Patient
VAR-OVARIAN-FRAIL · Algorithm: ALGO-OVARIAN-ADVANCED-1L
Clinical significance of mutations (ESCAT)
Tumor-board context — the engine does not use these tiers to rank tracks
| Biomarker | Variant | ESCAT | Evidence | Clinical significance | Drugs | Sources |
|---|
| BIO-HRD-STATUS | HRD-positive — BRCA1/2 mutation OR genomic instability score (GIS) above validated threshold (Myriad MyChoice ≥42 or equivalent FoundationOne CDx HRD signature); ~50% of high-grade serous ovarian carcinoma | IA | - SRC-NCCN-OVARIAN-2025
- SRC-ESMO-OVARIAN-2024
Evidence cited from clinical guidelines; per-source evidence levels not yet structured. See Phase-2-of-CIViC-pivot for re-cite roadmap. | HRD-positive high-grade serous ovarian carcinoma (~50% — encompassing BRCA1/2-mutated and BRCA-WT/HRD+): PARP inhibitor maintenance after platinum response is FDA-approved 1L. Olaparib monotherapy maintenance for BRCA1/2-mutated newly-diagnosed advanced ovarian after CR/PR to platinum (SOLO-1 Moore NEJM 2018 — mPFS not reached vs 13.8 mo, HR 0.30) per SRC-NCCN-OVARIAN-2025, SRC-ESMO-OVARIAN-2024. Olaparib + bevacizumab maintenance for HRD-positive (BRCA-mut OR HRD-genomic) post-1L platinum + bevacizumab (PAOLA-1 Ray-Coquard NEJM 2019 — HRD subgroup mPFS 37 vs 17 mo, HR 0.33). Niraparib monotherapy maintenance is approved for all-comers (PRIMA Gonzalez-Martin NEJM 2019), with the strongest benefit in HRD-positive subgroup. | olaparib monotherapy maintenance (1L BRCA1/2-mut per SRC-NCCN-OVARIAN-2025, SRC-ESMO-OVARIAN-2024)
olaparib + bevacizumab maintenance (1L HRD-positive non-BRCA per SRC-NCCN-OVARIAN-2025)
niraparib monotherapy maintenance (1L per SRC-NCCN-OVARIAN-2025, all-comers benefit, HRD-positive strongest)
rucaparib monotherapy (2L maintenance / treatment per SRC-NCCN-OVARIAN-2025) | - SRC-NCCN-OVARIAN-2025
- SRC-ESMO-OVARIAN-2024
|
| Biomarker | Status |
|---|
| BIO-FRA | BIO definition in KB; no ESCAT BMA entry — verify with clinician |
Primary current-line option
- Indication
- IND-OVARIAN-ADVANCED-1L-CARBO-PACLI-HRD-NEG
- Regimen
- Carboplatin + Paclitaxel (ovarian 3-weekly)
- Drugs + NSZU
- Carboplatin (DRUG-CARBOPLATIN) AUC 5-6 · IV day 1 every 21d · IV ✓ NSZU covered
- Paclitaxel (DRUG-PACLITAXEL) 175 mg/m² · IV day 1 every 21d · IV ✓ NSZU covered
- Reason
- Primary current-line option selected by ALGO-OVARIAN-ADVANCED-1L at step 5; branch-driving red flag: RF-OVARIAN-FRAILTY-AGE.
Other current-line alternatives (2 tracks)
Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.
- Indication
- IND-OVARIAN-ADVANCED-1L-CARBO-PACLI-HRD-OLAP
- Regimen
- Carboplatin + Paclitaxel (ovarian 3-weekly)
- Drugs + NSZU
- Carboplatin (DRUG-CARBOPLATIN) AUC 5-6 · IV day 1 every 21d · IV ✓ NSZU covered
- Paclitaxel (DRUG-PACLITAXEL) 175 mg/m² · IV day 1 every 21d · IV ✓ NSZU covered
- Reason
- Current-line alternative presented for HCP consideration
- Indication
- IND-OVARIAN-MAINTENANCE-OLAPARIB
- Regimen
- Olaparib maintenance (HRD+ ovarian post-platinum response)
- Drugs + NSZU
- Olaparib (DRUG-OLAPARIB) 300 mg PO BID continuous · Continuous · PO ✓ NSZU covered
- Reason
- Current-line alternative presented for HCP consideration
Why this branch was chosen
Triggers from the patient profile that fired and drove the chosen branch.
Step 5 → branch IND-OVARIAN-ADVANCED-1L-CARBO-PACLI-HRD-NEG
- RF-OVARIAN-FRAILTY-AGE ★ winner: Frailty profile precluding standard carbo+pacli + bev intensified induction in ovarian: ECOG ≥3, OR (age ≥75 + Charlson ≥3), OR composite (age ≥70 + ascites large-volume + albumin <3.0). Triggers carbo-mono OR weekly-dose-dense-pacli (less neuropathy / bone marrow).
