Ovarian cancer: recognition and initial management

Refer the woman using a suspected cancer pathway referral if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids).

Carry out tests in primary care (see the section on asking the right question – first tests) if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month:

• persistent abdominal distension (women often refer to this as 'bloating')

• feeling full (early satiety) and/or loss of appetite

• pelvic or abdominal pain

• increased urinary urgency and/or frequency.
  
  See also NICE's guideline on suspected cancer: recognition and referral.

Consider carrying out tests in primary care (see the section on asking the right question – first tests) if a woman reports unexplained weight loss, fatigue or changes in bowel habit.

Advise any woman who is not suspected of having ovarian cancer to return to her GP if her symptoms become more frequent and/or persistent.

Carry out appropriate tests for ovarian cancer (see the section on asking the right question – first tests) in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS), because IBS rarely presents for the first time in women of this age.

See NICE's guideline on irritable bowel syndrome in adults.

Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer (see the section on awareness of symptoms and signs).

If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis.

If the ultrasound suggests ovarian cancer, refer the woman for further investigation using a suspected cancer pathway referral.

For any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound:

• assess her carefully for other clinical causes of her symptoms and investigate if appropriate

• if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent.

Measure serum CA125 in secondary care in all women with suspected ovarian cancer, if this has not already been done in primary care.

In women under 40 with suspected ovarian cancer, measure levels of alpha fetoprotein (AFP) and beta human chorionic gonadotrophin (beta-hCG) as well as serum CA125, to identify women who may not have epithelial ovarian cancer.

Calculate a risk of malignancy index I (RMI I) score (after performing an ultrasound; see recommendation 1.2.3.1 in the section on imaging in the diagnostic pathway: which procedures?) and refer all women with an RMI I score of 250 or greater to a specialist multidisciplinary team.

See the appendix for details of how to calculate an RMI I score.

Perform an ultrasound of the abdomen and pelvis as the first imaging test in secondary care for women with suspected ovarian cancer, if this has not already been done in primary care.

If the ultrasound, serum CA125 and clinical status suggest ovarian cancer, perform a CT scan of the pelvis and abdomen to establish the extent of disease. Include the thorax if clinically indicated.

Do not use MRI routinely for assessing women with suspected ovarian cancer.

If offering cytotoxic chemotherapy to women with suspected advanced ovarian cancer, first obtain a confirmed tissue diagnosis by histology (or by cytology if histology is not appropriate) in all but exceptional cases.

Offer cytotoxic chemotherapy for suspected advanced ovarian cancer without a tissue diagnosis (histology or cytology) only:

• in exceptional cases, after discussion at the multidisciplinary team and

• after discussing with the woman the possible benefits and risks of starting chemotherapy without a tissue diagnosis.

If surgery has not been performed, use histology rather than cytology to obtain a tissue diagnosis. To obtain tissue for histology:

• use percutaneous image-guided biopsy if this is feasible

• consider laparoscopic biopsy if percutaneous image-guided biopsy is not feasible or has not produced an adequate sample.
  
  Use cytology if histology is not appropriate.

Perform retroperitoneal lymph node assessment as part of optimal surgical staging in women with suspected ovarian cancer whose disease appears to be confined to the ovaries (that is, who appear to have stage 1 disease).

Lymph node assessment involves sampling of retroperitoneal lymphatic tissue from the para-aortic area and pelvic side walls if there is a palpable abnormality, or random sampling if there is no palpable abnormality.

Optimal surgical staging constitutes: midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum; and retroperitoneal lymph node assessment (Winter-Roach et al. 2009).

Do not include systematic retroperitoneal lymphadenectomy (block dissection of lymph nodes from the pelvic side walls to the level of the renal veins) as part of standard surgical treatment in women with suspected ovarian cancer whose disease appears to be confined to the ovaries (that is, who appear to have stage 1 disease).

Do not offer adjuvant chemotherapy to women who have had optimal surgical staging and have low-risk stage 1 disease (grade 1 or 2, stage 1a or 1b).

Offer women with high-risk stage 1 disease (grade 3 or stage 1c) adjuvant chemotherapy consisting of 6 cycles of carboplatin.

Discuss the possible benefits and side effects of adjuvant chemotherapy with women who have had suboptimal surgical staging and appear to have stage 1 disease.

Optimal surgical staging constitutes: midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum; and retroperitoneal lymph node assessment (Winter-Roach et al. 2009).

If performing surgery for women with ovarian cancer, whether before chemotherapy or after neoadjuvant chemotherapy, the objective should be complete resection of all macroscopic disease.

Do not offer intraperitoneal chemotherapy to women with ovarian cancer, except as part of a clinical trial. See also NICE's interventional procedures guidance on cytoreduction surgery with hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis, which recommends that this procedure should only be used with special arrangements for clinical governance, consent, and audit or research.

Paclitaxel in combination with a platinum-based compound or platinum-based therapy alone (cisplatin or carboplatin) are recommended as options in NICE technology appraisal guidance for first-line chemotherapy for treating ovarian cancer. For full details, see the guidance on paclitaxel (TA55, 2005).

