.2023.07.011