Bevacizumab in first-line postoperative treatment of advanced ovarian cancer: from high-risk stratification to precision decision-making

Bevacizumab is an important component of first-line therapy for advanced epithelial ovarian cancer; however, the precise identification of patients who will benefit and how to optimize its use in the era of poly (ADP-ribose) polymerase inhibitors (PARPi) remains a core challenge in clinical practice. This review systematically revisits the pivotal phase III trials GOG-0218 and ICON7, together with their inherent limitations, with a particular focus on the role of KELIM score as a dynamic marker of chemotherapy sensitivity in predicting bevacizumab efficacy. Based on the interaction test from GOG-0218, the available evidence suggests that BRCA/homologous recombination deficiency (HRD) status does not alter the single-agent activity of bevacizumab; however, these genetic markers remain crucial for guiding PARPi or combination regimens. A key clinical dilemma arises when patients with a BRCA mutation have already received bevacizumab during first-line chemotherapy: should bevacizumab be continued or discontinued during the maintenance phase? This review presents a preference analysis and individualized decision-making factors based on available indirect evidence and current guidelines. Finally, a clinical decision pathway that integrates KELIM assessment with HRD testing is proposed to provide an evidence-based reference framework for the rational use of bevacizumab in first-line advanced ovarian cancer.