Systemic Therapy and Chemotherapy
Platinum is the backbone; the partner drug and the maintenance phase are what change
Ovarian cancer: carboplatin plus paclitaxel every 3 weeks for six cycles, with neoadjuvant chemotherapy permitted when primary debulking is not feasible. Bevacizumab is added for selected patients, and maintenance with a PARP inhibitor is chosen by BRCA mutation and homologous recombination status, not given indiscriminately. Endometrial cancer: carboplatin and paclitaxel for advanced or recurrent disease; add pembrolizumab or dostarlimab for mismatch repair–deficient or MSI-high tumors, where the benefit is largest. Hormonal therapy with a progestin or letrozole is reasonable for low-grade endometrioid disease. Cervical cancer: cisplatin plus paclitaxel with bevacizumab, and now pembrolizumab for PD-L1–positive recurrent or metastatic disease. Gestational trophoblastic neoplasia: single-agent methotrexate with folinic acid rescue or actinomycin D for low-risk disease; multiagent EMA-CO for high-risk disease.
Traps
Carboplatin is dosed to a target AUC using the Calvert formula, so renal function must be current. Cumulative paclitaxel neuropathy and carboplatin hypersensitivity are dose- and exposure-related. Bevacizumab is held around surgery and avoided with recent bowel obstruction or bleeding. Never confuse maintenance with a new line of therapy. PARP inhibitors are not for all comers.
Worked example
A 60-year-old with BRCA1-mutated stage IIIC high-grade serous carcinoma after complete cytoreduction receives carboplatin/paclitaxel with bevacizumab, followed by olaparib maintenance for 2 years. If she were BRCA wild-type and homologous recombination proficient, the PARP inhibitor decision would differ and the magnitude of benefit would be much smaller.