A 48-year-old woman with stage IIIC high-grade serous ovarian cancer completed 6 cycles of platinum-paclitaxel chemotherapy 3 months ago and achieved a complete radiological response. Her CA-125 has normalized. She has no residual disease on imaging. She is now asymptomatic with good performance status. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has achieved a complete response to first-line platinum-paclitaxel chemotherapy for stage IIIC high-grade serous ovarian cancer. She is now in remission with normalized CA-125 and no radiological evidence of disease. ## Maintenance Therapy in Ovarian Cancer **Key Point:** After complete response to platinum-based chemotherapy in advanced ovarian cancer, **bevacizumab maintenance therapy** significantly improves progression-free survival (PFS) and overall survival (OS) in high-risk patients. **High-Yield:** Bevacizumab maintenance therapy is indicated in: - **Stage III–IV epithelial ovarian cancer** (any histology) - **After completion of platinum-paclitaxel ± bevacizumab induction** - **Dosing:** 15 mg/kg IV every 3 weeks for 15 months (total 15 cycles) - **Mechanism:** Anti-VEGF agent; inhibits angiogenesis and delays recurrence ## Evidence Base | Trial | Population | Intervention | Primary Outcome | Benefit | | --- | --- | --- | --- | --- | | **GOG-218** | Stage III–IV, CR/PR to chemo | Bevacizumab induction + maintenance vs. placebo | PFS | +5.5 months PFS; OS benefit in stage IV | | **ICON7** | Stage III–IV, CR/PR to chemo | Bevacizumab induction + maintenance vs. observation | PFS | +3.7 months PFS; OS benefit in high-risk | **Clinical Pearl:** "High-risk" disease (stage IV, suboptimal debulking, or poor prognostic factors) derives greater OS benefit from bevacizumab maintenance. Even stage IIIC benefits from PFS prolongation. ## Management Algorithm ```mermaid flowchart TD A[Stage III-IV EOC<br/>Completed Pt-Taxol ± Bev]:::outcome --> B{Complete Response?}:::decision B -->|Yes| C{High-risk disease<br/>or stage IV?}:::decision B -->|No| D[Assess for secondary<br/>debulking or salvage chemo]:::action C -->|Yes| E[Bevacizumab maintenance<br/>15 months]:::action C -->|No| F[Consider maintenance<br/>per patient preference]:::action E --> G[Surveillance: CA-125<br/>+ imaging q3-6 months]:::action F --> G ``` **Mnemonic: BEVA-MAINT** (Bevacizumab Maintenance indications): - **B** = Beyond first-line chemotherapy completion - **E** = Epithelial ovarian cancer (any stage III–IV) - **V** = VEGF inhibition delays recurrence - **A** = Advanced disease (especially stage IV) - **M** = Maintenance for 15 months - **A** = Angiogenesis suppression - **I** = Improves PFS and OS - **N** = Normalized CA-125 preferred - **T** = Toxicity generally manageable **Warning:** Do not confuse with: - ~~PARP inhibitor maintenance~~ (olaparib/niraparib are used in BRCA-mutant or HRD-positive disease; this patient's status is unknown) - ~~Observation alone~~ (inferior PFS compared to bevacizumab maintenance) [cite:Park 26e Ch 18; Harrison 21e Ch 297]