Homologous recombination deficiency in Ovarian cancer: The game-changer for first-line maintenance therapy

Homologous recombination deficiency (HRD) plays a central role in the pathogenesis and therapeutic vulnerability of epithelial ovarian cancer (EOC), particularly in high-grade serous subtypes. HRD reflects the inability of tumor cells to accurately repair DNA double-strand breaks, rendering them sensitive to platinum-based chemotherapy and poly(ADP-ribose) polymerase (PARP) inhibitors. Several genomic assays have been developed to identify HRD status through the detection of genomic instability patterns, with varying degrees of clinical validation and regulatory approval. Beyond widely adopted assays such as Myriad myChoice® CDx and FoundationFocus™ CDx BRCA LOH, innovative approaches including the Leuven PARPi Benefit Test, circulating tumor DNA-based methods, and artificial intelligence-driven computational pathology are reshaping the diagnostic landscape. Nevertheless, important challenges remain, including the static nature of genomic scar assays, the impact of tumor heterogeneity, and the emergence of resistance through reversion mutations. Functional assays and integrative strategies may provide more dynamic insights into real-time DNA repair capacity, thereby supporting more accurate patient selection and treatment monitoring. Cost-effectiveness analyses further support the integration of HRD testing at diagnosis, highlighting its role in guiding optimal use of PARP inhibitors and improving healthcare resource allocation. This review summarizes the biological rationale, diagnostic methods, therapeutic implications, and economic considerations of HRD in EOC, with a focus on first-line maintenance strategies and future directions in precision oncology.