The use of primary cytoreductive surgery (PCS) for ovarian cancer has declined over the past decade, from 70% in 2010 to 37% in 2021, as neoadjuvant chemotherapy (NACT) emerged as an alternative to optimize surgical outcomes and reduce perioperative morbidity.^1,2 In response to evolving clinical evidence and shifting treatment patterns, the American Society of Clinical Oncology (ASCO) has released updated guidelines for newly diagnosed stage III or stage IV epithelial ovarian, fallopian tube, or primary peritoneal cancer.² These guidelines introduce refinements in patient selection, treatment strategies, and the integration of emerging therapeutic approaches to optimize patient outcomes while also tackling disparities in healthcare access.²

Ovarian cancer remains a global health concern, with an incidence of 6.6 and a mortality rate of 3.9 per 100,000 women.³ PCS was long the cornerstone of treatment, aiming for maximal tumor debulking followed by chemotherapy.^1,2,4 However, since ASCO’s 2016 guideline update, evolving clinical evidence with corresponding shifts in front-line treatment, and a growing emphasis on patient-centered care have prompted further revisions, leading to the recent 2025 update.²

The updated guidelines continue to endorse platinum/ taxane-based NACT but emphasize careful patient selection.² Patients who are eligible for PCS should proceed with surgery, while those with extensive disease burden or poor surgical candidacy should receive NACT followed by interval cytoreductive surgery (ICS).² This shift is driven by meta-analyses demonstrating a higher rate of surgical completeness and reduced risk of postsurgical death and infections with NACT.2 A notable addition to the updated guidelines is the emphasis on racial disparities in treatment access.² Recent findings also indicate that Black patients have a 38% lower likelihood of undergoing PCS compared to non-Black patients.² Additionally, Asian (OR=1.12; 95% CI: 1.02-1.22) and Black (OR=1.12; 95% CI: 0.99-1.28) women are more likely to receive NACT with interval debulking surgery rather than PCS with increased risk of all-cause mortality (HR=1.14; 95% CI: 1.09-1.20) compared to women who are White.² These disparities persist even after accounting for clinical factors, highlighting structural barriers to equitable cancer care.² The guidelines advocate for standardized treatment recommendations to mitigate these disparities.²

The new guidelines also refine the timing of ICS, recommending an optimal window after three to four cycles of NACT.² Postsurgical chemotherapy protocols have also been modified to allow for individualized treatment duration, considering patient response, performance status, and quality of life factors.² Additionally, the guidelines emphasize the necessity of genetic and molecular testing at diagnosis to guide treatment selection, especially in those with progressive disease on NACT.² Molecular profiling is crucial for determining eligibility for maintenance therapies, yet challenges remain in conducting somatic testing after NACT due to possibility of insufficient tumor tissue availability.^2,5

For the first time, the 2025 ASCO guidelines also include hyperthermic intraperitoneal chemotherapy (HIPEC) as a potential adjunct to treatment.² Clinical trials suggest that for patients undergoing NACT, HIPEC may offer an overall survival benefit.² However, its adoption is limited by the need for specialized training and institutional resources.² While not universally available, the inclusion of HIPEC underscores its potential role in improving long-term outcomes.²

The guidelines acknowledge significant barriers to implementation, particularly in resource-limited settings.² Limited access to gynecologic oncologists, insurance-related obstacles, and disparities in surgical expertise can hinder the consistent application of best practices.² Proposed solutions include enhanced collaboration between medical oncologists, gynecologic oncologists, radiologists, and pathologists to facilitate multidisciplinary decision-making.² Looking ahead, the field of ovarian cancer treatment continues to evolve, with emerging therapies to target the hallmarks of cancer on the horizon.6 Future updates to ASCO guidelines may incorporate these advancements, potentially shifting the treatment paradigm away from chemotherapy and toward more precise, tumor-directed approaches based on specific disease characteristics.⁶

In conclusion, the 2025 ASCO guidelines for newly diagnosed, advanced ovarian cancer reflect a growing emphasis on individualized treatment, equitable access, and evidence-based decision-making.² By refining patient selection criteria, optimizing chemotherapy regimens, and acknowledging disparities in care, these updates aim to improve outcomes and quality of life for patients with advanced ovarian cancer.² As research continues to advance, ongoing guideline revisions will be critical in shaping the future of ovarian cancer management.²