Bevacizumab with paclitaxel and carboplatin is not recommended in NICE technology appraisal guidance for first-line treatment of advanced ovarian cancer. For full details, see the guidance on bevacizumab (TA284, 2013). However, NHS England recommends bevacizumab with paclitaxel and carboplatin as an option for first-line induction treatment for advanced (stage 3 and 4) ovarian cancer at a dose of 7.5 mg/kg or 15 mg/kg. For more information, see the NHS England Cancer Drugs Fund list.

In April 2025, a dose of 7.5 mg/kg was an off-label use of bevacizumab. See NICE's information on prescribing medicines.

Rucaparib for maintenance treatment is recommended as an option in NICE technology appraisal guidance for BRCA mutation-negative and homologous recombination deficiency positive advanced (stage 3 and 4) high-grade epithelial ovarian cancer after complete or partial response to first-line platinum-based chemotherapy. For full details, see the guidance on rucaparib (TA1055, 2025).

Rucaparib for maintenance treatment is recommended as an option in NICE technology appraisal guidance for BRCA mutation-negative advanced (stage 3 and 4) high-grade epithelial ovarian cancer where homologous recombination deficiency status is negative or unknown and bevacizumab is not a treatment option, after complete or partial response to first-line platinum-based chemotherapy. For full details, see the guidance on rucaparib (TA1055, 2025).

Olaparib for maintenance treatment is recommended as an option in NICE technology appraisal guidance for BRCA mutation-positive advanced (stage 3 and 4) high-grade epithelial ovarian cancer after response to first-line platinum-based chemotherapy. For full details, see the guidance on olaparib (TA962, 2024).

Olaparib with bevacizumab for maintenance treatment is recommended as an option in NICE technology appraisal guidance for homologous recombination deficiency positive, advanced (stage 3 and 4), high-grade epithelial ovarian cancer after complete or partial response to first-line platinum-based chemotherapy with bevacizumab. For full details, see the guidance on olaparib with bevacizumab (TA946, 2024).

Niraparib for maintenance treatment is recommended as an option in NICE technology appraisal guidance within the Cancer Drugs Fund for advanced (stage 3 and 4) high-grade epithelial ovarian cancer after response to first-line platinum-based chemotherapy only if the conditions in the managed access agreement are followed. For full details, see the guidance on niraparib (TA673, 2021).

Bevacizumab for maintenance treatment is recommended as an option by NHS England for advanced (stage 3 and 4) ovarian cancer previously treated with a 7.5 mg/kg dose of bevacizumab in combination with carboplatin and paclitaxel. See the NHS England Cancer Drugs Fund list.

In April 2025, this was an off-label use of bevacizumab. See NICE's information on prescribing medicines.

For medicines recommended as options in NICE technology appraisal guidance for treating recurrent ovarian cancer, see the guidance on:

• paclitaxel in combination with platinum or as monotherapy (TA389, 2016)

• pegylated liposomal doxorubicin hydrochloride (PLDH) as monotherapy (TA389, 2016)

• PLDH in combination with platinum (TA389, 2016).

For medicines not recommended in NICE technology appraisal guidance for treating the first recurrence of platinum-sensitive ovarian cancer, see the guidance on:

• gemcitabine in combination with carboplatin (TA389, 2016)

• trabectedin in combination with PLDH (TA389, 2016)

• topotecan (TA389, 2016)

• bevacizumab in combination with gemcitabine and carboplatin (TA285, 2013).

Topotecan is not recommended in NICE technology appraisal guidance for treating recurrent platinum-resistant or platinum-refractory ovarian cancer. For full details, see the guidance on topotecan (TA389, 2016).

Trametinib is recommended as an option by NHS England for treating serous low-grade ovarian or peritoneal cancer that has recurred or progressed following at least 1 platinum-based chemotherapy. See the NHS England Cancer Drugs Fund list.

In April 2025, this was an off-label use of trametinib. See NICE's information on prescribing medicines.

Rucaparib for maintenance treatment is recommended as an option in NICE technology appraisal guidance for relapsed platinum-sensitive high-grade epithelial ovarian cancer that has completely or partially responded to platinum-based chemotherapy. For full details, see the guidance on rucaparib (TA1007, 2024).

Olaparib for maintenance treatment is recommended as an option in NICE technology appraisal guidance for BRCA mutation-positive relapsed, platinum-sensitive, high-grade epithelial ovarian cancer, after 2 or more courses of platinum-based chemotherapy. For full details, see the guidance on olaparib (TA908, 2023).

Niraparib for maintenance treatment is recommended as an option in NICE technology appraisal guidance for treating relapsed, platinum-sensitive high-grade serous epithelial ovarian cancer in adults that has responded to the most recent course of platinum-based chemotherapy if:

• they have a BRCA mutation and have had 2 courses of platinum-based chemotherapy, or

• they do not have a BRCA mutation and have had 2 or more courses of platinum-based chemotherapy.
  
  For full details, see the guidance on niraparib (TA784, 2022).