Table 1.

First line treatment

Statement 1	Selection of patients for neoadjuvant chemotherapy (NACT) or primary cytoreductive surgery (PCS) (Approval 32/33 groups, 1 opposed)
	PCS after assessment in an expert Gynecological Oncology unit is preferred. NACT followed by interval cytoreductive surgery (ICS) is a valid alternative only if PCS is not feasible.  1. PCS or 3–4 cycles of NACT followed by ICS are valid options after evaluation of the complexity of surgery, the likelihood of complete cytoreduction (R0) and the histological type confirmed by biopsy.   - PCS is preferred if a complete resection seems achievable or for patients with tumour histological types associated with limited response to platinum-based therapy, even if complete resection is questionable (e.g.low grade serous or mucinous carcinoma).   - NACT with ICS is the preferred option in patients with chemosensitive histological types AND with a low likelihood of an initial complete resection OR who are poor surgical candidates.  2. Optimal assessment includes a combination of patient status, biological factors, and disease extent by imaging and/or surgical evaluation.  3. The extent of disease at the beginning and at the end of cytoreductive surgery should be thoroughly documented.
Statement 2	Stratification factors (SF) (Approval 33/33 groups)
	First line trials should include validated prognostic stratification factors and predictive factors according to the protocol design and the intervention explored.  1. Prognostic factors such as BRCA status, FIGO stage, timing of surgery (PCS vs NACT), outcome of surgery (no residual versus any residual tumour), histological type (high grade serous ovarian cancer (HGSOC)/high grade endometrioid ovarian cancer (HGEOC) vs others non-HGSOC/HGEOC), or patient status should be included as stratification factors depending on the trial hypothesis.  2. Predictive biomarkers should be included as stratification factors, such as BRCA status and homologous recombination (HR) status (tested by a validated assay) especially in trials with poly-ADP ribose polymerase inhibitors (PARPi).  3. New biomarkers measured by a validated assay should be prospectively evaluated in first line trials properly powered for this endpoint.
Statement 3	Acceptable reference arms for systemic treatment? (Approval 33/33 groups)
	1. Backbone systemic therapy is based on the carboplatin-paclitaxel combination  - 6 cycles of IV 3-weekly carboplatin area under the curve (AUC) 5–6 and paclitaxel 175 mg/m2 remains the reference arm for first-line chemotherapy in advanced ovarian cancer. The addition of bevacizumab is acceptable.   ○ Dose dense weekly IV Paclitaxel 80 mg/m2 with 3-weekly carboplatin is an alternative reference arm to 3-weekly IV carboplatin/paclitaxel only in populations for whom level 1 evidence of a benefit exists.   ○ Weekly carboplatin AUC 2/paclitaxel 60 mg/m2 can be an acceptable option.  2. Maintenance therapy should be considered in the reference arm for HGSOC/HGEOC   - Patients with BRCA mutated (BRCAm) tumours (either germline or somatic) or BRCA wild type (BRCAwt)/HR deficient (HRd) should receive a PARPi as maintenance, with or without bevacizumab.   - The role of maintenance therapy for patients with HR-proficient tumours is not completely defined. These patients may receive PARPi or bevacizumab as maintenance, and even observation depending on the trial design.
Statement 4.	Challenges of maintenance therapy (Approval 33/33 groups)
	1. Progression-free survival (PFS) and overall survival (OS) should remain the primary endpoints. 2. PARPi may impact the effectiveness of subsequent treatments in the recurrence setting, therefore post-treatment progression data** and PFS2*** should also be considered key secondary endpoints. 3. Maintenance treatment trials should have validated patient reported outcomes (PROs) and safety assessments, such as proCTCAE and quality adjusted endpoints (Q-TWIST or quality adjusted PFS).
Statement 5	Intraperitoneal chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC) (Approval 30/33 groups, 2 opposed*, 1 abstain)
	1. Any form of IP therapy or HIPEC cannot be regarded as a reference treatment arm within clinical trials
Statement 6	Future trials for high-risk Stage I or Stage II disease (Approval 33/33 groups)
	High-risk stage I and II studies are needed, using international cooperation.  1. Separate trials should address specific questions for patients with high-risk stage I or stage II epithelial ovarian cancer, defined by histological, clinical and biological factors.  2. Platinum-based chemotherapy remains the reference arm.

^*See Supplement page 4

^**post-treatment progression data: type and timing of subsequent therapy

^***PFS2: time from randomisation to the second objective disease progression or death