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 the NICE 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) 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 I 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 I disease).

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

Offer women with high-risk stage I disease (grade 3 or stage Ic) 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 I 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.