Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Cancer on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.
Detection in Primary Care
Recommendations in this section update and replace recommendation 1.7.4 in Referral guidelines for suspected cancer ' (NICE clinical guideline 27).
Awareness of Symptoms and Signs
Refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids) (see also Referral guidelines for suspected cancer [NICE clinical guideline 27]).
Carry out tests in primary care 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 (see also Referral guidelines for suspected cancer [NICE clinical guideline 27]):
- 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
Consider carrying out tests in primary care 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 general practitioner (GP) if her symptoms become more frequent and/or persistent.
Carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS) (see the NGC summary of 'Irritable bowel syndrome in adults' [NICE clinical guideline 61]), because IBS rarely presents for the first time in women of this age.
Asking the Right Question – First Tests
Measure serum cancer antigen 125 (CA125) in primary care in women with symptoms that suggest ovarian cancer.
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 urgently for further investigation (see also Referral guidelines for suspected cancer [NICE clinical guideline 27]).
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.
Establishing the Diagnosis in Secondary Care
Tumour Markers: Which to Use?
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) and refer all women with an RMI I score of 250 or greater to a specialist multidisciplinary team. See Appendix D in the original guideline document for details of how to calculate an RMI I score.
Imaging in the Diagnostic Pathway: Which Procedures?
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 computed tomography (CT) scan of the pelvis and abdomen to establish the extent of disease. Include the thorax if clinically indicated.
Do not use magnetic resonance imaging (MRI) routinely for assessing women with suspected ovarian cancer.
Requirement for Tissue Diagnosis
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
Methods of Tissue Diagnosis Other Than Laparotomy
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.
Management of Suspected Early (Stage I) Ovarian Cancer
The Role of Systematic Retroperitoneal Lymphadenectomy
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).
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).
*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.
Adjuvant Systemic Chemotherapy for 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 six 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.
Management of Advanced (Stage II–IV) Ovarian Cancer
Note that recommendations 1.1 and 1.2 in NICE technology appraisal guidance 55 ('Guidance on the use of paclitaxel in the treatment of ovarian cancer'; available at www.nice.org.uk/guidance/TA55 ) are on first-line chemotherapy in the treatment of ovarian cancer.
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.
Support Needs of Women with Newly Diagnosed Ovarian Cancer
Offer all women with newly diagnosed ovarian cancer information about their disease, including psychosocial and psychosexual issues, that:
- Is available at the time they want it
- Includes the amount of detail that they want and are able to deal with
- Is in a suitable format, including written information
Ensure that information is available about:
- The stage of the disease, treatment options, and prognosis
- How to manage the side effects of both the disease and its treatments in order to maximise wellbeing
- Sexuality and sexual activity
- Fertility and hormone treatment
- Symptoms and signs of disease recurrence
- Genetics, including the chances of family members developing ovarian cancer
- Self-help strategies to optimise independence and coping
- Where to go for support, including support groups
- How to deal with emotions such as sadness, depression, anxiety, and a feeling of a lack of control over the outcome of the disease and treatment