SRC-NCCN-OVARIAN-2025SRC-ESMO-OVARIAN-2024
Pre-treatment investigations
Investigations before treatment start · critical / standard / desired · merged across tracks
| ID | Name | Priority | Category | Where to order | Needed for |
|---|
| TEST-CBC | Complete Blood Count with Differential | Critical | lab | — | aggressive |
Red flags — PRO / CONTRA aggressive
PRO-AGGRESSIVE
Triggers that push toward the aggressive track
- BRCA1 or BRCA2 pathogenic variant (germline OR somatic) in high-grade serous ovarian carcinoma — ~20-25% prevalence (15% germline + ~7% somatic). Olaparib maintenance after platinum-based 1L (SOLO-1 — mPFS 56.0 vs 13.8 mo BRCA-mut) is treatment-defining; rucaparib + niraparib alternatives. SOLO-2 — 2L+ relapse maintenance.
RF-OVARIAN-BRCA-MUT-ACTIONABLE
- Frailty profile precluding standard carbo+pacli + bev intensified induction in ovarian: ECOG ≥3, OR (age ≥75 + Charlson ≥3), OR composite (age ≥70 + ascites large-volume + albumin <3.0). Triggers carbo-mono OR weekly-dose-dense-pacli (less neuropathy / bone marrow).
RF-OVARIAN-FRAILTY-AGE
- HRD-positive (BRCA1/2 mutation OR Genomic Instability Score ≥42) high-grade serous ovarian carcinoma. Treatment-defining for PARPi maintenance after platinum-based induction. Olaparib (SOLO-1 BRCA-only, PAOLA-1 with bev) + niraparib (PRIMA all-comer) substantially improve PFS in HRD-positive subset.
RF-OVARIAN-HRD-ACTIONABILITY
- Homologous Recombination Deficiency (HRD)-positive high-grade serous ovarian carcinoma (BRCA1/2 mutation OR Genomic Instability Score ≥42). PARPi maintenance after platinum-based induction is treatment-defining: niraparib (PRIMA — mPFS 21.9 vs 10.4 mo HRD-pos), olaparib + bevacizumab (PAOLA-1 — mPFS 37.2 vs 17.7 mo HRD-pos).
RF-OVARIAN-HRD-POSITIVE-ACTIONABLE
- Suboptimal primary cytoreductive surgery (residual disease ≥1 cm) or unresectable at presentation in advanced (FIGO III-IV) ovarian carcinoma. MDT-trigger for neoadjuvant chemo (NACT) → interval debulking surgery (IDS) pathway per CHORUS / EORTC55971 trials, rather than primary debulking.
RF-OVARIAN-SUBOPTIMAL-DEBULKING
CONTRA-AGGRESSIVE
Hard contraindications to escalation
What NOT to do
Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity
Standard plan (IND-OVARIAN-ADVANCED-1L-CARBO-PACLI-HRD-NEG)
- Do NOT use olaparib maintenance in HRD-negative — minimal benefit, MDS/AML risk
- Do NOT initiate bev maintenance within 28 days of major surgery
Aggressive plan (IND-OVARIAN-ADVANCED-1L-CARBO-PACLI-HRD-OLAP)
- Do NOT skip HRD testing — defines maintenance choice (PARPi-only HRD+; niraparib-all-comer if HRD-negative weak benefit)
- Do NOT start olaparib without confirmed CR/PR to platinum induction
- Do NOT continue olaparib through Grade 3 anemia without dose reduction
Aggressive plan (IND-OVARIAN-MAINTENANCE-OLAPARIB)
- Do NOT start without confirmed CR/PR to platinum
- Do NOT continue past 2 years for non-BRCA HRD+ unless still benefiting (label allows ≤24 mo)
- Do NOT skip pre-treatment counseling on long-term MDS/AML risk
Timeline
Treatment timeline — derived from regimen + monitoring schedule
Standard plan
Induction · Carboplatin + Paclitaxel (ovarian 3-weekly)
21-day cycles × 6 cycles (per GOG-218 / ICON-7 induction); subsequent maintenance per HRD/biomarker stratification
MDT brief
Discussion questions (1, 0 blocking)
MDT talk tree (4 steps)
| # | Owner | Topic | Action |
|---|
| 1 | hematologist | Staging / disease burden | What is the current LDH? Marker of tumor burden and transformation. |
| 2 | clinical_pharmacist | Specialist review | Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication. |
| 3 | molecular_geneticist | Specialist review | Indication references an actionable genomic biomarker — mutation / target / actionability interpretation needed. |
| 4 | palliative_care | Specialist review | Reduced performance status / decompensated comorbidity — goals-of-care assessment needed. |
Skills (recommended) — for consideration (3)
- Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
- Molecular geneticist / molecular oncologist recommended
Indication references an actionable genomic biomarker — mutation / target / actionability interpretation needed.
- Palliative care recommended
Reduced performance status / decompensated comorbidity — goals-of-care assessment needed.
Data quality
Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.
- Biomarker coverage: 1/1 known (100%), 0 missing, 0 default-track gaps
- Unevaluated RedFlags: RF-BREAST-OVARIAN-HRD-ASSAY-DISTINCTION, RF-OVARIAN-BRCA-MUT-ACTIONABLE, RF-OVARIAN-FRA-HIGH-ACTIONABLE, RF-OVARIAN-FRAILTY-AGE, RF-OVARIAN-HRD-ACTIONABILITY, RF-OVARIAN-HRD-POSITIVE-ACTIONABLE, RF-OVARIAN-INFECTION-SCREENING, RF-OVARIAN-PERIOPERATIVE-VTE, RF-OVARIAN-PLATINUM-RESISTANT, RF-OVARIAN-PLATINUM-SENSITIVE, RF-OVARIAN-SUBOPTIMAL-DEBULKING, RF-OVARIAN-TRANSFORMATION-PROGRESSION, RF-PAN-BRCA-SOMATIC-PARPI-CANDIDATE
Technical MDT skill metadata (3/16 activated in this plan)
All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).
| Specialist | skill_id | Version | Last reviewed | Sign-offs | Domain |
|---|
| Cellular therapy specialist (CAR-T) | cellular_therapy_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
| Clinical pharmacist | clinical_pharmacist | v0.1.0 | 2026-04-25 | 0 | clinical_pharmacy |
| Hematologist / oncohematologist | hematologist | v0.1.0 | 2026-04-25 | 0 | hematology_oncology |
| Hematopathologist (lymphoma / leukemia / myeloma) | hematopathologist | v0.1.0 | 2026-04-25 | 0 | hematopathology |
| Infectious disease / hepatology | infectious_disease_hepatology | v0.1.0 | 2026-04-25 | 0 | infectious_diseases |
| Medical oncologist (solid-tumor chemotherapist) | medical_oncologist | v0.1.0 | 2026-04-25 | 0 | solid_oncology |
| Molecular geneticist / molecular oncologist | molecular_geneticist | v0.1.0 | 2026-04-25 | 0 | molecular_oncology |
| Palliative care | palliative_care | v0.1.0 | 2026-04-25 | 0 | palliative_care |
| Pathologist (general) | pathologist | v0.1.0 | 2026-04-25 | 0 | pathology |
| Primary care / family physician | primary_care | v0.1.0 | 2026-04-25 | 0 | primary_care |
| Psycho-oncologist | psychologist | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Radiation oncologist | radiation_oncologist | v0.1.0 | 2026-04-25 | 0 | radiation_oncology |
| Radiologist | radiologist | v0.1.0 | 2026-04-25 | 0 | diagnostic_imaging |
| Social worker / case manager | social_worker_case_manager | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Surgical oncologist | surgical_oncologist | v0.1.0 | 2026-04-25 | 0 | surgical_oncology |
| Transplant specialist (BMT) | transplant_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
Sources cited
- SRC-ESMO-OVARIAN-2024: ESMO Ovarian Cancer Clinical Practice Guideline (2024)
- SRC-NCCN-OVARIAN-2025: NCCN Ovarian Cancer (v.2.2025)
Experimental options (clinical trials)
Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-05-13.
| NCT | Title | Phase | Status | Sponsor | UA | Signals | Eligibility (excerpt) |
|---|
| NCT06152731 | HRD Tests for Ovarian cancER | PHASE2 | RECRUITING | — | Biomarker: unclear Single country | |
| NCT06377267 | Status of HRD That Lead to a Benefit From Olaparib in Combination With Bevacizumab (STROBE Trial) | PHASE2 | RECRUITING | — | Single country | |
| NCT06836219 | Measure of Outcomes in Patients With Advanced Ovarian Cancer According to Homologous Recombination Status and Matched Therapies in a Real-world Scenario | N/A | RECRUITING | — | Biomarker: unclear Single country | |
Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.
Option availability in Ukraine
Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).
| Option | UA registration | NSZU | Cost orientation | Access pathway |
|---|
| Standard plan Carboplatin + Paclitaxel (ovarian 3-weekly) (REG-CARBO-PACLI-OVARIAN) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
| Aggressive plan Carboplatin + Paclitaxel (ovarian 3-weekly) (REG-CARBO-PACLI-OVARIAN) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
| Aggressive plan Olaparib maintenance (HRD+ ovarian post-platinum response) (REG-OLAPARIB-MAINT-OVARIAN) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
| Trial · NCT06152731 HRD Tests for Ovarian cancER No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT06377267 Status of HRD That Lead to a Benefit From Olaparib in Combination With Bevacizumab (STROBE Trial) No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT06836219 Measure of Outcomes in Patients With Advanced Ovarian Cancer According to Homologous Recombination Status and Matched Therapies in a Real-world Scenario No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-05-13.